Conditional Overall Survival After Diagnosis of Non-Metastatic Colon Cancer: Impact of Laterality, MSI, and KRAS Status.

BACKGROUND: The prognostic relevance of laterality, microsatellite instability (MSI), and KRAS status in colon cancer has been established. However, their effect on conditional overall survival (COS) remains unknown. METHODS: COS is the probability of surviving additional years after a time from diagnosis. The National Cancer Database (2010-2017) was queried for adults with non-metastatic colon cancer and known mutation status undergoing curative resection. COS was investigated at 2 years. RESULTS: Of 4838 patients, 3716 survived at least 2 years: 15% had stage I, 38% stage II, and 46% stage III disease. Fifty-nine percent had a right-sided tumor, 16% were MSI-high, and 37% were mutated KRAS (mKRAS). The proportion of patients alive at 2 years was higher for stage I compared with stage II and III (65 vs. 61 vs. 54%). The 5-year overall survival for stage I-III was 80, 76, and 67% for the initial cohort, and 90, 88, and 86% for those alive at 2 years. After adjustment, higher pathologic T and N stage, tumor deposits, and no chemotherapy were associated with worse COS (p < 0.01). While laterality and MSI status were not associated with COS, mKRAS was independently associated with decreased COS (HR 1.35, 95% CI 1.12-1.62). CONCLUSION: Patients with mKRAS had worse COS, suggesting that these mutations confer an aggressive biologic behavior, with patients remaining at higher risk of death 2 years after diagnosis. Routine evaluation of KRAS status should be considered in patients with non-metastatic disease for prognostication and to identify those who might benefit from modified surveillance protocols.

Pathologic Complete Response, Total Neoadjuvant Therapy and the Survival Paradox in Locally Advanced Rectal Cancer.

BACKGROUND: Pathologic complete response (pCR) after preoperative chemoradiation (nCRT) correlates with improved overall survival for patients with locally advanced rectal cancers (LARCs). Escalation protocols including total neoadjuvant therapy (TNT), which delivers multi-agent chemotherapy and chemoradiation before surgery, are associated with increased complete response rates. However, TNT is not associated with improved overall survival. The authors hypothesized that the route to pCR may be an important predictor of oncologic outcome. METHODS: Adults with LARC between 2006 and 2017 were identified in the National Cancer Database. The cohort was limited to those who received neoadjuvant radiation (45-70 Gy) and underwent proctectomy. RESULTS: Of 25,880 patients, 16 % received TNT and 84 % had nCRT followed by either multi-agent (27 %), single-agent (14 %), or no adjuvant chemotherapy (44 %). Overall, 18 % achieved pCR, with higher rates in the TNT cohort than in the nCRT (18 %) or multi-agent (14 %) chemotherapy cohorts. With control for covariates, the OS in the pCR cohort was similar for the patients that received single-agent therapy and those that received multi-agent adjuvant therapy, and superior to the TNT and no adjuvant therapy cohorts. Conversely, among the patients who did not achieve pCR, those who received single-agent chemotherapy had OS comparable with those who had multi-agent adjuvant therapy and TNT, which was better than no adjuvant therapy. CONCLUSION: Patients achieving pCR after TNT had worse OS than those who had CRT alone, suggesting that the neoadjuvant route by which pCR is achieved is prognostically relevant. Therefore, in the era of neoadjuvant therapy escalation, pCR does not necessarily portend a uniformly favorable prognosis.

Evaluation of association between center colorectal neuroendocrine neoplasm volume and survival among patients with colorectal neuroendocrine carcinoma.

