Evaluation of Nationwide Trends in Nodal Sampling Guideline Adherence for Gastric Cancer: 2005-2017.

INTRODUCTION: Surgical resection is the primary curative treatment for localized gastric cancer. A multitude of research supports surgical nodal sampling guidelines. Though there are known disparities in adherence to nodal sampling, it is unclear how hospital program-level disparities have changed over time. The purpose of this study is to evaluate trends in program-level disparities in adherence to gastric cancer nodal sampling guidelines. METHODS: Patients who underwent resection of gastric cancer from 2005 to 2017 were identified in the National Cancer Database. Patients treated at academic programs were compared to those treated at nonacademic programs, and rates and trends of adherence to nodal sampling guidelines (defined as ≥15 lymph nodes) were determined. Adjusted multivariable analysis was used to determine likelihood of nodal sampling adherence while controlling for sociodemographic, clinical, hospital, and travel distance characteristics. RESULTS: A total of 55,421 patients were included with 27,201 (49.1%) of patients meeting adherence criteria for lymph node sampling. Academic programs treated 44.4% of the total cohort. Overall, lymph node sampling criteria were met in 59.2% of patients treated at high-volume academic programs and 37.0% of patients treated at low-volume nonacademic programs (incidence rate ratios 0.67, 95% confidence interval 0.63-0.72 versus high-volume academic programs). Adherence rates improved from 2005 to 2017 for both low-volume nonacademic programs (27.8% in 2005 to 50.1% in 2017) and high-volume academic programs (46.0% in 2005 to 69.8% in 2017, P < 0.001). CONCLUSIONS: Though adherence rates have improved from 2005 to 2017, high-volume academic programs were more likely to adhere to lymph node sampling guidelines for gastric cancer.

Association between travel distance and overall survival among patients with adrenocortical carcinoma.

BACKGROUND AND OBJECTIVES: Regionalization of care is associated with improved perioperative outcomes after adrenalectomy. However, the relationship between travel distance and treatment of adrenocortical carcinoma (ACC) is unknown. We investigated the association between travel distance, treatment, and overall survival (OS) among patients with ACC. METHODS: Patients diagnosed with ACC between 2004 and 2017 were identified with the National Cancer Database. Long distance was defined as the highest quintile of travel (≥42.2 miles). The likelihood of surgical management and adjuvant chemotherapy (AC) were determined. The association between travel distance, treatment, and OS was evaluated. RESULTS: Of 3492 patients with ACC included, 2337 (66.9%) received surgery. Rural residents were more likely to travel long distances for surgery than metropolitan residents (65.8% vs. 15.5%, p < 0.001), and surgery was associated with improved OS (HR 0.43, 95% CI 0.34-0.54). Overall, 807 (23.1%) patients received AC with rates decreasing approximately 1% per 4-mile travel distance increase. Also, long distance travel was associated with worse OS among surgically treated patients (HR 1.21, 95% CI 1.05-1.40). CONCLUSIONS: Surgery was associated with improved overall survival for patients with ACC. However, increased travel distance was associated with lower likelihood to receive adjuvant chemotherapy and decreased overall survival.

Relationship Between Residents' Physiological Stress and Faculty Leadership Skills in a Department of Surgery.

