Defining features of hereditary lobular breast cancer due to CDH1 with magnetic resonance imaging and tumor characteristics.

Women with germline pathogenic variants in CDH1, which encodes E-cadherin protein, are at increased lifetime risk of invasive lobular carcinoma (ILC). The associated tumor characteristics of hereditary lobular breast carcinoma (HLBC) in this high-risk population are not well-known. A single-center prospective cohort study was conducted to determine the imaging and pathologic features of HLBC compared to population-based ILC using Surveillance, Epidemiology, and End Results (SEER) data. One hundred fifty-eight women with CDH1 variants were evaluated, of whom 48 (30%) also had an ILC diagnosis. The median age at CDH1 diagnosis was 45 years [interquartile range, IQR 34-57 years] whereas the median age at diagnosis of CDH1 with concomitant ILC (HLBC) was 53 [IQR 45-62] years. Among women with HLBC, 83% (40/48) were identified with CDH1 mutation after diagnosis of ILC. Among 76 women (48%, 76/158) undergoing surveillance for ILC with breast magnetic resonance imaging (MRI), 29% (22/76) had an abnormal MRI result with available biopsy data for comparison. MRI detected ILC in 7 out of 8 biopsy-confirmed cases, corresponding with high sensitivity (88%), specificity (75%), and negative predictive value (98%); however, false-positive and false-discovery rates were elevated also (25% and 68%, respectively). HLBC was most frequently diagnosed at age 40-49 years (44%, 21/48), significantly younger than the common age of diagnosis of ILC in SEER general population data (most frequent age range 60-69 years, 28%; p < 0.001). HLBC tumors were smaller than SEER-documented ILC tumors (median 1.40 vs. 2.00 cm; p = 0.002) and had a higher incidence of background lobular carcinoma in situ (88% vs. 1%; p < 0.001) as well as progesterone receptor positivity (95% vs. 81%, p = 0.032). These findings suggest that HLBC is often detected via conventional screening methods as an early-stage hormone receptor-positive tumor, thus the clinical benefit of intensive screening with MRI may be limited to a subset of women with germline CDH1 variants.

Long-term outcomes following laparoscopic Roux-en-Y gastric bypass: weight loss and resolution of comorbidities at 15 years and beyond.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold-standard bariatric procedure with proven efficacy in morbidly obese populations. While the short-term benefits of LRYGB have been well-documented, durable weight loss and long-term resolution of obesity-related comorbidities have been less clearly described. METHODS: This single-center study prospectively reports weight loss and comorbidity resolution in patients undergoing LRYGB between August 2001 and September 2007 with at least 15-year follow-up. Data were collected at the time of surgery; 1, 3, 6, and 12 months postoperatively; and then annually thereafter. RESULTS: A total of 486 patients were included in this analysis. Patients were predominantly female (88.7%), and the median age was 36.0 [IQR 29.0-45.0] years. Patients were ethnically diverse, including Black/African American (43.6%), White/Caucasian (35.0%), Hispanic (18.3%), and other backgrounds (3.1%). Mean preoperative weight and body mass index were 133.0 ± 21.9 kg and 48.4 ± 6.5 kg/m2, and the median number of comorbidities was 6.0 [IQR 4.0-7.0]. Follow-up rates at 1, 5, 10, and 15 years were 75.3%, 37.2%, 35.2%, and 18.9%, respectively. On average, maximum percentage total weight loss (%TWL) occurred 2 years postoperatively (- 36.2 ± 9.5%), and ≥ 25% TWL was consistently achieved at 1, 5, 10, and 15-year time intervals (- 28.0 ± 13.0% at 15 years). Patients with comorbidities experienced improvement or resolution of their conditions within 1 year, including type 2 diabetes mellitus (83/84, 98.8%), obstructive sleep apnea (112/116, 96.6%), hypertension (142/150, 94.7%), and gastroesophageal reflux disease (217/223, 97.3%). Rates of improved/resolved comorbidities remained consistently high through at least 10 years after surgery. CONCLUSIONS: LRYGB provides durable weight loss for at least 15 years after surgery, with stable average relative weight loss of approximately 25% from baseline. This outcome corresponds with sustainable resolution of obesity-related comorbidities for at least 10 years after the initial operation.

