Prolonged Air Leak After Pulmonary Resection Increases Risk of Noncardiac Complications, Readmission, and Delayed Hospital Discharge: A Propensity Score-adjusted Analysis.

OBJECTIVE: The aim of the study was to determine whether prolonged air leak (PAL) is associated with postoperative morbidity and mortality following pulmonary resection after adjusting for differences in baseline characteristics using propensity score analysis. SUMMARY BACKGROUND DATA: Patients with PAL after lung resection have worse outcomes than those without PAL. However, adverse postoperative outcomes may also be secondary to baseline risk factors, such as poor lung function. METHODS: Patients who underwent pulmonary resection for lung cancer/nodules (1/2009-6/2014) were stratified by the presence of PAL [n = 183 with/1950 without; defined as >5 d postoperative air leak; n = 189 (8.3%)]; probability estimates for propensity for PAL from 31 pretreatment/intraoperative variables were generated. Inverse probability-of-treatment weights were applied and outcomes assessed with logistic regression. RESULTS: Standardized bias between groups was significantly reduced after propensity weighting (mean = 0.18 before vs 0.08 after, P < 0.01). After propensity weighting, PAL was associated with increased odds of empyema (OR = 8.5; P < 0.001), requirement for additional chest tubes for pneumothorax (OR = 7.5; P < 0.001), blood transfusion (OR = 2; P = 0.03), pulmonary complications (OR = 4; P < 0.001), unexpected return to operating room (OR = 4; P < 0.001), and 30-day readmission (OR = 2; P = 0.009). Among other complications, odds of cardiac complications (P = 0.493), unexpected ICU admission (P = 0.156), and 30-day mortality (P = 0.270) did not differ. Length of hospital stay was prolonged (5.04 d relative effect, 95% confidence interval, 3.77-6.30; P < 0.001). CONCLUSIONS: Pulmonary complications, readmission, and delayed hospital discharge are directly attributable to having a PAL, whereas cardiac complications, unexpected admission to the ICU, and 30-day mortality are not after propensity score adjustment.

Perception of Pulmonary Function in Children with Asthma and Cystic Fibrosis.

Background: Under-perception of pulmonary dysfunction may delay appropriate treatment, while over-perception may result in unnecessary treatments. Objectives: To evaluate the ability of patients with asthma or cystic fibrosis and their subspecialty caregivers to assess changes in lung function based on their subjective clinical impressions. Methods: Patients were asked to qualitatively describe how they felt compared to their prior visit (same/better/worse) and to quantitatively estimate their forced expiratory volume in 1 s (FEV1) after being reminded of their FEV1 at the prior visit. Providers made similar estimates based on history and physical examination and knowledge of prior FEV1. After adjusting for relevant clinical covariates, lung function estimates were categorized as accurate (±5% of measured FEV1), overestimated (>5% above measured), and underestimated (>5% below measured). Results: One hundred nine patients estimated FEV1 on 179 occasions. Concordance between patient qualitative assessment and FEV1-based categories was low (κ = 0.08); 44% of patients reported feeling better than the FEV1-based category showed. Quantitatively, 56% of patient estimates were accurate, 18% were underestimated, and 26% overestimated; accuracy improved with age (odds ratio = 1.16, P = 0.01). Concordance between provider qualitative assessments and FEV1-based category was moderate (κ = 0.35); about 19% said their patient looked better than the FEV1-based category showed. Quantitatively, 65% of provider estimates were accurate, 16% were underestimated, and 19% were overestimated; accuracy improved with years of experience. Conclusions: Patients' and providers' perceptions of lung function were low to moderately accurate. Relying on subjective impression may place patients at risk for unnecessary treatments or increased morbidity. These findings highlight the importance of objective lung function assessment.

Unplanned postoperative intensive care unit admission for ovarian cancer cytoreduction is associated with significant decrease in overall survival.

