A novel tool for arrhythmic risk stratification in desmoplakin gene variant carriers.

BACKGROUND AND AIMS: Pathogenic desmoplakin (DSP) gene variants are associated with the development of a distinct form of arrhythmogenic cardiomyopathy known as DSP cardiomyopathy. Patients harbouring these variants are at high risk for sustained ventricular arrhythmia (VA), but existing tools for individualized arrhythmic risk assessment have proven unreliable in this population. METHODS: Patients from the multi-national DSP-ERADOS (Desmoplakin SPecific Effort for a RAre Disease Outcome Study) Network patient registry who had pathogenic or likely pathogenic DSP variants and no sustained VA prior to enrolment were followed longitudinally for the development of first sustained VA event. Clinically guided, step-wise Cox regression analysis was used to develop a novel clinical tool predicting the development of incident VA. Model performance was assessed by c-statistic in both the model development cohort (n = 385) and in an external validation cohort (n = 86). RESULTS: In total, 471 DSP patients [mean age 37.8 years, 65.6% women, 38.6% probands, 26% with left ventricular ejection fraction (LVEF) < 50%] were followed for a median of 4.0 (interquartile range: 1.6-7.3) years; 71 experienced first sustained VA events {2.6% [95% confidence interval (CI): 2.0, 3.5] events/year}. Within the development cohort, five readily available clinical parameters were identified as independent predictors of VA and included in a novel DSP risk score: female sex [hazard ratio (HR) 1.9 (95% CI: 1.1-3.4)], history of non-sustained ventricular tachycardia [HR 1.7 (95% CI: 1.1-2.8)], natural logarithm of 24-h premature ventricular contraction burden [HR 1.3 (95% CI: 1.1-1.4)], LVEF < 50% [HR 1.5 (95% CI: .95-2.5)], and presence of moderate to severe right ventricular systolic dysfunction [HR 6.0 (95% CI: 2.9-12.5)]. The model demonstrated good risk discrimination within both the development [c-statistic .782 (95% CI: .77-.80)] and external validation [c-statistic .791 (95% CI: .75-.83)] cohorts. The negative predictive value for DSP patients in the external validation cohort deemed to be at low risk for VA (<5% at 5 years; n = 26) was 100%. CONCLUSIONS: The DSP risk score is a novel model that leverages readily available clinical parameters to provide individualized VA risk assessment for DSP patients. This tool may help guide decision-making for primary prevention implantable cardioverter-defibrillator placement in this high-risk population and supports a gene-first risk stratification approach.

Clinical T2N0M0 Esophageal Cancer-Is Treatment Pathway Associated With Overall Survival?

INTRODUCTION: Esophageal cancer therapy is commonly multimodal. The CROSS trial demonstrated a survival benefit of neoadjuvant chemoradiation versus surgery alone in T1N1 or T2-3N0-1 patients. Theoretically, chemoradiation should be most beneficial to patients with advanced disease. Treating the intermediary stage, T2N0M0, is challenging as national guidelines offer multiple options. This study aims to compare survival outcomes and associated factors in clinical T2N0M0 esophageal cancer via treatment modality and compare clinical to pathological stage. The authors conclude that neoadjuvant therapy use has increased; however, there is no associated survival benefit, which may be due to over- or under-staging. METHODS: A retrospective study was performed using the National Cancer Database (2006-2016). Patients who underwent neoadjuvant chemoradiation followed by surgery (NCRT + ESOPH) were compared to patients who underwent esophagectomy first (ESOPH). Multivariable logistic regression was used to determine factors associated with treatment pathway. Overall survival was compared using Kaplan-Meier estimates and log-rank tests at 1-, 3-, and 5-y post-treatment. Additionally, a multiple logistic regression analysis was conducted to identify factors associated with adjuvant therapy in ESOPH patients. RESULTS: There were 1662 patients (NCRT + ESOPH: 904 [54.4%], ESOPH: 758 [45.6%]). There was no difference in 5-y survival between NCRT + ESOPH and ESOPH patients. Despite this, NCRT + ESOPH treatment rates rose from 33% to 74% between 2006 and 2016. Patients who received NCRT + ESOPH were younger and more commonly had no Charlson-Deyo comorbidities. Notably, 41% of patients were over-staged (T1 or lower), and 32.8% were under-staged (N ≥ 1). CONCLUSIONS: T2N0M0 remains difficult to characterize, and pathological staging corresponds poorly to clinical staging. Neoadjuvant therapy use has increased; however, the lack of a significant survival benefit to correlate with such may be secondary to over- or under-staging.

