Routine versus no assessment of gastric residual volumes in preterm infants receiving enteral feeding via intermittent feeding tubes: a randomized controlled trial.

OBJECTIVE: To evaluate whether eliminating routine gastric residual volume (GRV) assessments would lead to quicker attainment of full feeding volumes in preterm infants. STUDY DESIGN: This is a prospective randomized controlled trial of infants ≤32 weeks gestation and birthweight ≤1250 g admitted to a tertiary care NICU. Infants were randomized to assess or not assess GRV before enteral tube feedings. The primary outcome was time to attain full enteral feeding volume defined as 120 ml/kg/day. The Wilcoxon rank sum test was used to compare the days to reach full enteral feeds between the two groups. RESULTS: 80 infants were randomized, 39 to the GRV assessing and 41 to the No-GRV assessing group. A predetermined interim analysis at 50% enrollment showed no difference in primary outcome and the study was stopped as recommended by the Data Safety Monitoring Committee. There was no significant difference in median days to reach full enteral feeds between the two groups [GRV assessment: 12d (5) vs. No-GRV assessment:13d (9)]. There was no mortality in either group, one infant in each group developed necrotizing enterocolitis stage 2 or greater. CONCLUSION: Eliminating the practice of gastric residual volume assessment before feeding did not result in shorter time to attain full feeding.

Impact of bariatric surgery on early-onset colorectal cancer risk: a systematic review and meta-analysis.

The aim of this meta-analysis is to determine the impact of bariatric surgery on the risk of early-onset colorectal neoplasia. This systematic review was conducted according to PRISMA recommendations. It was registered in the PROSPERO international database. A comprehensive search was conducted in electronic databases (MEDLINE, EMBASE, and Web of Science) for completed studies until May 2022. The Search was made using a mixture of indexed terms and title, abstract and keywords. The search included terms: obese, surgical weight loss intervention, colorectal cancer, and colorectal adenomas. Studies that included bariatric intervention patient's vs non-surgical obese patients younger than 50 years were considered. Inclusion criteria were patients with BMI more than 35 kg/m2 who underwent a colonoscopy. Studies with follow-up colonoscopy performed in less than 4 years after bariatric surgery and those that evaluated patients with a mean age difference of 5 or more years between groups were excluded. Outcomes analyzed in obese patients with surgical treatment vs control patients included colorectal cancer incidence. From 2008 to 2021, a total of 1536 records were identified. Five retrospective studies that included 48,916 patients were analyzed. Follow-up period ranged from 5 to 22.2 years. 20,663 (42.24%) patients underwent bariatric surgery and 28,253 (57.76%) were part of the control patients. Roux-en-Y gastric bypass was performed in 14,400 (69.7%) individuals. The intervention and control group were similar in age range, proportion of female participants and initial body mass index (35-48.3 vs 35-49.3, respectively). 126/20663 (0.61%) patients in the bariatric surgery group and 175/28253 (0.62%) individuals in the control group presented CRC. In this meta-analysis, we were unable to demonstrate a significant impact of the Bariatric Surgery on EOCRC risk. Prospective trials with longer follow-up periods should be done to prove the colorectal cancer risk reduction.

The CREATION Health Assessment Tool for Patients (CHAT-P): Development & Psychometric Testing.