BACKGROUND: Although correlation between center volume and survival has been reported for several complex cancers, it remains unknown if this is true for colorectal neuroendocrine carcinomas (CRNECs). We hypothesized that higher center annual volume of colorectal neuroendocrine neoplasm resections would be associated with overall survival (OS) for patients with CRNECs. METHODS: Patients in the National Cancer Database diagnosed with stages I-III CRNEC between 2006 and 2018 and who underwent surgical resection were identified. The mean annual colorectal neuroendocrine neoplasm resection volume threshold associated with significantly worse mortality hazard was determined using restricted cubic splines. Kaplan-Meier (KM) method was used to compare OS, while Cox proportional hazards model was used for multivariable analysis. RESULTS: There were 694 patients with CRNEC who met inclusion criteria across 1229 centers. Based on the cubic spline, centers treating fewer than one colorectal neuroendocrine neoplasm patient every 3 years on average had worse outcomes. Centers below this threshold were classified as low-volume (LV) centers corresponding with 42% of centers and about 15% of the patient cohort. In unadjusted survival analysis, LV patients had a median OS of 14 months (95% confidence interval [CI]: 10-19) while those treated at HV centers had a median OS of 33 months (95% CI: 25-49). In multivariable analysis, resection at a LV center was associated with increased risk of mortality (1.42 [95% CI: 1.01-2.00], p = 0.04). CONCLUSION: CRNEC patients have a dire prognosis; however, treatment at an HV center may be associated with decreased risk of mortality.

The performance of artificial intelligence large language model-linked chatbots in surgical decision-making for gastroesophageal reflux disease.

BACKGROUND: Large language model (LLM)-linked chatbots may be an efficient source of clinical recommendations for healthcare providers and patients. This study evaluated the performance of LLM-linked chatbots in providing recommendations for the surgical management of gastroesophageal reflux disease (GERD). METHODS: Nine patient cases were created based on key questions addressed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines for the surgical treatment of GERD. ChatGPT-3.5, ChatGPT-4, Copilot, Google Bard, and Perplexity AI were queried on November 16th, 2023, for recommendations regarding the surgical management of GERD. Accurate chatbot performance was defined as the number of responses aligning with SAGES guideline recommendations. Outcomes were reported with counts and percentages. RESULTS: Surgeons were given accurate recommendations for the surgical management of GERD in an adult patient for 5/7 (71.4%) KQs by ChatGPT-4, 3/7 (42.9%) KQs by Copilot, 6/7 (85.7%) KQs by Google Bard, and 3/7 (42.9%) KQs by Perplexity according to the SAGES guidelines. Patients were given accurate recommendations for 3/5 (60.0%) KQs by ChatGPT-4, 2/5 (40.0%) KQs by Copilot, 4/5 (80.0%) KQs by Google Bard, and 1/5 (20.0%) KQs by Perplexity, respectively. In a pediatric patient, surgeons were given accurate recommendations for 2/3 (66.7%) KQs by ChatGPT-4, 3/3 (100.0%) KQs by Copilot, 3/3 (100.0%) KQs by Google Bard, and 2/3 (66.7%) KQs by Perplexity. Patients were given appropriate guidance for 2/2 (100.0%) KQs by ChatGPT-4, 2/2 (100.0%) KQs by Copilot, 1/2 (50.0%) KQs by Google Bard, and 1/2 (50.0%) KQs by Perplexity. CONCLUSIONS: Gastrointestinal surgeons, gastroenterologists, and patients should recognize both the promise and pitfalls of LLM's when utilized for advice on surgical management of GERD. Additional training of LLM's using evidence-based health information is needed.

SAGES guidelines for the use of laparoscopy during pregnancy.

BACKGROUND: When pregnant patients present with nonobstetric pathology, the physicians caring for them may be uncertain about the optimal management strategy. The aim of this guideline is to develop evidence-based recommendations for pregnant patients presenting with common surgical pathologies including appendicitis, biliary disease, and inflammatory bowel disease (IBD). METHODS: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee convened a working group to address these issues. The group generated five key questions and completed a systematic review and meta-analysis of the literature. An expert panel then met to form evidence-based recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Expert opinion was utilized when the available evidence was deemed insufficient. RESULTS: The expert panel agreed on ten recommendations addressing the management of appendicitis, biliary disease, and IBD during pregnancy. CONCLUSIONS: Conditional recommendations were made in favor of appendectomy over nonoperative treatment of appendicitis, laparoscopic appendectomy over open appendectomy, and laparoscopic cholecystectomy over nonoperative treatment of biliary disease and acute cholecystitis specifically. Based on expert opinion, the panel also suggested either operative or nonoperative treatment of biliary diseases other than acute cholecystitis in the third trimester, endoscopic retrograde cholangiopancreatography rather than common bile duct exploration for symptomatic choledocholithiasis, applying the same criteria for emergent surgical intervention in pregnant and non-pregnant IBD patients, utilizing an open rather than minimally invasive approach for pregnant patients requiring emergent surgical treatment of IBD, and managing pregnant patients with active IBD flares in a multidisciplinary fashion at centers with IBD expertise.

