Influence of Pleurectomy and Decortication in Health-Related Quality of Life Among Patients with Malignant Pleural Mesothelioma.

BACKGROUND: Complete macroscopic resection surgery, pleurectomy and decortication (PD) improve survival in selected patients with malignant pleural mesothelioma (MPM). Yet its value has been questioned because of concern that this extensive surgical procedure may disrupt health-related quality of life (HRQoL). METHODS: HRQoL was studied in patients undergoing PD surgery for MPM using EORTC QLQ-C30 instrument at baseline (prior to surgery), 1, 4-5, 7-8, and 10-11 months following surgery. Global health and variables in function and symptom domains were investigated. Sub-groups analyses were performed for ECOG performance status (PS), histological sub-types and pathological tumor volume (pTV). Within-patient comparisons to baseline scores were made using Wilcoxon signed-rank test. Trends over time were evaluated using Cuzick's nonparametric test. RESULTS: There were 114 patients with median age of 70 years (range: 50-88) and PS 0: 35 (30.7%), epithelioid histology: 61 (53.5%) and volume <600 ml: 58 (50.9%). Patients with good PS (PS 0), epithelioid histology and small pTV had greater level of functioning and were less symptomatic at baseline. Overall global health worsened at the first postoperative month (p = 0.0005) with subsequent improvement. Non-epithelioid histology and patients with large pTV demonstrated greater improvement in global health, function and symptoms domains following a PD. CONCLUSIONS: At baseline, the overall health-related quality of life, function and symptom domains were adversely affected in non-epithelioid histology and patients with large pTV. However, greatest improvement in global health, symptom and function domains were observed first month after PD and during the follow-up in these sub-groups.

Clinical and molecular markers of long-term survival after oligometastasis-directed stereotactic body radiotherapy (SBRT).

BACKGROUND: The selection of patients for oligometastasis-directed ablative therapy remains a challenge. The authors report on clinical and molecular predictors of survival from a stereotactic body radiotherapy (SBRT) dose-escalation trial for oligometastases. METHODS: Patients who had from 1 to 5 metastases, a life expectancy of >3 months, and a Karnofsky performance status of >60 received escalating SBRT doses to all known cancer sites. Time to progression, progression-free survival, and overall survival (OS) were calculated at the completion of SBRT, and clinical predictors of OS were modeled. Primary tumor microRNA expression was analyzed to identify molecular predictors of OS. RESULTS: Sixty-one evaluable patients were enrolled from 2004 to 2009. The median follow-up was 2.3 years for all patients (range, 0.2-9.3 years) and 6.8 years for survivors (range, 2.0-9.3 years). The median, 2-year, and 5-year estimated OS were 2.4 years, 57%, and 32%, respectively. The rate of progression after SBRT was associated with an increased risk of death (hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.24-1.82). The time from initial cancer diagnosis to metastasis (HR, 0.98; 95% CI, 0.98-0.99), the time from metastasis to SBRT (HR, 0.98; 95% CI, 0.98-0.99), and breast cancer histology (HR, 0.12; 95% CI, 0.07-0.37) were significant predictors of OS. In an exploratory analysis, a candidate classifier using expression levels of 3 microRNAs (miR-23b, miR-449a, and miR-449b) predicted survival among 17 patients who had primary tumor microRNA expression data available. CONCLUSIONS: A subset of oligometastatic patients achieves long-term survival after metastasis-directed SBRT. Clinical features and primary tumor microRNA expression profiling, if validated in an independent dataset, may help select oligometastatic patients most likely to benefit from metastasis-directed therapy. Cancer 2016;122:2242-50. © 2016 American Cancer Society.

Phase II Evaluation of Magnetic Resonance Imaging Guided Focal Laser Ablation of Prostate Cancer.

