Real-World Use of Electronic Patient-Reported Outcome (ePRO) Tools Integrated in the Electronic Medical Record During Radiation Therapy for Head and Neck Cancer: Feasibility Study.

Purpose Use of electronic patient-reported outcome (ePRO) tools in routine oncology practice can be challenging despite evidence showing they can improve survival, improve patient and practitioner satisfaction, and reduce medical resource utilization. Head and neck cancer (HNC) patients receiving radiation therapy (RT) may be a group that would particularly benefit from interventions focused on early symptom management. Methods Patients undergoing definitive RT for HNC were enrolled in a feasibility study and received ePRO surveys integrated within the electronic medical record (EMR) on a weekly basis during RT. After completion of each ePRO survey, a radiation oncology registered nurse documented the findings and subsequent interventions within the EMR. Results Thirty-four patients with HNC who received curative RT at a single center were enrolled. The total number of surveys completed was 194 with a median of 7 surveys per patient (range 1-8). There was a total of 887 individual abnormal findings reported on the ePROs, and the authors found that all 887 had a corresponding documented intervention. Post-treatment practitioner questionnaires highlighted that ePROs were felt to be helpful for the care team in providing care to HNC patients. Conclusion For patients with HNC receiving RT, ePROs can be effectively utilized to address patient symptoms within an integrated health care system. Creating an infrastructure for the use of ePROs integrated within the EMR in routine care requires an approach that accounts for local workflows and buy-in from patients and the entire care team.

Evaluation of an emergency safe supply drugs and managed alcohol program in COVID-19 isolation hotel shelters for people experiencing homelessness.

BACKGROUND: During a COVID-19 outbreak in the congregate shelter system in Halifax, Nova Scotia, Canada, a healthcare team provided an emergency "safe supply" of medications and alcohol to facilitate isolation in COVID-19 hotel shelters for residents who use drugs and/or alcohol. We aimed to evaluate (a) substances and dosages provided, and (b) outcomes of the program. METHODS: We reviewed medical records of all COVID-19 isolation hotel shelter residents during May 2021. The primary outcome was successful completion of 14 days isolation, as directed by public health orders. Adverse events included (a) overdose; (b) intoxication; and (c) diversion, selling, or sharing of medications or alcohol. RESULTS: Seventy-seven isolation hotel residents were assessed (mean age 42 ± 14 years; 24% women). Sixty-two (81%) residents were provided medications, alcohol, or cigarettes. Seventeen residents (22%) received opioid agonist treatment (methadone, buprenorphine, or slow-release oral morphine) and 27 (35%) received hydromorphone. Thirty-one (40%) residents received prescriptions stimulants. Six (8%) residents received benzodiazepines and forty-two (55%) received alcohol. Over 14 days, mean daily dosages increased of hydromorphone (45 ± 32 - 57 ± 42 mg), methylphenidate (51 ± 28 - 77 ± 37 mg), and alcohol (12.3 ± 7.6 - 13.0 ± 6.9 standard drinks). Six residents (8%) left isolation prematurely, but four returned. During 1059 person-days, there were zero overdoses. Documented concerns regarding intoxication occurred six times (0.005 events/person-day) and medication diversion/sharing three times (0.003 events/person-day). CONCLUSIONS: COVID-19 isolation hotel residents participating in an emergency safe supply and managed alcohol program experienced high rates of successful completion of 14 days isolation and low rates of adverse events.

Primary cutaneous phalangeal neuroendocrine/squamous cell carcinoma with mixed axillary metastasis.

Cutaneous neuroendocrine tumours are rare and aggressive tumours associated with advanced age and immunosuppression. They are typically characterised by a high rate of local recurrence and nodal disease. The presence of a mixed squamous cell component is rare. These tumours are uncommonly found on the hand. We present a case and histological images of a 78-year-old woman with a primary CK20 negative TTF-1 positive cutaneous neuroendocrine tumour with squamous dedifferentiation arising from the fifth digit with axillary metastasis showing a mixed phenotype. Initial biopsy of the lesion was positive for chromogranin, synaptophysin and TTF-1, but negative for CK20, Melan-A and S100. After CT of the thorax abdomen and pelvis and octreotide single positron emission CT demonstrated a 15 mm axillary metastasis and no evidence of distal disease, our patient underwent an amputation of the affected digit and an axillary lymph node dissection. She is currently awaiting adjuvant chemoradiotherapy. Only two cases are reported in the literature to have mixed squamous/neuroendocrine features. We present the first case which is CK20 negative and TTF-1 positive.

