Early-Onset Colorectal Cancer Patients Do Not Require Shorter Intervals for Post-Surgical Surveillance Colonoscopy.

BACKGROUND: Early-onset colorectal cancer (EO-CRC), diagnosed before age 50, is rising in incidence worldwide. Although post-surgical colonoscopy surveillance strategies exist, appropriate intervals in EO-CRC remain elusive, as long-term surveillance outcomes remain scant. We sought to compare findings of surveillance colonoscopies of EO-CRC to average onset colorectal cancer (AO-CRC) patients to help define surveillance outcomes in these groups. METHODS: Single institution retrospective chart review identified EO-CRC and AO-CRC patients with colonoscopy and no evidence of disease. Surveillance intervals and time to development of advanced neoplasia (CRC and advanced polyps (adenoma/sessile serrated)) were examined. For each group, three serial surveillance colonoscopies were evaluated. Statistical analyses were performed utilizing log-ranked Kaplan-Meier method and Cox proportional hazards. RESULTS: A total of 1259 CRC patients were identified, with 612 and 647 patients in the EO-CRC and AO-CRC groups, respectively. Compared to AO-CRC patients, EO-CRC patients had a 29% decreased risk of developing advanced neoplasia from time of initial surgery to first surveillance colonoscopy (HR=0.71, 95% CI 0.52 - 1.0). Average follow-up time from surgical resection to first surveillance colonoscopy was 12.6 months for both cohorts. Overall surveillance findings differed between cohorts (p=0.003), and EO-CRC were found to have less advanced neoplasia compared to AO-CRC counterparts (12.4% vs 16.0%, respectively). Subsequent colonoscopies found that while EO-CRC patients returned for follow-up surveillance colonoscopy earlier than AO-CRC patients, the EO-CRC cohort did not have more advanced neoplasia nor non-advanced adenomas. CONCLUSIONS: EO-CRC patients do not have an increased risk of advanced neoplasia compared to AO-CRC patients and therefore do not require more frequent colonoscopy surveillance than current guidelines recommend.

Morbidity and mortality in patients with stage IV pancreatic adenocarcinoma and acute cholangitis: Outcomes and risk prognostication.

BACKGROUND: Acute cholangitis (AC) is a common complication of pancreatic ductal adenocarcinoma (PDAC). Herein, we evaluated outcomes after the first AC episode and predictors of mortality and AC recurrence in patients with stage IV PDAC. METHODS: We conducted a single-center, retrospective observational study using institutional databases. Clinical data and outcomes for patients with stage IV PDAC and at least one documented episode of AC, were assessed. Overall survival (OS) was estimated using the Kaplan-Meier method, and Cox regression model was employed to identify predictors of AC recurrence and mortality. RESULTS: One hundred and twenty-four patients with stage IV PDAC and AC identified between January 01, 2014 and October 31, 2020 were included. Median OS after first episode of AC was 4.1 months (95 % CI, 4.0-5.5), and 30-day, 6, and 12-month survival was 86.2 % (95 % CI, 80.3-92.5), 37 % (95 % CI, 29.3-46.6 %) and 18.9 % (95 % CI, 13.1-27.3 %), respectively. Primary tumor in pancreatic body/tail (HR 2.29, 95 % CI: 1.26 to 4.18, p = 0.011), concomitant metastases to liver and other sites (HR 1.96, 95 % CI: 1.16 to 3.31, p = 0.003) and grade 3 AC (HR 2.26, 95 % CI: 1.45 to 3.52, p < 0.001), predicted worse outcomes. Intensive care unit admission, sepsis, systemic therapy, treatment regimen, and time to intervention did not predict survival or risk of recurrence of AC. CONCLUSIONS: AC confers significant morbidity and mortality in advanced PDAC. Worse outcomes are associated with higher grade AC, primary tumor location in pancreatic body/tail, and metastases to liver and other sites.

Treatment of esophageal adenocarcinoma in patients with a history of bariatric surgery.