Long-term weight loss after bariatric procedures for morbidly obese adolescents and youth: a single-institution analysis with up to 19-year follow-up.

BACKGROUND: Obesity is a public health concern among adolescents and young adults. Bariatric surgery is the most effective treatment for morbid obesity and has been increasingly utilized in young patients. Long-term outcomes data for bariatric surgery in this age group are limited. METHODS: This is a single-institution, prospective analysis of 167 patients aged 15-24 years who underwent one of three laparoscopic bariatric procedures between 2001 and 2019: Roux-en-Y gastric bypass (LRYGB, n = 71), adjustable gastric banding (LAGB, n = 22), and sleeve gastrectomy (LSG, n = 74). Longitudinal weight and body mass index (BMI) measurements were compared to evaluate patterns of weight loss. RESULTS: All operations were completed laparoscopically using the same clinical pathways. Patients were predominantly female (82.6%), had a median age of 22.0 [Q1-Q3 20.0-23.0] years, and had a mean presurgical BMI of 48.5 ± 6.5 kg/m2 (range 38.4-68.1 kg/m2). All procedures produced significant weight loss by 1 year, peak weight loss by 2 years, and modest weight regain after 5 years. Mean percent weight/BMI losses at 5 years for LRYGB, LAGB, and LSG were - 36.7 ± 10.8%, - 14.5 ± 15.3%, and - 25.1 ± 13.4%, respectively (p < 0.001). LRYGB patients were most likely to achieve ≥ 25% weight loss at 1, 3, and 5 years and maintained significant average weight loss for more than 15 years after surgery. Reoperations were procedure-specific, with LAGB, LRYGB, and LSG having the highest, middle, and lowest reoperation rates, respectively (40.9% vs. 16.9% vs. 5.4%, p < 0.001). CONCLUSION: All procedures provided significant and durable weight loss. LRYGB patients achieved the best and most sustained weight loss. LSG patients experienced second-best weight loss between 1 and 5 years, with lowest chance of reoperation. LAGB patients had the least weight loss and the highest reoperation rate. Compared to other factors, type of bariatric procedure was independently predictive of successful weight loss over time. More studies with long-term follow-up are needed.

Blueprint for safe transition from a low- to high-volume pancreatic surgery center.

We describe a straightforward model to implement a high volume specialty surgery program at a community hospital. Using pancreatic surgery as an example, we employed published processes in three arenas. First, mandatory multidisciplinary tumor board presentations captured all the patients considered for surgery. Then, perioperative protocols using tools such as enhanced recovery and teamwork in the perioperative arena created a reproducible and safe environment for complex surgery. We critically reviewed all complications using the Clavien-Dindo methodology, and confirmed our favorable outcomes via the targeted NSQIP program. These standard steps can be used for implementation of a new complex surgical procedure.

Improved Water and Waste Management Practices Reduce Diarrhea Risk in Children under Age Five in Rural Tanzania: A Community-Based, Cross-Sectional Analysis.

Diarrhea remains a significant cause of morbidity and mortality among children in developing countries. Water, sanitation, and hygiene practices (WASH) have demonstrated improved diarrhea-related outcomes but may have limited implementation in certain communities. This study analyzes the adoption and effect of WASH-based practices on diarrhea in children under age five in the rural Busiya chiefdom in northwestern Tanzania. In a cross-sectional analysis spanning July-September 2019, 779 households representing 1338 under-five children were surveyed. Among households, 250 (32.1%) reported at least one child with diarrhea over a two-week interval. Diarrhea prevalence in under-five children was 25.6%. In per-household and per-child analyses, the strongest protective factors against childhood diarrhea included dedicated drinking water storage (OR 0.25, 95% CI 0.18−0.36; p < 0.001), improved waste management (OR 0.37, 95% CI 0.27−0.51; p < 0.001), and separation of drinking water (OR 0.38, 95% CI 0.24−0.59; p < 0.001). Improved water sources were associated with decreased risk of childhood diarrhea in per-household analysis (OR 0.72, 95% CI 0.52−0.99, p = 0.04), but not per-child analysis (OR 0.83, 95% CI 0.65−1.05, p = 0.13). Diarrhea was widely treated (87.5%), mostly with antibiotics (44.0%) and oral rehydration solution (27.3%). Targeting water transportation, storage, and sanitation is key to reducing diarrhea in rural populations with limited water access.