Patterns of prevalence and contemporary clinical management strategies in complicated acute biliary calculous disease: an ESTES 'snapshot audit' of practice.

BACKGROUND: Acute complications of biliary calculi are common, morbid, and complex to manage. Variability exists in the techniques utilized to treat these conditions at an individual surgeon and unit level. AIM: To identify, through an international prospective nonrandomized cohort study, the epidemiology and areas of practice variability in management of acute complicated calculous biliary disease (ACCBD) and to correlate them against reported outcomes. METHODS: A preplanned analysis of the European Society of Trauma and Emergency Surgery (ESTES) 2018 Complicated Biliary Calculous Disease audit was performed. Patients undergoing emergency hospital admission with ACCBD between 1 October 2018 and 31 October 2018 were included. All eligible patients with acute complicated biliary calculous disease were recorded contemporaneously using a standardized predetermined protocol and a secure online database and followed-up through to 60 days from their admission. ENDPOINTS: A two-stage data collection strategy collecting patient demographics, details of operative, endoscopic and radiologic intervention, and outcome metrics. Outcome measures included mortality, surgical morbidity, ICU stay, timing of operative intervention, and length of hospital stay. RESULTS: Three hundred thirty-eight patients were included, with a mean age of 65 years and 54% were female. Diagnosis at admission were: cholecystitis (45.6%), biliary pancreatitis (21%), choledocholithiasis with and without cholangitis (13.9% and 18%). Index admission cholecystectomy was performed in just 50% of cases, and 28% had an ERCP performed. Morbidity and mortality were low. CONCLUSION: This first ESTES snapshot audit, a purely descriptive collaborative study, gives rich 'real world' insights into local variability in surgical practice as compared to international guidelines, and how this may impact upon outcomes. These granular data will serve to improve overall patient care as well as being hypothesis generating and inform areas needing future prospective study.

Body composition is associated with operative and oncologic outcomes in the management of retroperitoneal and trunk soft tissue sarcoma.

BACKGROUND: Sarcopenia, myosteatosis and obesity in cancer may confer negative clinical outcomes, but their prevalence and impact among patients with retroperitoneal and trunk soft tissue sarcoma have not been systematically studied. The aim of this study was to determine body composition among patients with retroperitoneal and trunk sarcoma, and assess impact on operative and oncologic outcomes. METHODS: Consecutive patients undergoing treatment with curative intent from 2009 to 2019 were studied. Subcutaneous fat area and visceral fat areas, intramuscular adipose, lean body mass and fat mass were determined at diagnosis by CT at L3. Univariable and multivariable linear, logistic and Cox proportional hazards regression were performed. RESULTS: 95 patients (43.2% retroperitoneal, 48.4% trunk, 46.3% multivisceral resection) were studied. Visceral obesity was evident in 47.4%. Postoperative morbidity occurred in 25.9%, with preoperative radiotherapy (OR10.53 [95% CI 1.08-102.39], P = 0.042) and fat mass (OR1.41 [1.12-1.79], P = 0.004) independently predictive on multivariable analysis, while intramuscular adipose independently predicted inpatient LOS (P < 0.001), wound infection (P = 0.024, OR1.20 [1.02-1.40]) and major postoperative morbidity (P = 0.027, OR1.15 [1.02-1.31]). Increasing fat mass, subcutaneous fat area and intramuscular adipose were associated with greater tumor size (all P < 0.01), while intramuscular adipose predicted disease progression during neoadjuvant therapy (P = 0.024), and independently predicted disease specific survival (DSS) (P = 0.005, HR1.11 [1.03-1.20]) and overall survival (OS) on multivariable analysis (P < 0.001, HR1.19 [1.08-1.31]). CONCLUSION: Visceral obesity is common in retroperitoneal and trunk sarcoma, and measures of adiposity are associated with adverse operative, but not oncologic outcomes. Myosteatosis is independently associated with postoperative morbidity and adverse oncologic outcomes. Body composition may represent a marker of risk among patients with retroperitoneal and trunk sarcoma.