PURPOSE: Magnetic resonance imaging guided focal laser ablation is an investigational strategy for the treatment of prostate cancer. MATERIALS AND METHODS: This phase II evaluation of focal laser ablation included men with stage T1c-T2a, prostate specific antigen less than 15 ng/ml or prostate specific antigen density less than 0.15 ng/ml3, Gleason 7 or less in 25% or less of biopsies and magnetic resonance imaging with 1 or 2 lesions concordant with biopsy detected cancer. At 3 months all patients underwent magnetic resonance imaging with biopsy of ablation zone(s). At 12 months all underwent magnetic resonance imaging and systematic biopsy. I-PSS (International Prostate Symptom Score) and SHIM (Sexual Health Inventory for Men) scores were collected before focal laser ablation, and at 1, 3 and 12 months. The primary end point was no cancer on the 3-month ablation zone biopsy. Secondary end points were safety, 12-month biopsy, and urinary and sexual function. RESULTS: In the 27 men median age was 62 years and mean prostate specific antigen was 4.4 ng/ml. Biopsy Gleason score was 6 in 23 patients (85%) and Gleason 7 in 4 (15%). Seven men (26%) had low volume Gleason 6 disease outside the intended ablation zone(s). At 3 months 26 patients (96%) had no evidence of cancer on magnetic resonance imaging guided biopsy of the ablation zone. No significant I-PSS changes were observed (each p >0.05). SHIM was lower at 1 month (p = 0.03), marginally lower at 3 months (p = 0.05) and without a significant difference at 12 months (p = 0.38). At 12-month biopsy cancer was identified in 10 patients (37%), including in the ablation zone(s) in 3 (11%) and outside the ablation zone(s) in 8 (30%) with cancer in and outside the ablation zone in 1. CONCLUSIONS: In select men with localized prostate cancer and visible magnetic resonance imaging lesions focal laser ablation has an acceptable morbidity profile and is associated with encouraging short-term oncologic outcomes. Significantly longer followup is mandatory to fully assess this novel treatment.

Predictors of Physician Recommendation for Ethically Controversial Medical Procedures: Findings from an Exploratory National Survey of American Muslim Physicians.

Physician religiosity can influence their ethical attitude toward medical procedures and can thereby impact healthcare delivery. Using a national survey of American Muslim physicians, we explored the association between physician recommendation of three controversial medical procedures--tubal ligation, abortion, and porcine-based vaccine--and their (1) religiosity, (2) utilization of bioethics resources, and (3) perception of whether the procedure was a medical necessity and if the scenario represented a life threat. Generally, multivariate models found that physicians who read the Qur'an more often as well as those who perceived medical necessity and/or life threat had a higher odds recommending the procedures, whereas those who sought Islamic bioethical guidance from Islamic jurists (or juridical councils) more often had a lower odds. These associations suggest that the bioethical framework of Muslim physicians is influenced by their reading of scripture, and the opinions of Islamic jurists and that these influences may, paradoxically, be interpreted to be in opposition over some medical procedures.

Central venous catheters: incidence and predictive factors of venous thrombosis.

AIMS: Central venous catheter access in an acute setting can be a challenge given underlying disease and risk for venous thrombosis. Peripherally inserted central venous catheters (PICCs) are commonly placed but limit sites for fistula creation in patients with chronic renal failure (CKD). The aim of this study is to determine the incidence of venous thrombosis from small bore internal jugular (SBIJ) and PICC line placement. This investigation identifies populations of patients who may not be ideal candidates for a PICC and highlights the importance of peripheral vein preservation in patients with renal failure. MATERIALS AND METHODS: A venous Doppler ultrasound was performed at the time of SBIJ insertion and removal to evaluate for thrombosis in the internal jugular vein. Data was collected pre- and post-intervention to ascertain if increased vein preservation knowledge amongst the healthcare team led to less use of PICCs. Demographic factors were collected in the SBIJ and PICC groups and risk factor analysis was completed. RESULTS: 1,122 subjects had PICC placement and 23 had SBIJ placement. The incidence of thrombosis in the PICC group was 10%. One patient with an SBIJ had evidence of central vein thrombosis when the catheter was removed. Univariate and multivariate analysis demonstrated a history of transplant, and the indication of total parenteral nutrition was associated with thrombosis (p<0.001). The decrease in PICCs placed in patients with CKD 6 months before and after intervention was significant (p<0.05). CONCLUSIONS: There are subsets of patients ith high risk for thrombosis who may not be ideal candidates for a PICC.

