Patients with complete clinical response after neoadjuvant chemoradiotherapy for locally advanced esophageal cancer: A Markov decision analysis of esophagectomy versus active surveillance.

OBJECTIVE: Chemoradiation followed by esophagectomy is a standard treatment option for patients with locally advanced esophageal cancer (LAEC). Esophagectomy is a high-risk procedure, and recent evidence suggests select patients may benefit from omitting or delaying surgery. This study aims to compare surgery versus active surveillance for LAEC patients with complete clinical response (cCR) after neoadjuvant chemoradiotherapy (nCRT). METHODS: Decision analysis with Markov modeling was used. The base case was a 60-year-old man with T3N0M0 esophageal cancer with cCR after nCRT. The decision was modeled for a 5-year time horizon. Primary outcomes were life-years and quality-adjusted life-years (QALY). Probabilities and utilities were derived through the literature. Deterministic sensitivity analyses were performed using ranges from the literature with consideration for clinical plausibility. RESULTS: Surgery was favored for survival with an expected life-years of 2.89 versus 2.64. After incorporating quality of life, active surveillance was favored, with an expected QALY of 1.70 versus 1.56. The model was sensitive to probability of recurrence on active surveillance (threshold value 0.598), probability of recurrence being resectable (0.318), and disutility of previous esophagectomy (-0.091). The model was not sensitive to perioperative morbidity and mortality. CONCLUSIONS: Our study finds that surgery increases life expectancy but decreases QALY. Although the incremental change in QALY for either modality is insufficient to make broad clinical recommendations, our study demonstrates that either approach is acceptable. As probabilities of key factors are further defined in the literature, treatment decisions for patients with LAEC and a cCR after nCRT should consider histology, patient values, and quality of life.

Integration of the social determinants of health into quality indicators for colorectal cancer surgery: a scoping review protocol.

INTRODUCTION: Quality monitoring is a critical component of high-performing cancer care systems. Quality indicators (QIs) are standardised, evidence-based measures of healthcare quality that allow healthcare systems to track performance, identify gaps in healthcare delivery and inform areas of priority for strategic planning. Social structures and economic systems that allow for unequal access to power and resources that shape health and health inequities can be described through the social determinants of health (SDoH) framework. Therefore, granular analysis of healthcare quality through SDoH frameworks is required to identify patient subgroups who may experience health inequity. Given the high burden of disease of colorectal cancer (CRC) and well-defined cancer care pathways, CRC is often the first disease site targeted by health systems for quality improvement. The objective of this review is to examine how SDoH have been integrated into QIs for CRC surgery. This review aims to address three primary questions: (1) Have SDoH been integrated into the development, reporting and assessment of CRC surgery QIs? (2) When integrated, what measures and statistical methods have been applied? (3) In which direction do individual SDoH influence QIs outputs? METHODS: This review will follow Arksey and O'Malley frameworks for scoping reviews. We will search MEDLINE, EMBASE, HealthSTAR databases for papers that examine QIs for CRC surgery applicable to healthcare systems from database inception until January 2023. Interventional trials, prospective and retrospective observational studies, reviews, case series and qualitative study designs will be included. Two authors will independently review all titles, abstracts and full texts to determine which studies meet the inclusion criteria. ETHICS & DISSEMINATION: No ethics approval is required for this review. Results will be disseminated through scientific presentation and relevant conferences targeted for researchers examining healthcare quality and equity in cancer care. REGISTRATION DETAILS: osf.io/vfzd3-Open Science Framework.

Integrating equity frameworks into surgical quality improvement and health administrative databases: A narrative review.

Ensuring safe, timely, and effective surgery is critical for high-quality healthcare and is the goal of surgical quality monitoring systems. At the heart of these systems are health administrative databases which house patient clinico-demographic information, healthcare processes and outcomes. Through analysis of monitoring systems outputs, we can identify gaps within healthcare delivery, patient experience, and surgical outcomes. However, gaps in our healthcare can only be measured by the variables we collect. Equity stratifiers are sociodemographic descriptors that can identify patient populations who experience differences in health and healthcare that may be considered unjust or unfair. They include age, education, gender, geographic location, income, Indigenous identity, racialized group, and sex at birth. These equity stratifiers represent measurable components of the social determinants of health housed within health administrative databases and allow for standardized analysis and reporting of health inequity. However, not all databases collect these stratifiers - making granular analysis of patient subgroups who may experience health inequity impossible to measure. Moreover, in databases that do collect this information, a wide range in the classification systems used makes for comparisons across jurisdictions challenging. The focus of this narrative review will be to apply the principles of the equity stratifier framework to examine what measures are collected in surgical quality improvement databases, cancer monitoring systems and provincial/state health administrative databases in the United States of America and Canada. The goal of this narrative review is to 1) inform researchers, surgeons, and policymakers of the current landscape of social variables collected within common health administrative databases. 2) Outline the pros and cons of the current collection system. 3) Issue a call to action for policymakers to incorporate health equity frameworks into the collection and reporting of data.

Ethiopia's first minimally invasive surgery program: A novel approach in global surgical education.