Operative Shutdown and Recovery: Restructuring Surgical Operations During the SARS-CoV-2 Pandemic.

BACKGROUND: During the 2020 SARS-CoV-2 outbreak in New York City, hospitals canceled elective surgeries to increase capacity for critically ill patients. We present case volume data from our community hospital to demonstrate how this shutdown affected surgical care. METHODS: Between March 16 and June 14, 2020, all elective surgeries were canceled at our institution. All procedures performed during this operating room shutdown (ORS) were logged, as well as those 4 weeks before (PRE) and 4 weeks after (POST) for comparison. RESULTS: A total of 2,475 cases were included in our analysis, with 754 occurring during shutdown. Overall case numbers dropped significantly during ORS and increased during recovery (mean 245.0 ± 28.4 PRE versus 58.0 ± 30.9 ORS versus 186.0±19.4 POST cases/wk, P< 0.001). Emergency cases predominated during ORS (26.4% PRE versus 59.3% ORS versus 31.5% POST, P< 0.001) despite decreasing in frequency (mean 64.5 ± 7.9 PRE versus 34.4 ± 12.1 ORS versus 58.5 ± 4.0 POST cases/wk, P< 0.001). Open surgeries remained constant in all three phases (52.2-54.1%), whereas laparoscopic and robotic surgeries decreased (-3.4% and -3.0%, P< 0.001). General and/or vascular surgery, urology, and neurosurgery comprised a greater proportion of caseload (+9.5%, +3.0%, +2.8%), whereas orthopedics, gynecology, and otolaryngology/plastic surgery all decreased proportionally (-5.0%, -4.4%, -5.9%, P< 0.001). CONCLUSION: Operative volume significantly decreased during the SARS-CoV-2 outbreak. Emergency cases predominated during this time, although there were fewer emergency cases overall. General/vascular surgery became the most active service and open surgeries became more common. This reallocation of resources may be useful for future crisis planning among community hospitals.

Severe traumatic brain injury management in Tanzania: analysis of a prospective cohort.

OBJECTIVE: Given the high burden of neurotrauma in low- and middle-income countries (LMICs), in this observational study, the authors evaluated the treatment and outcomes of patients with severe traumatic brain injury (TBI) accessing care at the national neurosurgical institute in Tanzania. METHODS: A neurotrauma registry was established at Muhimbili Orthopaedic Institute, Dar-es-Salaam, and patients with severe TBI admitted within 24 hours of injury were included. Detailed emergency department and subsequent medical and surgical management of patients was recorded. Two-week mortality was measured and compared with estimates of predicted mortality computed with admission clinical variables using the Corticoid Randomisation After Significant Head Injury (CRASH) core model. RESULTS: In total, 462 patients (mean age 33.9 years) with severe TBI were enrolled over 4.5 years; 89% of patients were male. The mean time to arrival to the hospital after injury was 8 hours; 48.7% of patients had advanced airway management in the emergency department, 55% underwent cranial CT scanning, and 19.9% underwent surgical intervention. Tiered medical therapies for intracranial hypertension were used in less than 50% of patients. The observed 2-week mortality was 67%, which was 24% higher than expected based on the CRASH core model. CONCLUSIONS: The 2-week mortality from severe TBI at a tertiary referral center in Tanzania was 67%, which was significantly higher than the predicted estimates. The higher mortality was related to gaps in the continuum of care of patients with severe TBI, including cardiorespiratory monitoring, resuscitation, neuroimaging, and surgical rates, along with lower rates of utilization of available medical therapies. In ongoing work, the authors are attempting to identify reasons associated with the gaps in care to implement programmatic improvements. Capacity building by twinning provides an avenue for acquiring data to accurately estimate local needs and direct programmatic education and interventions to reduce excess in-hospital mortality from TBI.