Antigenicity and immunogenicity of transmitted/founder, consensus, and chronic envelope glycoproteins of human immunodeficiency virus type 1.

Human immunodeficiency virus type 1 (HIV-1) vaccine development requires selection of appropriate envelope (Env) immunogens. Twenty HIV-1 Env glycoproteins were examined for their ability to bind human anti-HIV-1 monoclonal antibodies (MAbs) and then used as immunogens in guinea pigs to identify promising immunogens. These included five Envs derived from chronically infected individuals, each representing one of five common clades and eight consensus Envs based on these five clades, as well as the consensus of the entire HIV-1 M group, and seven transmitted/founder (T/F) Envs from clades B and C. Sera from immunized guinea pigs were tested for neutralizing activity using 36 HIV-1 Env-pseudotyped viruses. All Envs bound to CD4 binding site, membrane-proximal, and V1/V2 MAbs with similar apparent affinities, although the T/F Envs bound with higher affinity to the MAb 17b, a CCR5 coreceptor binding site antibody. However, the various Envs differed in their ability to induce neutralizing antibodies. Consensus Envs elicited the most potent responses, but neutralized only a subset of viruses, including mostly easy-to-neutralize tier 1 and some more-difficult-to-neutralize tier 2 viruses. T/F Envs elicited fewer potent neutralizing antibodies but exhibited greater breadth than chronic or consensus Envs. Finally, chronic Envs elicited the lowest level and most limited breadth of neutralizing antibodies overall. Thus, each group of Env immunogens elicited a different antibody response profile. The complementary benefits of consensus and T/F Env immunogens raise the possibility that vaccines utilizing a combination of consensus and T/F Envs may be able to induce neutralizing responses with greater breadth and potency than single Env immunogens.

MR imaging-guided focal laser ablation for prostate cancer: phase I trial.

PURPOSE: To evaluate the feasibility and safety of magnetic resonance (MR) imaging-guided laser-based thermotherapy in men with clinically low-risk prostate cancer and a concordant lesion at biopsy and MR imaging. MATERIALS AND METHODS: This HIPAA-compliant phase I prospective study was approved by the institutional review board. Informed consent was obtained from all patients. Transperineal MR imaging-guided focal laser ablation for clinically low-risk prostate cancer was performed in patients with a Gleason score of 7 or less in three or fewer cores limited to one sextant obtained with transrectal ultrasonography (US)-guided biopsy and a concordant lesion at MR imaging. Lesions were targeted with a laser ablation system. Periprocedural complications were recorded. The International Prostate Symptom Score (IPSS) and the Sexual Health Inventory for Men (SHIM) score were collected before and after the procedure. MR imaging-guided biopsy of the ablation zone was performed 6 months after treatment. The prostate-specific antigen level, IPSS, and SHIM score before and after ablation were compared by using the Wilcoxon signed rank test. RESULTS: Treatment was successfully completed in nine patients (procedure duration, 2.5-4 hours; mean laser ablation duration, 4.3 minutes). Immediate contrast-enhanced posttreatment MR imaging showed a hypovascular defect in eight patients. Self-resolving perineal abrasion and focal paresthesia of the glans penis each occurred in one patient. The mean (± standard deviation) IPSS and SHIM score at baseline were 5.8 ± 5.3 and 19.0 ± 8.0, respectively. Average score changes were not significantly different from zero during follow-up (P = .18-.99). MR imaging-guided biopsy of the ablation zone showed no cancer in seven patients (78%) and Gleason grade 6 cancer in two (22%). CONCLUSION: Transperineal MR imaging-guided focal laser ablation appears to be a feasible and safe focal therapy option for clinically low-risk prostate cancer.

