External Validation of a Survival Nomogram for Non-Small Cell Lung Cancer Using the National Cancer Database.

PURPOSE: Survival nomograms offer individualized predictions using a more diverse set of factors than traditional staging measures, including the American Joint Committee on Cancer Tumor Node Metastasis (AJCC TNM) Staging System. A nomogram predicting overall survival (OS) for resected, non-metastatic non-small cell lung cancer (NSCLC) has been previously derived from Asian patients. The present study aims to determine the nomogram's predictive capability in the US using the National Cancer Database (NCDB). METHODS: This was a retrospective review of adults with resected, non-metastatic NSCLC entered into the NCDB between 2004 and 2012. Concordance indices and calibration plots analyzed discrimination and calibration, respectively. Multivariate analysis was also used. RESULTS: A total of 57,313 patients were included in this study. The predominant histologies were adenocarcinoma (48.2%) and squamous cell carcinoma (31.3%), and patients were diagnosed with stage I-A (38.3%), stage I-B (22.7%), stage II-A (14.2%), stage II-B (11.5%), and stage III-A (13.3%). Median OS was 74 months. 1-, 3- and 5-year OS rates were 89.8% [95% confidence interval (CI) 89.5-90.0%], 71.1% (95% CI 70.7-71.6%), and 55.7% (95% CI 54.7-56.6%), respectively. The nomogram's concordance index (C-index) was 0.804 (95% CI 0.792-0.817). AJCC TNM staging demonstrated higher discrimination (C-index 0.833, 95% CI 0.821-0.840). CONCLUSIONS: The nomogram's individualized estimates accurately predicted survival in this patient collective, demonstrating higher discrimination in this population than in the developer's cohorts. However, the generalized survival estimates provided by traditional staging demonstrated superior predictive capability; therefore, AJCC TNM staging should remain the gold standard for the prognostication of resected NSCLC in the US.

Utility of Prophylactic Antibiotics in Nonoperative Facial Fractures.

Facial fractures are commonly managed nonoperatively. Patients with facial fractures involving sinus cavities commonly receive 7 to 10 days of prophylactic antibiotics, yet no literature exists to support or refute this practice. The aim of this study was to compare the administration and duration of antibiotic prophylaxis on the incidence of soft tissue infection in nonoperative facial fractures. A total number of 289 patients who were admitted to our level I trauma center with nonoperative facial fractures from the beginning of 2012 to the end of 2014 were studied. Patients were categorized into 3 groups: no antibiotic prophylaxis, short-term antibiotic prophylaxis (1-5 days), and long-term antibiotic prophylaxis (>5 days). The primary outcome was the incidence of facial soft tissue infection and Clostridium difficile colitis. Fifty patients received no antibiotic prophylaxis. Sixty-three patients completed a short course of antibiotic prophylaxis and 176 patients received long-term antibiotics. Ampicillin/sulbactam, amoxicillin/clavulanic acid, or a combination of both were used in 216 patients. Twenty-three patients received clindamycin due to penicillin allergy. Short and long courses of antibiotic prophylaxis were administered more commonly in patients with concomitant maxillary and orbital fractures (P <0.0001). No mortality was found in any group. Soft tissue infection was not identified in any patient. C. difficile colitis was identified in 1 patient who had received a long course of antibiotic prophylaxis (P = 0.7246). There was no difference in the outcome of patients receiving short-term, long-term, and no antibiotic prophylaxis. Prospective randomized studies are needed to provide further clinical recommendations.

MAGIC versus MacDonald treatment regimens for gastric cancer: Trends and predictors of multimodal therapy for gastric cancer using the National Cancer Database.

BACKGROUND: Multimodal therapy is beneficial in gastric cancer, however this practice is not universal. This study examines trends, identifies associative factors, and examines overall survival (OS) benefit from multimodal therapy in gastric cancer. METHODS: Gastric cancer patients staged IB-III from 2005 to 2014, identified using the National Cancer Database, were categorized by treatment: surgery alone, perioperative chemotherapy, and adjuvant chemoradiation. Groups were analyzed to identify associative factors of perioperative therapy. RESULTS: We examined 9243 patients, with the majority receiving multimodal therapy (57%). The proportion of those receiving perioperative chemotherapy rose dramatically from 7.5% in 2006 to 46% in 2013. Academic center treatment was strongly associated with perioperative over adjuvant therapy (p < 0.0001). An OS advantage was clearly seen in those receiving multimodal therapy versus surgery alone (p < 0.0001), with no difference between perioperative and adjuvant therapies. CONCLUSIONS: Treatment of gastric cancer with multimodal therapy has risen significantly since 2005, largely due to increasing use of perioperative chemotherapy. As perioperative therapy becomes more prevalent, more patients will have the opportunity for the improved survival benefit of multimodal therapy.