The importance of monitoring endocrine-disrupting chemicals and essential elements in biological samples of fertilizer industry workers.

Exposure to endocrine-disrupting chemicals (EDCs) can lead to adverse health effects, including immune and endocrine system disruption, respiratory problems, metabolic issues, diabetes, obesity, cardiovascular problems, growth impairment, neurological and learning disabilities, and cancer. Fertilizers, which contain varying levels of heavy metals, are known to pose a significant risk to human health, especially for those residing or working near fertilizer industries. This study aimed to investigate the levels of toxic elements in biological samples of individuals working in a fertilizer industry's quality control and production units and those residing within 100-500 m of the industry. Biological samples, including scalp hair and whole blood, were collected from fertilizer workers, individuals living in the same residential area, and control age-matched persons from nonindustrial areas. The samples were oxidized by an acid mixture before analysis using atomic absorption spectrophotometry. The accuracy and validity of the methodology were verified through certified reference materials from scalp hair and whole blood. The results showed that the concentrations of toxic elements, such as cadmium and lead, were higher in biological samples of quality control and production employees. In contrast, lower essential element levels (iron and zinc) were detected in their samples. These levels were higher than those found in samples collected from residents living within 10-500 m of the fertilizer manufacturing facilities and unexposed areas. This study highlights the significance of adopting better practices to reduce exposure to harmful substances and protect the health of fertilizer industry workers and the environment. It also suggests that policymakers and industry leaders should take measures to minimize exposure to EDCs and heavy metals to promote worker safety and public health. These measures could include implementing strict regulations and better occupational health practices to reduce toxic exposure and promote a safer work environment.

Environmental impact of endocrine-disrupting chemicals and heavy metals in biological samples of petrochemical industry workers with perspective management.

Exposure to endocrine disrupting chemicals (EDCs) or heavy metals are synthetic compounds that can lead to negative effect on health, including immune and endocrine system disruption, respiratory problems, metabolic issues, diabetes, obesity, cardiovascular problems, growth impairment, neurological and learning disabilities, and cancer. Petrochemical industry drilling wastes, which contain varying levels of EDCs, are known to pose a significant risk to human health. This study aimed to investigate the levels of toxic elements in biological samples of individuals working in the petrochemical drilling sites. Biological samples, including scalp hair and whole blood, were collected from petrochemical drilling workers, individuals residing in the same residential area, and control age-matched persons from nonindustrial areas. The samples were oxidized by an acid mixture before analysis using atomic absorption spectrophotometry. The accuracy and validity of the methodology were verified through certified reference materials from scalp hair and whole blood. The results showed that the concentrations of toxic elements, such as cadmium and lead, were higher in biological samples of petrochemical drilling employees, while lower essential element levels (iron and zinc) were detected in their samples. This study highlights the significance of adopting better practices to reduce exposure to harmful substances and protect the health of petrochemical drilling workers and the environment. It also suggests that perspective management including policymakers and industry leaders should take measures to minimize exposure to EDCs and heavy metals to promote worker safety and public health. These measures could include the implementation of strict regulations and better occupational health practices to reduce toxic exposure and promote a safer work environment.

Correlation of endocrine disrupting chemicals with essential elements in biological samples of children (1-5 years) with different infectious diseases and impact on sustainable outdoor activities.

Endocrine disrupting chemicals (EDCs) have been extensively explored due to their harmful effects on individual health and the environment by interfering with hormone activity and disrupting the endocrine system. However, their relationship with essential trace elements remains uncertain. This research aimed to investigate the possible correlation between essential trace elements and toxic metals, including cadmium (Cd), and lead (Pb) in children aged 1-5 years with various infectious diseases, including gastrointestinal disorders, typhoid fever, and pneumonia. The study was conducted on biological testing and specimen (scalp hair and whole blood) of diseased and non-diseased children of the same residential area and referent/control age-matched children from developed cities consuming domestically treated water. The media of biological samples were oxidized by an acid mixture before being analyzed by atomic absorption spectrophotometry. The accuracy and validity of the methodology were verified through accredited reference material from scalp hair and whole blood sample. The study results revealed that diseased children had lower mean values of essential trace elements (iron, copper, and zinc) in both scalp hair and blood, except for copper, which was found to be higher in blood samples of diseased children. This implies that the deficiency of essential residue and trace elements in children from rural areas who consume groundwater is linked to various infectious diseases. The study highlights the need for more human biomonitoring of EDCs to better comprehend their non-classical toxic properties and their concealed costs on human health. The findings suggest that exposure to EDCs could be associated with unfavorable health outcomes and emphasizes the need for future regulatory policies to minimize exposure and safeguard the health of current and forthcoming generations of children. Furthermore, the study highlights the implication of essential trace elements in maintaining good health and their potential correlation with toxic metals in the environment.

