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BACKGROUND: Surgical and adjuvant management of mucinous cystic neoplasms (MCNs) lacks formal guidelines and data is limited to institutional studies. Factors associated with receipt of adjuvant therapy and any associated impact on survival remain to be clarified. In the absence of other data, guidelines that recommend adjuvant chemotherapy for invasive pancreatic adenocarcinoma have been extrapolated to MCN. PATIENTS AND METHODS: The National Cancer Database (2004-2019) was utilized to identify all patients that underwent pancreatic resection for invasive MCNs. Patients that received neoadjuvant therapy or did not undergo lymphadenectomy were excluded. Patient, tumor, and treatment factors associated with survival were assessed. RESULTS: For 161 patients with invasive MCN, median overall survival (OS) was 133 months and 45% of patients received adjuvant therapy. Multivariable analysis demonstrated that poorly differentiated tumors [odds ratio (OR) 4.19, 95% confidence interval (CI) 1.47-11.98; p = 0.008] and positive lymph node status (OR 2.67, 95% CI 1.02-6.98; p = 0.042) were independent predictors of receiving adjuvant therapy. Lymph node positivity [hazard ratio (HR) 2.90, 95% CI 1.47-5.73; p = 0.002], positive margins (HR 5.28, 95% CI 2.28-12.27; p < 0.001), and stage III disease (HR 12.46, 95% CI 1.40-111.05; p = 0.024) were associated with worse OS. Receipt of adjuvant systemic therapy was independently associated with decreased risk of mortality in node positive patients (HR 0.23, 95% CI 0.10-0.69; p = 0.002). Survival was not associated with adjuvant therapy in patients with negative lymph nodes or margin negative status. CONCLUSION: In contrast to pancreatic ductal adenocarcinoma (PDAC), where adjuvant therapy improves OS for every tumor stage, surgery alone for invasive MCN is not associated with improved OS compared with surgery plus adjuvant therapy in node-negative patients. Surgery alone is likely sufficient for a subset of invasive MCN.
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Our study aims to delineate the phenotypes of chronic neuropsychiatric symptoms among adult subjects recovering from their first COVID that occurred more than one year ago. We also aim to explore the clinical and socioeconomic risk factors of having a high loading of chronic neuropsychiatric symptoms. We recruited a post-COVID group who suffered from their first pre-Omicron COVID more than a year ago, and a control group who had never had COVID. The subjects completed app-based questionnaires on demographic, socioeconomic and health status, a COVID symptoms checklist, mental and sleep health measures, and neurocognitive tests. The post-COVID group has a statistically significantly higher level of fatigue compared to the control group (p < 0.001). Among the post-COVID group, the lack of any COVID vaccination before the first COVID and a higher level of material deprivation before the COVID pandemic predicts a higher load of chronic post-COVID neuropsychiatric symptoms. Partial correlation network analysis suggests that the chronic post-COVID neuropsychiatric symptoms can be clustered into two major (cognitive complaints -fatigue and anxiety-depression) and one minor (headache-dizziness) cluster. A higher level of material deprivation predicts a higher number of symptoms in both major clusters, but the lack of any COVID vaccination before the first COVID only predicts a higher number of symptoms in the cognitive complaints-fatigue cluster. Our result suggests heterogeneity among chronic post-COVID neuropsychiatric symptoms, which are associated with the complex interplay of biological and socioeconomic factors.