The CREATION Model is a whole-person wellness model facilitating patient-provider partnerships for health promotion. CREATION is an acronym that represents eight whole-person health principles: Choice, Rest, Environment-Interpersonal Relationships, Activity, Trust, Outlook, and Nutrition, all focusing on the relationship between individual choice and physical, psychological, social, and spiritual health. This study develops and tests the psychometric properties of the CREATION Health Assessment Tool for Patients (CHAT-P). A 125-item-bank using a 5-point Likert scale with 1 to 5 rating was generated through focus-groups of clinicians, patients, and healthcare leaders. An expert panel assessed content adequacy, reducing items to 82. Patient survey data (n = 599) from 15 inpatient medical units were randomly divided into two datasets. Exploratory Factor Analysis applied to Dataset 1 resulted in a 7-factor (Choice/Rest/Environment-Interpersonal Relationships/Activity/Trust/Outlook/Nutrition) and 28-item tool with factor loading 0.47-0.86. The model structure was confirmed by Structural Equation Modeling on Dataset 2 with goodness-of-fit test results: X2/df = 2.41 < 5.0, RMSEA = 0.05 < 0.08, GFI = 0.91 and AGFI = 0.90. Cronbach's Alpha = 0.83 showed satisfactory reliability. The final CHAT-P totals ranged from 28-140 (higher scores indicating better health/well-being). When assessing the effectiveness of educational/behavioral interventions, this tool can measure the improvement of a patient's overall mind-body-spirit well-being or measure well-being for individual CREATION principle(s). It fills that gap and facilitates healthcare providers' ability to assess and plan interventions to support holistic well-being.

Fluid Intake in the First Week of Life and the Duration of Hemodynamically Significant Patent Ductus Arteriosus in Extremely Preterm Infants.

OBJECTIVE: This study aimed to determine the association between daily fluid intake and the duration of hemodynamically significant patent ductus arteriosus (hsPDA). STUDY DESIGN: This is a retrospective cohort study of extremely preterm infants (<29 weeks) admitted in the Neonatal Intensive Care Unit of the Advent Health for Children from January 2013 to March 2016, if hsPDA was diagnosed in first week of life and serial echocardiograms were available. Diagnosis of hsPDA was based on a scoring system and its duration was estimated from serial echocardiograms. Cohort was divided into two groups based on duration of hsPDA (<1week, group A and ≥1 week, group B). Daily fluid intake was categorized as prescribed and actual. Prescribed volume was ordered by clinicians based on birth weight, not including trophic feeds, intravenous (IV) boluses or transfusions, etc. Actual intake was calculated by the electronic medical records based on daily weights and included all enteral or parenteral fluids. Multivariate analysis was performed to determine an association between total daily fluid intake over the first week of life and the duration of hsPDA. Two groups were compared to observe the difference between prescribed and actual daily fluid intakes. RESULTS: We enrolled 50 infants in group A and 76 in group B. Infants in group B were of significantly lower gestation and required prolonged ventilation and hospitalization. An association between higher fluid intake in the first 2 days of life and prolonged duration of hsPDA was confirmed by multivariate analysis. Actual fluid intake was significantly higher than prescribed total fluid intake in first 4 days of life for infants in both groups. CONCLUSION: In extremely preterm infants, higher fluid intake in first 2 days of life is associated with prolonged duration of hsPDA. Actual daily fluid intake can be significantly higher than prescribed daily fluids due to daily weight changes and additional fluid administration. KEY POINTS: · In preterm infants, actual daily fluid intake may be higher than prescribed volume.. · Higher daily fluid intake in first week of life is associated with prolonged duration of PDA.. · PDA scoring system can be helpful for objective assessment of PDA in preterm infants..

Employment Status of Nurses After a Psychoeducational Group Intervention: A Matched Case-Control Study.

OBJECTIVE: This matched case-control study compared the long-term employment status of direct care nurses based on participation in a psychoeducational group intervention and calculated the estimated cost savings. BACKGROUND: Chronic stress, in addition to lack of support and low autonomy, can lead to burnout among nurses. Burnout is a common reason for job dissatisfaction and turnover. Interventions combining education with therapeutic processing and peer support may lead to healing and growth in nurses already experiencing the effects of chronic stress and burnout. The COVID-19 pandemic also contributed to stress among nurses. METHODS: Fifty-four direct care nurses who participated in the intervention were paired with 54 direct care nurses who did not participate, matched on the following variables: age, gender, race, work setting, and campus. RESULTS: This study found a higher percentage of direct care nurses who participated in the intervention remained employed compared with the matched control subjects who did not participate. CONCLUSION: At a relatively low cost compared with the cost of turnover by each nurse, the psychoeducational group intervention may provide an opportunity to improve retention among nurses.