Total Neoadjuvant Therapy Versus Standard Neoadjuvant Chemoradiation in Patients with Locally Advanced Rectal Cancer: A Comparison of Short- and Long-term Oncologic Outcomes.

OBJECTIVE: To evaluate the impact of neoadjuvant multi-agent systemic chemotherapy and radiation (TNT) vs neoadjuvant single-agent chemoradiation (nCRT) and multi-agent adjuvant chemotherapy on overall survival (OS), tumor downstaging, and circumferential resection margin (CRM) status in patients with locally advanced rectal cancer. SUMMARY OF BACKGROUND DATA: Outside of clinical trials and small institutional reports, there is a paucity of data regarding the short and long-term oncologic impact of TNT as compared to nCRT. METHODS: Adult patients with stage II-III rectal adenocarcinoma were identified in the National Cancer Database [2006-2015]. RESULTS: Out of 8,548 patients, 36% received TNT and 64% nCRT. In the cohort, 13% had a pCR and 20% a neoadjuvant rectal (NAR) score <8. In multivariable analysis, as compared to nCRT, TNT demonstrated numerically higher pCR rates ( P = 0.05) but had similar incidence of positive CRM ( P = 0.11). Similar results were observed with NAR scores <8 as the primary endpoint. After adjusting for confounders, OS was comparable between the 2 groups. Additional factors independently associated with lower OS included male gender, uninsured status, low income status, high comorbidity score, poorly differentiated tumors, abdominoperineal resection, and positive surgical margins (all P <0.01). In separate models, both pCR and a NAR score <8 were associated with improved OS. CONCLUSION: In this national cohort, TNT was not associated with better survival and/or CRM negative status in comparison with nCRT, despite numerically higher downstaging rates. Further refinement of patient selection and treatment regimens are needed to establish effective neoadjuvant platforms to improve outcomes of patients with rectal cancer.

B-cell depletion with obinutuzumab for the treatment of proliferative lupus nephritis: a randomised, double-blind, placebo-controlled trial.

OBJECTIVE: Randomised trials of type I anti-CD20 antibodies rituximab and ocrelizumab failed to show benefit in proliferative lupus nephritis (LN). We compared obinutuzumab, a humanised type II anti-CD20 monoclonal antibody that induces potent B-cell depletion, with placebo for the treatment of LN in combination with standard therapies. METHODS: Patients with LN receiving mycophenolate and corticosteroids were randomised to obinutuzumab 1000 mg or placebo on day 1 and weeks 2, 24 and 26, and followed through week 104. The primary endpoint was complete renal response (CRR) at week 52. Exploratory analyses through week 104 were conducted. The prespecified alpha level was 0.2. RESULTS: A total of 125 patients were randomised and received blinded infusions. Achievement of CRR was greater with obinutuzumab at week 52 (primary endpoint, 22 (35%) vs 14 (23%) with placebo; percentage difference, 12% (95% CI -3.4% to 28%), p=0.115) and at week 104 (26 (41%) vs 14 (23%); percentage difference, 19% (95% CI 2.7% to 35%), p=0.026). Improvements in other renal response measures, serologies, estimated glomerular filtration rate and proteinuria were greater with obinutuzumab. Obinutuzumab was not associated with increases in serious adverse events, serious infections or deaths. Non-serious infusion-related reactions occurred more frequently with obinutuzumab. CONCLUSIONS: Improved renal responses through week 104 were observed in patients with LN who received obinutuzumab plus standard therapies compared with standard therapies alone. Obinutuzumab was well tolerated and no new safety signals were identified. TRIAL REGISTRATION NUMBER: NCT02550652.

