Esophageal Adenocarcinoma Metastasizing to a Solitary Fibrous Tumor: An Unprecedented Case of Tumor-to-tumor Metastasis.

BACKGROUND: Tumor-to-tumor (TMT) metastasis is a rare phenomenon in which a primary malignancy undergoes metastasis to an additional synchronous or metachronous primary tumor. CASE REPORT: This is a case report of a tumor-to-tumor metastasis from a poorly differentiated adenocarcinoma of the esophagus to a solitary fibrous tumor (SFT) of the right posterior neck, in a 70-year-old-male with a solitary right vertebral artery. After appropriate work-up and involvement of the necessary specialties, the patient underwent a complex surgical resection with negative margins. CONCLUSION: We present the unique case of a patient with TMT from esophageal adenocarcinoma to an SFT in the posterior neck, not previously reported in the literature. This rare condition with unique oncologic implications highlights the need for a multidisciplinary approach, in this case involving thoracic surgery, head-and-neck surgery, medical oncology, radiation oncology, pathology, and neurosurgical sub-specialty services.

Improved documentation following the implementation of a trauma registry: A means of sustainability for trauma registries in low- and middle-income countries.

INTRODUCTION: Trauma registries in low- and middle-income countries (LMICs) are critical for improving trauma care; however, while some registries have been established in low-income settings, few are sustained due to a lack of sustainable funding. In many LMIC institutions, funding is dependent on documentation of trauma patients, but patient records may be of poor quality, missing, or incomplete. The development of a trauma registry and electronic patient registration system could be used to improve documentation of trauma patients in a low-income setting and lead to increased funding for trauma care. METHODS: A retrospective chart review of trauma patients at Mbarara Regional Referral Hospital in Uganda was performed, documenting the monthly admissions from January 2015-July 2016 prior to the establishment of a trauma registry. A trauma registry and electronic patient registration system were established in 2017, and monthly admissions from February 2017-December 2019 were documented. A negative binomial regression analysis was performed comparing the incident rate of admission pre-implementation of the registry compared to post-implementation, adjusting for month and year. Completeness of trauma patient records was also assessed. RESULTS: Prior to the implementation of the trauma registry and patient registration system (2015-2016), there was a mean of 5.2 (SD 4.4) trauma records per month identified. Following the implementation of the trauma registry, a mean of 103.4 trauma records per month were documented (SD 32.0) for an increased incident rate ratio of 20.9 (95% CI 15.7-27.6, p<0.001). There was also a significant increase in percentage of documents completed (OR 49.1, CI 12.4-193.7, p<0.001). DISCUSSION: Following the implementation of a trauma registry and electronic patient registration system at this low-income country hospital, an increase of 20.9 times completed trauma patient documentation was identified, and completion of the records improved. This more accurate documentation could be used to apply for increased government funding for trauma patients and sustain the trauma registry in the long term and could represent a means of long-term sustainability for other trauma registries in LMICs.

Ethical considerations in global surgery: a scoping review.

Introduction: An unmet burden of surgical disease exists worldwide and is disproportionately shouldered by low-income and middle-income countries (LMICs). As the field of global surgery grows to meet this need, ethical considerations need to be addressed. Currently, there are no formal guidelines to help inform relevant stakeholders of the ethical challenges and considerations facing global surgical collaborations. The aim of this scoping review is to synthesise the existing literature on ethics in global surgery and identify gaps in the current knowledge. Methods: A scoping review of relevant databases to identify the literature pertaining to ethics in global surgery was performed. Eligible articles addressed at least one ethical consideration in global surgery. A grounded theory approach to content analysis was used to identify themes in the included literature and guide the identification of gaps in existing literature. Results: Four major ethical domains were identified in the literature: clinical care and delivery; education and exchange of trainees; research, monitoring and evaluation; and engagement in collaborations and partnerships. The majority of published literature related to issues of clinical care and delivery of the individual patient. Most of the published literature was published exclusively by authors in high-income countries (HICs) (80%), and the majority of articles were in the form of editorials or commentaries (69.1%). Only 12.7% of articles published were original research studies. Conclusion: The literature on ethics in global surgery remains sparse, with most publications coming from HICs, and focusing on clinical care and short-term surgical missions. Given that LMICs are frequently the recipients of global surgical initiatives, the relative absence of literature from their perspective needs to be addressed. Furthermore, there is a need for more literature focusing on the ethics surrounding sustainable collaborations and partnerships.