Relationship between functional profile of HIV-1 specific CD8 T cells and epitope variability with the selection of escape mutants in acute HIV-1 infection.

In the present study, we analyzed the functional profile of CD8+ T-cell responses directed against autologous transmitted/founder HIV-1 isolates during acute and early infection, and examined whether multifunctionality is required for selection of virus escape mutations. Seven anti-retroviral therapy-naïve subjects were studied in detail between 1 and 87 weeks following onset of symptoms of acute HIV-1 infection. Synthetic peptides representing the autologous transmitted/founder HIV-1 sequences were used in multiparameter flow cytometry assays to determine the functionality of HIV-1-specific CD8+ T memory cells. In all seven patients, the earliest T cell responses were predominantly oligofunctional, although the relative contribution of multifunctional cell responses increased significantly with time from infection. Interestingly, only the magnitude of the total and not of the poly-functional T-cell responses was significantly associated with the selection of escape mutants. However, the high contribution of MIP-1ß-producing CD8+ T-cells to the total response suggests that mechanisms not limited to cytotoxicity could be exerting immune pressure during acute infection. Lastly, we show that epitope entropy, reflecting the capacity of the epitope to tolerate mutational change and defined as the diversity of epitope sequences at the population level, was also correlated with rate of emergence of escape mutants.

Assessment of the Degree of Variation of Histologic Inflammation in Ulcerative Colitis.

INTRODUCTION: Treatment of ulcerative colitis (UC) now includes mucosal healing. Adoption of histologic end points is hindered by a lack of evidence guiding optimal sampling, interpretation, and reproducibility of results. METHODS: We analyzed biopsy fragments from colonoscopies in 92 patients with UC. Fragments were scored using 6-point histologic inflammatory activity (HIA) scale. Variability was determined using ordinal representations of HIA scores. The most frequently observed score and percentage of biopsy fragments with that score were determined for each biopsy, each segment, and across all 3 segments for each colonoscopy. Mean percentages and 95% confidence intervals (CIs) were calculated. RESULTS: We reviewed 1802 biopsy fragments. The mean percentages of intrasegment biopsy fragments with the same HIA score were 85.5% (95% CI, 80.9% to 92.9%), 79.6% (95% CI, 76.0% to 87.3%), and 82.7% (95% CI, 79.1% to 90.0%) for the rectum, left colon, and right colon, respectively. The mean percentage of intersegment biopsy fragments with the same HIA score was 70.2% (95% CI, 65.7% to 82.5%). The mean percentages of intrabiopsy fragments with the same HIA score were 83.3% (95% CI, 77.6% to 93.5%), 83.6% (95% CI, 80.1% to 89.7%), and 90.2% (95% CI, 87.6% to 94.7%) for the rectum, left colon, and right colon, respectively. All 3 analyses revealed increased variation when a greater degree of histologic inflammation was present in the biopsies (mean HIA score ≥2). CONCLUSIONS: We found minimal variability between degree of inflammation among biopsy fragments within and among different colorectal segments in UC, suggesting that even a single biopsy would adequately reflect the inflammation of the entire colorectum. These findings have significant implications for the use of histology as a clinical target and trial end point in UC.

"Tumoral pseudoblush" identified within gliomas at high-spatial-resolution ultrahigh-field-strength gradient-echo MR imaging corresponds to microvascularity at stereotactic biopsy.