Adherence Disparities and Utilization Trends of Oncotype Dx Assay: A National Cancer Database Study.

INTRODUCTION: Oncotype Dx (ODX) is a genetic assay that analyzes tumor recurrence risk and provides chemotherapy recommendations for T1-T2 stage, hormone receptor-positive, human epidermal growth factor receptor-negative, and nodal-negative breast cancer patients. Despite its established validity, the utilization of this assay is suboptimal. The study aims to evaluate factors that are associated with adherence rate with the testing guidelines and examine changes in utilization trends. METHODS: This is a retrospective study, utilizing data from the National Cancer Database from 2010 to 2017. Patients who met the ODX testing guidelines were first evaluated for testing adherence. Secondly, all patients who underwent ODX testing were assessed to evaluate the trend in ODX utilization. RESULTS: A total of 429,648 patients met the criteria for ODX, and 43.4% of this population underwent testing. Advanced age, racial minorities, low-income status, well-differentiated tumor grade, uninsured status, and treatment at community cancer centers were associated with a decreased likelihood of receiving ODX in eligible patients. Additionally, a notable amount of testing was performed on patients who did not meet the ODX testing criteria. Among the 295,326 patients that underwent ODX testing, 16.6% of patients were node-positive and 1.8% had T3 or T4 stage tumors. CONCLUSIONS: A considerable number of patients who were eligible for ODX did not receive it, indicating potential barriers to care and disparities in breast cancer treatment. ODX usage has been expanded to broader patient populations, indicating more research is needed to validate the effectiveness of the assay in these patient groups.

Falls from Tree Stands Have Become the Leading Cause of Deer Hunting Accidents in Pennsylvania.

OBJECTIVES: This study aimed to describe, using a statewide trauma registry, the incidence, trends, and injuries for tree stand falls while deer hunting in Pennsylvania. METHODS: Falls from tree stands were abstracted from the Pennsylvania Trauma Systems Foundation registry (1990-2017) and combined with the number of licensed deer hunters, deer hunting days, and deer hunting-related shooting incidents (HRSIs) provided by the Pennsylvania Game Commission to calculate tree stand fall and HRSI rates (per 1 million deer hunting days) and age-group specific fall rates (per 100,000 licensed deer hunters). Poisson regression was used to assess the significance of the annual and age group rate trends (significance P < 0.05). Case fatality rate (percentage of number of deaths per number of injured hunters) also was calculated. RESULTS: There were 1229 victims of tree stand falls and 560 victims of HRSIs between 1990 and 2017. Fall rates increased from 1.5 to 10.4 (P < 0.0001), and HRSI rates decreased from 4.9 to 1.2 (P = 0.001). Fall rates surpassed HRSI rates in 1999 and increased with advancing age (P = 0.007), peaking at 7.2 for hunters aged 50 to 59 years. Most (77%) injured hunters sustained multiple injuries. The case fatality rate was only 0.8%, but 26% of the injured hunters had a dependent functional limitation at hospital discharge. CONCLUSIONS: Tree stand falls are now the leading cause of Pennsylvania deer hunting accidents. Fall victims usually sustain multiple nonfatal but often disabling injuries. Study findings support the need for surveillance of these accidents and additional tree stand safety education.

Multicenter Study of the Treatment of Appendicitis in America: Acute, Perforated, and Gangrenous (MUSTANG), an EAST Multicenter Study.