BACKGROUND: The relationship among obesity, bariatric surgery, and esophageal adenocarcinoma (EAC) is complex, given that some bariatric procedures are thought to be associated with increased incidence of reflux and Barrett's esophagus. Previous bariatric surgery may complicate the use of the stomach as a conduit for esophagectomy. In this study, we presented our experience with patients who developed EAC after bariatric surgery and described the challenges encountered and the techniques used. METHODS: We conducted a retrospective review of our institutional database to identify all patients at our institution who were treated for EAC after previously undergoing bariatric surgery. RESULTS: In total, 19 patients underwent resection with curative intent for EAC after bariatric surgery, including 10 patients who underwent sleeve gastrectomy. The median age at diagnosis of EAC was 63 years; patients who underwent sleeve gastrectomy were younger (median age, 56 years). The median time from bariatric surgery to EAC was 7 years. Most patients had a body mass index (BMI) score of >30 kg/m2 at the time of diagnosis of EAC; approximately 40% had class III obesity (BMI score > 40 kg/m2). Six patients (32%) had known Barrett's esophagus before undergoing a reflux-increasing bariatric procedure. Sleeve gastrectomy patients underwent esophagectomy with gastric conduit, colonic interposition, or esophagojejunostomy. Only 1 patient had an anastomotic leak (after esophagojejunostomy). CONCLUSION: Endoscopy should be required both before (for treatment selection) and after all bariatric surgical procedures. Resection of EAC after bariatric surgery requires a highly individualized approach but is safe and feasible.

Noninvasive imaging modalities in coronary artery disease: a meta analysis comparing coronary computed tomography angiography and standard of care.

Introduction: Coronary artery disease has become a global pandemic and a major cause of death. The risk-factor calculation for coronary artery damage is an invasive procedure. Aim: To compare coronary computed tomography angiography (CCTA) with standard of care (SOC) to calculate need for revascularization, invasive coronary angiography as well as for myocardial infarction (MI) incidence and all-cause mortality. Methodology, results & conclusion: CCTA is significantly correlated with a reduction in MI episodes (RR = 0.752, 95% CI = 0.578-1.409; p < 0.033) and an increase in revascularizations (RR = 1.401, 95% CI = 1.315-1.492; p < 0.001) and invasive coronary angiography procedures (RR = 1.304, 95% CI = 1.208-1.409; p < 0.001). However, it was found that it did not affect all-cause mortality. On the contrary, standard care approaches were associated with greater rates of MI but lesser referrals for invasive coronary angiography and revascularization.

The World Health Organization classification of pancreaticobiliary cytopathology stratifies risk of malignancy and outcome for endoscopic ultrasound-guided fine-needle aspiration of the pancreas.

BACKGROUND: The World Health Organization (WHO) has recently published a classification for reporting pancreaticobiliary cytopathology with differences compared to the Papanicolaou Society of Cytopathology (PSC) classification. METHODS: Retrospective data were collected from pancreatic endoscopic ultrasound-guided fine-needle aspirations from 2014 to 2017 at a pancreatic cancer center. Absolute risk of malignancy (AROM), relative risk (to benign), performance characteristics, and overall survival were calculated for the entire cohort with comparison of cysts and solid lesions. RESULTS: In total, 2562 cases were included: 16% cyst (n = 411) and 84% solid (n = 2151). The histologic confirmation rate was 43% (n = 1101) and the median follow-up (for benign) was 56 months. For WHO I-VII, overall AROM (%) was 23, 22, 62, 13, 65, 97, and 100; cyst AROM was 7, 0, 19, 13, 38, 78, and 100; and solid AROM was 50, 29, 70, 15, 100, 99, and 100. For PSC I-VI, overall AROM (%) was 23, 29, 64, 0 (IVa), 60 (IVb), 97, and 100; cyst AROM was 7, 0, 19, 0, 21, 78, and 100; and solid AROM was 50, 35, 73, 0, 92, 99, and 100. The difference in relative risk for a cyst (vs. solid) overall was 0.38 for WHO and 0.26 for PSC. WHO and PSC categories showed stratification for the probability of overall survival. CONCLUSIONS: Cystic versus solid lesion type can dramatically affect AROM, particularly for nondiagnostic (I), benign (II), atypical (III), and WHO V categories. WHO IV conveys a similarly low AROM for cystic and solid types. Both classifications stratify the probability of overall survival, including the newly introduced categories WHO IV and WHO V.

Social Determinants of Health and Parenting Self-Efficacy Among Mothers of Preterm Infants.