Laparoscopic versus robotic adrenalectomy: a review of the national inpatient sample.

BACKGROUND: Laparoscopic adrenalectomy (LA) has become the standard treatment of adrenal lesions. Recently, robotic-assisted adrenalectomy (RA) has become an option, however, short-term outcomes for RA have not been well studied and benefits over LA are debatable. The aim of this study was to explore differences in short-term outcomes between LA and RA using the national inpatient sample (NIS) database. METHODS: Patient data were collected from the NIS. All patients undergoing LA or RA from January 2009 to December 2012 were included. Univariate analysis and propensity matching were performed to look for differences between the groups. RESULTS: A total of 1006 patients (66.4% in LA group and 33.6% in RA group) were identified. Patient age group, gender, race, risk of mortality, severity of illness or indication for adrenalectomy did not differ significantly between the LA or RA cohorts. Insurance type predicted procedure type (45% of medicare patients underwent RA versus 29% of patients with private insurance, p < 0.0001). Patients living in the highest income areas were more likely to receive the laparoscopic approach (31.7 versus 17.4%, p < 0.0001). Hospital volume, bed size and teaching status of the hospital were not significant factors in the decision of RA versus LA. There was no difference in complication and conversion rates between RA versus LA. The mean length of stay was shorter in the RA group (2.2 versus 1.9 days, p = 0.03). Total charges were higher in the RA group ($42,659 versus $33,748, p < 0.0001). There was a significant trend towards more adrenalectomies being performed robotic assisted by year. Only 22% of adrenalectomies were performed robotic-assisted in 2009 compared with 48% in 2012. CONCLUSIONS: The overall benefit for RA remains small and higher total charges for RA may currently outweigh the benefits. These findings may change as more cases are performed robotically assisted and robotic technology improves.

Disparities in Care: Impact of Socioeconomic Factors on Pancreatic Surgery: Exploring the National Cancer Database.

Studies have shown high-volume institutions have decreased mortality and increased survival for pancreatectomy. However, not all patients can travel to high-volume centers. Socioeconomic factors may influence treatment decisions. The goal of this study is to examine socioeconomic factors that determine where a patient is treated and how that location affects outcome. This is a retrospective study of the National Cancer Database of patients diagnosed with pancreatic cancer from 2004 to 2014. The primary outcome was to examine socioeconomic factors that predicted where a patient underwent their pancreatectomy. Patients treated at academic programs (APs) had to travel a mean distance of 80.9 miles, whereas patients treated at community programs (CPs) had to travel 31.7 miles (P < 0.0001). Spanish and Hispanic patients were less likely to travel to an AP (69% had surgery at an AP versus 76% of non-Hispanic patients, P < 0.001). Patients with higher comorbidities were also more likely to have care at CPs. Patients who had pancreatic cancer surgery at CPs were more likely to be Hispanic or with higher medical comorbidities. Those who had surgery at AP traveled further distances but had better perioperative outcomes and had an improvement in overall survival.

Lymph Node Harvest as a Measure of Quality and Effect on Overall Survival in Esophageal Cancer: A National Cancer Database Assessment.

Surgical therapy for esophageal cancer is the cornerstone of treatment, and the highest quality operation should lead to the highest cure rate. Evaluated lymph node (ELN) count is one quality measure that has been championed. The objective of this study was to explore ELN in esophagectomy, examine predictors of harvesting ≥12 nodes, and determine whether higher ELN improves overall survival (OS). ELN was examined in patients with resected esophageal cancer using the National Cancer Database from 2004 to 2013. In this study, 41,746 patients met the inclusion criteria. Fifty-two per cent of patients had 12 or more nodes harvested. Academic programs were most likely to harvest ≥12 nodes (58% of cases) compared with other programs (43-56% of cases). Seventy per cent of cases with ≥12 nodes harvested were performed at high-volume centers. Preoperative radiation or preoperative chemoradiation led to lower ELN (46% and 48%) versus preoperative chemotherapy alone (66%). Multivariate analysis showed that patients who had ≥12 nodes removed had better OS (Hazard Ratio 0.843 [95 confidence interval 0.820-0.867]). In addition, care at a high-volume facility, care at an academic facility, private insurance, and income ≥$63,000 were all associated with improved OS. Higher ELN count is associated with OS in patients with esophageal cancer. Patients who receive care at high-volume centers and academic centers are more likely to undergo more extensive lymphadenectomy. All centers should strive to examine at least 12 nodes to provide a quality esophagectomy.