Maternal Body Mass Index and Risk of Bronchopulmonary Dysplasia in Extremely Preterm Infants.

OBJECTIVE: We evaluated the relationship between maternal body mass index (BMI) and death or bronchopulmonary dysplasia (BPD). We hypothesized that in extremely low birth weight (ELBW; BW < 1,000 g) infants, the risk of death or BPD would be greater if the maternal BMI deviated further from the ideal BMI of 24. STUDY DESIGN: ELBW infants admitted to AdventHealth Neonatal Intensive Care Unit (NICU) between calendar years 2012 and 2017 were included in this retrospective observational study. BPD was defined as continuous supplemental oxygen use at 36 weeks post-menstrual age. RESULT: There was no association between the deviation of maternal BMI from the ideal of 24 and the composite outcome of death or BPD (6.9 ± 6.7 vs. 7.06 ± 6.6, pp = 0.966). However, there was a lower risk of death with a higher maternal BMI (p = 0.024). BPD was also associated with a higher maternal BMI (p = 0.045). CONCLUSION: Maternal BMI was not associated with the composite variable of death or BPD in ELBW infants. The lack of association was due to the contrast between high BMI and a lower risk of death and a higher risk for BPD. KEY POINTS: · Maternal BMI was not associated with the composite outcome of death or BPD.. · Elevated BMI was associated with a higher risk of BPD.. · Elevated BMI was associated with a lower risk of death..

Evaluating "The REST of Your Life," a Workplace Health Program to Improve Employee Sleep, Health, Energy, and Productivity.

PURPOSE: Sleep is critical for employee health, well-being, and productivity. Our purpose is to evaluate a sleep-focused interactive workplace health promotion program. DESIGN: We evaluate sleep and mental health before and after exposure to the program using a pre/post quasi-experimental pilot study design with surveys administered at baseline and 1-, 6-, and 12 months post-exposure (Phase 1). We design program evaluation surveys for dissemination when the program is offered broadly to hospital employees (Phase 2). SETTING: The study was conducted at a large teaching hospital in the Southeast U.S. in 2016. SUBJECTS: Subjects were full-time hospital employees. INTERVENTION: The program was presented to subjects in one four-hour interactive session. MEASURES: In Phase 1 (n = 55), surveys included the validated Apnea Risk Evaluation System, Dysfunctional Beliefs About Sleep, Generalized Anxiety Disorder-7, Pittsburgh Sleep Quality Index and Patient Health Questionnaire. Phase 2 (n = 3935) utilized program evaluation surveys. ANALYSIS: We compare survey responses between pre- and post-program using a repeated measures analysis of variance with post-hoc tests. RESULTS: Statistically significant improvement in all sleep and mental health domains was demonstrated. In Phase 2, 81.9% reported "strongly agree" to willingness to recommend the program to co-workers. CONCLUSION: We demonstrate improvement in employee sleep and mental health after exposure to a novel workplace health promotion program to improve sleep.

Carcinomatosis in Early-Stage Cervical Cancer Treated with Robotic Radical Hysterectomy: Recurrence Patterns, Risk Factors, and Survival.