High-risk medications in older patients with trauma: a cross-sectional study of risk mitigation

Background: The Beers Criteria for Potentially Inappropriate Medication Use inOlder Adults is a framework that can assess the nature of high-risk medication use. The objective of this study was to use the Beers Criteria to assess the prevalence and nature of polypharmacy, the magnitude of medication changes during the hospital stay and the impact of Beers Criteria medications on outcomes in older patients with trauma. Methods: We used the Alberta Trauma Registry to conduct a retrospective review of patients aged 65 years or older with major trauma (Injury Severity Score ≥ 12) who were admitted to a level 1 trauma centre between January 2013 and December 2014. We analyzed changes in medication prescriptions during the hospital stay using descriptive statistics and assessed the association between Beers Criteria medications and relevant outcomes using multivariable regression analysis. Results: There was no significant change in the number of Beers Criteria medications prescribed before and after admission. The adjusted odds ratio for 30-day mortality for each additional Beers Criteria medication prescribed was 2.02 (95% confidence interval [CI] 1.16­3.51) versus 1.24 (95% CI 1.04­1.59) for each additional medication of any type. The corresponding adjusted incidence rate ratios for length of stay were 1.15 (95% CI 1.03­1.30) versus 1.05 (95% CI 1.01­1.10). Conclusion: Beers Criteria medications were not discontinued during trauma admissions. Using the Beers Criteria as a process indicator for quality improvement in trauma care may provide interdisciplinary trauma teams an opportunity to audit patient medications and stop potentially harmful medications in a vulnerable population.

Contexte: Les critères de Beers sur les médicaments potentiellement inappropriés chez les adultes âgés constituent un cadre qui permet d'évaluer la nature d'une pharmacothérapie à risque élevé. L'objectif de cette étude était d'utiliser les critères de Beers pour évaluer la prévalence et la nature de la polypharmacologie, l'ampleur des changements de prescriptions en cours d'hospitalisation et l'impact des médicaments potentiellement inappropriés sur l'évolution de l'état de personnes âgées victimes de traumatismes. Méthodes: Nous avons utilisé le Registre albertain des traumatismes pour procéder à une revue rétrospective des patients de 65 ans et plus victimes d'un traumatisme grave (indice de gravité des blessures ≥ 12) admis dans un centre de traumatologie entre janvier 2013 et décembre 2014. Nous avons analysé les changements de médicaments prescrits durant le séjour hospitalier au moyen de statistiques descriptives et nous avons évalué le lien entre les médicaments potentiellement inappropriés et les variables pertinentes au moyen d'une analyse de régression multivariée. Résultats: On n'a noté aucun changement significatif entre les médicaments potentiellement inappropriés prescrits avant et après l'admission. Le rapport des cotes ajusté pour la mortalité à 30 jours pour chaque médicament potentiellement inapproprié prescrit a été de 2,02 (intervalle de confiance [IC] à 95 % 1,16­3,51) contre 1,24 (IC à 95 % 1,04­1,59) pour chaque médicament additionnel, de tout type. Les rapports des taux d'incidence ajustés correspondants pour la durée de l'hospitalisation ont été de 1,15 (IC à 95 % 1,03­1,30) contre 1,05 (IC à 95 % 1,01­1,10). Conclusion: Les médicaments potentiellement inappropriés (selon les critères de Beers) n'ont pas été cessés durant les admissions pour traumatisme. L'utilisation des critères de Beers comme indicateur de processus pour l'amélioration de la qualité des soins en traumatologie pourrait fournir aux équipes interdisciplinaires une occasion de vérifier les médicaments prescrits et de cesser ceux qui sont nuisibles à une population vulnérable.

The bacteriophage WORiC is the active phage element in wRi of Drosophila simulans and represents a conserved class of WO phages.

BACKGROUND: The alphaproteobacterium Wolbachia pipientis, the most common endosymbiont in eukaryotes, is found predominantly in insects including many Drosophila species. Although Wolbachia is primarily vertically transmitted, analysis of its genome provides evidence for frequent horizontal transfer, extensive recombination and numerous mobile genetic elements. The genome sequence of Wolbachia in Drosophila simulans Riverside (wRi) is available along with the integrated bacteriophages, enabling a detailed examination of phage genes and the role of these genes in the biology of Wolbachia and its host organisms. Wolbachia is widely known for its ability to modify the reproductive patterns of insects. One particular modification, cytoplasmic incompatibility, has previously been shown to be dependent on Wolbachia density and inversely related to the titer of lytic phage. The wRi genome has four phage regions, two WORiBs, one WORiA and one WORiC. RESULTS: In this study specific primers were designed to distinguish between these four prophage types in wRi, and quantitative PCR was used to measure the titer of bacteriophages in testes, ovaries, embryos and adult flies. In all tissues tested, WORiA and WORiB were not found to be present in excess of their integrated prophages; WORiC, however, was found to be present extrachromosomally. WORiC is undergoing extrachromosomal replication in wRi. The density of phage particles was found to be consistent in individual larvae in a laboratory population. The WORiC genome is organized in conserved blocks of genes and aligns most closely with other known lytic WO phages, WOVitA and WOCauB. CONCLUSIONS: The results presented here suggest that WORiC is the lytic form of WO in D. simulans, is undergoing extrachromosomal replication in wRi, and belongs to a conserved family of phages in Wolbachia.