Objective: To explore the relationships between social and environmental factors and parenting self-efficacy (PSE) among mothers of preterm infants hospitalized in neonatal intensive care units (NICUs) using a social determinants of health (SDoH) framework. Method: We analyzed data from a prospective cohort study that included 187 mother-infant dyads admitted to four NICUs in the Mountain West region between June 2017 and December 2019. We used multivariable linear regression models to assess the independent associations between maternal and infant characteristics and PSE. Results: Our final multiple linear regression model predicting the efficacy score including maternal race/ethnicity, age, insurance, employment status before giving birth, gestational age, depression, and having other children was significant (F(12,160) = 3.17, p = .0004, adjusted R¬2 = .131). Significant predictors of PSE were race/ethnicity (ß= 3.3, p = .022), having another child/children (ß= 4.2, p = .005), and depression (ß= -4.2, p = .004). Conclusions: Findings suggest that social workers and medical practitioners should consider SDoH, such as insurance type, household income, and employment, along with traditional clinical indicators when assessing families' infant care needs. Social workers, medical practitioners, and researchers should be mindful of how implicit bias may influence the allocation of care and parental supports.

NICU Visitation Time and Adherence to Safe Sleep Practices Among Mothers of Very Preterm Infants.

BACKGROUND: Sleep-associated infant death is the leading cause of postneonatal mortality in the United States. Preterm infants are at higher risk for sleep-associated death, but maternal adherence to safe sleep practices is lower than for mothers of full-term infants. Data are lacking on whether maternal neonatal intensive care unit (NICU) visitation time impacts safe sleep compliance after hospital discharge. PURPOSE: For mothers of preterm infants, to investigate the association of time days per week spent in the NICU and adherence to safe sleep practices after discharge. METHODS: A prospective observational study of 109 mothers with infants born at less than 32 weeks from 4 Colorado NICUs who completed a survey at 6 weeks after discharge about infant sleep practices. Maternal time spent in the NICU was defined as the average number of days spent in the NICU per week of infant hospitalization, as documented in the electronic medical record. Multivariable logistic regression models assessed the relationship between time in the NICU and safe sleep adherence. Covariates included maternal/infant characteristics significant at P < .2 level in bivariate analysis. RESULTS: Predictors of compliance with all safe infant sleep practices included public/no insurance compared with private insurance (adjusted odds ratio [AOR] 0.29; 95% confidence interval [CI] 0.09-0.96), some college/associate-level education versus bachelor's degree (AOR 5.88; 95% CI 1.21-28.67), and depression/anxiety symptoms (AOR 0.37; 95% CI 0.14-0.97). NICU visitation days was not associated with adherence to safe sleep practices. IMPLICATIONS FOR PRACTICE AND RESEARCH: Maternal visitation days was not associated with adherence to safe infant sleep practices after discharge, highlighting the need to identify barriers and facilitators to engaging families about SUID risk-reducing behaviors.

Diagnostic features of low- and high-grade mucinous neoplasms in pancreatic cyst FNA cytology.

BACKGROUND: Pancreatic cyst cytology evaluates for neoplastic mucin and epithelial grade. This study describes cytological features of low- and high-grade mucinous neoplasms (MNs) using gastrointestinal contaminants for comparison. METHODS: Histologically confirmed pancreatic cystic neoplasms were reviewed by a panel of cytopathologists to identify which, among 26 selected cytologic features, correlate significantly with low- and high-grade MN. A test for greater than or equal to four of eight high-grade features (three-dimensional architecture, high nuclear:cytoplasmic ratio, moderate nuclear membrane abnormalities, loss of nuclear polarity, hyperchromasia, >4:1 nuclear size variation in one cluster, karyorrhexis, and necrosis) was assessed for identifying a high-grade neoplasms. Additional characteristics of the cohort such as cyst fluid carcinoembryonic antigen results, molecular testing, Papanicolaou Society of Cytopathology classification, and select high-risk clinical features are described. RESULTS: Endoscopic ultrasound fine-needle aspirations from 134 MN and 17 serous cystadenomas containing gastrointestinal contaminants were included. The MN consisted of 112 (84%) intraductal papillary MNs (low-grade = 69, 62%; high-grade = 24, 21%; and invasive = 19, 17%) and mucinous cystic neoplasms (low-grade = 20, 90%; high-grade = 2, 10%). Half had greater than five clusters of epithelium for analysis. Compared with gastrointestinal contaminants, mucin from MN was thick and colloid-like (40% vs. 6%, p < .01), covered >20% of the smear area (32% vs. none, p < .01), and contained histiocytes (46% vs. 18%, p = .04). Greater than or equal to four of eight select high-grade features was present in 36% of high-grade MN with sensitivity 37% and 98% specificity. CONCLUSION: Colloid-like features, >20% of smear, and histiocytes correlated with MN. Testing for greater than or equal to four high-grade features had low sensitivity and high specificity for high-grade MN.