PURPOSE: Minimally invasive radical hysterectomy has been associated with increased recurrence of disease and worse survival compared with open radical hysterectomy for early-stage cervical cancer. We evaluated patterns of recurrence and histopathologic risk factors in patients who underwent robotic radical hysterectomy (RRH). METHODS: Patients who underwent RRH (4/2007-12/2018) were evaluated for specific locations of recurrent disease, disease-free survival, overall survival (OS), and histopathologic risk factors for recurrence. Inclusion criteria were follow-up ≥ 1 year, histology with adenocarcinoma, adenosquamous, or squamous carcinoma and clinical stage IA2 to IB ≤ 4-cm tumor size cervical cancers (FIGO-2018). RESULTS: A total of 140 patients underwent RRH and 112 met criteria. Median tumor size was 2.1 cm [interquartile range (IQR): 1.1-3.3]. Median follow-up was 61 months (IQR: 36-102). Fifty (45%) patients underwent adjuvant radiation ± cisplatin with either Sedlis' or Peters' risk factors. There were 11 (9.8%) recurrences with median disease-free survival of 12 (IQR 8.5) months. All patients with recurrence had measured tumor size ≥ 2 cm (median tumor size 3-cm (IQR: 2.6-4.0). Tumor size > 2 cm was associated with Sedlis' intermediate-risk factors (p < 0.05) and Peters' high-risk factors (p < 0.05). Forty patients underwent preoperative conization, and two (5%) with deep positive margins in lesions > 2 cm recurred. Five (4.5%) of patients had carcinomatosis representing 45% of all recurrences. Carcinomatosis was associated with reduced OS compared with other recurrence patterns (22 months vs. 7.8 years, p < 0.05). CONCLUSIONS: Carcinomatosis was observed in early-stage cervical cancers treated with RRH and was associated with reduced OS. All recurrences were associated with lesions ≥ 2 cm, and no recurrences were identified with negative conization margins.

Contrast-Enhanced CT May Identify High-Risk Esophageal Varices in Patients With Cirrhosis.

OBJECTIVE. The Baveno VI consensus established guidelines to reduce unnecessary screening esophagogastroduodenoscopy (EGD) for esophageal varices (EVs). We assessed whether EVs that would require intervention at EGD can be identified on CT and evaluated if recommending EGD on the basis of CT findings would result in unnecessary EGD according to the Baveno VI consensus guidelines. MATERIALS AND METHODS. This single-institution retrospective study identified 97 contrast-enhanced CT examinations within 3 months of EGD in 93 patients with cirrhosis from 2008 to 2018. Demographic information, EGD findings, interventions, and laboratory data were reviewed. CT scans were reviewed for EVs and compared with EGD findings. Var-ices that were 4 mm or larger were considered large, and those requiring intervention were considered high risk. RESULTS. The presence of large EVs on CT was 80% sensitive and 87% specific for high-risk varices at EGD. Large EVs on CT were associated with bleeding as the indication for EGD (p = 0.03) and the presence of high-risk varices at EGD (p < 0.001). The positive predictive value that a large EV on CT corresponded to a high-risk EV at EGD was 90.4% (95% CI, 0.78-0.96). Patients with large EVs on CT were 9.4 times more likely to have a grade III or grade IV EV at EGD. CONCLUSION. Large EVs on CT correlated with high-risk varices at EGD and may be a useful indicator that EGD should be considered for confirmatory diagnosis and treatment. Recommending EGD for patients with EVs of 4 mm or larger did not result in EGD that would be deemed unnecessary according to the Baveno VI consensus guidelines.

A Randomized Controlled Trial of a Motivational Interviewing Intervention to Improve Whole-Person Lifestyle.

The purpose of this randomized controlled trial was to examine the effects of a motivational interviewing intervention to improve whole-person lifestyle and reduce cardiovascular disease risk profile. A sample of 111 adults with type 2 diabetes and/or hypertension was recruited from a primary care physician practice. The intervention was facilitated by a program specialist trained in motivational interviewing. Outcomes included body mass index, cholesterol, hemoglobin A1c, blood pressure, waist circumference, wellness scores, and substance use. Differences in the changes in body mass index and waist circumference existed between the intervention and control groups after 6 months. In the intervention group, the proportion of high wellness scores increased after the program. A whole-person lifestyle intervention with motivational interviewing for patients with metabolic syndrome can improve one's health in terms of components in the cardiovascular disease risk profile, as well as overall wellness. Efforts to improve the health of these patients may incorporate motivational interviewing to guide goal setting and address mental and spiritual health in addition to physical health.

Marijuana use and coronary artery disease in young adults.