OBJECTIVES: Previous studies have identified age, nutritional status, and hematocrit as risk factors for unplanned ICU admission in gynecologic oncology patients. We sought to identify additional perioperative factors that can be predictive of unplanned ICU admission and its impact on outcomes in women with ovarian cancer undergoing ovarian cancer cytoreductive procedures. METHODS: This was a case-control study of patients with unplanned ICU admission after primary surgery for ovarian cancer from January 2007 to December 2013. Controls were selected in a 2:1 ratio matching for primary surgeon and date of surgery. Clinical data was abstracted and compared between cases and controls using conditional logistic regression. RESULTS: The dataset consisted of 324 patients (108 ICU admissions, 216 controls). On multivariable analysis, failure to optimally cytoreduce (p = 0.001, OR 3.76) and higher EBL (p < 0.001, OR 1.20 per 100 cm3) remained significant predictors of unplanned ICU admission. On multivariable analysis of outcomes, ICU admission was independently associated with increased length of stay (12 days vs. 6 days, p < 0.001), increased number of postop complications (2 vs. 0, p < 0.001), and increased risk of readmission within 30 days (p = 0.041, OR 2.46). Even controlling for debulking status, ICU admission remained associated with a worse median OS (27.3 vs 57.9 months, p < 0.001). CONCLUSIONS: ICU admission for women undergoing cytoreductive surgery for ovarian cancer is associated with a significant decrease in OS and increase in number of postoperative complications. For this inherently high-risk population, this information is critical when counseling patients about peri-operative risks in primary cytoreductive surgery.

Clinical experience with temporary right ventricular mechanical circulatory support.

OBJECTIVES: This study sought to determine if indication for support affects the outcomes after temporary right ventricular mechanical circulatory support after postcardiotomy cardiogenic shock, cardiac transplant, or left ventricular assist device placement. METHODS: A retrospective review was performed on 80 patients receiving a right ventricular assist device. Data were collected from a prospectively maintained database. Kaplan-Meier survival analysis was performed to compare survival between groups. Multivariate regression analysis was performed to identify risk factors for failure to wean from support. RESULTS: The indication for support was postcardiotomy cardiogenic shock in 13 patients (16%), cardiac transplant in 25 patients (31%), and left ventricular assist device in 42 patients (53%). Median support time was 6 days. Device was successfully weaned in 6 postcardiotomy cardiogenic shock cases (46%), 21 cardiac transplant cases (84%), and 35 left ventricular assist device cases (83%). Survival was worse for patients with postcardiotomy cardiogenic shock compared with patients with a left ventricular assist device. Survival up to 3 months was better for patients who received immediate (n = 43) versus delayed (n = 37) support (79% vs 46%, P = .003). Weaning and survival remained static across implant era. Risk factor analysis identified postcardiotomy cardiogenic shock indication (odds ratio, 0.161; P = .007; confidence interval, 0.043-0.600) as an independent negative predictor of weaning from mechanical support. CONCLUSIONS: Temporary right ventricular mechanical support remains an effective treatment strategy after left ventricular assist device placement with immediate support resulting in superior short-term survival. Caution should be applied in postcardiotomy cardiogenic shock when weaning and survival are poor. Overall survival outcomes have remained relatively static over time.

Prolapse recurrence following sacrocolpopexy vs uterosacral ligament suspension: a comparison stratified by Pelvic Organ Prolapse Quantification stage.