"We're all going through it": impact of an online group coaching program for medical trainees: a qualitative analysis.

BACKGROUND: Trainees in graduate medical education are affected by burnout at disproportionate rates. Trainees experience tremendous growth in clinical skills and reasoning, however little time is dedicated to metacognition to process their experiences or deliberate identity formation to create individualized definitions of success and wellbeing. The purpose of this study was to understand the perspectives and experiences of trainees who participated in a 6-month, web-based, group coaching program for women residents in training. METHODS: Better Together Physician Coaching is a six-month, self-paced, online, asynchronous, coaching program with multiple components including live coaching calls, unlimited written coaching, and self-study modules. Semi-structured interviews of seventeen participants of Better Together from twelve GME programs within a single institution in Colorado were conducted from May to June of 2021. All identified as women and had participated in a 6-month coaching program. Both inductive and deductive methods were used in collecting and analyzing the data with an aim to understand learners' perceptions of the coaching program, including "how and why" the coaching program affected training experiences and wellbeing. RESULTS: Three main themes emerged as benefits to the coaching program from the data: 1) practicing metacognition as a tool for healthy coping 2) building a sense of community, and 3) the value of a customizable experience. CONCLUSIONS: Female trainees who participated in a group coaching program expressed that they found value in learning how to cope with stressors through metacognition-focused coaching. They also described that building a community and being able to customize the experience were positive aspects of the program. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05280964 . Date of registration: March 15th 2022. Retrospectively registered. URL of trial registry record.

Effect of a Novel Online Group-Coaching Program to Reduce Burnout in Female Resident Physicians: A Randomized Clinical Trial.

Importance: Female resident physicians are disproportionately affected by burnout, which can have serious consequences for their well-being and career trajectory. Growing evidence supports the use of professional coaching to reduce burnout in resident physicians, yet individual coaching is resource intensive and infeasible for many training programs. Objective: To assess whether a structured professional group-coaching program for female resident physicians would lead to decreased burnout. Design, Setting, and Participants: This pilot randomized clinical trial was conducted from January 1 to June 30, 2021, among 101 female resident physicians in graduate medical education at the University of Colorado who voluntarily enrolled in the trial after a recruitment period. Surveys were administered to participants before and after the intervention. Intervention: With the use of a computer-generated 1:1 algorithm, 50 participants were randomly assigned to the intervention group and 51 participants were randomly assigned to the control group. The intervention group was offered a 6-month, web-based group-coaching program, Better Together Physician Coaching, developed and facilitated by trained life coaches and physicians. The control group received residency training as usual, with no coaching during the study. The control group was offered the 6-month coaching program after study completion. Main Outcomes and Measures: The primary outcome of burnout was measured using the Maslach Burnout Inventory, defined by 3 Likert-type 7-point subscales: emotional exhaustion, depersonalization, and professional accomplishment. Higher scores on the emotional exhaustion and depersonalization subscales and lower scores on the professional accomplishment subscale indicate higher burnout. Secondary outcomes of impostor syndrome, self-compassion, and moral injury were assessed using the Young Impostor Syndrome Scale, Neff's Self-Compassion Scale-Short Form, and the Moral Injury Symptom Scale-Healthcare Professionals, respectively. An intention-to-treat analysis was performed. Results: Among the 101 female residents in the study, the mean (SD) age was 29.4 (2.3) years, 96 (95.0%) identified as heterosexual, and 81 (80.2%) identified as White. There were 19 residents (18.8%) from surgical subspecialties, with a range of training levels represented. After 6 months of professional coaching, emotional exhaustion decreased in the intervention group by a mean (SE) of 3.26 (1.25) points compared with a mean (SE) increase of 1.07 (1.12) points in the control group by the end of the study (P = .01). The intervention group experienced a significant reduction in presence of impostor syndrome compared with controls (mean [SE], -1.16 [0.31] vs 0.11 [0.27] points; P = .003). Self-compassion scores increased in the intervention group by a mean (SE) of 5.55 (0.89) points compared with a mean (SE) reduction of 1.32 (0.80) points in the control group (P < .001). No statistically significant differences in depersonalization, professional accomplishment, or moral injury scores were observed. Owing to the differential follow-up response rates in the treatment groups (88.2% in the control group [45 of 51]; 68.0% in the intervention group [34 of 50]), a sensitivity analysis was performed to account for the missing outcomes, with similar findings. Conclusions and Relevance: In this randomized clinical trial, professional coaching reduced emotional exhaustion and impostor syndrome scores and increased self-compassion scores among female resident physicians. Trial Registration: ClinicalTrials.gov Identifier: NCT05280964.