PURPOSE: To use directed biopsy sampling to determine whether microvascular assessment within gliomas, by means of ultrahigh-field-strength high-spatial-resolution gradient-echo (GRE) magnetic resonance (MR) imaging at 8 T, correlates with histopathologic assessment of microvascularity. MATERIALS AND METHODS: The study was institutional review board approved and HIPAA compliant. Informed consent was obtained. Thirty-five subjects with gliomas underwent 8-T and 80-cm MR imaging by using a GRE sequence (repetition time, 600-750 msec; echo time, 10 msec; in-plane resolution, 196 mm). Haphazardly arranged serpentine low-signal-intensity structures, often associated with areas of low signal intensity within the tumor bed ("tumoral pseudoblush") at MR imaging, were presumed to be related to tumoral microvascularity. Microvessel density (MVD) and microvessel size (MVS) ranked with a semiquantitative three-tier scale (high, medium, and low) relative to cortical penetrating veins were assessed from regions of interest identified at MR imaging and were compared with a similar assessment of stereotactic biopsy specimens by using Kendall τb. Tumor grade (high vs low) was compared with ultrahigh-field-strength high-resolution GRE MR analysis by using Pearson χ2. Discrepancies between 8-T and histopathologic assessment were identified and analyzed. RESULTS: Ultrahigh-field-strength high-resolution GRE MR imaging and histopathologic assessment concurred for MVS (P<.0001) and MVD (P<.0001). World Health Organization classification tumor grade was associated with number (P<.0005) and size (P<.0005) of foci of microvascularity within the tumor bed at 8-T MR imaging. Radiation-induced microvessel hyalinosis mimicked tumor microvascularity at 8-T MR imaging. Potential confounders could result from radiofrequency inhomogeneity and displaced normal microvasculature. CONCLUSION: Microvascularity identified as a tumoral pseudoblush at ultrahigh-field-strength high-resolution GRE MR imaging without contrast material shows promise as a marker for increased tumoral microvascularity.

A cohort study showing correspondence of low wall shear stress and cephalic arch stenosis in brachiocephalic arteriovenous fistula access.

BACKGROUND: A brachiocephalic fistula is frequently placed for hemodialysis; unfortunately, cephalic arch stenosis commonly develops, leading to failure. We hypothesized that a contribution to brachiocephalic fistula failure is low wall shear stress resulting in neointimal hyperplasia leading to venous stenosis. The objective of this investigation is to determine correspondence of low wall shear stress and the development of cephalic arch stenosis. METHODS: Forty subjects receiving hemodialysis with a primary brachiocephalic fistula access were followed from time of placement for 3 years or until cephalic arch stenosis. Venogram, Doppler, and viscosity were performed at time of fistula maturation, annually for 3 years or to time of cephalic arch stenosis. Computational hemodynamics modeling was performed to determine location and percent low wall shear stress in the arch. The relationship between wall shear stress at time of maturation and location of cephalic arch stenosis were estimated by correlating computational modeling and quadrant location of cephalic arch stenosis. RESULTS: In total, 32 subjects developed cephalic arch stenosis with 26 displaying correspondence between location of low wall shear stress at time of maturation and subsequent cephalic arch stenosis, whereas 6 subjects did not (p = 0.0015). Most subjects with correspondence had low wall shear stress areas evident in greater than 20% of the arch (p = 0.0006). Low wall shear stress was associated with a higher risk of cephalic arch stenosis in the 23-to-45 age group (p = 0.0029). CONCLUSIONS: The presence and magnitude of low wall shear stress in the cephalic arch is a factor associated with development of cephalic arch stenosis in patients with brachiocephalic fistula. Attenuation of low wall shear stress at time of maturation may help prevent the development of cephalic arch stenosis which is difficult to treat once it develops.

Amount of Epithelioid Differentiation Is a Predictor of Survival in Malignant Pleural Mesothelioma.