BACKGROUND: Insufficient evidence evaluates which pelvic organ prolapse surgery is best suited to an individual woman based on the stage of her prolapse. OBJECTIVE: We sought to compare prolapse recurrence rates following sacrocolpopexy and uterosacral ligament suspension after stratifying by preoperative Pelvic Organ Prolapse Quantification stage. STUDY DESIGN: We compared all women who underwent minimally invasive sacrocolpopexy or vaginal or minimally invasive uterosacral ligament suspension from 2009 through 2015 at a large academic center. All women with preoperative and postoperative Pelvic Organ Prolapse Quantification data were included. Patients were grouped by preoperative Pelvic Organ Prolapse Quantification stage for analysis. Recurrence rates following sacrocolpopexy and uterosacral ligament suspension were compared for patients presenting with stage II, III, and IV prolapse, adjusting for potential confounders in regression models. Prolapse recurrence was defined as any retreatment for prolapse or any Pelvic Organ Prolapse Quantification point beyond the hymen. RESULTS: Of 756 women, 633 underwent sacrocolpopexy (83.7%) and 123 (16.3%) underwent uterosacral ligament suspension. In all, 189 (25%) had preoperative Pelvic Organ Prolapse Quantification stage II prolapse, 527 (69.7%) stage III, and 40 (5.3%) stage IV. Patients were predominantly Caucasian (97.3%) with mean age 59.8 ± 9.5 years. Compared to uterosacral ligament suspension patients, more sacrocolpopexy patients had undergone prior prolapse repair (20.9% vs 5.7%, P < .001) and fewer had known diabetes mellitus (7.9% vs 13.8%, P = .034). Characteristics of the groups were otherwise similar. Median follow-up was 41.0 (interquartile range 13.0-88.8) weeks. Stage II prolapse patients had similar recurrence rates following sacrocolpopexy or uterosacral ligament suspension (6.0% vs 5.0, P = 1.00). However, stage III prolapse patients were more likely to experience recurrence following uterosacral ligament suspension (25.7% vs 7.8%, P < .001). This difference persisted after controlling for age, body mass index, smoking, diabetes, and prior prolapse repair (odds ratio, 4.3; 95% confidence interval, 2.2-8.2). There was no discernable difference in recurrence rates for women with stage IV prolapse, although sample size was limited. CONCLUSION: Sacrocolpopexy resulted in a lower prolapse recurrence rate than uterosacral ligament suspension for stage III prolapse. However, there was no difference in recurrence rate among women with preoperative stage II prolapse, suggesting mesh augmentation may not be indicated for these patients. Larger prospective trials are necessary for confirmation.

Characterization and Preoperative Risk Analysis of Leiomyosarcomas at a High-Volume Tertiary Care Center.

INTRODUCTION: Uterine morcellation in minimally invasive surgery has recently come under scrutiny because of inadvertent dissemination of malignant tissue, including leiomyosarcomas commonly mistaken for fibroids. Identification of preoperative risk factors is crucial to ensure that oncologic care is delivered when suspicion for malignancy is high, while offering minimally invasive hysterectomies to the remaining patients. OBJECTIVES: The aim of this study was to characterize risk factors for uterine leiomyosarcomas by reviewing preoperative, intraoperative, and postoperative data with an emphasis on the presence of concurrent fibroids. METHODS: A retrospective case-control study of women undergoing hysterectomy with pathologic diagnosis of uterine leiomyosarcoma at a tertiary care center between January 2005 and April 2014. RESULTS: Thirty-one women were identified with leiomyosarcoma and matched to 124 controls. Cases with leiomyosarcoma were more likely to have undergone menopause and to present with larger uteri (19- vs 9-week sized), with the most common presenting complaint being a pelvic mass (35.5% vs 8.9%). Controls were ten times more likely to have undergone a tubal ligation (30.6% vs 3.2%). Endometrial sampling detected malignancy preoperatively in only 50% of cases. Leiomyosarcomas were more commonly present when pelvic masses were identified in addition to fibroids on preoperative imaging. Most leiomyosarcoma cases (77.4%) were performed by oncologists via an abdominal approach (83.9%), with only 2 of 31 leiomyosarcomas being morcellated. Comparative analysis of preoperative imaging and postoperative pathology showed that in patients with leiomyosarcoma, fibroids were misdiagnosed 58.1% of the time, and leiomyosarcomas arose directly from fibroids in only 6.5% of cases. CONCLUSIONS: Leiomyosarcoma risk factors include older age/postmenopausal status, enlarged uteri of greater than 10 weeks, and lack of previous tubal ligation. Preoperative testing failed to definitively identify leiomyosarcomas, although the presence of synchronous pelvic masses in fibroid uteri should raise clinical suspicion. Given the difficulty of preoperative identification, future efforts should focus on the development of safer minimally invasive techniques for uterine morcellation.