BACKGROUND: Marijuana is the most popular drug of abuse in the United States. The association between its use and coronary artery disease has not yet been fully elucidated. This study aims to determine the frequency of coronary artery disease among young to middle aged adults presenting with chest pain who currently use marijuana as compared to nonusers. METHODS: In this retrospective study, 1,420 patients with chest pain or angina equivalent were studied. Only men between 18 and 40 years and women between 18 and 50 years of age without history of cardiac disease were included. All patients were queried about current or prior cannabis use and underwent coronary CT angiography. Each coronary artery on coronary CT angiography was assessed based on the CAD-RADS reporting system. RESULTS: A total of 146 (10.3%) out of 1,420 patients with chest pain were identified as marijuana users. Only 6.8% of the 146 marijuana users had evidence of coronary artery disease on coronary CT angiography. In comparison, the rate was 15.0% among the 1,274 marijuana nonusers (p = 0.008). After accounting for other cardiac risk factors in a multivariate analysis, the negative association between marijuana use and coronary artery disease on coronary CT angiography diminished (p = 0.12, 95% CI 0.299-1.15). A majority of marijuana users were younger than nonusers and had a lower frequency of hypertension and diabetes than nonusers. There was no statistical difference in lipid panel values between the two groups. Only 2 out of 10 marijuana users with coronary artery disease on coronary CT angiography had hemodynamically significant stenosis. CONCLUSION: Among younger patients being evaluated for chest pain, self-reported cannabis use conferred no additional risk of coronary artery disease as detected on coronary CT angiography.

Sedation with Propofol During Catheter-Directed Thrombolysis for Acute Submassive Pulmonary Embolism Is Associated with Increased Mortality.

PURPOSE: To evaluate if sedation with propofol during catheter-directed thrombolysis (CDT) in patients with acute submassive pulmonary embolism (PE) affects survival. MATERIALS AND METHODS: This single-institution, retrospective study identified 136 patients from 2011-2017 who underwent CDT for acute submassive PE. Patients were grouped based on procedural sedation-propofol versus fentanyl and/or midazolam. Groups were compared for differences in baseline characteristics. Primary endpoint was in-hospital mortality. Logistic regression analysis was performed to evaluate for independent variables predictive of mortality. Propensity-matched analysis was also performed. RESULTS: Propofol was given to 18% (n = 25) of patients, and fentanyl and/or midazolam was given to 82% (n = 111) of patients. Mortality was 28% (n = 7) in the propofol group versus 3% (n = 3) in the fentanyl/midazolam group (P = .0003). Patients receiving propofol had 10.4 times the risk of cardiopulmonary arrest or dying during hospitalization compared with patients receiving fentanyl and/or midazolam (95% confidence interval, 2.9-37.3, P = .0003). The number needed to harm was 4 (95% confidence interval, 2.8-6.8). Logistic regression model analysis including Pulmonary Embolism Severity Index score, right-to-left ventricle diameter ratio and age was not predictive of mortality (P = .19). Adding type of sedation made the model predictive of mortality (P < .001). Propensity-matched analysis controlling for baseline differences in age, adjunctive maneuvers, American Society of Anesthesiologists class, and intubation before the procedure revealed that statistical significance between groups remained (P = .01). CONCLUSIONS: Sedation with propofol during CDT for acute submassive PE is associated with increased mortality and should be used with caution.

GammaKnife versus VMAT radiosurgery plan quality for many brain metastases.