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COVID-19 , Humanos , COVID-19/psicología , COVID-19/complicaciones , Masculino , Estudios de Casos y Controles , Femenino , Adulto , Persona de Mediana Edad , Fatiga/etiología , Depresión/psicología , SARS-CoV-2 , Ansiedad/psicología , Enfermedad Crónica , Factores de Riesgo , Pruebas Neuropsicológicas , Factores Socioeconómicos , Síndrome Post Agudo de COVID-19RESUMEN
PURPOSE: Little is known about the shared decision-making (SDM) needs, barriers, and facilitators of patients with newly diagnosed advanced cancer in the hospital. Understanding this may improve SDM and cancer care quality in this vulnerable population. METHODS: A single-site, mixed-methods study of hospitalized patients with newly diagnosed advanced cancer, caregivers, and oncologists was conducted. After discharge, patient ± caregiver semi-structured interviews exploring SDM needs, barriers, and facilitators regarding their most important upcoming cancer-related decision were conducted. Oncologists were surveyed about patient knowledge and SDM needs using closed- and open-ended questions, respectively. Thematic analysis was performed for qualitative data with a focus on themes unique to or amplified by hospitalization. Descriptive statistics and the Chi-squared test were performed for quantitative data. RESULTS: Patients and caregivers reported high SDM needs surrounding treatment and prognostic information, leading to decisional conflict. Eight themes emerged: anticipated cancer treatment decisions, variable control preferences in decision-making, high cancer-related information needs and uncertainty, barriers and facilitators to information gathering during and post hospitalization, and decision-making facilitators. Among 32 oncologists, most (56%) reported patients were poorly informed about treatment and prognosis. Oncologists reported variable expectations about patient knowledge after hospitalization, facilitators to patient decision-making, and patient uncertainty while awaiting an outpatient oncologist appointment. CONCLUSION: Patients newly diagnosed with advanced cancer in the hospital have high SDM needs and experience decisional conflict. This may be due to barriers unique to or exacerbated by hospitalization. Further research is needed to develop strategies to address these barriers and enhance the facilitators identified in this study.
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Toma de Decisiones Conjunta , Neoplasias , Humanos , Neoplasias/terapia , Neoplasias/psicología , Masculino , Femenino , Persona de Mediana Edad , Anciano , Adulto , Cuidadores/psicología , Hospitalización/estadística & datos numéricos , Participación del Paciente/métodos , Investigación Cualitativa , Anciano de 80 o más Años , Oncólogos/psicología , Conocimientos, Actitudes y Práctica en Salud , Relaciones Médico-PacienteRESUMEN
BACKGROUND: There is a paucity of evidence supporting the use of adjuvant radiation therapy in resected biliary cancer. Supporting evidence for use comes mainly from the small SWOG S0809 trial, which demonstrated an overall median survival of 35 months. We aimed to use a large national database to evaluate the use of adjuvant chemoradiation in resected extrahepatic bile duct and gallbladder cancer. METHODS: Using the National Cancer Database, we selected patients from 2004 to 2017 with pT2-4, pN0-1, M0 extrahepatic bile duct or gallbladder adenocarcinoma with either R0 or R1 resection margins, and examined factors associated with overall survival (OS). We examined OS in a cohort of patients mimicking the SWOG S0809 protocol as a large validation cohort. Lastly, we compared patients who received chemotherapy only with patients who received adjuvant chemotherapy and radiation using entropy balancing propensity score matching. RESULTS: Overall, 4997 patients with gallbladder or extrahepatic bile duct adenocarcinoma with available survival information meeting the SWOG S0809 criteria were selected, 469 of whom received both adjuvant chemotherapy and radiotherapy. Median OS in patients undergoing chemoradiation was 36.9 months, and was not different between primary sites (p = 0.841). In a propensity score matched cohort, receipt of adjuvant chemoradiation had a survival benefit compared with adjuvant chemotherapy only (hazard ratio 0.86, 95% confidence interval 0.77-0.95; p = 0.004). CONCLUSION: Using a large national database, we support the findings of SWOG S0809 with a similar median OS in patients receiving chemoradiation. These data further support the consideration of adjuvant multimodal therapy in resected biliary cancers.