Vancomycin-resistant enterococci in acute myeloid leukemia and myelodysplastic syndrome patients undergoing induction chemotherapy with idarubicin and cytarabine.

We conducted a retrospective study to determine the risk factors associated with vancomycin-resistant enterococci (VRE) acquisition/infection in newly diagnosed acute myeloid leukemia and myelodysplastic syndrome patients undergoing chemotherapy with the 7 + 3 regimen of cytarabine and idarubicin. Although only 2.5% (6/235) patients were colonized with VRE on admission, 59% (134/229) of patients acquired VRE during their hospitalization. Multivariable analysis identified the use of intravenous vancomycin (p = .024; HR: 1.548) and cephalosporin (p = .009; HR: 1.596) as the risk factors for VRE acquisition. VRE infection developed in 14% (33/229) of patients, with bloodstream infections accounting for 82% (27/33) of cases. VRE infection occurred in 25/126 (20%) of the VRE-colonized patients, but only 8/103 (8%) of those who were not (p = .01). Our study provides the evidence for the role of intravenous cephalosporin and vancomycin in VRE acquisition and highlights the clinical significance of VRE colonization in these patients.

A clinical prediction model for prolonged air leak after pulmonary resection.

OBJECTIVE: Prolonged air leak increases costs and worsens outcomes after pulmonary resection. We aimed to develop a clinical prediction tool for prolonged air leak using pretreatment and intraoperative variables. METHODS: Patients who underwent pulmonary resection for lung cancer/nodules (from January 2009 to June 2014) were stratified by prolonged parenchymal air leak (>5 days). Using backward stepwise logistic regression with bootstrap resampling for internal validation, candidate variables were identified and a nomogram risk calculator was developed. RESULTS: A total of 2317 patients underwent pulmonary resection for lung cancer/nodules. Prolonged air leak (8.6%, n = 200) was associated with significantly longer hospital stay (median 10 vs 4 days; P < .001). Final model variables associated with increased risk included low percent forced expiratory volume in 1 second, smoking history, bilobectomy, higher annual surgeon caseload, previous chest surgery, Zubrod score >2, and interaction terms for right-sided thoracotomy and wedge resection by thoracotomy. Wedge resection, higher body mass index, and unmeasured percent forced expiratory volume in 1 second were protective. Derived nomogram discriminatory accuracy was 76% (95% confidence interval [CI], 0.72-0.79) and facilitated patient stratification into low-, intermediate- and high-risk groups with monotonic increase in observed prolonged air leaks (2.0%, 8.9%, and 19.2%, respectively; P < .001). Patients at intermediate and high risk were 4.80 times (95% CI, 2.86-8.07) and 11.86 times (95% CI, 7.21-19.52) more likely to have prolonged air leak compared with patients at low risk. CONCLUSIONS: Using readily available candidate variables, our nomogram predicts increasing risk of prolonged air leak with good discriminatory ability. Risk stratification can support surgical decision making, and help initiate proactive, patient-specific surgical management.

Dysplastic nevi with severe atypia: Long-term outcomes in patients with and without re-excision.

BACKGROUND: Dysplastic nevi with severe atypia (severely dysplastic nevi [SDN]) are frequently re-excised because of the concern that these lesions may in fact represent early melanoma. Data on long-term follow-up of these patients are limited. OBJECTIVE: We sought to determine the rate of subsequent melanoma development in patients with SDN who underwent re-excision versus those who did not and to determine factors associated with decision to re-excise. METHODS: A retrospective single institutional study was conducted with 451 adult patients (mean age 41.3 years) with SDN biopsied between November 1994 and November 2004, with clinical follow-up of at least 5 years. RESULTS: In 451 patients with SDN, re-excision was performed on 36.6%. Two melanomas were diagnosed in the re-excision specimens. Subsequent metastatic melanoma developed in 7 patients, all of whom had a history of melanoma. Margin comments influenced decision to re-excise. LIMITATIONS: This was a retrospective study at a single institution. CONCLUSION: Re-excision of all SDN may not be necessary.

