Patterns of gastric cancer metastasis in the United States.

BACKGROUND: Literature on the epidemiology of gastric cancer metastasis is limited, although outcomes are known to be poor. We describe patterns of gastric cancer metastasis and treatment in the United States. METHODS: Patients with metastatic gastric adenocarcinoma were identified in the NCDB from 2004 to 2016. We describe univariate associations between sites of metastasis and clinicopathologic characteristics and treatment modalities, using chi-square and Kruskal-Wallis tests. Overall survival was calculated using Kaplan-Meier estimation. RESULTS: 43% (n = 2028) of patients presented with peritoneal metastases, 26% (n = 1228) with liver metastases, 20% (n = 941) with distant nodes, and 11% (n = 552) with bone, brain or lung metastases. Compared to liver metastases, peritoneal metastases were more likely from an antral primary site (28% v. 16%); associated with signet ring histology (34% v. 6%); tumor grade of III/IV (85% vs. 60%) (p < 0.0001 for all). Isolated metastasis to distant lymph nodes had the longest median overall survival (7.6 months, p < 0.0001). CONCLUSIONS: Most patients with metastatic gastric cancer in the USA present with peritoneal disease. Predictors for peritoneal metastases include primary antral site, signet ring histology and higher tumor grades.

Impact of Frailty on Clinical and Financial Outcomes Following Minor Lower Extremity Amputation: A Nationwide Analysis.

Frailty has been shown to portend worse outcomes in surgical patients. Our goal was to identify the impact of frailty on outcomes and resource utilization among patients undergoing minor lower extremity amputation in the United States. Using the Nationwide Readmission Database, we identified all adults undergoing a minor amputation between 2010 and 2015, and assessed 90-day outcomes, including readmission, reamputation, mortality, and cumulative hospitalization costs. Frailty was defined by International Classification of Diseases codes consistent with the ten frailty clusters as defined by the Johns Hopkins Adjusted Clinical Group System. Multivariable regression models were developed for risk adjustment. An estimated 302 798 patients (mean age = 61.8 years) were identified, of which 15.2% were categorized as Frail. Before adjustment, frailty was associated with increased rates of readmission (44% vs. 36%, P < .001) and in-hospital mortality (4% vs. 2%, P < .001). Frailty was also associated with increased cumulative costs of care ($39 417 vs. $27 244, P < .001). After risk adjustment, frailty remained an independent predictor of readmission (Adjusted odds ratio [AOR] 1.18, CI 1.14-1.23), in-hospital mortality (AOR 1.48, CI 1.34-1.65), and incremental costs (+$7 646, CI $6927-$8365). Frailty is an independent marker of worse outcomes following minor foot amputation, and may be utilized to direct quality improvement efforts.

Reduction in Prescribed Opioids after General Surgery Procedures at a Public Hospital.

Overdose of opioids is the number one cause of accidental death in the United States, and surgeons are overprescribing these medications. The aim of this study was to assess the feasibility of implementing postoperative opioid prescribing guidelines for general surgery procedures at a public hospital, where patients have lower socioeconomic status, public insurance, and limited access to care. We implemented a quality improvement project, which included in-service training for surgical staff and distribution of standardized guidelines. An infographic for patients was created to facilitate education on postoperative pain management. Pre- and postintervention opioid prescriptions and emergency room visits were compared for patients undergoing common general surgery procedures (inguinal hernia repair, appendectomy, and laparoscopic cholecystectomy). The median number of narcotic pills prescribed significantly decreased from 30 (n = 64) to 15 (n = 63) after the intervention (P < 0.0001). Morphine milligram equivalents decreased from a median [range] of 150 [20,600] to 90 [5,300] (P < 0.0001). The percentage of patients with postoperative pain-related emergency department visits remained low (1.6%). Standardization of postoperative opioid prescription practices was successfully implemented at a public hospital without an increase in the number of emergency room visits for pain.

The Utility of Cranial Ultrasound for Detection of Intracranial Hemorrhage in Infants.

OBJECTIVE: The objective of this study was to evaluate the sensitivity and specificity of cranial ultrasound (CUS) for detection of intracranial hemorrhage (ICH) in infants with open fontanels. METHODS: This was a retrospective study of infants younger than 2 years who had a CUS performed for the evaluation of potential ICH. We excluded patient with CUSs that were done for reasons related to prematurity, transplant or oncologic evaluations, routine follow-up or preoperative screen, or congenital and known perinatal anomalies. Two clinicians independently classified each of the patients with ICH into significant or insignificant based on the radiology reports. RESULTS: Of 4948 CUS studies performed during the 5-year study period, 283 studies fit the inclusion criteria. Patient age ranged from 0 to 458 days, with a median of 33 days. There were 39 total cases of ICH detected, with 27 significant bleeds and 12 insignificant bleeds. Using computed tomography, magnetic resonance imaging, or clinical outcome as criterion standard, the overall ultrasound sensitivity and specificity for bleed were 67% (confidence interval [CI], 50%-81%) and 99% (CI, 97%-100%), respectively. For those with significant bleeds, the overall sensitivity was 81% (CI, 62%-94%), and for those with insignificant bleeds, it was 33% (CI, 1%-65%). CONCLUSIONS: The sensitivity of CUS is inadequate to justify its use as a screening tool for detection of ICH in young infants.