Endoscopic stenting for malignant biliary obstruction is technically successful in patients with preexisting duodenal stents.

Background and study aims There are limited data on the success of endoscopic retrograde cholangiopancreatography (ERCP) in patients with malignant biliary and duodenal obstruction with a preexisting duodenal stent. The aim of this study was to evaluate patient and procedural outcomes of a cohort of patients with preexisting duodenal stents who underwent an attempt at ERCP for malignant biliary obstruction (MBO). Patients and methods This was a single-center retrospective study on consecutive patients with a preexisting duodenal stent who underwent attempted ERCP for MBO. Technical success was defined as successful cannulation of the common bile duct, with successful dilation and/or deployment of a biliary stent under fluoroscopy. Clinical success was defined as number of patients in the entire group who underwent ERCP successfully with resolution of symptoms. Results We identified 64 patients (73 % men, 74 % white, median age 62 years) with a preexisting duodenal stent who underwent 85 attempts at ERCP. ERCP was technically successful in 50 of 85 procedures (59 %). Overall ERCP was successful in 41 of 85 patients (48 %). ERCP was more likely to be successful in patients with Type 1 and 3 duodenal strictures than with Type 2 strictures (83 % and 92 % vs. 42 %, P  < 0.01), in patients with a preexisting sphincterotomy (79% vs. 20 %, P  = 0.01) or preexisting biliary stent (66 % vs. 34 %, P  = 0.04). Adverse events included bleeding (n = 3), post-procedure fever (n = 3) and abdominal pain (n = 1). Conclusions Although biliary stenting via ERCP is often technically challenging in patients with a prior duodenal stent, it is a safe and effective method of biliary drainage. ERCP should be attempted in patients with Type 1 and 3 duodenal strictures, a prior sphincterotomy or an indwelling biliary stent.

The Role of the TP53 Pathway in Predicting Response to Neoadjuvant Therapy in Esophageal Adenocarcinoma.

PURPOSE: In patients with locally advanced esophageal adenocarcinoma, response to neoadjuvant therapy strongly predicts survival, but robust molecular predictors of response have been lacking. We therefore sought to discover meaningful predictors of response in these patients. EXPERIMENTAL DESIGN: We retrospectively identified all patients with adenocarcinoma of the lower esophagus or gastroesophageal junction who (i) were treated with multimodality therapy with curative intent at our institution from 2014 through 2020 and (ii) underwent prospective sequencing by Memorial Sloan Kettering-Integrated Mutation Profiling of Actionable Cancer Targets. Clinicopathologic and genomic data were analyzed to identify potential genomic features, somatic alterations, and oncogenic pathways associated with treatment response. RESULTS: In total, 237 patients were included. MDM2 amplification was independently associated with poor response to neoadjuvant therapy [OR, 0.10 (95% confidence interval, 0.01-0.55); P = 0.032], when accounting for significant clinicopathologic variables, including clinical stage, tumor grade, and chemotherapy regimen. Moreover, TP53 pathway alterations, grouped according to inferred severity of TP53 dysfunction, were significantly associated with response to neoadjuvant therapy (P = 0.004, q = 0.07). Patients with MDM2 amplifications or truncating biallelic TP53 mutations had similar outcomes in terms of poor responses to neoadjuvant therapy and, consequently, shorter progression-free survival, compared with patients with TP53 pathway wild-type tumors. Thus, worsening TP53 dysfunction was directly correlated with worse outcomes. CONCLUSIONS: MDM2 amplification and TP53 status are associated with response to therapy in patients with esophageal adenocarcinoma. Given the dearth of actionable targets in esophageal adenocarcinoma, MDM2 inhibition, in combination with cytotoxic chemotherapy, may represent an important therapeutic strategy to overcome treatment resistance and improve outcomes in these patients.