Sarcopenia and obesity among patients with soft tissue sarcoma - Association with clinicopathologic characteristics, complications and oncologic outcome: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Sarcopenia and obesity may be associated with negative outcomes in many cancers, but their prevalence and impact in modern regimens for soft-tissue sarcoma (STS) have not been systematically studied. This study summarises and critically evaluates the current evidence-based literature on body mass index (BMI) and body composition among patients with STS, with respect to clinical and pathologic characteristics, treatment-associated morbidity and oncologic outcome. METHODS: A systematic literature search of the PubMed, Embase and Cochrane databases was performed. Meta-analysis of the relationship between BMI, body composition and pathologic characteristics, operative morbidity and oncologic outcome was undertaken using RevMan v.5.4 using fixed or random effects methods as appropriate. RESULTS: 14 studies including 3598 patients met inclusion criteria. Ten studies reported on BMI, two on CT and two on PET-CT assessment of body composition. BMI ranged from 14.6 to 63.7 kg/m2, with obesity in 18%-39% of patients. Although some studies demonstrated larger tumours among patients with obesity, this was not significant on meta-analysis (P = 0.31, I2 = 99%). There was no significant difference in tumour grade or histologic type according to BMI. Postoperatively, obesity was associated with increased risk of overall morbidity (odds ratio (OR) 2.03 [95% CI 1.41-2.92], P = 0.0001, I2 = 22%), and wound morbidity (OR 1.32 [95% CI 1.02-1.71], P = 0.03, I2 = 0%). Similar effects were observed in studies of visceral adiposity. No differences in functional outcomes were observed. There was a trend towards reduced local recurrence among patients with obesity (HR 0.64 [95% CI 0.38-1.08], P = 0.10, I2 = 0%), but no difference in distant metastasis (HR 1.00 [95% CI 0.76-1.30], P = 0.98, I2 = 0%) or overall survival (HR 0.98 [95% CI 0.43-2.22], P = 0.95, I2 = 64%). Various measures of sarcopenia were associated with poorer survival outcomes. CONCLUSION: While obesity is associated with increased postoperative morbidity, it had no significant association with long-term oncologic outcomes. Sarcopenia may be associated with a poorer long-term prognosis. A greater understanding of the impact of nutritional status on disease characteristics and treatment outcomes is essential to facilitate improvements in clinical care for patients with STS.

Patients over 65 years with Acute Complicated Calculous Biliary Disease are Treated Differently-Results and Insights from the ESTES Snapshot Audit.

BACKGROUND: Accrued comorbidities are perceived to increase operative risk. Surgeons may offer operative treatments less often to their older patients with acute complicated calculous biliary disease (ACCBD). We set out to capture ACCBD incidence in older patients across Europe and the currently used treatment algorithms. METHODS: The European Society of Trauma and Emergency Surgery (ESTES) undertook a snapshot audit of patients undergoing emergency hospital admission for ACCBD between October 1 and 31 2018, comparing patients under and ≥ 65 years. Mortality, postoperative complications, time to operative intervention, post-acute disposition, and length of hospital stay (LOS) were compared between groups. Within the ≥ 65 cohort, comorbidity burden, mortality, LOS, and disposition outcomes were further compared between patients undergoing operative and non-operative management. RESULTS: The median age of the 338 admitted patients was 67 years; 185 patients (54.7%) of these were the age of 65 or over. Significantly fewer patients ≥ 65 underwent surgical treatment (37.8% vs. 64.7%, p < 0.001). Surgical complications were more frequent in the ≥ 65 cohort than younger patients, and the mean postoperative LOS was significantly longer. Postoperative mortality was seen in 2.2% of patients ≥ 65 (vs. 0.7%, p = 0.253). However, operated elderly patients did not differ from non-operated in terms of comorbidity burden, mortality, LOS, or post-discharge rehabilitation need. CONCLUSIONS: Few elderly patients receive surgical treatment for ACCBD. Expectedly, postoperative morbidity, LOS, and the requirement for post-discharge rehabilitation are higher in the elderly than younger patients but do not differ from elderly patients managed non-operatively. With multidisciplinary perioperative optimization, elderly patients may be safely offered optimal treatment. TRIAL REGISTRATION: ClinicalTrials.gov (Trial # NCT03610308).

