Changes Over Time in COVID-19 Severity and Mortality in Patients Undergoing Cancer Treatment in the United States: Initial Report From the ASCO Registry.

PURPOSE: People with cancer are at increased risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. ASCO's COVID-19 registry promotes systematic data collection across US oncology practices. METHODS: Participating practices enter data on patients with SARS-CoV-2 infection in cancer treatment. In this analysis, we focus on all patients with hematologic or regional or metastatic solid tumor malignancies. Primary outcomes are 30- and 90-day mortality rates and change over time. RESULTS: Thirty-eight practices provided data for 453 patients from April to October 2020. Sixty-two percent had regional or metastatic solid tumors. Median age was 64 years. Forty-three percent were current or previous cigarette users. Patients with B-cell malignancies age 61-70 years had twice mortality risk (hazard ratio = 2.1 [95% CI, 1.3 to 3.3]) and those age > 70 years had 4.5 times mortality risk (95% CI, 1.8 to 11.1) compared with patients age ≤ 60 years. Association between survival and age was not significant in patients with metastatic solid tumors (P = .12). Tobacco users had 30-day mortality estimate of 21% compared with 11% for never users (log-rank P = .005). Patients diagnosed with SARS-CoV-2 before June 2020 had 30-day mortality rate of 20% (95% CI, 14% to 25%) compared with 13% (8% to 18%) for those diagnosed in or after June 2020 (P = .08). The 90-day mortality rate for pre-June patients was 28% (21% to 34%) compared with 21% (13% to 28%; P = .20). CONCLUSION: Older patients with B-cell malignancies were at increased risk for death (unlike older patients with metastatic solid tumors), as were all patients with cancer who smoke tobacco. Diagnosis of SARS-CoV-2 later in 2020 was associated with more favorable 30- and 90-day mortality, likely related to more asymptomatic cases and improved clinical management.

Preoperative Predictive Factors of Positive Margin Status After Breast Conserving Therapy (BCT) with Intraoperative Radiation Therapy (IORT): A Retrospective Study of 400 Patients.

INTRODUCTION: Single-fraction intraoperative radiation therapy (IORT) has emerged as a therapeutic option in patients undergoing breast conserving therapy (BCT) for early stage breast cancer, often eliminating the need for postoperative external beam radiation therapy. However, if a positive margin is encountered after BCT, the patient will ultimately require external beam radiation therapy. The purpose of this study was to identify preoperative factors from patient demographics, preoperative workup, or biopsy results that may be predictive of postoperative margin status. MATERIALS AND METHODS: A retrospective chart review was performed on 396 patients who underwent BCT with IORT. Logistic regression models were utilized for statistical analysis. RESULTS: The majority of studied variables were similar; however, differences were noted for high-grade tumors, in situ status, and progesterone receptor-negative (PR-) tumors. Grade 3 tumors were significantly associated with positive margin status when compared with Grade 1 (odds ratio, 2.30; P = .036). PR- status tumors were found to be approximately 2 times more likely to have a positive margin (P = .028). Patients with in situ (stage 0) status tumors were 1.986 times more likely to have positive margins when compared with those with an invasive tumor (P = .030). CONCLUSIONS: Higher grade PR- tumors are at increased risk of having a positive margin, which should be taken into consideration when considering treatment with IORT.

Decreasing Postoperative Opioid Prescribing through Education.

OBJECTIVES: To study how an educational intervention given to surgical residents affected postoperative opioid prescribing. To determine whether decreased opioid prescription amounts increased patients' rate of refills, emergency department visits, or readmissions. DESIGN: Prospective sequential cohort study. SETTING: Level 1 tertiary care center in Savannah, Georgia. PARTICIPANTS: Opioid-naive patients who underwent general surgery (appendectomy, cholecystectomy, colectomy, hernia repair, lumpectomy, and mastectomy) between November 2017 and February 2018. RESULTS: Over a 6 month period, morphine milligram equivalents (MME) prescribed after general surgery per patient was decreased by 21.8% on average, with the largest reductions seen after breast and gallbladder surgeries (38% and 25% respectively). Patients who underwent laparoscopic surgery were prescribed 18.3% fewer MME. There was no significant change in MME prescribed after open abdominal surgery. Smaller prescription amounts were not associated with an increased rate of opioid refills. There was no increase in pain-related calls to clinic offices, emergency department visits, or readmissions for pain. CONCLUSION: After a single education intervention given to surgical residents, MME prescribed after common general surgeries can be decreased significantly without increasing rates of refills or utilization of care.