Non-Elective Paraesophageal Hernia Repair Portends Worse Outcomes in Comparable Patients: a Propensity-Adjusted Analysis.

INTRODUCTION: Patients undergoing non-elective paraesophageal hernia repair (PEHR) have worse perioperative outcomes. Because they are usually older and sicker, however, these patients may be more prone to adverse events, independent of surgical urgency. Our study aimed to determine whether non-elective PEHR is associated with differential postoperative outcome compared to elective repair, using propensity-score weighting. METHODS: We abstracted data for patients undergoing PEHR (n = 924; non-elective n = 171 (19 %); 1997-2010). Using boosted regression, we generated a propensity-weighted dataset. Odds of 30-day/in-hospital mortality and major complications after non-elective surgery were determined. RESULTS: Patients undergoing non-elective repair were significantly older, had more adverse prognostic factors, and significantly more major complications (38 versus 18 %; p < 0.001) and death (8 versus 1 %; p < 0.001). After propensity weighting, median absolute percentage bias across 28 propensity-score variables improved from 19 % (significant imbalance) to 5.6 % (well-balanced). After adjusting propensity-weighted data for age and comorbidity score, odds of major complications were still nearly two times greater (OR 1.67, CI 1.07-2.61) and mortality nearly three times greater (OR 2.74, CI 0.93-8.1) than for elective repair. CONCLUSIONS: Even after balancing significant differences in baseline characteristics, non-elective PEHR was associated with worse outcomes than elective repair. Symptomatic patients should be referred for elective repair by experienced surgeons.

Cognitive functioning in children from Nigeria with sickle cell anemia.

BACKGROUND: Cognitive impairment is a major neurological complication of sickle cell anemia (SCA) in the United States, but there are limited studies of cognitive impairment in Nigeria, the country with the highest SCA burden. We hypothesized that children from Nigeria with SCA have worse cognitive functioning than comparison children and explored the association between lower cognitive functioning and key laboratory demographic and socioeconomic variables among children with SCA. PROCEDURE: We conducted a cross-sectional survey, supplemented by anthropomorphic and laboratory data, among a convenience sample of children from Nigeria with and without SCA. We administered the Wechsler Intelligence Scale for Children, Version IV. Our primary outcome measures included (1) estimated IQ (Est. IQ), (2) working memory (WM), and (3) processing speed (PS). RESULTS: The sample included 56 children with SCA (mean age 9.20 [SD 2.75], 46.43% girls) and 44 comparison children (mean age 9.41 [SD 2.49], 40.91% girls). Children with SCA performed worse on Est. IQ (84.58 vs. 96.10, P = 0.006) and PS (86.69 vs 96.91, P = 0.009) than comparison children. There was no significant difference in WM between both groups. Factors associated with lower Est. IQ and PS among children with SCA included age, maternal education, weight-for-age Z scores, and height-for age Z scores. CONCLUSION: In this small sample of children from Nigeria, we found worse cognitive functioning in children with SCA than in comparison children, and that sociodemographic and anthropomorphic factors were correlated with cognitive functioning.

Cancer Recurrence After Esophagectomy: Impact of Postoperative Infection in Propensity-Matched Cohorts.