OBJECTIVE: We sought to describe contemporary presentation, treatment, and outcomes of patients presenting with acute (A), perforated (P), and gangrenous (G) appendicitis in the United States. SUMMARY BACKGROUND DATA: Recent European trials have reported that medical (antibiotics only) treatment of acute appendicitis is an acceptable alternative to surgical appendectomy. However, the type of operation (open appendectomy) and average duration of stay are not consistent with current American practice and therefore their conclusions do not apply to modern American surgeons. METHODS: This multicenter prospective observational study enrolled adults with appendicitis from January 2017 to June 2018. Descriptive statistics were performed. P and G were combined into a "complicated" outcome variable and risk factors were assessed using multivariable logistic regression. RESULTS: A total 3597 subjects were enrolled across 28 sites: median age was 37 (27-52) years, 1918 (53%) were male, 90% underwent computed tomography (CT) imaging, 91% were initially treated by appendectomy (98% laparoscopic), and median hospital stay was 1 (1-2) day. The 30-day rates of Emergency Department (ED) visit and readmission were 10% and 6%. Of 219 initially treated with antibiotics, 35 (16%) required appendectomy during index hospitalization and 12 (5%) underwent appendectomy within 30 days, for a cumulative failure rate of 21%. Overall, 2403 (77%) patients had A, whereas 487 (16%) and 218 (7%) patients had P and G, respectively. On regression analysis, age, symptoms >48 hours, temperature, WBC, Alvarado score, and appendicolith were predictive of "complicated" appendicitis, whereas co-morbidities, smoking, and ED triage to appendectomy >6 hours or >12 hours were not. CONCLUSION: In the United States, the majority of patients presenting with appendicitis receive CT imaging, undergo laparoscopic appendectomy, and stay in the hospital for 1 day. One in five patients selected for initial non-operative management required appendectomy within 30 days. In-hospital delay to appendectomy is not a risk factor for "complicated" appendicitis.

Predicting Positive Margins in Pancreatic Head Adenocarcinoma After Neoadjuvant Therapy: Investigating Disparities in Quality Care Using the National Cancer Database.

BACKGROUND: In pancreatic cancer, surgical resection with neoadjuvant therapy improves survival, but survival relies significantly on the margin status of the resected tissue. This study aimed to develop a model that predicts margin positivity, and then to identify facility-specific factors that influence the observed-to-expected (O/E) ratio for positive margins among facilities. METHODS: This retrospective review analyzed patients in the National Cancer Database (2004-2016) with pancreatic head adenocarcinoma [tumor-node-metastasis (TNM) stage 1 or 2] who received neoadjuvant therapy for a pancreaticoduodenectomy. Logistic regression was used to develop a model that predicts margin positivity. This model then was used to identify outlier facilities with regard to the O/E ratio. Hospital volume was defined as the total number of pancreaticoduodenectomies per year. RESULTS: The study enrolled 4085 patients, and 16.8% of these patients had positive margins. Most of the patients (64%) had a tumor size of 2 to 4 cm, and approximately 51% of the patients did not have positive lymph nodes at resection. A logistic regression model showed that the predictors of positive margins after resection with neoadjuvant therapy were male sex, larger tumor size, and positive lymph nodes. This model was validated to yield a bootstrap-corrected concordance index of 0.632. The study calculated O/E ratios with the model, identifying 12 low- and 17 high O/E-ratio outlier facilities among 401 studied hospitals. The outlier hospitals did not differ in facility type (i.e., academic vs integrated network), but did differ significantly in terms of yearly hospital volume (low outlier of 20.6 vs high outlier of 10.7; p = 0.008). CONCLUSIONS: An association of lower-volume facilities with higher than expected rates of positive margins was found to indicate a disparity in care. This disparity was identified via an O/E ratio as a quality indicator for facilities. Facilities can gauge the efficiency of their own practices by referencing their O/E ratios, and they also can improve their practices by analyzing the framework of low O/E-ratio facilities.

Use and Outcomes of Epidural Analgesia in Upper Gastrointestinal Tract Cancer Resections.

BACKGROUND: Epidural analgesia (EA) is an appealing adjunct for esophageal and gastric cancer patients. It remains unclear whether EA usage affects postoperative outcomes. There are no national data on the trends of EA utilization for these procedures. This study aims to use the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to study the utilization and outcomes of EA in open upper GI tract cancer resections. MATERIALS AND METHODS: A retrospective review of NSQIP was performed for patients undergoing open elective esophagectomies and gastrectomies for nonmetastatic cancer between 2014 and 2017. An Armitage trend test was performed. The population was propensity matched and assessed. RESULTS: There were 4802 esophagectomies performed. Twenty-nine percent of patients received EA. Of 2599 gastrectomies, 18% of patients received EA. The recent trends of EA use for esophagectomies (EA range [26.9%, 30.3%] P = 0.6535) and gastrectomies (EA [16.9%, 18.4%], P = 0.7797) remain stable. Propensity matching was performed, and the groups with and without EA were compared. For esophagectomies, EA was associated with blood transfusions (EA 14% versus No EA 10.8%, P = 0.0156). For gastrectomies, EA was associated with longer length of stay (LOS) (EA median [IQR] 8 [7,11] versus No EA 7 [6,11], P = 0.0002). CONCLUSIONS: Despite the current opioid epidemic, the recent trends of EA for esophageal and gastric cancer patients remain stable. EA was associated with blood transfusions for esophagectomies and with a longer LOS for gastrectomies. Therefore, EA should be carefully considered, and its analgesic efficacy in this population should be investigated closely in future studies.