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Adenocarcinoma , Quimioradioterapia Adyuvante , Bases de Datos Factuales , Neoplasias de la Vesícula Biliar , Humanos , Femenino , Masculino , Adenocarcinoma/terapia , Adenocarcinoma/patología , Adenocarcinoma/mortalidad , Tasa de Supervivencia , Anciano , Persona de Mediana Edad , Neoplasias de la Vesícula Biliar/terapia , Neoplasias de la Vesícula Biliar/patología , Neoplasias de la Vesícula Biliar/mortalidad , Estudios de Seguimiento , Neoplasias de los Conductos Biliares/terapia , Neoplasias de los Conductos Biliares/patología , Pronóstico , Conductos Biliares Extrahepáticos/patologíaRESUMEN
BACKGROUND: Despite significant advancements in the treatment of patients with colorectal liver metastases (CRLMs), only a minority will experience long-term survival. This study aimed to determine the effect of chemotherapy (CT) and immunotherapy (IT) compared with that of CT alone on patient survival after surgical resection. METHODS: Patients undergoing curative-intent liver resection followed by adjuvant systemic therapy for stage IV colon cancer were identified using the National Cancer Database. Patients were stratified into type of therapy (CT alone vs CT + IT) and microsatellite status. Propensity score-weighted analysis was performed through 1:1 matching based on the nearest neighbor method. RESULTS: Of 9943 patients who underwent resection of CRLMs, 7971 (80%) received systemic adjuvant therapy. Of 7971 patients, 1432 (18%) received a combination of CT and IT. Microsatellite status was not associated with overall survival (OS). Adjuvant CT + IT was associated with increased 3-year OS compared with that of CT alone in both the unmatched cohort (55% vs 48%, respectively; P < .001) and matched cohort (52% vs 48%, respectively; P = .050). On multivariate analysis, older age, positive resection margins, and KRAS mutation were independent predictors of poor survival, whereas the administration of adjuvant CT + IT was an independent predictor of improved survival. CONCLUSION: IT combined with CT was associated with improved survival compared with that of CT alone after curative-intent resection of CRLMs, regardless of microsatellite instability status. Clinical trials to determine optimal patient selection, IT regimen, and long-term efficacy to improve outcomes of patients with CRLMs are warranted.
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Neoplasias del Colon , Neoplasias Hepáticas , Humanos , Inmunoterapia , Neoplasias Hepáticas/terapia , Quimioterapia Adyuvante , Hepatectomía , Neoplasias del Colon/terapiaRESUMEN
BACKGROUND: Metastatic melanoma to the small bowel is an aggressive disease often accompanied by obstruction, abdominal pain, and gastrointestinal bleeding. With advancements in melanoma treatment, the role for metastasectomy continues to evolve. Inclusion of novel immunotherapeutic agents, such as checkpoint inhibitors, into standard treatment regimens presents potential survival benefits for patients receiving metastasectomy. CASE PRESENTATION: We report an institutional experience of 15 patients (12 male, 3 female) between 2014-2022 that underwent small bowel metastasectomy for metastatic melanoma and received perioperative systemic treatment. Median age of patients was 64 years (range: 35-83 years). No patients died within 30 days of their surgery, and the median hospital length of stay was 5 days. Median overall survival in these patients was 30.1 months (range: 2-115 months). Five patients died from disease (67 days, 252 days, 426 days, 572 days, 692 days postoperatively), one patient died of non-disease related causes (1312 days postoperatively), six patients are alive with disease, and three remain disease free. CONCLUSIONS: This case series presents an updated perspective of the utility of metastasectomy for small bowel metastasis in the age of novel immunotherapeutic agents as standard systemic treatment. Small bowel metastasectomy for advanced melanoma performed in conjunction with perioperative systemic therapy is safe and appears to promote long-term survival and enhanced quality of life.
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Melanoma , Metastasectomía , Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Melanoma/terapia , Melanoma/patología , Calidad de Vida , Inmunoterapia , Intestino Delgado/patología , Estudios RetrospectivosRESUMEN
Background and Objective: With the development of novel active systemic therapies, the landscape of hepatocellular carcinoma (HCC) management is rapidly changing. However, HCC lacks sensitive and specific biomarkers to predict prognosis, monitor for minimal residual disease after locoregional therapy, and predict treatment response. In this review, we aim to summarize the best supporting evidence for refining existing, and development of novel biomarkers for staging, prognosis, determination of minimal residual disease and monitoring treatment response in HCC, focusing on those with evidence in clinical trials. Methods: PubMed and Embase databases were searched using the keywords; hepatocellular carcinoma, biomarker, minimal residual disease, surveillance, prognosis, staging, alpha-fetoprotein (AFP), liquid biopsy, treatment response, adjuvant, immunotherapy. Relevant clinical studies were included. Key Content and Findings: AFP remains the major workhorse as the most widely used biomarker in HCC, however, its lack of wide applicability due to the high proportion of patients with HCC who are AFP negative, limits its value throughout all stages of HCC management. Significant work has been done to combine AFP with other clinical and serologic factors to increase its accuracy and utility as a biomarkers. However, it is likely that other more novel biomarkers such as those obtained through liquid biopsy will provide the prognostic power necessary for applications such as detecting recurrence and predicting treatment response. Liquid biopsy provides not only a wealth of potential biomarkers including circulating tumor cells and cell-free RNA/DNA, but also the ability to examine the mutational characteristics of the tumor with next generation sequencing. While early evidence supports the potential impact of many new biomarkers, validation in large clinical trials is lacking. Conclusions: This review highlights the paucity of sensitive and specific, widely applicable biomarkers, throughout all phases of management of HCC and summarizes evidence on biomarkers currently in use, as well as those in development and validation. Inclusion of biomarker analysis through clinical trials in HCC is critical to development of optimal therapeutic regimens, and improve patient outcomes.