Cancel that PICC line order; cholecystostomy tube and short course of antibiotics.

BACKGROUND: Current guidelines do not specifically address optimal antibiotic duration following cholecystostomy. This study compares outcomes for short-course (<7 days) and long-course (≥7 days) antibiotics post-cholecystostomy. METHODS: This was a retrospective review of cholecystostomy patients (≥18 years) admitted (1/1/2007-12/31/2017) to one healthcare system. RESULTS: Overall, 214 patients were studied. Demographics were similar, except short-course patients had higher Charlson Comorbidity Index (p < 0.0001). There were no intergroup differences in tachycardia (22.5%[short-course] vs 23.3%[long-course]) or leukocytosis (67.1%[short-course] vs 64.4%[long-course]) at drain placement nor time to normalization for pulse, temperature or leukocytosis. There were no differences regarding Clostridium Difficile infection (5.0%[short-course] vs 1.6%[long-course]) or cholecystitis recurrence (8.8%[short-course] vs 10.9%[long-course]). No differences were observed regarding gallbladder-related unplanned readmissions (30-day:18.8%[short-course] vs 17.2%[long-course]; 90-day: 20.0%[short-course] vs 25.8%[long-course]). There were no 30- or 90-day mortality differences (overall mortality: 18.3%). CONCLUSION: Post-cholecystostomy outcomes were comparable between short-course and long-course antibiotics, consistent with emerging literature supporting short-course antibiotics for intra-abdominal infection with source control.

What about informed consent in first-trimester ultrasound screening for Down syndrome?

OBJECTIVES: We evaluate the level of information and informed consent given for the screening of Down syndrome (DS) before the first-trimester ultrasound scan. We evaluate the nature of the medical information given and the patient's understanding. This makes it possible to analyze the existence of the necessary elements (level of information and consent) for the patients to exercise their autonomy as to their decision making during the first-trimester ultrasound scan. METHODS: A total of 350 patients were recruited prospectively in 2 hospitals. Patients were divided into 3 groups according to the results of maternal serum screening for DS. Group 1: Patients at high risk of having a child with DS with the second-trimester maternal serum screening (MSS) (risk >1/250). Group 2: Patients having a low risk (risk <1/250). Group 3: Patients who did not undergo maternal serum screening test. A questionnaire was completed before the medical consultation, to assess the quality of the medical consultation before the ultrasound, the level of prior knowledge and the maternal consent. RESULTS: We excluded 45 of the 350 questionnaires from the analysis because they were incomplete (13.1%). We therefore analyzed a total of 305 questionnaires. The three groups analysed were: Group 1: 89 patients (29.2%) identified as at high risk after MSS. Group 2: 137 patients (44.9%) identified as at low risk accordingly to MSS. Group 3: 79 women (25.9%) who did not undergo maternal serum screening test for diverse reasons. The frequency of genuine informed consent was significantly (p < 0.001) higher in group 3 (56.9%) than in group 1 (52.8%) or group 2 (32.1%). Finally, the number of completely uninformed patients was significantly higher in group 2 (18%) than in the other two groups (7.8% for group 1 and 6.3% for group 3, p < 0.001). With multiple regression analysis, we found that maternal consent depended on 4 independent components: (1) Educational level ( or =10). The negative responses to the various questions calls into question the legitimacy of consent for first-trimester ultrasound scans, particularly as concerns the measurement of nucal translucency.

Ten Year Projections for US Residency Positions: Will There be Enough Positions to Accommodate the Growing Number of U.S. Medical School Graduates?