Identifying Outlier Hospitals in Gastric Cancer Lymph Node Yield Using the National Cancer Database.

BACKGROUND: Lymph node (LN) yield is a key quality indicator that is associated with improved staging in surgically resected gastric cancer. The National Comprehensive Cancer Network recommends a yield of ≥15 LNs for proper staging, yet most facilities in the United States fail to achieve this number. The present study aimed to identify factors that could affect LN yield on a facility level and identify outlier hospitals. METHODS: This was a retrospective review of adults (aged ≥18 y) with gastric cancer (Tumor-Node-Metastasis Stages I-III) who underwent gastrectomy. Data were analyzed from the National Cancer Database (2004-2016). Multivariate analysis identified patient and tumor characteristics, whereas an observed-to-expected ratio of identified outlier hospitals. Facility factors were compared between high and low outliers. RESULTS: A total of 26,590 patients were included in this study. Of these patients, only 50.3% had an LN yield ≥15. The multivariate model of patient and tumor characteristics demonstrated a concordance index was 0.684. A total of 1245 facilities were included. There were 198 low outlier LN yield hospitals and 135 high outlier LN yield hospitals (observed-to-expected ratio of 0.42 ± 0.24 versus 1.38 ± 0.19, P < 0.0001). There was a difference in facility type between low and high outliers (P < 0.0001). High LN yield hospitals had a larger surgical volume than low LN yield hospitals (median 8.4 [4.9, 13.5] versus 3.5 [2.4, 5.2]; P < 0.0001). CONCLUSIONS: Nearly half of the population exhibited low compliance to National Comprehensive Cancer Network recommendations. Facility-level disparities exist as high yearly surgical volume and academic facility status distinguished high-performing outlier hospitals.

Urgent Surgery for Gastric Adenocarcinoma: A Study of the National Cancer Database.

BACKGROUND: Gastric adenocarcinoma is a leading cause of cancer death worldwide and, in the United States, can present emergently with upper GI hemorrhage, obstruction, or perforation. No large studies have examined how urgent surgery affects patient outcomes. This study examines the outcomes of urgent versus elective surgery for gastric cancer. MATERIALS AND METHODS: Patients with gastric adenocarcinoma from the National Cancer Database from 2004 to 2015 were examined retrospectively. Patients with metastatic disease or incomplete data were excluded. Urgent surgery was defined as definitive surgery within 3 d of diagnosis. Univariate and multivariate analysis of patient factors, surgical outcomes, and oncologic data was performed. P-values <0.05 were statistically significant. RESULTS: Of 26,116 total patients, 2964 had urgent surgery and 23,468 had elective surgery. Urgent surgery patients were significantly older, were female, were nonwhite, had higher pathologic stage, and were treated at a low-volume center. Urgent surgery was associated with decreased quality lymph node harvest (odds ratio [OR] 0.68 95% confidence interval {CI} [0.62, 0.74]), increased positive surgical margin (OR 1.48, 95% CI [1.32, 1.65]), increased 30-d mortality (OR 1.38, 95% CI [1.16, 1.65]), increased 90-d mortality (OR 1.30, 95% CI [1.14, 1.49]), and decreased overall survival (hazard ratio 1.21, 95% CI [1.15, 1.27]). CONCLUSIONS: Urgent surgery for gastric cancer is associated with significantly worse outcomes than elective surgery. Stable patients requiring urgent surgical resection for gastric cancer may benefit from referral to a high-volume center for resection by an experienced surgeon. Patients undergoing urgent resection for gastric cancer should be referred to surgical and medical oncologists to ensure they receive appropriate adjuvant therapy and surveillance.

External Validation of a Survival Nomogram for Non-Small Cell Lung Cancer Using the National Cancer Database.