A rare case of perforated gastric duplication cyst associated with gastric diverticulum.

A 50-year-old man presented to the emergency department with a 1-day history of severe epigastric pain, vomiting and fever. He had a background of alcohol excess and smoking. The patient was tachycardic and febrile with an elevated white blood cell count and C reactive protein. CT demonstrated extensive upper abdominal free fluid, without free air, with a large cystic lesion arising from the greater curvature of the stomach, and a second smaller cystic lesion arising from the posterior aspect of the gastric fundus. The patient was managed with nasogastric drainage, parenteral nutrition, intravenous antibiotics and proton pump inhibitors, and CT-guided abdominal drainage, with resolution of sepsis, and further outpatient care was transferred to our unit. Follow-up endoscopy demonstrated a diverticulum arising from the posterior aspect of the gastric fundus, with normal mucosa throughout the remaining stomach, while CT showed an additional cystic lesion arising from the greater curvature, with thickening of the adjacent gastric wall consistent with a gastric duplication cyst (GDC). Laparoscopy confirmed a small diverticulum at the fundus, and a large GDC anteriorly with associated omental adhesions consistent with prior perforation-two wedge resections were performed. Histology demonstrated no evidence of malignancy or ectopic mucosa. The patient recovered uneventfully and remained free from recurrent symptoms at 6 weeks postoperatively. GDC is a rare entity, which may be associated with ectopic mucosa, malignant transformation and upper gastrointestinal perforation. No previous report describes the coexistence of a GDC and gastric diverticulum. Herein we describe the investigation and management of this condition, and review the associated peer-reviewed literature.

Bile duct clearance and cholecystectomy for choledocholithiasis: Definitive single-stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography versus staged procedures.

BACKGROUND: Clinical equipoise exists regarding optimal sequencing in the definitive management of choledocholithiasis. Our current study compares sequential biliary ductal clearance and cholecystectomy at an interval to simultaneous laparoendoscopic management on index admission in a pragmatic retrospective manner. METHODS: Records were reviewed for all patients admitted between January 2015 and December 2018 to a Swedish and an Irish university hospital. Both hospitals differ in their practice patterns for definitive management of choledocholithiasis. At the Swedish hospital, patients with choledocholithiasis underwent laparoscopic cholecystectomy with intraoperative rendezvous endoscopic retrograde cholangiopancreatography (ERCP) at index admission (one stage). In contrast, interval day-case laparoscopic cholecystectomy followed index admission ERCP (two stages) at the Irish hospital. Clinical characteristics, postprocedural complications, and inpatient duration were compared between cohorts. RESULTS: Three hundred fifty-seven patients underwent treatment for choledocholithiasis during the study period, of whom 222 (62.2%) underwent a one-stage procedure in Sweden, while 135 (37.8%) underwent treatment in two stages in Ireland. Patients in both cohorts were closely matched in terms of age, sex, and preoperative serum total bilirubin. Patients in the one-stage group exhibited a greater inflammatory reaction on index admission (peak C-reactive protein, 136 ± 137 vs. 95 ± 102 mg/L; p = 0.024), had higher incidence of comorbidities (age-adjusted Charlson Comorbidity Index, ≥3; 37.8% vs. 20.0%; p = 0.003), and overall were less fit for surgery (American Society of Anesthesiologists, ≥3; 11.7% vs. 3.7%; p < 0.001). Despite this, a significantly shorter mean time to definitive treatment, that is, cholecystectomy (3.1 ± 2.5 vs. 40.3 ± 127 days, p = 0.017), without excess morbidity, was seen in the one-stage compared with the two-stage cohort. Patients in the one-stage cohort experienced shorter mean postprocedure length of stay (3.0 ± 4.7 vs. 5.0 ± 4.6 days, p < 0.001) and total length of hospital stay (6.5 ± 4.6 vs. 9.0 ± 7.3 days, p = 0.002). The only significant difference in postoperative complications between the cohorts was urinary retention, with a higher incidence in the one-stage cohort (19% vs. 1%, p = 0.004). CONCLUSION: Where appropriate expertise and logistics exist within developing models of acute care surgery worldwide, consideration should be given to index-admission laparoscopic cholecystectomy with intraoperative ERCP for the treatment of choledocholithiasis. Our data suggest that this strategy significantly shortens the time to definitive treatment and decreases total hospital stay without any excess in adverse outcomes. LEVEL OF EVIDENCE: Therapeutic/Care Management Level IV.