BACKGROUND: Macroscopic complete surgical resection with adjuvant chemotherapy can provide a survival advantage in patients with malignant pleural mesothelioma (MPM). Patients with nonepithelioid histology are largely excluded from such radical operations even though they might benefit. The degree of epithelioid differentiation varies in biphasic histology. We report the outcomes of pleurectomy and decortication and the effect of epithelioid differentiation on overall survival of patients with MPM. METHODS: This report is based on the outcomes of 144 patients who underwent pleurectomy and decortication at a single institution between 2008 and 2015. The variables assessed were age, gender, histology, and pathologic T and N stage. No patients with pure sarcomatoid histology were included. Two independent pathologists estimated the percentage of epithelioid histology. A Cox regression model was used to identify significant predictors of survival. The Kaplan-Meier method was used to summarize overall and subgroup survival. RESULTS: Included were 116 men and 28 women with a median age of 69 years (range, 43 to 88 years). The 2-year survival from pleurectomy and decortication was 20%. Median survival overall was 13.34 months and was 20.1 months for the 100% epithelioid subgroup (n = 77), 11.8 months for the 51% to 99% epithelioid subgroup (n = 39), and 6.62 months for the less than 50% epithelioid subgroup (n = 28). The amount of epithelioid differentiation was a significant predictor of survival (p < 0.001). Differences in survival based on the T, but N stage, were not statistically significant. CONCLUSIONS: The percentage of epithelioid differentiation is an independent predictor of survival in MPM and should be taken into careful consideration when recommending surgical treatment for patients with biphasic MPM.

Specimen weight and volume: important predictors of survival in malignant pleural mesothelioma.

OBJECTIVES: The tumour/node/metastasis (TNM) staging system for malignant pleural mesothelioma (MPM) is a worldwide standard, but has many limitations. Tumour volume has been suggested as a predictor of survival. Due to the complex anatomy, estimation of tumour volume via CT scan can be challenging. Surgical volume may be more accurate. Therefore, we prospectively determined resected specimen volumes and weights in consecutive patients undergoing extended pleurectomy and decortication (EPD) and correlated this with overall survival and T and N stage. METHODS: We evaluated 116 patients undergoing EPD for MPM in a single university centre over a 6-year period. All resected specimens were weighed, and the volume was measured by a fluid displacement method. A Cox regression model was used to identify significant predictors of survival; hazard ratios were calculated. A Kaplan-Meier method was used to summarize overall and subgroup survival. Logistic regression models were used to identify predictors of T and N stage. RESULTS: There were 95 males and 21 females with a median age of 68 range 43-88 years. Forty-one patients had an ECOG performance status (PS) 0, 70 had 1 and 4 had 2. The median time between initial diagnosis and surgery was 134 days. Histology was epithelioid in 59, biphasic in 55 and sarcomatoid in 2. The mean volume was 641 ml with an SD of 393.34 ml. The median volume was 567.5 ml. The mean weight was 620.8 g with an SD of 361.92 g. The median weight was 552.0 g. Two-year survival from initial diagnosis and from EPD was 44 and 28%, respectively. PS (P = 0.002), epithelioid histology (P < 0.001), specimen weight (P < 0.001), volume (P < 0.001), platelet count (P = 0.015), T1 stage (P = 0.04) and adjuvant therapy (P = 01) were predictive of survival. Tumour volume was a predictor of T stage (P = 0.048) and survival (P = 0.03). There was no relationship between N stage and tumour volume, weight or histology. CONCLUSIONS: PS, specimen weight, volume, epithelioid histology platelet count and adjuvant chemotherapy are significant predictors of survival in patients undergoing EPD for MPM. There is a correlation between specimen volume and T stage. These data suggest that tumour weight and volume may be valuable components for staging MPM.

Increased Inlet Blood Flow Velocity Predicts Low Wall Shear Stress in the Cephalic Arch of Patients with Brachiocephalic Fistula Access.

BACKGROUND: An autogenous arteriovenous fistula is the optimal vascular access for hemodialysis. In the case of brachiocephalic fistula, cephalic arch stenosis commonly develops leading to access failure. We have hypothesized that a contribution to fistula failure is low wall shear stress resulting from post-fistula creation hemodynamic changes that occur in the cephalic arch. METHODS: Twenty-two subjects with advanced renal failure had brachiocephalic fistulae placed. The following procedures were performed at mapping (pre-operative) and at fistula maturation (8-32 weeks post-operative): venogram, Doppler to measure venous blood flow velocity, and whole blood viscosity. Geometric and computational modeling was performed to determine wall shear stress and other geometric parameters. The relationship between hemodynamic parameters and clinical findings was examined using univariate analysis and linear regression. RESULTS: The percent low wall shear stress was linearly related to the increase in blood flow velocity (p < 0.01). This relationship was more significant in non-diabetic patients (p < 0.01) than diabetic patients. The change in global measures of arch curvature and asymmetry also evolve with time to maturation (p < 0.05). CONCLUSIONS: The curvature and hemodynamic changes during fistula maturation increase the percentage of low wall shear stress regions within the cephalic arch. Low wall shear stress may contribute to subsequent neointimal hyperplasia and resultant cephalic arch stenosis. If this hypothesis remains tenable with further studies, ways of protecting the arch through control of blood flow velocity may need to be developed.