PURPOSE: Survival nomograms offer individualized predictions using a more diverse set of factors than traditional staging measures, including the American Joint Committee on Cancer Tumor Node Metastasis (AJCC TNM) Staging System. A nomogram predicting overall survival (OS) for resected, non-metastatic non-small cell lung cancer (NSCLC) has been previously derived from Asian patients. The present study aims to determine the nomogram's predictive capability in the US using the National Cancer Database (NCDB). METHODS: This was a retrospective review of adults with resected, non-metastatic NSCLC entered into the NCDB between 2004 and 2012. Concordance indices and calibration plots analyzed discrimination and calibration, respectively. Multivariate analysis was also used. RESULTS: A total of 57,313 patients were included in this study. The predominant histologies were adenocarcinoma (48.2%) and squamous cell carcinoma (31.3%), and patients were diagnosed with stage I-A (38.3%), stage I-B (22.7%), stage II-A (14.2%), stage II-B (11.5%), and stage III-A (13.3%). Median OS was 74 months. 1-, 3- and 5-year OS rates were 89.8% [95% confidence interval (CI) 89.5-90.0%], 71.1% (95% CI 70.7-71.6%), and 55.7% (95% CI 54.7-56.6%), respectively. The nomogram's concordance index (C-index) was 0.804 (95% CI 0.792-0.817). AJCC TNM staging demonstrated higher discrimination (C-index 0.833, 95% CI 0.821-0.840). CONCLUSIONS: The nomogram's individualized estimates accurately predicted survival in this patient collective, demonstrating higher discrimination in this population than in the developer's cohorts. However, the generalized survival estimates provided by traditional staging demonstrated superior predictive capability; therefore, AJCC TNM staging should remain the gold standard for the prognostication of resected NSCLC in the US.

Alcohol Consumption Decreases Oxytocin Neurons in the Anterior Paraventricular Nucleus of the Hypothalamus in Prairie Voles.

BACKGROUND: Alcohol use disorders are associated with dysfunctional social relationships and stress responses. The neuropeptides oxytocin (OT) and vasopressin (AVP) are known to orchestrate or mediate many aspects of social behavior, stress responses, and ingestive behaviors. Because of the overlap between the effects of alcohol and the roles of OT and AVP, we sought to determine whether alcohol consumption altered expression of OT and AVP in the paraventricular nucleus (PVN) of the hypothalamus, one of the key sites for OT and AVP synthesis. METHODS: Pair-housed adult male prairie voles were allowed to consume 15% ethanol versus water in the home cage continuously (Continuous-Access [CA] group) or every other day for 4 hours (Intermittent-Access [IA] group). Control animals never had access to alcohol. After 7 weeks, animals were sacrificed and their brains were removed and immunohistochemical analysis of OT- and AVP-immunopositive neurons was performed. RESULTS: OT-immunopositive neurons were significantly decreased in the anterior PVN in the CA but not IA group, relative to Control animals, suggesting that continuous alcohol consumption decreases the number of OT neurons. There was no effect of alcohol consumption on posterior PVN OT neurons, and no effect on PVN AVP neurons. CONCLUSIONS: These data show that continuous-access voluntary alcohol consumption is associated with decreased OT neurons in the anterior PVN, suggesting that alcohol-induced alterations in the OT system should be investigated as a mechanism for alcohol-related changes in social behavior, stress responses, and exacerbation of alcohol use disorders.

Fewer Levels of Dedicated Trauma Care Leads to Better Outcomes.

BACKGROUND: Dedicated trauma intensive care units (ICUs) staffed by surgical intensivists lead to better patient outcomes. Increased length of stay (LOS) leads to worse outcomes. Little research has focused on the effect of dedicated trauma medical-surgical units or ICU/medicalsurgical systems. In 2018, our Level 1 trauma center transitioned from 3 non-dedicated levels of care (ICU/stepdown unit/medical-surgical) to 2 dedicated levels of care (ICU/medical-surgical). Our objective was to look at patient outcomes pre- and post-intervention. METHODS: Retrospective analysis of trauma registry data was performed on patients (age ≥18) admitted to the trauma service at a Level 1 rural trauma center over 46-months. In the pre-intervention group, step down and medical-surgical patients were combined as "Non-ICU" for analysis. Standard statistical analysis was performed. RESULTS: Analysis included 6103 patients. The group demographics were similar, except pre-intervention patients had higher ISS and fewer comorbidities. Emergency department LOS decreased from 30 versus 13.9% (P < .0001) and 15.9 versus 5.8% (P < .0001) for greater than 3 and 6 hours, respectively. Median LOS decreased for all patients (P < .0001). Mortality dropped from 9.0 versus 5.5% (P = .0009) for ICU and 1.7 versus 0.26% (P = .0013) for non-ICU patients. Overall patient mortality was level at 3.7%. Inpatient complications dropped from 9.9 versus 8.5% (P = .07). Unplanned ICU readmissions were unchanged (P = .4169). For patients with 3+ comorbidities, overall LOS dropped by 2 days (P < .0001) and home discharge increased from 42.8 versus 51% (P < .0001). CONCLUSION: Implementation of 2 levels of dedicated care has decreased ED and hospital LOS for all trauma patients without increasing mortality or complications. Patients with extensive comorbidities saw the most improvements.

