The impact of race/ethnicity on pancreaticoduodenectomy outcomes for pancreatic cancer.

PURPOSE: To investigate the impact of race/ethnicity on surgical outcomes following pancreaticoduodenectomy for pancreatic cancer. METHODS: A retrospective review of patients undergoing pancreaticoduodenectomy for adenocarcinoma in the National Surgical Quality Improvement Program (NSQIP) database from 2014 to 2019. Patient and tumor characteristics and 30-day postoperative outcomes were compared. Multivariable logistic and linear regression models were conducted to investigate the relationship between race/ethnicity and surgical outcomes. RESULTS: Six thousand five hundred and sixty-two patients were included (84.5% White, 7.9% Black, 3% Hispanic, 4.6% Asian). Larger proportions of Blacks had preoperative American Society of Anesthesiologists class 3 or 4. There were no significant differences in tumor characteristics or operative techniques. A smaller proportion of Asians and Hispanics received neoadjuvant chemotherapy and/or radiation than Blacks and Whites. Relative to White, the Black race was independently associated with postoperative sepsis and reoperation. Both Black and Hispanic race/ethnicity were associated with prolonged intubation and delayed gastric emptying, and minorities races/ethnicities were associated with longer length of hospital stay. Relative to White, Hispanic, and Asian race/ethnicity were independently associated with a lower likelihood of neoadjuvant therapy (NAT) receipt. CONCLUSION: In ACS-NSQIP participating hospitals, non-White race/ethnicity was independently associated with adverse outcomes after pancreatic cancer resection. A possible disparity in NAT receipt may exist in Asian and Hispanic patients undergoing surgical resection.

CivaSheet intraoperative radiation therapy for pancreatic cancer.

The treatment of borderline resectable (BR) pancreatic cancer is challenging and requires a multidisciplinary approach with chemotherapy, radiation and surgical resection. Despite using chemotherapy and radiotherapy in the neoadjuvant setting, achievement of negative surgical margins remains technically challenging. Positive margins are associated with increased local recurrences and worse overall survival and there are no standard options for treatment. The CivaSheet is an FDA-cleared implantable sheet with a matrix of unidirectional planar low-dose-rate (LDR) Palladium-103 (Pd-103) sources. The sources are shielded on one side with gold to spare radio-sensitive structures such as the bowel. The sheet can easily be customized and implanted at the time of surgery when there is concern for close or positive margins. The CivaSheet provides an interesting solution to target the region of close/positive margins after pancreatectomy. Here we discuss the physical properties, the dosimetry, clinical workflow and early patient outcomes with the CivaSheet in pancreatic cancer.

Defining the Applicant Pool for Postgraduate Year-2 Categorical General Surgery Positions.

OBJECTIVE: In the spring of 2010, a categorical general surgery postgraduate year (PGY)-2 position became available at our academic medical center secondary to attrition of a PGY-1 resident. We sought to study the unique characteristics of applicants to that position and to describe the selection process with hopes to stimulate additional studies about the unique challenges of recruiting applicants into advanced standing positions. DESIGN: Applications were received via e-mail and reviewed to characterize the applicant pool. An Excel spreadsheet was used to organize data. Characteristics assessed included United States Medical Licensing Examination (USMLE) scores, Educational Commission for Foreign Medical Graduates status, Alpha Omega Alpha Honor Society status, sex, academic performance, number of case logs, volunteer and job experience, leadership roles, research experience including submissions, and advanced degrees. These characteristics were compared to those of the PGY-1 applicants through the Match that year. SETTING: Academic medical center. PARTICIPANTS: Applicants for a categorical general surgery PGY-2 position in 2010. RESULTS: A total of 129 applicants provided the requested documents. There were 104 males, 25 females, no Alpha Omega Alpha Honor Society candidates, and 82 international candidates. Of all, 46 candidates experienced academic difficulties. Quantitative averages include USMLE 1: 214.17, USMLE 2: 215.74, American Board of Surgery In Training Examination (ABSITE) percentile = 51.96, ABSITE 2 = 46.00, grand total case log: 192.10. Advanced degrees included 2 MBAs, 6 MPHs, and 7 nonphysiology MSs. The selection process to fill the position started on 3/25/2010 when the announcement was published and ended on 5/11/2010 when the offer of acceptance was sent. The selected applicant integrated well with the peers and just graduated from our residency as one of the leaders of the graduating class. CONCLUSIONS: Although the attrition rate in general surgery remains high, there is a dearth of literature about how best to replace residents. The hardship of replacing residents highlights the importance of studying this group to improve the recruitment process and the quality of replacement residents. The selection process was time consuming and presented its own challenges given the lack of a computerized system for screening. It lasted nearly 7 weeks requiring faculty time commitment to mine through application data/e-mails, correspond with applicants, conduct interviews, and ultimately select an applicant for the position. This is the first study to investigate the applicant pool to advanced standing positions in general surgery and we present it as a pilot study to stimulate further research efforts.

COPI-mediated blood meal digestion in vector mosquitoes is independent of midgut ARF-GEF and ARF-GAP regulatory activities.

We have previously shown that defects in COPI coatomer proteins cause 80% mortality in blood fed Aedes aegypti mosquitoes by 96 h post-feeding. In this study we show that similar deficiencies in COPII and clathrin mediated vesicle transport do not disrupt blood meal digestion and are not lethal, even though both COPII and clathrin functions are required for ovarian development. Since COPI vesicle transport is controlled in mammalian cells by upstream G proteins and associated regulatory factors, we investigated the function of the orthologous ADP-ribosylation factor 1 (ARF1) and ARF4 proteins in mosquito tissues. We found that both ARF1 and ARF4 function upstream of COPI vesicle transport in blood fed mosquitoes given that an ARF1/ARF4 double deficiency is required to phenocopy the feeding-induced mortality observed in COPI coatomer deficient mosquitoes. Small molecule inhibitors of guanine nucleotide exchange factors (GEFs) and GTPase-activating proteins (GAPs) are often transitory, and therefore, we investigated the role of five Ae. aegypti ARF-GEF and ARF-GAP proteins in blood meal digestion using RNA interference. Surprisingly, we found that ARF-GEF and ARF-GAP functions are not required for blood meal digestion, even though both vitellogenesis and ovarian development in Ae. aegypti are dependent on GBF1 (ARF-GEF) and GAP1/GAP2 (ARF-GAPs) proteins. Moreover, deficiencies in orthologous COPI regulating genes in Anopheles stephensi mosquitoes had similar phenotypes, indicating conserved functions in these two mosquito species. We propose that based on the need for rapid initiation of protein digestion and peritrophic membrane formation, COPI vesicle transport in midgut epithelial cells is not dependent on ARF-GEF and ARF-GAP regulatory proteins to mediate vesicle recycling within the first 48 h post-feeding.