The "Classification Pendulum" of Stage I Colorectal Cancer: A National Level Analysis of the Survival Difference Between T1 and T2 Colorectal Cancer.

BACKGROUND: The eighth edition of the American Joint Committee on Cancer classifies nonmetastatic, node-negative colorectal cancers invading the submucosa (T1) and muscularis propria (T2) as stage I tumors without additional subclassification. OBJECTIVE: The aim of the study was to compare survival of T1N0M0 versus T2N0M0 colorectal cancers and to investigate factors associated with decreased survival. DESIGN: This was an analysis of 2 large population-based data sets. SETTINGS: The study was conducted analyzing data from the Surveillance Epidemiology and End Result program and the National Cancer Database. PATIENTS: Adult patients undergoing major resection without additional therapy for stage I colorectal cancer were included. MAIN OUTCOME MEASURES: Overall and disease-specific survival for T1 versus T2 cancers were measured. Subgroup analyses by tumor location (colon versus rectum) were performed. RESULTS: A total of 30,228 (36.4% T1 and 63.6% T2) and 41,670 (41.1% T1 and 58.9% T2) patients were identified in the Surveillance Epidemiology and End Result database and the National Cancer Database. The 5-year overall survival rates were 87.1% and 86.2% for patients with T1 versus 82.7% and 80.7% for patients with T2 (p < 0.001) in the Surveillance Epidemiology and End Result database and the National Cancer Database. The 10-year overall survival rates were 71.3% and 66.3% for patients with T1 versus 62.2% and 57.2% for patients with T2 tumors (p < 0.001) in the Surveillance Epidemiology and End Result database and the National Cancer Database. The 5- and 10-year disease-specific survival for colorectal cancer in the Surveillance Epidemiology and End Result database was 97.0% (T1) versus 95.2% (T2) and 94.1% (T1) versus 90.3% (T2). Black race (HR = 1.26 and 1.65 for overall survival and disease-specific survival in the Surveillance Epidemiology and End Result database; HR = 1.20 for overall survival in the National Cancer Database) was associated with worse survival. LIMITATIONS: The study was limited by intrinsic biases related to large administrative data sets. CONCLUSIONS: Within stage I colorectal cancer, T2 tumors have decreased overall survival and disease-specific survival as compared with T1 cancers. This survival difference may justify revising the American Joint Committee on Cancer staging system to include the subclassification of stage Ia (T1N0M0) and stage Ib (T2N0M0). See Video Abstract at http://links.lww.com/DCR/B659. LA CLASIFICACIN PNDULO PARA EL CNCER COLORRECTAL EN ESTADIO I UN ANLISIS A NIVEL NACIONAL DE LA DIFERENCIA DE SOBREVIDA ENTRE EL CNCER COLORRECTAL T Y T: ANTECEDENTES:La octava edición del American Joint Committee on Cancer, clasifica los cánceres colorrectales no metastásicos con ganglios negativos, que invaden la submucosa (T1) y la muscularis propia (T2) como tumores en estadio I sin subclasificación adicional.OBJETIVO:El objetivo del estudio fue comparar la sobrevida de los cánceres colorrectales T1N0M0 versus T2N0M0 e investigar los factores asociados con la disminución de la sobrevida.DISEÑO:Análisis de dos grandes conjuntos de datos poblacionales.MARCO:El estudio se realizó analizando datos del Programa de Epidemiología de Vigilancia y Resultados Finales (SEER) y la Base de Datos Nacional del Cáncer.PACIENTES:Pacientes adultos en los cuales se realizó una resección mayor sin terapia adicional por cáncer colorrectal en estadio I.PRINCIPALES VARIABLES ANALIZADAS:Sobrevida global y específica de la enfermedad para los cánceres T1 versus T2. Se realizó un análisis de subgrupos según la ubicación del tumor (colon versus recto).RESULTADOS:Se incluyeron un total de 30.228 (36,4% T1 y 63,6% T2) y 41.670 (41,1% T1 y 58,9% T2) pacientes en las bases de datos SEER y la Base de Datos Nacional del Cáncer, respectivamente. La sobrevida global a 5 años fue del 87,1% y el 86,2% para los pacientes con T1 frente al 82,7% y el 80,7% de los pacientes con T2 (p < 0,001) en el SEER y la Base de Datos Nacional del Cáncer, respectivamente. La sobrevida global a 10 años fue del 71,3% y el 66,3% para los pacientes con T1 frente al 62,2% y el 57,2% de los pacientes con tumores T2 (p < 0,001) en el SEER y la Base de Datos Nacional del Cáncer, respectivamente. La sobrevida específica de la enfermedad a 5 y 10 años para el cáncer colorrectal en el SEER fue del 97,0% (T1) frente al 95,2% (T2) y del 94,1% (T1) frente al 90,3% (T2), respectivamente. La grupo étnico afroamericano se asoció con una sobrevida menor (Hazard Ratio -HR 1,26 y 1,65 para la sobrevida general y sobrevida específica de la enfermedad-SEER; HR 1,20 para la sobrevida general-Base de de Datos Nacional del Cáncer).LIMITACIONES:Sesgos intrínsecos relacionados con el análisis de grandes conjuntos de datos.CONCLUSIONES:Dentro del cáncer colorrectal en estadio I, los tumores T2 han disminuido la sobrevida general y la sobrevida específica de la enfermedad, en comparación con los cánceres T1. Esta diferencia de sobrevida puede justificar la revisión del sistema de estadificación del American Joint Committee on Cancer para incluir la subclasificación del estadio Ia (T1N0M0) y el estadio Ib (T2N0M0). Consulte Video Resumen en http://links.lww.com/DCR/B659.