Short-term Outcomes of Emergent Versus Elective Gastrectomy for Gastric Adenocarcinoma: A National Surgical Quality Improvement Program Study.

BACKGROUND: Gastric adenocarcinoma is a leading cause of cancer death worldwide and in the United States, and can present emergently with upper GI hemorrhage, obstruction, or perforation. Few large studies have examined how emergency surgery for gastric cancer affects patient outcomes. METHODS: All patients from National Surgical Quality Improvement Program with gastric adenocarcinoma from 2005 to 2017 were examined retrospectively. Univariate and multivariate analysis of patient factors and perioperative outcomes was performed. P-values < .05 were significant. RESULTS: Of 4663 total patients, 115 had emergency surgery and 4548 had elective surgery. Emergency surgery patients were more likely to be non-white, underweight, higher ASA class, require a preoperative blood transfusion, and were less likely to be functionally independent. Multivariate analysis demonstrates an increased likelihood of unplanned intubation, prolonged ventilation, and deep vein thrombosis (DVT). DISCUSSION: There are no significant differences in mortality, reoperation, or infection when comparing emergent surgery for gastric cancer and elective surgery; however, there is an increased risk of reintubation, prolonged intubation, and DVT in patients undergoing emergent surgery. Patients requiring emergent surgery have more comorbidities, higher blood transfusion requirements, and worse preoperative functional status, and this study demonstrates that they also have worse perioperative outcomes. Previous studies have shown that long-term oncologic outcomes are worse for patients undergoing urgent surgery, and this study shows that perioperative outcomes are also somewhat worse. Thus, definitive surgery performed on a patient who presents emergently with gastric cancer should be considered but may come at the cost of increased perioperative respiratory complications, DVTs, and worse oncologic outcomes.

Broad Needs Assessment of Pain Education in Graduate Medical Education.

This article describes a survey-based study of graduate medical residents and fellows in an integrated health system. The study explores pain curricula, learner perspectives about pain education, and learner knowledge, attitudes, and confidence. Results indicate that pain education in the graduate medical setting is inadequate to meet learner needs.

Anticoagulation therapy in patients with traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter prospective study.

BACKGROUND: Trauma care providers often face a dilemma regarding anticoagulation therapy initiation in patients with traumatic brain injury owing to the associated risks of traumatic brain injury progression. The aims of this study were the following: (1) to describe the current practice of anticoagulation therapy in traumatic brain injury patients and their outcomes and (2) to identify factors associated with the progression of traumatic brain injury after anticoagulation therapy. METHODS: In this multicenter prospective observational study, we included computed tomography-proven traumatic brain injury patients who received anticoagulation therapy within 30 days of hospital admission. Our primary outcome was the incidence of clinically significant progression of traumatic brain injury after anticoagulation therapy initiation. RESULTS: A total of 168 patients were enrolled more than 22 months. Atrial fibrillation and venous thromboembolism were the most common pre-injury and postinjury anticoagulation therapy indications, respectively. Overall, 16 patients (9.6%) experienced clinically significant traumatic brain injury progression after anticoagulation therapy, out of which 9 (5.4%) patients subsequently required neurosurgical interventions. Between patients with clinical progression of traumatic brain injury and patients who showed no such progression, there were no significant differences in the baseline demographics and severity of traumatic brain injury. However, anticoagulation therapy was initiated significantly earlier in patients of the deterioration group than those of the no-deterioration group (4.5 days vs 11 days, P = .015). In a multiple logistic regression model, patients who received anticoagulation therapy later after injury had significantly lower risk of clinically significant traumatic brain injury progression (odds ratio: 0.915 for each day, 95% confidence interval: 0.841-0.995, P = .037). CONCLUSION: Our results suggest that early anticoagulation therapy is associated with higher risk of traumatic brain injury progression, thus a balance between bleeding and thromboembolic risks should be carefully evaluated in each case before initiating anticoagulation therapy.