Splenectomy for isolated splenic metastasis from primary lung adenocarcinoma.

A 73-year-old woman was referred to a tertiary centre with isolated splenic metastasis from previous pT1aNo stage 1a lung adenocarcinoma. The patient underwent a right lower lobe lobectomy and mediastinal lymph node dissection 2 years ago for invasive adenocarcinoma with no adjuvant therapy. An incidental finding of new splenic cyst was noted on surveillance imaging, which was fluorodeoxyglucose positive on positron emission tomography, and confirmed on cytology to be metastatic lung adenocarcinoma. After multi-disciplinary team's review, the patient underwent splenectomy, with partial excision of diaphragm due to local infiltration. Her postoperative course was eventful, and was complicated by a simple fluid collection in the surgical bed (amylase negative), a left sided pneumonia and atelectasis and left sided pleural effusion, requiring antibiotics and radiological drainage of the abdominal and pleural collection. The patient recovered well and is currently doing well 9 months postoperatively with no evidence of recurrence or metastatic disease.

Robot Assisted Surgical Ward Rounds: Virtually Always There.

BACKGROUND:  While an explosion in technological sophistication has revolutionized surgery within the operating theatre, delivery of surgical ward-based care has seen little innovation.  Use of telepresence allowing off-site clinicians communicate with patients has been largely restricted to outpatient settings or use of complex, expensive, static devices.  We designed a prospective study to ascertain feasibility and face validity of a remotely controlled mobile audiovisual drone (LUCY) to access inpatients.  This device is, uniquely, lightweight, freely mobile and emulates 'human' interaction by swiveling and adjusting height to patients' eye-level.   METHODS: Robot-assisted ward rounds(RASWR) were conducted over 3 months. A remotely located consultant surgeon communicated with patients/bedside teams via encrypted audiovisual telepresence robot (DoubleRoboticstm, California USA).  Likert-scale satisfaction questionnaires, incorporating free-text sections for mixed-methods data collection, were disseminated to patient and staff volunteers following RASWRs.  The same cohort completed a linked questionnaire following conventional (gold-standard) rounds, acting as control group. Data were paired, and non-parametric analysis performed.  RESULTS: RASWRs are feasible (>90% completed without technical difficulty). The RASWR(n=52 observations) demonstrated face validity with strong correlations (r>0.7; Spearman, p-value <0.05) between robotic and conventional ward rounds among patients and staff on core themes, including dignity/confidentiality/communication/satisfaction with management plan. Patients (96.08%, n=25) agreed RASWR were a satisfactory alternative when consultant physical presence was not possible. There was acceptance of nursing/NCHD cohort (100% (n=11) willing to regularly partake in RASWR).  CONCLUSION: RASWRs receive high levels of patient and staff acceptance, and offer a valid alternative to conventional ward rounds when a consultant cannot be physically present.

Post-ERCP Emphysematous Cholecystitis in a Young Woman: A Rare and Potentially Fatal Complication.

A 45-year-old woman with suspected Functional Biliary Sphincter Disorder (FBSD) developed Clostridium perfringens related emphysematous cholecystitis after ERCP. A low index of suspicion for emphysematous cholecystitis in this young, otherwise healthy woman led to a significant delay in making the correct diagnosis, and air in the gallbladder was wrongly attributed to a possible gallbladder perforation. ERCP is associated with significant risks, particularly in patients with FBSD, where diagnostic uncertainty renders the balance of risk versus benefit even more critical. Post-ERCP emphysematous cholecystitis secondary to Clostridium perfringens is a rare but potentially fatal complication.

Glomus tumors treated with stereotactic radiosurgery: A retrospective study.