OBJECTIVE: Recently, a multitude of new U.S. medical schools have been established and existing medical schools have expanded their enrollments. The National Residency Match Program (NRMP) reports that in 2016 there were 23,339 categorical residency positions offered in the match and 26,836 overall applicants with 17,789 (66.29%) of the total candidates being U.S. allopathic graduates. In view of the rapid growth of medical school graduates, the aim of this study is to determine if current trends suggest a shortage of residency positions within the next ten years. DESIGN: The total number of graduates from U.S. medical schools was obtained from the Association of American Medical Colleges (AAMC) for 2005-2014 academic years and was trended linearly for a 10-year prediction for the number of graduates. The yearly number of categorical positions filled by U.S. graduates for calendar years 2006-2015 was obtained from the NRMP and was trended longitudinally 10 years into the future. Analysis of subspecialty data focused on the comparison of differences in growth rates and potential foreseeable deficits in available categorical positions in U.S. residency programs. RESULTS: According to trended data from AAMC, the total number of graduates from U.S. medical schools has increased 1.52 percent annually (15,927 in 2005 to 18,705 in 2014); with a forecast of 22,280 U.S. medical school graduates in 2026. The growth rate of all categorical positions available in U.S. residency programs was 2.55 percent annually, predicting 29,880 positions available in 2026. In view of these results, an analysis of specific residencies was done to determine potential shortages in specific residencies. With 17.4 percent of all U.S. graduates matching into internal medicine and a 3.17 percent growth rate in residency positions, in 2026 the number of internal medicine residency positions will be 9,026 with 3,874 U.S. graduates predicted to match into these positions. In general surgery, residency positions note a growth rate of 1.55 percent. Of all U.S. graduates, 5.6 percent match into general surgery. Overall this projects 1,445 general surgery residency positions in 2026 with 1,257 U.S. graduates matching. In orthopedics with a growth rate of 1.35 percent and a match rate of 3.75 percent, there are projected to be 827 positions available with 836 U.S. graduates projected to match. CONCLUSIONS: Despite the increasing number of medical school graduates, our model suggests the rate of growth of residency positions continues to be higher than the rate of growth of U.S. medical school graduates. While there is no apparent shortage of categorical positions overall, highly competitive subspecialties like orthopedics may develop a shortage within the next ten years.

Disparities in compliance with the Oncotype DX breast cancer test in the United States: A National Cancer Data Base assessment.

BACKGROUND: Oncotype DX (ODX) is a multi-gene tumor assay for breast cancer patients. Our objective is to assess whether eligible ODX patients received the test and whether recommendations were followed based on respective risk. METHODS: We retrospectively analyzed testing in patients deemed eligible for ODX using the National Cancer Data Base. RESULTS: A total of 158,235 patients met ODX eligibility criteria. Sixty-four percent of eligible patients did not receive the test. Non-testing rose with age. White patients were more likely to be tested (56%) versus black patients (46%, p < 0.0001). Testing was highest at academic facilities (40%). Privately insured patients were more likely to get the test compared to uninsured (45 versus 34%, p < 0.0001). Those in the highest income quartile were more likely to be tested (p < 0.001). CONCLUSIONS: ODX is under-utilized, with racial and socio-economic factors influencing testing. Further studies are necessary to identify ways to remove disparities and increase testing when appropriate.

Analyzing the Impact of Compliance with National Guidelines for Pancreatic Cancer Care Using the National Cancer Database.

IMPORTANCE: Management of pancreatic cancer is complex, requiring coordination of multiple providers. National Comprehensive Cancer Network guidelines, developed for standardization and quality improvement, recommend a multimodal approach. OBJECTIVE: This study analyzed national rates of compliance with National Comprehensive Cancer Network recommendations, assessed factors affecting compliance, and evaluated whether compliance with evidence-based guidelines improved overall survival. DESIGN: This is a retrospective review of adults diagnosed with pancreatic cancer entered into the National Cancer Database. Patients included had stage I and II pancreatic cancer, and complete data in the database. Patients were classified as compliant if they underwent both surgery and a second treatment modality (chemotherapy, radiation, or chemoradiation). Clinico-pathologic variables were analyzed using univariate and multivariate models to predict overall survival. SETTING: Hospital-based national study population. PARTICIPANTS: Patients with stage I or II pancreatic cancer. MAIN OUTCOMES AND MEASURES: Compliance with National Comprehensive Cancer Network recommendations, factors affecting compliance, and overall survival based on compliance. RESULTS: A total of 52,450 patients were included; 19,272 patients (37%) were compliant. Patients were found to be most compliant in the 50-59-year-old range (49% complaint), with decreased compliance at the extremes of age. Male patients were more compliant than female patients (39 vs 34%, p < 0.0001). Caucasians were more compliant (39%) than African Americans (32%) or other races (32%, p < 0.0001). Patients treated at academic/research centers were more compliant than patients treated at other facilities (39% compliant, p < 0.0001). Patients with stage II disease were more compliant compared with stage I disease (43 vs 18%, p < 0.0001). Compliance was shown to improve overall survival (p < 0.0001). CONCLUSION: Adherence to National Comprehensive Cancer Network guidelines for pancreatic cancer patients improves survival. Compliance nationwide is low, especially for older patients and minorities and those treated outside academic centers. More studies will need to be performed to identify factors that hinder compliance.