Weight loss dynamics following laparoscopic Roux-en-Y gastric bypass. An analysis of 10-year follow-up data.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) still remains the gold-standard bariatric procedure. Short-term weight loss and improvement of type 2 diabetes mellitus (DM2) after LRYGB are well-documented. Little data are available on long-term weight loss and continued remission of DM2 in these patients. METHODS: This study reports on weight loss and remission of DM2 in 576 consecutive patients who underwent primary LRYGB between August 2001 and August 2009 with at least 10-year follow up. All patients were treated at a single institution by a single surgeon. All data were collected and entered into the database prospectively. RESULTS: A total of 576 patients were included in the study. Patients' mean age was 38.2 ± 10.9 years and females represented 88.2% of patients. Patients' ethnicity was diverse, including African Americans (44.4%), Caucasians (34.0%), Hispanics (18.1%), and 3.5% from other backgrounds. On average, there were 6.9 ± 2.7 comorbidities per patient and DM2 was initially present in 150/576 patients (26.0%). Mean preoperative weight and BMI were 132.4 ± 22.0 kg and 48.3 ± 6.7 kg/m2, respectively. Ten-year follow-up reporting rate was 145/576 (25.2%). Maximum weight loss occurred at 18 months (mean weight 83.4 ± 16.5 kg, mean BMI 30.5 ± kg/m2). At 10 years, mean weight was maintained at 94.8 ± 20.5 kg and mean BMI was 34.3 ± 6.8 kg/m2. The average weight regain between one and ten years was 8.27 kg. Among patients with preoperative DM2, continued remission of DM2 at 10 years occurred in 19/32 (59.4%) patients. CONCLUSIONS: LRYGB provides durable long-term weight loss, as well as successful remission of DM2 at 10 years. More long-term follow-up studies evaluating weight loss and comorbidities extending beyond the initial 10-year period are needed. Such studies are essential for projecting late outcomes of LRYGB, particularly in younger patients with life expectancy exceeding several decades.

Utility of d-dimer for diagnosis of deep vein thrombosis in coronavirus disease-19 infection.

OBJECTIVE: The objective of this study was to investigate the clinical usefulness of d-dimer in excluding a diagnosis of deep vein thrombosis (DVT) in patients with coronavirus disease (COVID-19) infection, potentially limiting the need for venous duplex ultrasound examination. METHODS: We retrospectively reviewed consecutive patients admitted to our institution with confirmed COVID-19 status by polymerase chain reaction between March 1, 2020, and May 13, 2020, and selected those who underwent both d-dimer and venous duplex ultrasound examination. This cohort was divided into two groups, those with and without DVT based on duplex ultrasound examination. These groups were then compared to determine the value of d-dimer in establishing this diagnosis. RESULTS: A total of 1170 patients were admitted with COVID-19, of which 158 were selected for this study. Of the 158, there were 52 patients with DVT and 106 without DVT. There were no differences in sex, age, race, or ethnicity between groups. Diabetes and routine hemodialysis were less commonly seen in the group with DVT. More than 90% of patients in both groups received prophylactic anticoagulation, but the use of low-molecular-weight heparin or subcutaneous heparin prophylaxis was not predictive of DVT. All patients had elevated acute-phase d-dimer levels using conventional criteria, and 154 of the 158 (97.5%) had elevated levels with age-adjusted criteria (mean d-dimer 16,163 ± 5395 ng/mL). Those with DVT had higher acute-phase d-dimer levels than those without DVT (median, 13,602 [interquartile range, 6616-36,543 ng/mL] vs 2880 [interquartile range, 1030-9126 ng/mL], P < .001). An optimal d-dimer cutoff of 6494 ng/mL was determined to differentiate those with and without DVT (sensitivity 80.8%, specificity 68.9%, negative predictive value 88.0%). Wells DVT criteria was not found to be a significant predictor of DVT. Elevated d-dimer as defined by our optimal metric was a statistically significant predictor of DVT in both univariate and multivariable analyses when adjusting for other factors (odds ratio, 6.12; 95% confidence interval, 2.79-13.39; P < .001). CONCLUSIONS: d-dimer levels are uniformly elevated in patients with COVID-19. Although standard predictive criteria failed to predict DVT, our analysis showed a d-dimer of less than 6494 ng/mL may exclude DVT, potentially limiting the need for venous duplex ultrasound examination.