Comparisons of Three Measures of Maternal Engagement Activities in the Neonatal Intensive Care Unit.

BACKGROUND: Mothers' engagement with their hospitalized preterm infant(s) is recognized as an important aspect of treatment in neonatal intensive care units (NICUs). However, no gold standard exists for measuring maternal engagement, and the various methods used to measure mothers' time have documented limitations. OBJECTIVES: This study sought to compare three measurement methods of maternal engagement (a five-item maternal cross-sectional survey, time use diaries, and electronic health records [EHRs]) to identify whether these methods capture consistent data and patterns in detected differences in measures of engagement. METHODS: Maternal engagement was defined as time spent visiting the infant in the NICU (presence), holding (blanket holding in the mother's arms or by kangaroo care [KC]), and caregiving (e.g., bathing and changing diapers). The survey estimating daily maternal engagement was administered in two Level III NICUs and one Level IV NICU at study enrollment, at least 2 weeks after admission. Mothers then completed the daily time use diaries until infant discharge. Data were also collected from participants' EHRs, charted by nursing staff. Wilcoxon signed-rank tests were used for pairwise analysis of the three measures for maternal engagement activities. RESULTS: A total of 146 participants had data across all three measurement types and were included in the analysis. In the Level III NICUs (n = 101), EHR data showed significantly more time spent with all engagement activities than the diary data. In the Level IV data, only differences in time holding were significant when comparing EHR data with survey data, with mothers reporting more time doing KC and less time blanket holding. Comparison of EHR data with diary data showed more time in all activities except KC. DISCUSSION: In most cases, time spent in engagement activities measured in the EHR was higher than in the surveys or time use diaries. Accuracy of measurements could not be determined because of limitations in data collection, and there is no gold standard for comparison. Nevertheless, findings contribute to ongoing efforts to develop the most valuable and accurate strategies for measuring maternal engagement-a significant predictor of maternal and infant health.

The Association of Social Factors and Time Spent in the NICU for Mothers of Very Preterm Infants.

OBJECTIVES: Evaluate the association between maternal social factors and maternal time spent in the NICU for very preterm infants admitted to 4 level III and IV NICUs. METHODS: In this prospective observational cohort study, we enrolled mother-infant dyads whose infants were born <32 weeks' gestation. Enrollment occurred after 2 weeks of NICU exposure, when maternal social factors and demographic information was collected. Maternal time spent in the NICU was abstracted from the electronic medical record and was dichotomized into 0 to 6 days and ≥6 days per week. Demographic differences between the 2 groups were compared by using χ2 tests. Logistic regression was used to assess the independent association between maternal social factors and the average number of days per week spent in the NICU. RESULTS: A total of 169 mother-infant dyads were analyzed. Maternal social factors associated with more time spent in the NICU included an annual household income of >$100 000, compared with those with an annual household income of <$50 000 (adjusted odds ratio [aOR]: 5.68; 95% confidence interval [CI] 1.77-18.19), a travel time <30 minutes to the NICU (compared with those who traveled >60 minutes [aOR: 7.85; 95% CI 2.81-21.96]), and the lack of other children in the household, compared with women with other children (aOR: 3.15; 95% CI 1.39-7.11). CONCLUSIONS: Maternal time spent in the NICU during a prolonged birth hospitalization of a very preterm infant differed by socioeconomic status, travel time, and presence of other dependents. Strategies to better identify and reduce these disparities to optimize engagement and, subsequently, improve infant health outcomes is needed.