Hospital-Based Study of Compliance with NCCN Guidelines and Predictive Factors of Sentinel Lymph Node Biopsy in the Setting of Thin Melanoma Using the National Cancer Database.

Thin melanoma is the most common form of melanoma in the United States. The National Comprehensive Cancer Network (NCCN) has guidelines for sentinel lymph node biopsy (SLNB) which recommend "discuss and consider" SLNB for invasion >0.75 mm and "discuss and offer" SLNB for invasion >0.75 mm with suspicious features. This study looked at compliance with NCCN guidelines and factors that are predictive of a positive SLNB. This is a retrospective study of patients diagnosed with thin melanoma 2012-2013 using the National Cancer Database. A total of 26,456 patients met study qualifications. Univariate analysis showed that 76 per cent of patients meeting criteria underwent SLNB. Patients recommended to "discuss and consider" received SLNB 53 per cent of the time and those not recommended for SLNB received SLNB 20 per cent of the time. On multivariate analysis, depth was not predictive for positive SLNB whereas mitoses and ulceration were. Other factors predictive of positive SLNB were nodular cell type, lymphovascular invasion, and Clark's level greater than or equal to IV. Patients with thin melanoma that meet NCCN guidelines for SLNB undergo this procedure in good compliance but those who do not meet criteria continue to receive SLNB. Positive predictive factors for positive SLNB include mitoses, ulceration, Clark's level, and primary site.

Neoadjuvant versus Adjuvant Chemotherapy for Resectable Pancreatic Adenocarcinoma: A National Cancer Database Analysis.

There is controversy regarding the role of neoadjuvant versus adjuvant chemotherapy for pancreatic cancer (PAC). Neoadjuvant therapy has been touted as a method to improve survival in PAC patients. This study's objective is to investigate predictors and potential benefits of neoadjuvant therapy in resectable PAC patients. The National Cancer Data Base was used to retrospectively analyze stage I and II surgically resected PAC patients receiving adjuvant or neoadjuvant therapy from 2004 to 2012. A total of 12,983 patients were identified. A significant increase in the rate of neoadjuvant therapy was observed over time with 5 per cent receiving neoadjuvant therapy in 2004 versus 17 per cent in 2012 (P < 0.0001). Multivariate analysis showed that patients were more likely to receive neoadjuvant therapy if they were treated at an academic facility. Private insurance was associated with higher odds of neoadjuvant chemotherapy (P < 0.0001). Pathological outcomes were improved in neoadjuvant patients compared with adjuvant patients on multivariate analysis with neoadjuvant patients having higher rates of negative surgical margins (OR: 1.273, 95% Confidence interval: 1.099-1.474) and negative lymph nodes (OR: 2.852, 95% Confidence interval: 2.547-3.194). Pathological outcomes are improved after neoadjuvant therapy compared with adjuvant therapy, with more patients achieving negative margins and negative lymph nodes. Prospective studies are needed to compare these two treatment modalities in a head to head comparison.

Sarcopenia predicts poor outcomes in urgent exploratory laparotomy.

BACKGROUND: Emergent laparotomies are associated with higher rates of morbidity and mortality. Recent studies suggest sarcopenia predicts worse outcomes in elective operations. The purpose of this study is to examine outcomes following urgent exploratory laparotomy in sarcopenic patients. METHODS: This was a retrospective review of patients in a rural tertiary care facility between 2010 and 2014. Patients underwent a laparotomy within 72 h of admission and had an abdomen/pelvis CT scan were included. Primary outcomes were predictors of morbidity and mortality. Sarcopenia is the lowest quartile cross sectional area of the psoas muscles. RESULTS: Multivariate analysis of 967 patients found that sarcopenic patients had higher mortality, complication rate, were less likely to be discharged home, were more likely to undergo unplanned re-operation, and had a longer length of stay. Increasing abdominal wall fat has favorable outcomes in mortality, discharge destination, and complications. CONCLUSIONS: Sarcopenia is measured from CT scans, making it an accessible outcome predictor. In urgent laparotomies, sarcopenia was associated with higher morbidity, mortality, length of stay, and worse discharge destination.

Outcomes of complicated appendicitis: Is conservative management as smooth as it seems?