Male gender, smoking, younger age, and preoperative pain found to increase postoperative opioid requirements in 592 elective colorectal resections.

PURPOSE: With increased awareness of the opioid epidemic, understanding contributing factors to postoperative opioid use is important. The purpose of this study was to evaluate patient and perioperative factors that contribute to postoperative opioid use after colorectal resections and their relation to pre-existing pain conditions and psychiatric diagnoses. METHODS: A retrospective review was conducted identifying adult patients who underwent elective colorectal resection at a single tertiary center between 2015 and 2018. Patient demographics, preoperative factors, surgical approach, and perioperative pain management were evaluated to determine standard conversion morphine milligram equivalents required for postoperative days 0 to 3 and total hospital stay. RESULTS: Five hundred and ninety-two patients: 46% male, median age 58 years undergoing colorectal resections for indications including cancer, inflammatory bowel disease, and diverticulitis were identified. Less opioid use was found to be associated with female gender (ß = - 42), patients who received perioperative lidocaine infusion (ß = - 30), and older adults (equivalents/year) (ß = - 4, all p < 0.01). Preoperative opioid use, preoperative abdominal pain, epidural use, and smoking were all independently associated with increased postoperative opioid requirements. CONCLUSIONS: In this study of patients undergoing elective colorectal resection, factors that were associated with higher perioperative opioid use included male gender, smoking, younger age, preoperative opioid use, preoperative abdominal pain, and epidural use. Perioperative administration of lidocaine was associated with decreased opioid requirements. Understanding risk factors and stratifying postoperative pain regimens may aid in improved pain control and decrease long-term dependency.

Determining the level of essential elements in patients with Ewing Sarcoma: A correlation.

BACKGROUND: Metal ion aberrant metabolism is essential for health and disease, and its research has sparked a lot of interest. This study aims to compare the critical mineral resources-magnesium (Mg), sodium (Na), calcium (Ca) and potassium (K)-in biological materials (scalp hair, blood, and serum) of 87 Ewing Sarcoma (ES) hypertensive men and women, age range 31-60 years, in an urban area, with 62 nonhypertensive subjects from the same age range and living area. METHODS: An atomic-absorption spectrophotometer was used after microwave-induced acid digestion to determine elemental concentrations. The results' authenticity and precision were verified using a traditional wet acid digestion procedure and accredited reference materials. The average convalesces from all elements have been within the 99.2%-99.7% of certified values. RESULTS: In the biological samples from patients with ES hypertension, the amount of Na was found to be higher than in controls. Patients with ES hypertension had lower Mg, K, and Ca levels in their biological samples (scalp hair and blood) than healthy controls of both genders. CONCLUSIONS: Ca, Mg, and K deficiency can work with other ES hypertension risk factors. These findings will help physicians and other healthcare professionals determine the depletion of essential micronutrients in the biological samples (blood and scalp hair) of patients with hypertension. After microwave-induced acid digestion, the elemental concentration was determined using an atomic absorption spectrophotometer. The results' authenticity and precision were confirmed using a traditional wet-acid digestion procedure and accredited oriented materials. The average recoveries from all elements have been within the 99.2%-99.7% of certified values.