BACKGROUND: Leadership skills of team leaders can impact the functioning of their teams. It is unknown whether attending surgeons' leadership skills impact residents' physiological stress. This study sought to (1) assess the relationship between attending surgeons' leadership skills and residents' physiological stress and (2) to characterize lifestyle behaviors associated with resident physiological stress. We hypothesized that strong attending leadership skills would be associated with low resident physiological stress. STUDY DESIGN: This prospective observational cohort study was conducted at a single urban, academic medical center in the US, over 12 months. Residents were enrolled during their rotation of 1 to 2 months on the Trauma and ICU services. The primary predictor was the attending surgeons' leadership skills that were measured using a weekly survey filled out by residents, using the Surgeons' Leadership Inventory (SLI). The SLI uses a 4-point Likert scale to measure surgeons' leadership skills across eight domains. The primary outcome was residents' physiological stress, which was measured by their Heart Rate Variability (HRV). We recorded the residents' HRV with a WHOOP strap that was continuously worn on the wrist or the bicep. We used multivariate repeated measures gamma regression to assess the relationship between attending leadership skills and residents' physiological stress, adjusting for hours of sleep, age, and service. RESULTS: Sixteen residents were enrolled over 12 months. The median attending surgeons' leadership score was 3.8 (IQR: 3.2-4.0). The median residents' percent of maximal HRV was 70.8% (IQR: 56.7-83.7). Repeated measure gamma regression model demonstrated a minimal nonsignificant increase of 1.6 % (95% CI: -5.6, 8.9; p-value = 0.65) in the percent of maximal HRV (less resident physiological stress) for every unit increase in leadership score. There was an increase of 2.9% (95% CI= 1.6, 4.2; p-value < 0.001) in the percent of maximal HRV per hour increase in sleep and a significant decrease of 10.9% (95% CI= -16.8, -5.2; < 0.001) in the percent of HRV when working in the ICU compared to the Trauma service. CONCLUSION: This study revealed that more residents' sleep was associated with lower physiological stress. Attending surgeons' leadership skills were not associated with residents' physiological stress.

Measuring response to neoadjuvant therapy using biomarkers in pancreatic cancer: a narrative review.

BACKGROUND AND OBJECTIVE: Pancreatic cancer is the 4th leading cause of cancer death in the US, with incidence increasing over the last 20 years. Recently neoadjuvant therapy (NAT) has emerged as an important tool in improving resectability and overall survival. The objective is to describe and discuss the current literature on the use of biomarkers in measuring response to NAT in pancreatic adenocarcinoma. METHODS: An electronic review of PubMed, Google Scholar and Cochrane was performed to obtain key literature on serum, imaging, clinical, and histologic biomarkers utilized to measure response to NAT in pancreatic cancer. This literature review included publications in English written between January 1, 2011 to March 31, 2022. KEY CONTENT AND FINDINGS: An overview of four categories of biomarkers was evaluated for their utility in assessing both pathologic response and overall survival following NAT in pancreatic adenocarcinoma. Serum CA19-9 as well as CT radiomic features, FDG PET response and development of histologic grading system all show promise as markers of response to NAT. CONCLUSIONS: While multiple promising modalities exist, all require some form of standardization in terms of predicting response to NAT. Further investigation and large-scale studies to evaluate the efficacy of various imaging modalities are necessary. Additionally, there needs to be standardization of histologic grading system post NAT, and consensus on CA19-9 cutoff values in determining NAT response.

Developing sustainable prehospital trauma education in Rwanda.

INTRODUCTION: Every year, >5 million people worldwide die from trauma. In Kigali, Rwanda, 50% of prehospital care provided by SAMU, the public prehospital system, is for trauma. Our collaboration developed and implemented a context-specific, prehospital Emergency Trauma Care Course (ETCC) and train-the-trainers program for SAMU, based on established international best practices. METHODS: A context-appropriate two-day ETCC was developed using established best practices consisting of traditional 30-minute lectures followed by 20-minute practical scenario-based team-driven simulation sessions. Also, hands-on skill sessions covered intravenous access, needle thoracostomy and endotracheal intubation among others. Two cohorts participated - SAMU staff who would form an instructor core and emergency staff from ten district, provincial and referral hospitals who are likely to respond to local emergencies in the community. The instructor core completed ETCC 1 and a one-day educator course and then taught the second cohort (ETCC2). Pre and post course assessments were conducted and analyzed using Student's t-test and matched paired t-tests. RESULTS: ETCC 1 had 17 SAMU staff and ETCC 2 had 19 hospital staff. ETCC 1 mean scores increased from 40% to 63% and ETCC 2 increased from 41% to 78% after the course (p < 0.001 using matched pair analysis). A one-way ANOVA mean square analysis showed that regardless of the baseline level of training for each participant, all trainees reached similar post-course assessment scores, F (1) = 15.18, p = 0.0004. DISCUSSION: This study demonstrates effective implementation of a context-appropriate prehospital trauma training program for prehospital staff in Kigali, Rwanda. The course resulted in improved knowledge for an instructor core and for staff from district and provincial hospitals confirming the effectiveness of a train-the-trainers model. This program may be effective to support capacity development for prehospital trauma care in the country using a qualified local source of instructors.