The purpose of this work was to compare dose distributions between two radiosurgery modalities, single-isocenter volumetric modulated arc therapy (VMAT), and GammaKnife Perfexion (GK), in the treatment of a large number (≥7) of brain metastases. Twelve patients with 103 brain metastases were analyzed. The median number of targets per patient was 8 (range: 7-14). GK plans were compared to noncoplanar VMAT plans using both 6-MV flattening filter-free (FFF) and 10-MV FFF modes. Parameters analyzed included radiation therapy oncology group conformity index (CI), 12, 6, and 3 Gy isodose volumes (V12 Gy, V6 Gy, V3 Gy), mean and maximum hippocampal dose, and maximum skin dose. There were statistically significant differences in CI (2.5 ± 1.6 vs 1.6 ± 0.8 and 1.7 ± 0.9, P < 0.001, P < 0.001), V12 Gy (2.8 ± 6.1 cc vs 3.0 ± 5.2 cc and 3.1 ± 5.4 cc, P = 0.003, P < 0.001), and V3 Gy (323.0 ± 294.8 cc vs, 880.1 ± 369.1 cc and 937.9 ±  vs 361.9 cc, P = 0.005, P = 0.001) between GK versus both 6-MV FFF and 10-MV FFF. No significant differences existed for maximum hippocampal or skin doses. In conclusion, highly optimized VMAT produced improved conformity at the expense of a higher V12 Gy and V3 Gy volume when compared with highly optimized GK.

Natural History of Postnatal Cardiopulmonary Adaptation in Infants Born Extremely Preterm and Risk for Death or Bronchopulmonary Dysplasia.

OBJECTIVE: To study the natural history of postnatal cardiopulmonary adaptation in infants born extremely preterm and establish its association with death or bronchopulmonary dysplasia (BPD). STUDY DESIGN: This was a prospective, observational, cohort study of infants born extremely preterm (<29 weeks). Initial echocardiogram was performed at <48 hours of life, followed by serial echocardiograms every 24-48 hours until 14 days of life. Resolution or no resolution of pulmonary hypertension (PH) at 72-96 hours was considered normal or delayed postnatal cardiopulmonary adaptation, respectively. PH between 96 hours and 14 days was defined as subsequent PH. Elevated pulmonary artery pressure throughout the 14 days of life was considered persistent PH. BPD was assessed at 36 weeks of postmenstrual age. RESULTS: Sixty infants were enrolled; 2 died before a sequential echocardiogram could be done at 72-96 hours. Normal and delayed cardiopulmonary adaptation were noted in 26 (45%) and 32 (55%) infants, respectively. Five patterns of postnatal cardiopulmonary adaptation were recognized: normal without subsequent PH (n = 20), normal with subsequent PH (n = 6), delayed adaptation without subsequent PH (n = 6), delayed adaptation with subsequent PH (n = 16), and persistent PH (n = 10). Infants with delayed cardiopulmonary adaptation were of lower gestation and birth weight and required prolonged ventilation and supplemental oxygen (P < .05). On multivariate analysis, the incidence of death or BPD was significantly greater among infants with delayed adaptation (P < .001). CONCLUSION: Infants born extremely preterm have normal or delayed postnatal cardiopulmonary adaptation that can be complicated by subsequent or persistent PH. Delayed cardiopulmonary adaptation is associated independently with death or BPD.

Variations in practice patterns and resource utilization in patients treated for chronic obstructive pulmonary disease.

RATIONALE, AIMS, AND OBJECTIVES: Several studies have looked at patient-related variables influencing hospital length of stay (LOS) in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). However, there has been increasing recognition that physician-related factors also play a significant role. This study aims to evaluate differences in practice patterns between teaching and nonteaching services and their effect on LOS in a large community hospital. METHODS: A retrospective study of 354 patients admitted to Florida Hospital, Orlando, with AECOPD between January 2009 and December 2011. Patients who presented with acute respiratory failure requiring mechanical ventilation were excluded. Practice patterns of interest were use of oral versus intravenous systemic steroids, use of oral versus intravenous antibiotics, and utilization of consultations. RESULTS: Length of stay was significantly lower in the teaching compared with the nonteaching group (2.80 vs. 5.04 days, P < .001). There was significantly greater use of oral steroids (85% vs. 8.9%, P < .001), greater use of oral antibiotics (72% vs. 33%, P < .001), and lower utilization of consults (0.3 vs. 1.4 consults per patient, P < .001) in the teaching compared with the nonteaching group. The teaching service was independently associated with decreased LOS in a multivariable regression model. However, after adjustment for the difference in practice patterns between the 2 groups, the teaching service was no longer associated with decreased LOS. Of the practice patterns, only utilization of consults was independently associated with increased LOS. CONCLUSIONS: The teaching service had decreased LOS compared with the nonteaching service in patients hospitalized for AECOPD. The observed difference was completely explained by differences in practice patterns between the 2 groups. The study identifies an opportunity for more efficient and cost-effective care of AECOPD patients through streamlining of consultations, use of oral steroids in lieu of IV steroids, and antibiotic stewardship.