Pediatric golf cart trauma: Not par for the course.

INTRODUCTION: Golf cart trauma in southeast Georgia represents a significant source of morbidity in the pediatric population. We believe these events are related to the introduction of new state legislation that allows local authorities to govern golf cart operation. METHODS: We performed a retrospective review from 2010 to 2016 of children involved in golf cart traumas (n = 46). We recorded age, gender, Glasgow Coma Scale score (GCS), Injury Severity Score (ISS), location of event, and patient position during event. Outcomes included injury type and length of stay (LOS). RESULTS: The most common position in a golf cart was a passenger (52.2%). Events varied regionally and correlated with stringency of local legislation. Skull fractures afflicted 48% (n = 22) of children and traumatic brain injuries (TBIs) were noted in 35% (n = 17) of patients. TBIs (LOS = 4.6 days, p = 0.006) and abdominal injuries (LOS = 8.5 days, p = 0.017) lengthened mean hospital stay. Increasing ISS was associated with an increased probability of sustaining a TBI (OR 1.295, p = 0.004). Younger children were more likely to sustain a skull fracture (OR 1.170, p = 0.034) while older children incurred more orthopedic injuries (OR 1.217, p = 0.045). CONCLUSION: Skull fractures and TBIs are common following pediatric golf cart trauma. Georgia's varying municipality legislation likely contributes to the growing frequency of this trend. LEVEL OF EVIDENCE: Retrospective study, IV.

Community distress predicts youth gun violence.

BACKGROUND: The purpose of this study was to investigate our institution's experience with pediatric firearm events. We sought to determine the relationship between a community's level of socioeconomic distress and the incidence of youth gun violence. METHODS: We performed a retrospective review of children <18 years involved in firearm events. Using visual cluster analysis, we portrayed all firearm events and violent firearm events (assaults + homicides). Distressed community indices (DCIs) were obtained from an interface that uses US Census Bureau data. Incident rate ratios (IRRs) were calculated for firearm circumstances (i.e. assault, homicide, suicide) using a DCI. Significant IRRs were analyzed to discern which DCI metrics contributed most to gun violence. RESULTS: There were 114 children involved in firearm events; 66 were county residents. The DCI of injury location significantly predicted total firearm events (IRR 1.02, 95% CI 1.01-1.03), assaults (IRR 1.02, 95% CI 1.01-1.05), and violent firearm events (IRR 1.03, 95% CI 1.01-1.05). The proportion of adults without a high school diploma, poverty rate, median income ratio, and housing vacancy rate were highly predictive of gun violence (VIP >1). CONCLUSION: Community distress significantly predicts pediatric firearm violence. Local interventions should target neighborhoods with high levels of distress to prevent further youth gun violence. LEVEL OF EVIDENCE: Retrospective study, IV.

Effect of topical microporous polysaccharide hemospheres on the duration and amount of fluid drainage following mastectomy: a prospective randomized clinical trial.