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Multiple forms of stigmatization are experienced by caregivers of children with autism among ethnic minority (EM) groups in various countries. Such forms of stigmatization can lead to delayed assessment and services for mental health among children and caregivers. This review identified the research literature on the types of stigmatization experienced by caregivers of children with autism with an EM background. A total of 19 studies published after 2010 (i.e., 12 from the USA, 2 from the UK, 1 from Canada, and 1 from New Zealand) of caregivers of 20 ethnicities were identified and reviewed, and their reporting qualities systematically also assessed. Four main themes: (1) self-stigma, (2) social stigma, (3) stigma towards EM parents of children on the autism spectrum, and (4) service utilization stigma, and nine sub-themes were identified. The discrimination experienced by caregivers were extracted, synthesized, and further discussed. While the reporting quality of the studies included is good, the depth of the understanding of this under-researched yet important phenomenon is very limited. The multiple forms of stigmatization experiences are complex, and it may be difficult to disentangle whether the causes of stigmatization were autism and/or EM related, and the types of stigmatization can vary enormously among different ethnic groups in different societies. More quantitative studies are needed to quantify the impacts of multiple forms of stigmatization on families of children with autism in EM groups so that more socially inclusive support for caregivers with an EM background in host countries can be developed.
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Trastorno Autístico , Estereotipo , Niño , Humanos , Trastorno Autístico/psicología , Etnicidad , Cuidadores/psicología , Minorías Étnicas y Raciales , Grupos Minoritarios , Estigma SocialRESUMEN
BACKGROUND AND OBJECTIVES: Textbook oncologic outcome (TOO) is a benchmark for high-quality surgical cancer care but has not been studied at safety-net hospitals (SNH). The study sought to understand how SNH burden affects TOO achievement in colorectal cancer. METHODS: The National Cancer Database was queried for colorectal cancer patients who underwent resection for stage I-III plus stage IV with liver-only metastases (2010-2019). TOO was defined as R0 resection, AJCC-compliant lymphadenectomy (>12 nodes), no prolonged LOS, no 30-day mortality/readmission, and receipt of stage-appropriate adjuvant chemotherapy. RESULTS: Of 487,195 patients, 66.7% achieved TOO. Lower achievement was explained by adequate lymphadenectomy (87.3%), non-prolonged LOS (76.3%), and receipt of adjuvant chemotherapy in stage III (60.3%) and IV (54.1%). Treatment at high burden hospitals (HBH, >10% Medicaid/uninsured) was a predictor of non-TOO (Stage I/II: OR 0.83, III: OR 0.86, IV: OR 0.83; all p < 0.001). Achieving TOO was associated with decreased mortality (Stage I/II: HR 0.49, III: HR 0.48, IV: HR 0.57; all p < 0.001), and HBH treatment was a predictor of mortality (Stage I/II: HR 1.09, III: HR 1.05, IV: HR 1.07; all p < 0.05). CONCLUSIONS: Treatment at higher SNH burden hospitals was associated with less frequent TOO achievement and increased mortality. Quality improvement targets include receipt of adjuvant chemotherapy and avoidance of prolonged LOS.