BACKGROUND: Postoperative infection increases cancer recurrence and worsens survival in colorectal cancer, but the relationship for esophagogastric adenocarcinoma after esophagectomy is not well defined. We aimed to determine whether recurrence and survival after minimally invasive esophagectomy for esophagogastric adenocarcinoma were influenced by postoperative infection using propensity-matched analysis. METHODS: We abstracted data for 810 patients (1997-2010) and defined exposure as at least 1 in-hospital or 30-day infectious complication (n = 206 [25%]). Using 29 pretreatment/intraoperative variables, patients were propensity-score matched (caliper = 0.05). Time to cancer recurrence and survival (Kaplan-Meier curves and the Breslow test), and associated factors (Cox regression with shared frailty) were assessed. RESULTS: After propensity matching (n = 167 pairs), median bias across propensity-score variables was reduced from 12.9% (p < 0.001) to 4.4% (p = 1.000). Postoperative infection was not associated with rate (n = 60 versus 63; McNemar p = 0.736) or time to recurrence in those in whom disease recurred (median, 10.7 versus 11.1 months; Wilcoxon signed-rank p = 0.455) but was associated with shorter overall survival (n = 124 versus 102 deaths; median, 26 versus 41 months; Breslow p = 0.002). After adjusting for age, body mass index, neoadjuvant therapy, sex, comorbidity score, positive resection margins, pathologic stage, R0 resection, and recurrence, postoperative infection was associated with a 44% greater hazard for death (hazard ratio, 1.44; 95% confidence interval, 1.10-1.89). CONCLUSIONS: In patients with esophagogastric adenocarcinoma, infections after esophagectomy were not associated with an increased rate or earlier time to recurrence when baseline characteristics associated with infection risk were balanced using propensity-score matching. Despite this, overall survival was shorter in patients with infectious complications. After adjusting for other important survival predictors, infections after esophagectomy continued to be independently associated with worse survival.

Neurologic Outcomes After Low-Volume, Ultrasound-Guided Interscalene Block and Ambulatory Shoulder Surgery.

BACKGROUND AND OBJECTIVES: Postoperative neurologic symptoms after interscalene block and shoulder surgery have been reported to be relatively frequent. Reports of such symptoms after ultrasound-guided block have been variable. We evaluated 300 patients for neurologic symptoms after low-volume, ultrasound-guided interscalene block and arthroscopic shoulder surgery. METHODS: Patients underwent ultrasound-guided interscalene block with 16 to 20 mL of 0.5% bupivacaine or a mix of 0.2% bupivacaine/1.2% mepivacaine solution, followed by propofol/ketamine sedation for ambulatory arthroscopic shoulder surgery. Patients were called at 10 days for evaluation of neurologic symptoms, and those with persistent symptoms were called again at 30 days, at which point neurologic evaluation was initiated. Details of patient demographics and block characteristics were collected to assess any association with persistent neurologic symptoms. RESULTS: Six of 300 patients reported symptoms at 10 days (2%), with one of these patients having persistent symptoms at 30 days (0.3%). This was significantly lower than rates of neurologic symptoms reported in preultrasound investigations with focused neurologic follow-up and similar to other studies performed in the ultrasound era. There was a modest correlation between the number of needle redirections during the block procedure and the presence of postoperative neurologic symptoms. CONCLUSIONS: Ultrasound guidance of interscalene block with 16- to 20-mL volumes of local anesthetic solution results in a lower frequency of postoperative neurologic symptoms at 10 and 30 days as compared with investigations in the preultrasound period.

Propensity-score analysis in thoracic surgery: When, why, and an introduction to how.

Propensity score matching is a valuable tool for dealing with observational data and nonrandom treatment assignment, which often results in groups that differ systematically in numerous measured and unmeasured variables. When these systematically different variables are associated with both group assignment and the outcome(s) of interest, bias is introduced. Propensity score matching assigns a propensity for group assignment, which is then used to create 2 groups that are balanced across all possible variables that might influence exposure assignment. When used in the proper conditions, these analytics allow for more accurate and precise estimates of risk for a variety of outcomes.

Predictors of Foreign Body Aspiration in Children.