Objective: Complex lung diseases are among the leading causes of death in Ethiopia. Access to thoracic surgery is limited, and before 2016 no thoracic surgeons were trained in minimally invasive surgery. A global academic partnership was formed between the University of Toronto and Addis Ababa University. We describe implementation of the first minimally invasive surgery training program in sub-Sahara Africa and evaluate its safety. Methods: We performed a retrospective cohort analysis of open versus minimally invasive thoracic and upper gastrointestinal procedures performed at Addis Ababa University from January 2016 to June 2021. Baseline demographic, diagnostic, operative, and postoperative outcomes including length of stay and complications were compared. Results: In our bilateral model of surgical education, training is provided in Ethiopia and Canada over 2 years with a focus on capacity building through egalitarian forms of knowledge exchange. Program features included certification in Fundamentals of Laparoscopic Surgery, high-fidelity lobectomy simulation, and hands-on training. Overall, 41 open and 56 minimally invasive surgery cases were included in the final statistical analysis. The average length of stay in the minimally invasive surgery group was 5.2 days versus 11.0 days in the open group (P < .001). The overall complication rate was 18% in the minimally invasive surgery group versus 39% in the open group (P = .020). Conclusions: We demonstrated the successful initiation of sub-Sahara Africa's first minimally invasive surgery program in thoracic and upper gastrointestinal surgery and characterize its patient safety. We envision the minimally invasive surgery program as a template to continue expanding global partnerships and improving surgical care in other resource-limited settings.

Novel patient-centred outcome in cancer care, days at home: a scoping review protocol.

INTRODUCTION: Patient-centred care is valued by patients and providers. As management of cancer becomes increasingly complex, the value of providing care that incorporates an individual's values and preferences along with demographic and tumour factors is increasingly important. To improve care, patients with cancer need easily accessible information on the outcomes important to them. The patient-centred outcome, days at home (DAH), is based on a construct that measures the time a patient spends alive and out of hospitals and healthcare institutions. DAH is accurately measured from various data sources and has shown construct validity with many patient-centred outcomes. There is significant heterogeneity in terms used and definitions for DAH in cancer care. This scoping review aims to consolidate information on the outcome DAH in cancer care and to review definitions and terms used to date to guide future use of DAH as a patient-centred care, research and policy tool. METHODS AND ANALYSIS: This scoping review protocol has been designed with joint guidance from the JBI Manual for Evidence Synthesis and the expanded framework from Arksey and O'Malley. We will systematically search MEDLINE, Embase and Scopus for studies measuring DAH, or equivalent, in the context of active adult cancer care. Broad inclusion criteria have been developed, given the recent introduction of DAH into cancer literature. Editorials, opinion pieces, case reports, abstracts, dissertations, protocols, reviews, narrative studies and grey literature will be excluded. Two authors will independently perform full-text selection. Data will be extracted, charted and summarised both qualitatively and quantitively. ETHICS AND DISSEMINATION: No ethics approval is required for this scoping review. Results will be disseminated through scientific publication and presentation at relevant conferences.

The Otolaryngology boot camp: a scoping review evaluating commonalities and appraisal for curriculum design and delivery.

OBJECTIVE: Surgical boot camps are becoming increasingly popular in Otolaryngology-Head and Neck Surgery (OHNS) residency programs. Despite pioneering virtual reality and simulation-based surgical education, these boot camps have lacked critical appraisal. The objective of this article was to examine the adoption and utility of surgical boot camps in OHNS residency training programs around the world. DATA SOURCES: Ovid Medline and PubMed databases were systematically searched in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews. Additionally, a grey literature search was performed. REVIEW METHODS: Inclusion criteria were peer-reviewed publications and grey literature sources that reported on OHNS boot camps for the novice learner. The search was restricted to human studies published in English. Studies were excluded if they were not examining junior trainees. RESULTS: A total of 551 articles were identified. Following removal of duplicates, screening, and full text review, 16 articles were included for analysis. Seven major boot camps were identified across various academic sites in the world. Most boot camps were one-day intensive camps incorporating a mixture of didactic, skill specific, and simulation sessions using an array of task trainers and high-fidelity simulators focusing on OHNS emergencies. Studies measuring trainee outcomes demonstrated improvement in trainee confidence, immediate knowledge, and skill acquisition. CONCLUSION: Surgical boot camps appear to be an effective tool for short term knowledge and skill acquisition. Further studies should examine retention of skill and maintenance of confidence over longer intervals, as little is known about these lasting effects.

Shiga Toxin/Lipopolysaccharide Activates Caspase-4 and Gasdermin D to Trigger Mitochondrial Reactive Oxygen Species Upstream of the NLRP3 Inflammasome.

The non-canonical caspase-4 and canonical NLRP3 inflammasomes are both activated by intracellular lipopolysaccharide (LPS), but the crosstalk between these two pathways remains unclear. Shiga toxin 2 (Stx2)/LPS complex, from pathogenic enterohemorrhagic Escherichia coli, activates caspase-4, gasdermin D (GSDMD), and the NLRP3 inflammasome in human THP-1 macrophages, but not mouse macrophages that lack the Stx receptor CD77. Stx2/LPS-mediated IL-1ß secretion and pyroptosis are dependent on mitochondrial reactive oxygen species (ROS) downstream of the non-canonical caspase-4 inflammasome and cleaved GSDMD, which is enriched at the mitochondria. Blockade of caspase-4 activation and ROS generation as well as GSDMD deficiency significantly reduces Stx2/LPS-induced IL-1ß production and pyroptosis. The NLRP3 inflammasome plays a significant role in amplifying Stx2/LPS-induced GSDMD cleavage and pyroptosis, with significant reduction of these responses in NLRP3-deficient THP-1 cells. Together, these data show that Stx2/LPS complex activates the non-canonical inflammasome and mitochondrial ROS upstream of the NLRP3 inflammasome to promote cytokine maturation and pyroptosis.