Next-Generation Sequencing of 487 Esophageal Adenocarcinomas Reveals Independently Prognostic Genomic Driver Alterations and Pathways.

PURPOSE: To delineate recurrent oncogenic driver alterations and dysregulated pathways in esophageal adenocarcinoma and to assess their prognostic value. EXPERIMENTAL DESIGN: We analyzed a large cohort of patients with lower esophageal and junctional adenocarcinoma, prospectively sequenced by MSK-IMPACT with high-quality clinical annotation. Patients were subdivided according to treatment intent, curative versus palliative, which closely mirrored clinical staging. Genomic features, alterations, and pathways were examined for association with overall survival using Cox proportional hazard models, adjusted for relevant clinicopathologic factors knowable at the time of diagnosis. RESULTS: Analysis of 487 patients revealed 16 oncogenic driver alterations, mostly amplifications, present in ≥5% of patients. Patients in the palliative-intent cohort, compared with those in the curative-intent cohort, were more likely to have metastatic disease, ERBB2 amplifications, Cell-cycle and RTK-RAS pathway alterations, as well as a higher fraction of genome altered and rate of whole-genome doubling. In multivariable analyses, CDKN2A alterations, SMAD4 alterations, KRAS amplifications, Cell-cycle and TGFß pathways, and overall number of oncogenic drivers were independently associated with worse overall survival. ERBB2 amplification was associated with improved survival, presumably due to trastuzumab therapy. CONCLUSIONS: Our study suggests that higher levels of genomic instability are associated with more advanced disease in esophageal adenocarcinoma. Furthermore, CDKN2A, KRAS, and SMAD4 represent prognostic biomarkers, given their strong association with poor survival.

Defining low-risk lesions in early-stage esophageal adenocarcinoma.

OBJECTIVE: As endoscopic approaches become more widely used to treat early-stage esophageal cancer, reliably identifying patients with less-aggressive tumors is paramount. We sought to identify risk factors for recurrence in patients with completely resected T1 esophageal adenocarcinoma. METHODS: We retrospectively analyzed a single-institutional database for all patients with completely resected pathologic T1 esophageal adenocarcinoma (1996-2016). Risk factors for recurrence were identified using competing-risk regression methods. Risk stratification was performed on the basis of known preoperative clinicopathologic factors; this model's discriminative power for overall survival was evaluated using a Cox proportional hazards model. RESULTS: Of 243 patients, 32 experienced recurrence. At a median follow-up among survivors of 4 years (range, 0.05-19 years), the 5-year cumulative incidence of recurrence was 15%, and median time to recurrence was 2 years (range, 0.26-6.13 years). On univariable analysis, submucosal invasion, N1 disease, poor differentiation, tumor length, lymphovascular invasion, and multicentricity were significantly associated with recurrence. On multivariable analysis, N1 disease (hazard ratio, 2.93; 95% confidence interval, 1.17-7.34; P = .022) and tumor length (hazard ratio, 1.44; 95% confidence interval, 1.12-1.86; P = .004) were independently associated with recurrence. Risk stratification showed that patients without lymphovascular invasion and a with median tumor length of 0.8 cm (range, 0.10-1.70 cm) had a <10% risk of recurrence and improved survival. CONCLUSIONS: Pathologic T1 tumors have a 5-year cumulative incidence of recurrence of 15%. Nodal involvement and tumor length were independent risk factors for recurrence, whereas tumors <2 cm in length without lymphovascular invasion were associated with a low risk of recurrence.

Dissemination of Information About Climate Change by State and Local Public Health Departments: United States, 2019-2020.

Objectives. To determine if and how state and local public health departments present information about climate change on their Web sites, their most public-facing platform.Methods. We collected data from every functioning state (n = 50), county (n = 2090), and city (n = 585) public health department Web site in the United States in 2019 and 2020. We analyzed data for presence and type of climate-related content and to determine whether there existed clear ways to find climate change information. We analyzed Web sites providing original content about climate change for explanatory or attributional language.Results. Fewer than half (40%) of state health department Web sites, and only 1.6% of county and 3.9% of city Web sites, provided clear ways to find climate change information, whether through provision of original content or links to external agencies' Web sites. Among Web sites providing original content, 48% provided no explanation of climate change causes.Conclusions. National and global public health associations have identified climate change as a public health emergency, but most state and local public health departments are not delivering that message. These departments must be better supported to facilitate dissemination of reliable, scientific information about climate change and its effects on health.