OBJECTIVES: To examine the sensitivity and specificity of history, physical examination, and radiologic studies as predictors of foreign body aspiration in children. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: Medical records were reviewed for 102 children who presented to our institution from 2006 to 2013 with suspected foreign body aspiration and who underwent endoscopy. Data included symptoms, physical examination, radiologic, and endoscopy findings. Descriptive statistics, sensitivity and specificity, and univariate and multivariable analyses were performed. RESULTS: A total of 102 patients were included (62% male). The mean age was 3.3 years (SD, 3.7). A foreign body was identified on endoscopy in 69 cases (68%). The most common presenting symptoms were cough (88%), choking/gagging (67%), and wheezing (57%). Decreased breath sounds and wheezing on examination were independently associated with increased odds of foreign body. The most common abnormal radiographic finding was air trapping (33%). The most frequent items retrieved were fragments of seeds and nuts (49%). There were no serious complications related to endoscopy. The sensitivity and specificity of any finding on history, physical examination, and imaging were 100% and 3%, 90% and 33%, 61% and 77%, respectively. Having a positive history, examination, and chest radiograph combined was 46% sensitive and 79% specific. CONCLUSIONS: Patients with airway foreign bodies have varied presentations. The presence of any radiologic finding suggests that endoscopy should be performed, as a foreign body is probable. The absence of any history or physical examination finding was associated with a low likelihood of a foreign body.

A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair.

BACKGROUND: Equipoise exists regarding whether mesh cruroplasty during laparoscopic large hiatal hernia repair improves symptomatic outcomes compared with suture repair. DATA SOURCE: Systematic literature review (MEDLINE and EMBASE) identified 13 studies (1,194 patients; 521 suture and 673 mesh) comparing mesh versus suture cruroplasty during laparoscopic repair of large hiatal hernia. We abstracted data regarding symptom assessment, objective recurrence, and reoperation and performed meta-analysis. CONCLUSIONS: The majority of studies reported significant symptom improvement. Data were insufficient to evaluate symptomatic versus asymptomatic recurrence. Time to evaluation was skewed toward longer follow-up after suture cruroplasty. Odds of recurrence (odds ratio .51, 95% confidence interval .30 to .87; overall P = .014) but not need for reoperation (odds ratio .42, 95% confidence interval .13 to 1.37; overall P = .149) were less after mesh cruroplasty. Quality of evidence supporting routine use of mesh cruroplasty is low. Mesh should be used at surgeon discretion until additional studies evaluating symptomatic outcomes, quality of life, and long-term recurrence are available.

Computer-aided classification of melanocytic lesions using dermoscopic images.

BACKGROUND: Computer-assisted diagnosis of dermoscopic images of skin lesions has the potential to improve melanoma early detection. OBJECTIVE: We sought to evaluate the performance of a novel classifier that uses decision forest classification of dermoscopic images to generate a lesion severity score. METHODS: Severity scores were calculated for 173 dermoscopic images of skin lesions with known histologic diagnosis (39 melanomas, 14 nonmelanoma skin cancers, and 120 benign lesions). A threshold score was used to measure classifier sensitivity and specificity. A reader study was conducted to compare the sensitivity and specificity of the classifier with those of 30 dermatology clinicians. RESULTS: The classifier sensitivity for melanoma was 97.4%; specificity was 44.2% in a test set of images. In the reader study, the classifier's sensitivity to melanoma was higher (P < .001) and specificity was lower (P < .001) than that of clinicians. LIMITATIONS: This is a retrospective study using existing images primarily chosen for biopsy by a dermatologist. The size of the test set is small. CONCLUSIONS: Our classifier may aid clinicians in deciding if a skin lesion should be biopsied and can easily be incorporated into a portable tool (that uses no proprietary equipment) that could aid clinicians in noninvasively evaluating cutaneous lesions.

The revised American Joint Committee on Cancer staging system (7th edition) improves prognostic stratification after minimally invasive esophagectomy for esophagogastric adenocarcinoma.