BACKGROUND: Glomus tumors are difficult to manage surgically because they are vascular tumors that are topographically associated with important vascular and neuronal structures. Hence, there is a strong risk of incomplete resection and a high morbidity rate. In addition, they grow slowly. Recent treatments have increasingly involved a combination of surgical resection and radiosurgery. We present our experience in treating glomus tumors of the skull base with stereotactic radiosurgery as an upfront therapy. METHODS: We analyzed data from 13 consecutive patients with glomus tumors that were initially treated with stereotactic radiosurgery in our institute from February 2010 to April 2012. The tumor control rate, resolution of symptoms, and the complication rate were tabulated. RESULTS: All patients were female with a median age of 63 (mean 62.7+/-14.6 years). The median treatment dose was 25.8 Gy (27.6 Gy +/- 9.5 Gy) and the median tumor volume 10.4 mL (9.2 +/- 6.5). The median follow-up was 47.4 months (51.8+/-11.2 months, range 31-74). The tumor control rate was 92.3%; 46.7% of the patients had noticeable tumor shrinkage. This happened at a median interval of 17 months (18.7+/-6.8) after treatment. Most patients with tinnitus had resolution of their symptoms (87.5%). Four patients presented with new symptoms and four patients with worsening of pre-existing symptoms. The time course of symptomatic improvement followed that of tumor size reduction. However, there was no statistical correlation between the amount of tumor reduction and symptomatic relief. CONCLUSION: Stereotactic radiosurgery (SRS) is an effective upfront treatment option in the management of glomus tumors.

An international survey of medical licensing requirements for immigrating physicians, focusing on communication evaluation.

OBJECTIVE: To identify current entry requirements set by international medical licensing bodies for immigrating physicians, focusing on postgraduate level communication skills, clinical and technical skill assessments. METHODS: A standardised, author developed survey was administered to a selection of national, state and provincial licensing institutions across 6 continents. Representative institutions were selected from the most populated regions of each continent. Surveys were administered by email and telephone. The information was also searched by website review. Website information alone was used if no response was received by the targeted institution after 2 phone/2 email attempts. Statistical analysis of the non-parametric data was conducted using SPSS (v.21). RESULTS: Thirty-seven licensing bodies were contacted from 30 countries; verifiable information was available for 29; twenty-six responded to the communication inquiry. Sixty five 65.4% (n=17) surveyed communication skills, 100% involved language proficiency testing; 11.5% tested other forms of communication skills. For clinical and technical skills, 86.2% (n=25) assessed candidates by credential review, 72.4% (n=21) required both credential review and exam and 62.1% (n=18) used country-specific examination. A mentorship period were required by 37.9% (n=11), ranging from 3 months to 1 year. Only 2 countries identified examinations for recertification. No technical/clinical skills nor communication skill evaluation (beyond language proficiency) are routinely assessed at the postgraduate level. CONCLUSIONS: International assessments of migrating physicians are heterogeneous. Communication skills, beyond language proficiency, are not routinely assessed in foreign trained physicians seeking entry. The majority of clinical and technical skills are assessed by credential review only. This study highlights the lack of standardisation of assessment internationally and the need for steps toward a global agreement on training schemes and summative assessment.

Evidence based management of polyps of the gall bladder: A systematic review of the risk factors of malignancy.

BACKGROUND: There are no evidence-based guidelines to dictate when Gallbladder Polyps (GBPs) of varying sizes should be resected. AIM: To identify factors that accurately predict malignant disease in GBP; to provide an evidence-based algorithm for management. METHODS: A systematic review following PRISMA guidelines was performed using terms "gallbladder polyps" AND "polypoid lesion of gallbladder", from January 1993 and September 2013. Inclusion criteria required histopathological report or follow-up of 2 years. RTI-IB tool was used for quality analysis. Correlation with GBP size and malignant potential was analysed using Euclidean distance; a logistics mixed effects model was used for assessing independent risk factors for malignancy. RESULTS: Fifty-three articles were included in review. Data from 21 studies was pooled for analysis. Optimum size cut-off for resection of GBPs was 10 mm. Probability of malignancy is approximately zero at size <4.15 mm. Patient age >50 years, sessile and single polyps were independent risk factors for malignancy. For polyps sized 4 mm-10 mm, a risk assessment model was formulated. CONCLUSIONS: This review and analysis has provided an evidence-based algorithm for the management of GBPs. Longitudinal studies are needed to better understand the behaviour of polyps <10 mm, that are not at a high risk of malignancy, but may change over time.