Human exposure to toxic elements through facial cosmetic products: Dermal risk assessment.

Facial cosmetics are the most commonly consumed product, mainly by the women from all over the world irrespective of their age. The facial cosmetics may be contaminated with several toxic elements, which can get absorb on to the facial skin and migrate to the blood vessels. Hence the absorbed toxic elements can cause further adverse effects on the human body. The present study aims to assess the toxic element contents (arsenic, lead, nickel, mercury, and cadmium) in commonly consumed facial cosmetics (face powder, foundation, lightning creams, moisturizer, eye shadow, lipsticks, eyeliner, blush, mascara, sunscreen) and to carry out the risk assessment through different methods. The dermal risk was evaluated as SED, NOAEL, MoS, HQ and ILCR, which is linked with the exposure of selected toxic elements. The total CDDE for all selected elements in facial cosmetic products was found in increasing order as follow: face powder > foundation > lightning creams > moisturizer > eye shadow > lipsticks > eyeliner > blush > mascara > sunscreen. The HQ and HI values for selected elements were found to be < 1 in all facial cosmetics. Whereas the probable MoS of selected toxic elements in all facial cosmetics except eyeliner were found to be 3-4 folds lower than the minimum value of 100 regulated by the WHO.

Favourable prognosis in metastatic adrenal carcinoma: An unexpected outcome.

The case of a 45-year-old male patient diagnosed with European Network for the Study of Adrenal Tumours (ENSAT) criteria, stage IV adrenocortical carcinoma (ACC) with unexpectedly prolonged survival is being reported. The patient underwent resection of stage IV ACC and despite suboptimal adherence to postoperative mitotane and chemotherapy, had a prolonged survival spanning almost seven years. The possible reasons for such an outcome are discussed. ACC is a rare tumour with stage 4 disease known to be associated with a particularly grim prognosis. A low grade on histology (mitotic index 11-12 per 50 HPF) was likely responsible for the prolonged survival of our patient. Low grade disease may predict extended survival in stage IV ACC.

Presentation, Management, and Prognosis of Primary Gastrointestinal Melanoma: A Population-Based Study.

BACKGROUND: Primary gastrointestinal (GI) melanomas, compared with cutaneous melanomas, have a much lower incidence. As a result, there is a paucity of data regarding their presentation, treatment, and prognosis. The aim of this study was to analyze the incidence, patient characteristics, treatment patterns, and survival of primary GI melanomas in comparison with cutaneous melanomas using a population-based cohort. METHODS: Patients diagnosed with primary GI and cutaneous melanomas were identified from Surveillance, Epidemiology, and End Results 1973-2016 data. RESULTS: A total of 872 primary GI melanomas and 319,327 cutaneous melanomas were identified. GI melanoma incidence increased by an annual percent change of 1.82 (P < 0.05) during the study period. The most common sites for GI melanoma were the anus (50%) and rectum (34%). Compared to cutaneous melanoma, patients diagnosed with GI melanomas were older, women (58% versus 45%), non-White (16% versus 6%), and presented with a higher stage (36% versus 4% distant stage, all P < 0.001). GI melanomas had significantly worse cancer-specific survival (CSS) than cutaneous melanoma. Despite the poor prognosis, the CSS has increased in recent years. Among patients with anorectal melanomas, local excision with chemotherapy and/or radiation had a similar CSS compared with those with major surgery only. CONCLUSIONS: Despite a steady increasing incidence since 1975, GI melanomas are rare, present with advanced stages, and have worse outcomes than cutaneous melanomas. The improved prognosis of these tumors in recent years might reflect the impact of novel targeted treatments and the more common use of local tumor excision over major resections.

Provider Viewpoints in the Management and Referral of Rectal Cancer.