BACKGROUND: Staging for esophagogastric adenocarcinoma lacked sufficient prognostic accuracy and was revised. We compared survival prognostication between American Joint Committee on Cancer (AJCC) 6th and 7th editions. METHODS: We abstracted data for 836 patients who underwent minimally invasive esophagectomy for esophagogastric adenocarcinoma (n = 256 neoadjuvant). Monotonicity and strength of survival trends, by stage, were assessed (log-rank test of trend chi-square statistic) and compared using permutation testing. Overall survival (Cox regression) and model fit (Akaike Information Criterion) were determined. RESULTS: A greater log-rank test of trend statistic indicated stronger survival trends by stage in AJCC 7th (152.872 vs 167.623; permutation test P < .001) edition. Greater Cox likelihood chi-square value (162.957 vs 173.951) and lower Akaike Information Criterion (4,831.011 vs 4,820.016) indicated better model fit. Superior performance was also shown after neoadjuvant therapy. CONCLUSION: AJCC 7th edition staging for esophagogastric adenocarcinoma provides superior prognostic stratification after minimally invasive esophagectomy, overall and after neoadjuvant therapy compared with AJCC 6th edition.

Reintubation in critically ill patients: procedural complications and implications for care.

INTRODUCTION: In critically ill patients, re-intubation is common and may be a high-risk procedure. Anticipating a difficult airway and identifying high-risk patients can allow time for life-saving preparation. Unfortunately, prospective studies have not compared the difficulty or complication rates associated with reintubation in this population. METHODS: We performed a secondary analysis of a prospective registry of in-hospital emergency airway management, focusing on patients that underwent multiple out-of-operating room intubations during a single hospitalization. Our main outcomes of interest were technical difficulty of intubation (number of attempts, need for adjuncts to direct laryngoscopy, best Cormack-Lehane grade and training level of final intubator) and the frequency of procedural complications (aspiration, arrhythmia, airway trauma, new hypotension, new hypoxia, esophageal intubation and cardiac arrest). We compared the cohort of reintubated patients to a matched cohort of singly intubated patients and compared each repeatedly intubated patient's first and last intubation. RESULTS: Our registry included 1053 patients, of which 151 patients (14%) were repeatedly intubated (median two per patient). Complications were significantly more common during last intubation compared to first (13% versus 5%, P = 0.02). The most common complications were hypotension (41%) and hypoxia (35%). These occurred despite no difference in any measure of technical difficultly across intubations. CONCLUSION: In this cohort of reintubated patients, clinically important procedural complications were significantly more common on last intubation compared to first.

A propensity-matched analysis comparing survival after primary minimally invasive esophagectomy followed by adjuvant therapy to neoadjuvant therapy for esophagogastric adenocarcinoma.

OBJECTIVES: Prognosis for patients with locally advanced esophagogastric adenocarcinoma (EAC) is poor with surgery alone, and adjuvant therapy after open esophagectomy is frequently not tolerated. After minimally invasive esophagectomy (MIE); however, earlier return to normal function may render patients better able to receive adjuvant therapy. We examined whether primary MIE followed by adjuvant chemotherapy influenced survival compared with propensity-matched patients treated with neoadjuvant therapy. METHODS: Patients with stage II or higher EAC treated with MIE (N = 375) were identified. Using 30 pretreatment covariates, propensity for assignment to either neoadjuvant followed by MIE (n = 183; 54%) or MIE as primary therapy (n = 156; 46%) was calculated, generating 97 closely matched pairs. Hazard ratios were adjusted for age, sex, body mass index, smoking, comorbidity, and final pathologic stage. RESULTS: In propensity-matched pairs, adjusted hazard ratio for death did not differ significantly for primary MIE compared with neoadjuvant (hazard ratio, 0.83; 95% confidence interval, 0.60-1.16). Recurrence patterns were similar between groups and 65% of patients with IIb or greater pathologic stage received adjuvant therapy. Clinical staging was inaccurate in 37 out of 105 patients (35%) who underwent primary MIE (n = 18 upstaged and n = 19 downstaged). CONCLUSIONS: Primary MIE followed by adjuvant chemotherapy guided by pathologic findings did not negatively influence survival and allowed for accurate staging compared with clinical staging. Our data suggest that primary MIE in patients with resectable EAC may be a reasonable approach, improving stage-based prognostication and potentially minimizing overtreatment in patients with early stage disease through accurate stage assignments. A randomized controlled trial testing this hypothesis is needed.