Have the Characteristics for Success as a Surgeon Changed? A Century of Perspective Through the American College of Surgeons.

BACKGROUND: The Presidential Address of the American College of Surgeons (ACS) is an influential platform during the convocation for new Fellows every year. Recent work reported that most ACS presidents primarily discuss personal characteristics for success; however, these qualities were never specified. Therefore, this study aimed to identify the personal characteristics that are espoused in ACS presidential addresses as essential for success as a surgeon. STUDY DESIGN: Thematic analysis was completed for every ACS presidential address (98 addresses between 1913 and 2019). Full-text addresses were reviewed (2 team members), personal characteristics were coded (1 team member) and then assembled into patterns and themes (3 team-members' consensus). A temporal frame was adopted in grouping these themes in that personal qualities that appeared consistently throughout this period were classified as Enduring Characteristics and those that emerged only in later years were classified as Recent Characteristics. RESULTS: Enduring Characteristics that were present throughout the century included sincere compassion for patients; integrity; engagement (willingness to help shape the changing field at the institutional or national level); and commitment to lifelong learning. Recent Characteristics included humility and the interpersonal attributes of inclusivity and the ability to be a collaborative team leader. CONCLUSIONS: Surgery has experienced countless paradigm shifts since 1913, and the perceived characteristics for success have similarly evolved to include more interpersonal abilities. The importance of sincere compassion for patients, integrity, engagement, and commitment to lifelong learning remained consistent for more than a century.

Quality Improvement for Surgical Resection of Pancreatic Head Adenocarcinoma : Hospital and Surgeon Predictors of Higher Than Expected R1 Resection Using the National Cancer Database.

BACKGROUND: The mainstay of treatment for pancreatic cancer is surgical resection; however, positive surgical margins remain commonplace. We identified hospitals with higher than predicted rates of positive margins and isolated factors that caused this discordance. METHODS: This is a retrospective review of patients with head of the pancreas adenocarcinoma in the National Cancer Database between 2004 and 2015. A nomogram was used to calculate the observed to expected positive margin rates (O/E) for facilities. If the O/E differed significantly (P < .05), it was considered an outlier. RESULTS: Among a total of 19 968 patients, 24.3% had positive margins. Among hospitals with lower than expected positive margin rates, 73.6% were academic or research programs, 17% were comprehensive community cancer programs, and none were community cancer programs (P = .0002). Within the group with higher than expected positive margin rates, 47% were comprehensive community cancer programs and 38.6% were academic or research programs (P = .0002). The mean hospital volume was higher in the low positive margin group (110.4 vs 48.8, P < .0001). CONCLUSIONS: Facility type and hospital volume can predict improvement in the O/E ratio for margin positivity in pancreatic adenocarcinoma resection. Surgeons should consider referral to academic or research facilities with higher case volumes for improved surgical resection.

Prevalence and Predictors of Obstructive Coronary Artery Disease in Nonlow-risk Acute Chest Pain Patients Who Rule Out for Myocardial Infarction in the High-sensitivity Troponin Era.

OBJECTIVES: The best management approach for chest pain patients who rule out for myocardial infarction (MI) in the high-sensitivity troponin (hsTn) era remains elusive. Patients, especially those with nonlow clinical risk scores, are often referred for inpatient ischemic testing to uncover obstructive coronary artery disease (CAD). Whether the prevalence of obstructive CAD in this cohort is high enough to justify routine testing is not known. METHODS: We conducted a retrospective cohort analysis of 1517 emergency department chest pain patients who ruled out for MI by virtue of a stable high-sensitivity troponin T (hsTnT) levels (defined as <5 ng/L intermeasurements increase) and were admitted for inpatient testing. RESULTS: Abnormal ischemia evaluation (including 5.9% with evidence of fixed wall motion or perfusion defects) was 11.9%. Of those undergoing invasive angiography (n = 292), significant coronary stenoses (≥70% or unstable lesions) and multivessel CAD occurred in 16.8% and 5.5%, respectively. In a multivariate logistic regression model, known CAD, prior MI, chest pain character, mildly elevated hsTnT, and left ventricular ejection fraction <40% were predictive of an abnormal ischemia evaluation result, whereas electrocardiography findings and the modified History, EKG, Age, Risk factors, and troponin (HEART) score were not. Of note, 30-day adverse cardiac events were strikingly low at 0.4% with no deaths despite an overwhelming majority (>90%) of patients scoring intermediate or high on the modified HEART score. CONCLUSIONS: A considerable percentage of acute chest pain patients who rule out for MI by hsTn had evidence of obstructive CAD, and the modified HEART score was not predictive of an abnormal ischemia evaluation.