Minimal change disease and malaria.

Malaria is a tropical disease secondary to the Plasmodium parasite with clinical features ranging from febrile illness to acute renal failure and further renal sequelae. We present a case of a woman minimal change disease secondary to Plasmodium falciparum who developed nephrotic range proteinuria and ultimately acute renal failure requiring renal replacement therapy. With proper treatment of her malarial infection as well as long-term renal replacement therapy, she made a full recovery. This case is one of the few cases that highlight the association between severe malarial infections and renal failure necessitating long-term hemodialysis.

Direct Percutaneous Endoscopic Jejunostomy: Procedural and Nutrition Outcomes in a Large Patient Cohort.

BACKGROUND: Direct percutaneous endoscopic jejunostomy (DPEJ) is used for enteral nutrition (EN) in patients with postoperative anastomotic leaks after esophagectomy/gastrectomy and at high risk for aspiration. We characterized the indications, technical success, procedural/nutrition outcomes, and adverse events in a large cohort of patients undergoing DPEJ insertion. METHODS: Patients undergoing DPEJ insertion between January 2009 and March 2015 were identified from an institutional endoscopy database. Demographic, procedural, and nutrition outcome data were collected from electronic medical records. Regression analyses were used to identify predictors of adverse events and procedural success. RESULTS: A total of 452 patients underwent 480 attempts at DPEJ insertion. Indications included preoperative or postoperative weight loss (64%), postoperative upper gastrointestinal (UGI) anastomotic leak (13%), aspiration prevention (10%), and other (13%). Of attempted procedures, 398 (83%) were successful. Feeding was initiated in 389 (98%) of patients; a median of 1775 calories was delivered daily. Median body mass index (BMI) at baseline was 22.9 (11.4-44.7) and did not change over follow-up. Median change in BMI after DPEJ was similar in groups that received EN with palliative and curative intent. Adverse events following 480 attempted DPEJ insertions included 13 (3%) immediate and 74 (15%) delayed, 13 (3%) of which were serious. Patients with head and neck cancer had more adverse events than those with esophageal cancer (P = .020). CONCLUSION: DPEJ is a successful and safe procedure that effectively provides access for EN support in malnourished patients and patients with postoperative UGI cancer.

Predictors of Nodal Metastases for Clinical T2N0 Esophageal Adenocarcinoma.

BACKGROUND: Induction therapy has not been proven to be beneficial for patients with clinical T2N0 esophageal adenocarcinoma. Surgery alone is associated with disappointing survival for patients found to have nodal disease on final pathologic examination. The aim of this study was to identify factors that predict pathologic nodal involvement in patients with endoscopic ultrasound (EUS)-proven T2N0 esophageal adenocarcinoma. METHODS: We retrospectively reviewed patients with EUS-staged T2N0 (uT2N0) esophageal adenocarcinoma treated with surgery alone. Final pathologic staging was compared with clinical staging. Demographic and clinicopathologic variables were evaluated as putative risk factors for nodal metastases. Logistic regression models were used to identify factors associated with nodal involvement. Kaplan-Meier analysis was performed to compare overall and recurrence-free survival between patients with (N+) and without (N-) nodal disease. RESULTS: We identified 80 patients with uT2N0 esophageal adenocarcinoma treated with surgery alone. Clinical staging with EUS was inaccurate for 73 patients (91%). Twenty-eight patients (35%) had pathologic N+ disease at resection. Five-year overall survival was 67% for N- patients and 41% for N+ patients (p = 0.006). Recurrence-free survival was 65% for N- patients and 32% for N+ patients (p = 0.0043). Univariable analysis identified vascular invasion and neural invasion as risk factors for nodal metastasis. Multivariable analysis identified vascular invasion as an independent predictor of pathologic nodal involvement. CONCLUSIONS: EUS is inaccurate for staging of T2N0 esophageal adenocarcinoma and often fails to identify nodal involvement. Identification of vascular invasion on preoperative biopsy should be explored as a prognostic marker to select patients for induction therapy.