Age as a prognostic indicator for adjuvant therapy in patients who underwent pancreatic resections for cancer.

PURPOSE: In pancreatic cancer, the greatest increase in survival is attained by surgical resection followed by adjuvant chemotherapy. Although surgical complications and functional status are recognized as independent factors for halting adjuvant therapy in patients that undergo pancreatic resections, other elements may play a role in deciding which patients get treated postoperatively. Here we determined demographic and clinical characteristics of patients receiving adjuvant chemotherapy, with the primary intent to investigate if age alone affects rates of adjuvant therapy. METHODS/MATERIALS: National Cancer Database (NCDB) was queried for patients that underwent surgery for pancreatic cancer. Groups were divided into: adjuvant chemotherapy (n=17,924) and no adjuvant chemotherapy (n=12,947). Basic demographics and treatment characteristics were analyzed. Age was compared with an independent means test; other comparisons used Chi-square test of independence. RESULTS: There was a statistical difference in age (adjuvant therapy 64.86±9.89 vs. no therapy 67.78±11.22, p<0.001), insurance type, facility type, and cancer stage for patients that received adjuvant therapy and those that did not. Average age of patients not receiving chemotherapy was significantly older at each pathologic stage. Subset analysis of patients treated with chemotherapy showed that the majority of patients received single agent regimens (62%), at an average of 59days following surgery, and at academic cancer programs (52%). CONCLUSIONS: Regardless of postoperative complications and functional status, age alone appears to affect rates of adjuvant therapy in patients with resected pancreatic cancer. Older patients should be offered tailored regimens that would allow them to complete the intended extent of treatment.

Routine versus selective upper gastrointestinal contrast series after omental patch repair for gastric or duodenal perforation.

BACKGROUND: There are no guidelines on the routine or selective use of contrast upper gastrointestinal series (UGI) after omental patch repair (OPR) of a gastric (GP) or duodenal perforation (DP). This study aims to elucidate whether the use of selective versus routine contrast study will lead to worse clinical outcomes. METHODS: A retrospective analysis of 115 (n = 115) patients with OPR of GP or DP was performed. Data were obtained from seven Florida Hospital campuses. Patients aged 18 and older from 2006 to 2016 were identified by ICD9 billing information. Patients were divided into two groups: UGI and no UGI. The UGI group was subdivided into selective versus routine. A selective UGI was defined as one or more of the following after post-operative day 3: WBC >12,000, peritonitis, fever >100.4 F, tachycardia >110 bpm on three or more assessments, and any UGI performed after POD 7. Perioperative symptoms, perforation location, size, abdominal contamination, laparoscopic or open, leak detection, length of stay, mortality, and reoperation within 2 weeks were also examined. RESULTS: No differences between the UGI group and non-UGI group relating to preoperative symptoms, leak detection, death, and reoperation rate were revealed. Differences in length of stay were found to be statistically significant with the UGI group and non-UGI at a median of 15.5 and 8 days, respectively. In the UGI subgroup, 20 of the 29 patients received selective studies. There were no statistical differences identified in leak detection, death, and reoperation. CONCLUSIONS: Rates of leak detection, reoperation, and death in patients with GP or DP repaired with omental patch utilizing an UGI study were not statistically significant. An increased length of stay was observed within the UGI group. There was no advantage demonstrated between a selective versus routine UGI; therefore, the use of selective UGI should be based upon clinical indications.

A Prospective Cohort Study Comparing Colorimetric and Fluorescent Imaging for Sentinel Lymph Node Mapping in Endometrial Cancer.