Genomic Screening for Pathogenic Transthyretin Variants Finds Evidence of Underdiagnosed Amyloid Cardiomyopathy From Health Records.

BACKGROUND: New treatments for transthyretin amyloidosis improve survival, but diagnosis remains challenging. Pathogenic or likely pathogenic (P/LP) variants in the transthyretin (TTR) gene are one cause of transthyretin amyloidosis, and genomic screening has been proposed to identify at-risk individuals. However, data on disease features and penetrance are lacking to inform the utility of such population-based genomic screening for TTR. OBJECTIVES: This study characterized the prevalence of P/LP variants in TTR identified through exome sequencing and the burden of associated disease from electronic health records for individuals with these variants from a large (N = 134,753), primarily European-ancestry cohort. METHODS: We compared frequencies of common disease features and cardiac imaging findings between individuals with and without P/LP TTR variants. RESULTS: We identified 157 of 134,753 (0.12%) individuals with P/LP TTR variants (43% male, median age 52 [Q1-Q3: 37-61] years). Seven P/LP variants accounted for all observations, the majority being V122I (p.V142I; 113, 0.08%). Approximately 60% (n = 91) of individuals with P/LP TTR variants (all V122I) had African ancestry. Diagnoses of amyloidosis were limited (2 of 157 patients), although related heart disease diagnoses, including cardiomyopathy and heart failure, were significantly increased in individuals with P/LP TTR variants who were aged >60 years. Fourteen percent (7 of 49) of individuals aged ≥60 or older with a P/LP TTR variant had heart disease and ventricular septal thickness >1.2 cm, only one of whom was diagnosed with amyloidosis. CONCLUSIONS: Individuals with P/LP TTR variants identified by genomic screening have increased odds of heart disease after age 60 years, although amyloidosis is likely underdiagnosed without knowledge of the genetic variant.

The effect of prolonged antibiotics on postoperative complications for common bile duct stones: A post hoc analysis of an EAST multicenter study.

BACKGROUND: Antimicrobial guidance for common bile duct (CBD) stones is limited. We sought to examine the effect of antibiotic duration on infectious complications in patients with choledocholithiasis and/or gallstone pancreatitis. METHODS: We performed a post hoc analysis of a prospective, observational, multicenter study of patients undergoing same admission cholecystectomy for choledocholithiasis and gallstone pancreatitis between 2016 and 2019. We excluded patients with cholangitis and/or cholecystitis. Patients were divided into groups based on duration of antibiotics: prophylactic (<24 hours) or prolonged (≥24 hours). We analyzed these two groups in the preoperative and postoperative periods. Outcomes included infectious complications, acute kidney injury (AKI), and hospital length of stay (LOS). RESULTS: There were 755 patients in the cohort. Increasing age, CBD diameter, and a preoperative endoscopic retrograde cholangiopancreatography (odds ratio, 1.91; 95% confidence interval, 1.34-2.73; p < 0.001) significantly predicted prolonged preoperative antibiotic use. Increasing age, operative duration, and a postoperative endoscopic retrograde cholangiopancreatography (odds ratio, 4.8; 95% confidence interval, 1.85-13.65; p < 0.001) significantly predicted prolonged postoperative antibiotic use. Rates of infectious complications were similar between groups, but LOS was 2 days longer for patients receiving overall prolonged antibiotics (p < 0.0001). Patients with AKI received two more days of overall antibiotic therapy (p = 0.02) compared with those without AKI. CONCLUSION: Rates of postoperative infectious complications were similar among patients treated with a prolonged or prophylactic course of antibiotics. Prolonged antibiotic use was associated with a longer LOS and AKI. LEVEL OF EVIDENCE: Therapeutic, Level IV.