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Neoplasias Colorrectales , Neoplasias Hepáticas , Estados Unidos/epidemiología , Humanos , Proveedores de Redes de Seguridad , Quimioterapia Adyuvante , Hospitales , Estudios RetrospectivosRESUMEN
BACKGROUND: Childhood sexual abuse (CSA) is a form of maltreatment that involves a child in sexual activity that she or he cannot fully comprehend or is unable to give informed consent to. The empirical link between child neglect and contact child sexual abuse is well established but little research examines mediators that explain this link. OBJECTIVE: This study tests online risk behaviors and unwanted sexual experiences online as sequential mediators of the neglect - CSA relationship. PARTICIPANT AND SETTING: The study uses a representative cross-sectional sample of 1097 Hong Kong adolescents. METHODS: Preacher and Hayes' (2008) non-parametric bootstrap approach was used to test three mediation hypotheses. RESULTS: Baseline logistic regression models showed neglected children had 11.2 times higher odds of reporting contact CSA (p < .001). Similarly, neglect was associated with 3.5 times higher odds of more online risk behavior (p < .001), which in turn was associated with 2.7 times higher odds of more online invasive exploitation (p < .001). Online invasive exploitation was associated with 2.7 times higher odds of reporting offline contact CSA (p < .001). The study found online risk behaviors to be a significant mediator of the relationship between neglect and online invasive exploitation (unwanted online sexual experiences). Online invasive exploitation, in turn, mediated the relationship between online risk behaviors and offline contact CSA. CONCLUSION: The findings highlight the importance of intervening against neglect as it appears to play a vital role in the etiology of contact CSA in Hong Kong.
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Abuso Sexual Infantil , Maltrato a los Niños , Femenino , Adolescente , Humanos , Niño , Hong Kong/epidemiología , Estudios Transversales , Conducta SexualRESUMEN
Aims: Limited research has explored the stressors experienced by veterinarians in East Asia. Metropolitan cities like Hong Kong may have overlooked factors that significantly contribute to veterinarians' stress. This paper examines how client-related stressors and contextual factors contribute to the stress levels of Hong Kong-based veterinarians. Methods: Veterinarians from small domestic animal practices in Hong Kong were recruited using purposive and targeted snowball samplings until thematic saturation was achieved. Semi-structured in-depth interviews were conducted, audio-recorded, transcribed, coded, and analysed using reflexive thematic analysis with an interpretivist paradigm based on Heidegger's phenomenological approach. Results: A total of 18 participating veterinarians described the expectations of and communication with the animal-health enthusiast (AHE) community, including clients, pet owners, and animal lovers, as their primary source of stress. Discrepant expectations and miscommunication between the AHE and veterinary communities, along with contextual factors, such as convenience in clinic switching, negative online reviews, and the relatively short history of the veterinary profession in the multilingual city, were identified as contributing factors to their stress. Recent socio-political events and the pandemic further intensified societal emotions, leading some clients to project frustrations onto perceived authority figures, including health professionals. Conclusion: The study highlights that client-related stress extends beyond the health of animal patients, encompassing the expectations of the AHE community, which requires professional-level communication skills to build a mutually respectful three-party relationship. Besides, Hong Kong's unique contextual and historical factors subtly but chronically impact veterinary practices, which can be easily overlooked. Recognising these influences and how they interact is crucial for collaboration, within and beyond the profession, at the policy level to improve veterinary training and practices. Implications: Our findings highlight the importance of expectation management and improving communication quality to foster healthy relationships among animals, the AHE community, and veterinary professionals. These efforts are believed to alleviate veterinarians' stress and enhance the well-being of all parties involved. We recommend incorporating effective communication and self-care discussions into the veterinary curriculum and advocating ongoing training for practising veterinarians. At the community level, encouraging open dialogues between animal caregivers and veterinary professionals can help address expectation discrepancies.
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BACKGROUND: Tertiary medical centers in the USA provide specialized, high-volume surgical cancer care, contributing standards for quality and outcomes. For the most vulnerable populations, safety-net hospitals (SNHs) remain the predominant provider of both complex and routine healthcare needs. The objective of this study was to evaluate access to and quality of surgical oncology care within SNHs. METHODS: A comprehensive and systematic review of the literature was conducted using PubMed, EMBASE, and Cochrane Library databases to identify all studies (January 2000-October 2021) reporting the delivery of surgical cancer care at SNHs in the USA (PROSPERO #CRD42021290092). These studies describe the process and/or outcomes of surgical care for gastrointestinal, hepatopancreatobiliary, or breast cancer patients seeking treatment at SNHs. RESULTS: Of 3753 records, 37 studies met the inclusion criteria. Surgical care for breast cancer (43%) was the most represented, followed by colorectal (30%) and hepatopancreatobiliary (16%) cancers. Financial constraints, cultural and language barriers, and limitations to insurance coverage were cited as common reasons for disparities in care within SNHs. Advanced disease at presentation was common among cancer patients seeking care at SNHs (range, 24-61% of patients). Though reports comparing cancer survival between SNHs and non-SNHs were few, results were mixed, underscoring the variability in care seen across SNHs. CONCLUSIONS: These findings highlight barriers in care facing many cancer patients. Continued efforts should address improving both access and quality of care for SNH patients. Future models include a transition away from a two-tiered system of resourced and under-resourced hospitals toward an integrated cancer system.