BACKGROUND: Patients with rectal cancer treated at specialized or high-volume hospitals have better outcomes, but a minority of these patients are treated there. Physician recommendations are important considerations for patients with rectal cancer when making treatment decisions, yet little is known about the factors that affect these physician referral patterns. METHODS: Semistructured telephone interviews were conducted in 2018-2019 with Iowa gastroenterologists (GIs) and general surgeons (GSs) who performed colonoscopies in a community setting. A thematic approach was used to analyze and code qualitative data. RESULTS: We interviewed 10 GIs and 6 GSs with self-reported averages of 15.5 y in practice, 1100 endoscopic procedures annually, and 6 rectal cancer diagnoses annually. Physicians believed surgeon experience and colorectal specialization were directly related to positive outcomes in rectal cancer resections. Most GSs performed resections on patients they diagnosed and typically only referred patients to colorectal surgeons (CRS) in complex cases. Conversely, GIs generally referred to CRS in all cases. Adhering to existing referral patterns due to the pressure of health care networks was a salient theme for both GIs and GSs. CONCLUSIONS: While respondents believe that high volume/specialization is related to improved surgical outcomes, referral recommendations are heavily influenced by existing referral networks. Referral practices also differ by diagnosing specialty and suggest rural patients may be less likely to be referred to a CRS because more GSs perform colonoscopies in rural areas and tend to keep patients for resection. System-level interventions that target referral networks may improve rectal cancer outcomes at the population level.

Impact of KRAS status on tumor response and survival after neoadjuvant treatment of locally advanced rectal cancer.

BACKGROUND: Mutation of the KRAS oncogene (mKRAS) in colorectal cancer has been associated with aggressive tumor biology, resistance to epidermal growth factor inhibitors, and decreased overall survival (OS). The aim of the current study was to analyze the association of mKRAS with pathologic complete response (pCR) and neoadjuvant rectal (NAR) score, and its impact on the survival of patients with locally advanced rectal cancer who were managed with multimodality therapy. METHODS: The National Cancer Database was queried for stage II-III rectal cancer patients with a known KRAS status who underwent neoadjuvant chemoradiation therapy (nCRT) and proctectomy between 2004 and 2015. RESULTS: In total, 1886 patients were identified; 12% had pCR and 36% had mKRAS. Patients with mKRAS were more likely to have advanced pathologic T stage, tumor deposits, perineural invasion, and elevated carcinoembryonic antigen levels (all p ≤ .05). After adjustment for available confounders, mKRAS status was not associated with pCR or NAR score. In multivariable analysis, patients with pCR and lower NAR score had better OS, whereas mKRAS was independently associated with a worse prognosis. CONCLUSION: In this cohort of locally advanced rectal cancer patients who underwent proctectomy after nCRT, mKRAS was not associated with lower pCR rates or NAR scores; however, these patients experienced worse survival.

Optimizing Bariatric Surgery outcomes: the impact of preoperative elevated hemoglobin A1c levels on composite perioperative outcome measures.

INTRODUCTION: The use of bariatric surgery in the management of obesity and its related morbidity has significantly increased in the US over the past decade. There is a lack of data on the impact of optimal preoperative glycemic control on the morbidity and mortality following bariatric surgery. The aim of this study was to analyze the impact of hemoglobin (Hb) A1c > 7 on outcomes among patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). METHODS: Data were extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (2017) and limited to patients undergoing an elective laparoscopic RYGB or SG. Multivariable logistic regression was conducted to adjust for other preoperative variables. RESULTS: A total number of 31,060 (69.3%) patients underwent SG, while 13,754 (30.7%) received RYGB. Patients who were older, male, non-Hispanic, smokers, and those with a higher American Society of Anesthesiologist Classification (ASA) score were more likely to have elevated HbA1c levels. Compared to individuals with normal HbA1c levels, patients with elevated levels had no significant difference in mortality (p = 0.902) but did have a difference in composite morbidity and mortality (p < 0.001). On multivariable analysis, elevated HbA1c, older age, increasing body mass index (BMI), elevated creatinine, longer operations, African American race, receiving RYGB, and having a trainee as surgical assistant were found to increase the odds of having an adverse outcome. No significant difference was found within smoking status, sex, ASA Classification, robotic vs laparoscopic, or if a second attending surgeon was assisting. CONCLUSIONS: HbA1c levels and presence of trainees in the OR are modifiable preoperative risk factors for adverse events following bariatric surgery. Improving preoperative glycemic control may be an effective and achievable quality improvement measure.