BACKGROUND: Seroma formation is the most common complication after mastectomy and places patients at risk of associated morbidities. Microporous polysaccharide hemospheres (MPH) consists of hydrophilic, plant based, polysaccharide particles and is currently used as an absorbable hemostatic agent. An animal model evaluating MPH and seroma formation after mastectomy with axillary lymph node dissection showed a significant decrease in seroma volume. Study aim was to evaluate topical MPH on the risk of post-mastectomy seroma formation as measured by total drain output and total drain days. METHODS: Prospective randomized single-blinded clinical trial of patients undergoing mastectomy for the treatment of breast cancer. MPH was applied to the surgical site in the study group and no application in the control group. RESULTS: Fifty patients were enrolled; eight were excluded due to missing data. Forty-two patients were evaluated, control (n = 21) vs. MPH (n = 21). No difference was identified between the two groups regarding demographics, tumor stage, total drain days, total drain output, number of clinic visits, or complication rates. On a subset analysis, body mass index (BMI) greater than 30 was identified as an independent risk factor for high drain output. Post hoc analyses of MPH controlling for BMI also revealed no statistical difference. CONCLUSIONS: Unlike the data presented in an animal model, no difference was demonstrated in the duration and quantity of serosanguinous drainage related to the use of MPH in patients undergoing mastectomy for the treatment of breast cancer. BMI greater than 30 was identified as an independent risk factor for high drain output and this risk was not affected by MPH use. NCT03647930, retrospectively registered 08/2018.

Assessing the Safety and Efficacy of Converting Laparoscopic Gastric Band to Sleeve Gastrectomy: A Rural Tertiary Center's Experience.

Gastric banding for surgical treatment of morbid obesity has a complication rate of 20 to 50 per cent. Complications include band erosion, band slippage, and failed weight loss. One salvage procedure used is the laparoscopic sleeve gastrectomy. We aimed to compare our results between single-stage and two-stage conversation of gastric band with sleeve gastrectomy. We performed a retrospective review of 27 gastric band patients converted to sleeve gastrectomy. Hospital length of stay, surgical complications, and weight loss were compared. Twelve patients had a two-stage conversion and 15 patients had a single-stage conversion. There were no surgical complications in either group. There was a significant reduction in BMI after conversion, starting at one month and continuing forward to 12 months. The average BMI reduction over the two-year follow-up period was 8.19. There was no significant difference in length of hospital stay between the groups. Single-stage conversion of gastric band to sleeve gastrectomy does not lead to increased hospital length of stay or surgical morbidity. In the presence of gastric band slip or erosion, a two-stage approach is preferable. Conversion resulted in statistically significant weight loss in all patients.

Dead or alive? New confirmatory test using quantitative analysis of computed tomographic angiography.

BACKGROUND: When clinical examination is not reliable for brain death (BD) diagnosis, the preferred confirmatory test at our institution is nuclear medicine perfusion test (NMPT). Computed tomographic angiography (CTA) has been described as an alternative for BD confirmation. This study was designed to quantitatively analyze CTA, assess its accuracy compared with NMPT, and define set parameters for BD confirmation. METHODS: This is a prospective clinical study, from 2007 to 2014, evaluating a consecutive series of clinically BD patients (n = 60) and randomly selected control group with normal CTA findings (n = 20). NMPT, used as the reference standard, was performed on all study patients followed immediately by CTA. Assessment of NMPT and quantitative CTA Hounsfield units of the horizontal segment of middle cerebral artery (M1), precommunicating segment of anterior cerebral artery (A1), and basilar artery (BA) was performed. RESULTS: In the study cohort, 88% demonstrated absence of cerebral blood flow (CBF) on NMPT; however, only 50% demonstrated absence on CTA. Together, 50% had no CBF on NMPT and CTA (Group 1), 38% had no CBF on NMPT but persistent CBF on CTA (Group 2), 12% had persistent CBF on both NMPT and CTA (Group 3). Analysis of variance demonstrated that all groups varied significantly for M1, A1, and BA (p < 0.001). We were able to establish criteria that differentiate persistent CBF on CTA as either preserved cerebral perfusion or stasis filling. CONCLUSION: We propose that a CTA Hounsfield units less than 80 in M1, A1, and BA is concordant with no CBF on NMPT, therefore indicative of a lack of physiologic cerebral perfusion, and thus allows the confirmation of BD with 97% sensitivity and 100% specificity. LEVEL OF EVIDENCE: Diagnostic study, level II.