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Neoplasias de la Mama , Proveedores de Redes de Seguridad , Humanos , Femenino , Hospitales , Neoplasias de la Mama/cirugíaRESUMEN
The professional quality of life (ProQOL) in the veterinary profession has gained increasing attention, yet little is known about its association with the mental health status of Hong Kong veterinarians. This study aimed to examine the impact of elements that make up ProQOL on the risk of suicide, depression, and anxiety among Hong Kong veterinarians. All veterinarians registered and practicing in Hong Kong at the time of recruitment were eligible to take part in the e-survey study between 1 January and 31 March 2022. Binary logistic regression was used to analyze the data from 56 participants. The results showed that 22.0% of the participants were at risk of suicide, 19.6% had current suicidal ideation, 29.4% had depression, and 29.4% had anxiety symptoms. The findings suggested poor mental health status among Hong Kong veterinarians and were comparable to or more prevalent than those reported in Anglophone and European countries. Results from the binary logistic regression suggested that burnout was a predictor of depressive symptoms, and that secondary traumatic stress showed potential in predicting suicide risk. Our study, however, did not find conclusive evidence supporting compassion satisfaction as a predictor of reduced symptoms of common mental issues. Further investigation into contextual factors affecting the mental health of veterinarians in Hong Kong is warranted. Improving the profession's mental health literacy and self-efficacy should be prioritized as a suicide prevention strategy to enhance mental health awareness.
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In this paper, we argue for the need to rethink mental health beyond the medical model because much of human suffering cannot be diagnosed by the DSM-5. During the pandemic and post-pandemic, people have learned to accept the fact that no one is immune from suffering. Given the universality and complexity of human suffering, it is natural for people to wrestle with existential questions such as "Why struggle when all life end in death?" and "How can one flourish when life is so hard?" Existential positive psychology (EPP or PP2.0) was developed to address these existential concerns. After explaining the inherent limitations of the medical model and the need for EPP as an alternative vision for mental health, we provide illustrative clinical cases to demonstrate the advantages of this broader existential framework for both case conceptualization and interventions. According to EPP, mental illness is reconceptualized as both deficiency in knowledge and skills in coping with the demands of life and deficiency in meeting the basic needs for livelihood and mental health, the Soul's yearnings for faith, hope, and love. Finally, we introduce integrative meaning therapy as a therapeutic framework which can equip people with the needed skills to achieve healing, wholeness, and total wellbeing.
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Severe mitral valve regurgitation (MR) is a heart valve disease that progresses to end-stage congestive heart failure and death if left untreated. Surgical repair or replacement of the mitral valve (MV) remains the gold standard for treatment of severe MR, with repair techniques aiming to restore the native geometry of the MV. However, patients with extensive co-morbidities may be ineligible for surgical intervention. With the emergence of transcatheter MV repair (TMVR) treatment paradigms for MR will evolve. The longer-term outcomes of TMVR and its effectiveness compared to surgical repair remain unknown given the differing patient eligibility for either treatment at this time. Advances in computational modeling will elucidate answers to these questions, employing techniques such as finite element method and fluid structure interactions. Use of clinical imaging will permit patient-specific MV models to be created with high accuracy and replicate MV pathophysiology. It is anticipated that TMVR technology will gradually expand to treat lower-risk patient groups, thus pre-procedural computational modeling will play a crucial role guiding clinicians towards the optimal intervention. Additionally, concerted efforts to create MV models will establish atlases of pathologies and biomechanics profiles which could delineate which patient populations would best benefit from specific surgical vs. TMVR options. In this review, we describe recent literature on MV computational modeling, its relevance to MV repair techniques, and future directions for translational application of computational modeling for treatment of MR.