Knowledge, Attitudes, and Ordering Patterns for Routine HIV Screening among Resident Physicians at an Urban Medical Center.

BACKGROUND: We sought to measure resident physician knowledge of HIV epidemiology and screening guidelines, attitudes toward testing, testing practices, and barriers and facilitators to routine testing. METHODS: Resident physicians in internal medicine, pediatrics, obstetrics and gynecology, and emergency medicine were surveyed. RESULTS: Overall response rate was 63% (162 of 259). Half knew details of the HIV screening guidelines, but few follow these recommendations. Less than one-third reported always or usually performing routine testing. A significant proportion reported only sometimes or never screening patients with risk factors. This was despite a strong belief that HIV screening improves patient care and public health. The most common barriers to testing were competing priorities and forgetting to order the test. Elimination of written consent and electronic reminders was identified as facilitators to routine testing. Although an institutional policy assigns responsibility for test notification and linkage of HIV-positive patients to care to the HIV care program, only 29% were aware of this. CONCLUSIONS: Few resident physicians routinely screen for HIV infection and some don't test patients with risk factors. While competing priorities remain a significant barrier, elimination of written consent form and electronic reminders has facilitated testing. Increasing the awareness of policies regarding test notification and linkage to care may improve screening.

Characterization of the cephalic arch and location of stenosis.

PURPOSE: The purpose of this study is to accurately characterize the cephalic arch segments into four domains and to enable more specific evaluation of cephalic arch stenosis (CAS) and determine the frequency of stenosis in each domain. METHODS: After Institutional Review Board (IRB) approval, a retrospective chart review was done to define a population of patients receiving hemodialysis who developed CAS as apparent on clinically indicated radiologic imaging. A standardized approach was devised to categorize four domains of the cephalic arch. Domain I was defined as the peripheral portion of the arch and Domain IV was the distal portion of the cephalic vein near termination with the axillary vein. The magnitude of stenosis as measured by percentage was determined and compared in the four domains. RESULTS: The most frequent location for stenosis was found in domain IV when compared with domains II or I (p<0.01). The magnitude of stenosis differed across all domains (p<0.001) with the least common place for CAS in domain I. Treatment of CAS included angioplasty in all, thrombectomy in eight, and stent placement in five. CONCLUSIONS: CAS occurs most commonly in the terminal portion of the arch. Four standardized domains have been defined; future work will validate these findings and determine the best intervention for each domain.

Postpartum Contraception Use by Urban/Rural Status: An Analysis of the Michigan Pregnancy Risk Assessment Monitoring System Data.

OBJECTIVE: We sought to examine rural/urban differences in postpartum contraceptive use, which are underexplored in the literature. METHODS: We analyzed phase 5 (2004-2008) of the Michigan Pregnancy Risk Assessment Monitoring System (PRAMS) survey. Using Rural-Urban Commuting Area codes and weighted multinomial logistic regression, we examined the association between self-reported postpartum contraceptive method and rural/urban residence among postpartum women not desiring pregnancy (n = 6,468). RESULTS: Postpartum (mean, 16.5 weeks after delivery), 14.4% of respondents were using sterilization, 6.7% long-acting reversible contraception (LARC), 37.3% moderately effective hormonal methods, 38.4% less effective methods or no method, and 3.2% abstinence. Multivariable analysis yielded sporadic geographic patterns. Odds of method use varied significantly by age, parity, body mass index, and breastfeeding status. Not discussing contraception with a prenatal healthcare provider decreased odds of postpartum LARC use (odds ratio, 0.52; 95% CI, 0.36-0.75). Number of prenatal visits and weeks since delivery were not associated with postpartum contraception method. CONCLUSIONS: We did not observe strong variation in postpartum contraceptive use based on geography. Low uptake of highly effective contraception across rural and urban areas suggests a need for education and outreach regarding these methods.