BACKGROUND: This prospective cohort study aimed to assess sentinel lymph node (SLN) mapping using isosulfan blue (ISB) compared with ISB plus indocyanine green (ICG) and near-infrared imaging (NIR) for patients with endometrial cancer. METHODS: In this study, 200 patients with endometrial cancer underwent SLN assessments and were randomized to ISB + ICG (n = 180) or ISB alone (n = 20). Blue dye determinations were recorded for all 200 cases followed by NIR imaging of ICG for 180 randomized subjects. All the patients underwent robotically assisted hysterectomy with pelvic ± aortic lymphadenectomy. RESULTS: The mean age of the patients was 64.5 ± 8.4 years, and the mean body mass index (BMI) was 33 ± 7.6 kg/m2. The histologies were endometrioid G1 (43%), G2 (30%), G3 (7%), and type 2 (20%). The mean time from dye injection to initiation of mapping was 13.4 ± 6.2 min, and the time to removal of SLN was 17.4 ± 11.2 min. Detection of SLN for the 20 ISB control cases did not differ from that for the 180 ISB + ICG cases (p > 0.05). The rates of SLN detection for ISB + ICG/NIR (n = 180) versus ISB (n = 200) were as follows: bilateral (83.9 vs. 40%), unilateral (12.2 vs. 36%), and none (3.9 vs. 24%) (p < 0.001). The median SLN per case was 2 (range 0-4). Positive SLNs were found in 21.1% (n = 38) of the ISB + ICG cases compared with 13.5% (n = 27) of the ISB cases (p = 0.056). The false-negative rate for SLN biopsy was 2.5% (95% confidence interval, 0.1-14.7%). In 61% (25/41) of the node-positive cases, SLN was the only positive lymph node (LN). Isolated tumor cells were found in 39.5% (15/38) of the SLN metastasis cases compared with 26.7% (4/15) of the non-SLN metastasis cases (p = 0.528). CONCLUSIONS: In this prospective study, ISB + ICG and NIR detected more SLNs and more LN metastases than ISB alone. Assessment of SLN with ICG + ISB/NIR imaging had excellent sensitivity for detection of metastasis and no safety issues.

CT-Guided Microwave Ablation of 45 Renal Tumors: Analysis of Procedure Complexity Utilizing a Percutaneous Renal Ablation Complexity Scoring System.

PURPOSE: To develop a scoring system that stratifies complexity of percutaneous ablation of renal tumors. MATERIALS AND METHODS: Analysis was performed of 36 consecutive patients (mean age, 64 y; range, 30-89 y) who underwent CT-guided microwave (MW) ablation of 45 renal tumors (mean tumor diameter, 2.4 cm; range, 1.2-4.0 cm). Technical success and effectiveness were determined based on intraprocedural and follow-up imaging studies. The RENAL score and the proposed percutaneous renal ablation complexity (P-RAC) score were calculated for each tumor. RESULTS: Technical success was 93.3% (n = 42). Biopsy of 38 of 45 renal tumors revealed 23 renal cell carcinomas. Median follow-up period was 9.7 months (range, 2.9-46.8 months). There were no tumor recurrences. One major complication, ureteropelvic junction stricture, occurred (2.6%). The P-RAC score was found to differ statistically from the RENAL score (t = 3.754, df = 44, P = .001). A positive correlation was found between the P-RAC score and number of antenna insertions (r = .378, n = 45, P = .011) and procedure duration (r = .328, n = 45, P = .028). No correlation was found between the RENAL score and number of MW antenna insertions (r = .110, n = 45, P = .472) or procedure duration (r = .263, n = 45, P = .081). Hydrodissection was significantly more common in the P-RAC high-complexity category than in low-complexity category (χ2 = 12.073, df = 2, P = .002). CONCLUSIONS: The P-RAC score may be useful in stratifying percutaneous renal ablation complexity. Further studies with larger sample sizes are necessary to validate the P-RAC score and to determine if it can predict risk of complications.