Epidemiological study of soft-tissue sarcomas in Ireland.

Soft-tissue sarcomas (STS) account for 1% of adult and 7% of pediatric malignancies. Histopathology and classification of these rare tumors requires further refinements. The aim of this paper is to describe the current incidence and survival of STS from 1994 to 2012 in Ireland and compare these with comparably coded international published reports. This is a retrospective, population study based on the data from the National Cancer Registry of Ireland (NCRI). Incidence and relative survival rates for STS in Ireland were generated. Incidence of STS based on gender, age and anatomical location was examined. Annual mean incidence rate (European Age Standardized) in Ireland between 1994 and 2012 was 4.48 ± 0.15 per 100,000 person-years. The overall relative 5-year survival rate of STS for the period 1994-2011 in Ireland was 56%, which was similar to that reported in the U.K. but lower than in most of Europe and U.S.A. Survival rate fluctuated over the period examined, declining slightly in females but showing an increase in males. STS incidence trends in Ireland were comparable to international reports. Survival trends of STS were significantly different between Ireland and other European countries, requiring further study to understand causation.

Pilot evaluation of a novel observational tool for collaboration and communication within multidisciplinary team meetings (MDTs).

BACKGROUND: Despite widespread use of multidisciplinary team meetings (MDTs) to facilitate patient care, little evidence exists that MDTs improve patient survival or impact care. Research into MDT function and outcome is limited. This pilot study looks to validate a novel tool developed to assess MDT functioning. METHODS: A tool was developed with predefined Likert behaviour stems in the areas of structure, communication and collaboration. The tool was evaluated in nine MDTs by three independent observers and included participant evaluation. Inter-rater reliability was calculated with intraclass-correlation coefficients (ICC); Student's t-test was used to calculate significance in participant evaluation and matched observations. RESULTS: The tool was used to evaluate 9 MDTs, discussing 133 cases. The overall ICC for the three coders was 0.935; for each MDT: 0.776-0.917. The inter-rater reliability for each MDT observation ranged from 0.245-0.923; the majority with an ICC >0.8. No significant difference was noted between participant evaluation and observer response. DISCUSSION: MDTs provide a means of coordinating complex care for patients. This tool provides a means of evaluating group interaction within MDTs and is designed for use by different medical personnel. The pilot study has shown promising ICC; further evaluation is needed using a broader group of MDTs and including case complexity and outcome.

Does EUS-FNA molecular analysis carry additional value when compared to cytology in the diagnosis of pancreatic cystic neoplasm? A systematic review.

BACKGROUND: Endoscopic ultrasonography with fine needle aspiration (EUS-FNA) has become an integral tool in the diagnosis of pancreatic cystic lesions (PCLs) and the analysis of molecular/DNA abnormalities might improve the accuracy of pre-operative diagnosis. A review was conducted of all studies using EUS-FNA aspirates of PCLs to assess the accuracy and added benefit that molecular analysis provides to cytological analysis. METHODS: A systematic review of the literature was conducted using PRISMA guidelines and electronic databases: PubMed/SCOPUS/EMBASE/Cochrane/CINAHL. Surgical pathology was used as the definitive reference standard. The QUADAS-2 tool was used for quality assessment. RESULTS: In total, 162 articles were identified; 12 articles met inclusion/exclusion criteria. Ten studies reported on cytology and 8 studies reported k-ras mutational analysis. 362 patients (of 1115 total) had surgical pathology available. The sensitivity and specificity of cytology was 0.42 and 0.99; the sensitivity and specificity of k-ras was 0.39 and 0.95; and the sensitivity and specificity of the combined test of cytology and k-ras was 0.71 and 0.88, respectively. CONCLUSIONS: k-ras mutational analysis used as an individual screening test has a poor diagnostic accuracy, as does cytology when used alone. The benefit comes with utilization in a combined fashion. More studies are needed to evaluate the correct sequence and utility of these tests for cyst differentiation.