Assessment of Tandem Measurements of pH and Total Gut Transit Time in Healthy Volunteers.

OBJECTIVES: The variation of luminal pH and transit time in an individual is unknown, yet is necessary to interpret single measurements. This study aimed to assess the intrasubject variability of gut pH and transit time in healthy volunteers using SmartPill devices (Covidien, Minneapolis, MN). METHODS: Each subject (n=10) ingested two SmartPill devices separated by 24 h. Mean pH values were calculated for 30 min after gastric emptying (AGE), before the ileocecal (BIC) valve, after the ileocecal (AIC) valve, and before body exit (BBE). Intrasubject variability was determined by comparing mean values from both ingestions for an individual subject using standard deviations, 95% limits of agreement, and Bland-Altman plots. RESULTS: Tandem device ingestion occurred without complication. The median (full range) intrasubject standard deviations for pH were 0.02 (0.0002-0.2048) for AGE, 0.06 (0.0002-0.3445) for BIC, 0.14 (0.0018-0.3042) for AIC, and 0.08 (0.0098-0.5202) for BBE. There was a significant change in pH for AIC (mean difference: -0.45±0.31, P=0.0015) observed across all subjects. The mean coefficients of variation for transit time were 12.0±7.4% and 25.8±15.8% for small and large bowels, respectively (P=0.01). CONCLUSIONS: This study demonstrates the safety and feasibility of tandem gut transit and pH assessments using the SmartPill device. In healthy individuals and over 24 h, the gut pH profile does not markedly fluctuate in a given region with more variation seen in the colon compared with the small bowel, which has important implications for future physiology and drug delivery studies.

Extended Pleurectomy and Decortication for Malignant Pleural Mesothelioma Is an Effective and Safe Cytoreductive Surgery in the Elderly.

BACKGROUND: A survival advantage has been observed among patients with malignant pleural mesothelioma undergoing maximal cytoreductive surgery and adjuvant therapy. Elderly patients are considered higher risk for these radical operations and are commonly not offered surgical treatment. We reviewed our experience with extended pleurectomy and decortication among patients 70 years or older and compared them with a cohort of younger patients undergoing extended pleurectomy and decortication for malignant pleural mesothelioma. METHODS: We performed a retrospective review of 117 consecutive patients undergoing extended pleurectomy and decortication at a university hospital from January 2008 to December 2013. Patients 70 years and older were compared with younger patients for postoperative outcome and survival. Survival was estimated using the Kaplan-Meier method. RESULTS: Fifty-four patients were 70 years or older; 63 were younger than 70 years. Older patients had more hypertension (71.2% versus 45.2%; p = 0.004) and coronary artery disease (22.6% versus 6.5%; p = 0.006). Major complications occurred in 3 patients (5.5%) in the older group and in 7 patients (11.1%) of the younger group (not significant). There were 2 deaths in each group after surgery (3.7% older versus 3.2% younger; not significant). Median survival was 15.6 months in the older patients and 14.0 months in the younger patients (not significant). Kaplan-Meier survival curves based on age groups were not significantly different with 1- and 2-year survivals of 64% versus 55% and 29% versus 32%, respectively. CONCLUSIONS: Our study demonstrates that whereas age may be associated with more comorbid conditions in patients with malignant pleural mesothelioma undergoing extended pleurectomy and decortication, this does not necessarily translate into increased operative morbidity or mortality or shorter long-term survival.