BACKGROUND: This study characterized the failure rate of non-operative management (NOM) for complicated appendicitis (CA; perforation, abscess, phlegmon), and compared outcomes among patients undergoing acute appendectomy (AA), elective interval appendectomy (EIA), and unplanned appendectomy after failing to improve with NOM. METHODS: Adults treated at one facility between 2007 and 2014 were retrospectively studied. RESULTS: Ninety-five patients presented with CA. Sixty individuals underwent AA. The remaining 35 patients initially underwent NOM: 14 underwent EIA, nine (25.7%) failed NOM, 12 never underwent surgery. All patients failing NOM had an open operation with most (55.6%) requiring bowel resection. AA and EIA were comparable in surgical approach, bowel resection and post-operative readmission. However, AA demonstrated a lower incidence of bowel resection (3.3% vs 17.1%, P = 0.048) when compared to all patients initially undergoing NOM. CONCLUSIONS: Due to the high incidence of failed NOM and the morbidity associated with failure, AA may be appropriate for CA.

Learning preferences of surgery residents: a multi-institutional study.

BACKGROUND: The VARK model categorizes learners by preferences for 4 modalities: visual, aural, read/write, and kinesthetic. Previous single-institution studies found that VARK preferences are associated with academic performance. This multi-institutional study was conducted to test the hypothesis that the VARK learning preferences of residents differ from the general population and that they are associated with performance on the American Board of Surgery In-Training Examination (ABSITE). METHODS: The VARK inventory was administered to residents at 5 general surgery programs. The distribution of the VARK preferences of residents was compared with the general population. ABSITE results were analyzed for associations with VARK preferences. χ2, Analysis of variance, and multiple linear regression were used for statistical analysis. RESULTS: A total of 132 residents completed the VARK inventory. The distribution of the VARK preferences of residents was different than the general population (P < .001). The number of aural responses on the VARK inventory was an independent predictor of ABSITE percentile rank (P = .03), percent of questions correct (P = .01), and standard score (P = .01). CONCLUSION: This study represents the first multi-institutional study to examine VARK preferences among surgery residents. The distribution of preferences among residents was different than that of the general population. Residents with a greater number of aural responses on VARK had greater ABSITE scores. The VARK model may have potential to improve learning efficiency among residents.

Disparities in the Care of Differentiated Thyroid Cancer in the United States: Exploring the National Cancer Database.

Differentiated thyroid cancer (DTC) treatment is multifaceted, and may be influenced by socioeconomic factors. The goal of this study is to examine disparities in DTC treatment. DTC patients from 1998 to 2012 were identified using the National Cancer Database. DTC was identified in 262,041 patients. The mean age was 48.2. The majority of patients (52%) received care at Comprehensive Community Cancer Programs (CCCPs). Total thyroidectomy was less common at Community Cancer Programs (CCPs) [odds ratio (OR): 0.735; 95% confidence interval (CI): 0.707-0.764), and more common at academic centers (OR: 1.129; 95% CI: 1.102-1.157) compared with CCCP. A central neck dissection was performed most often at academic center (20.6%) versus CCP (10.0%). Black patients were less likely to undergo central neck dissection compared with white patients (OR: 0.468; 95% CI: 0.452-0.484). Patients more likely to receive radioactive iodine were white compared with black patients (hazard ratio: 0.833; 95% CI: 0.806-0.861), privately insured compared with uninsured patients (hazard ratio: 1.272; 95% CI: 1.210-1.341), and patients treated at CCCP. Disparities exist in DTC treatment. Individuals at risk for under-treatment are black patients, uninsured patients, and those treated at CCP. As the Affordable Care Act changes access to health care, future studies will be needed to readdress disparities.

Predictors of Utilization and Quality Assessment in Robotic Rectal Cancer Resection: A Review of the National Cancer Database.

Robotic surgery (RS) is a novel treatment for rectal cancer resection (RCR); however, this technology is not widely accessible. The objective of this study is to evaluate the utilization of RS in RCR compared with open and laparoscopic techniques and to assess the quality of resection. RCR from 2010 to 2012 were identified using the National Cancer Database and placed into categories: open, laparoscopic, and robotic. A total of 23,857 patients who received open, laparoscopic, and robotic RCR were included (n = 14,735 (61.8%); 7,185 (30.1%); 1,937 (8.1%), respectively). Patients over 70 had a lower likelihood of robotic RCR. Patients with insurance were 2 times more likely to have robotic RCR. Patients at an academic/research program were more likely to undergo RS compared with a community cancer program (OR 3.6, 95% CI [2.79, 4.78]; P < 0.0001). Length of stay (LOS) was longer in open (7.9 ± 7.1) versus laparoscopic (6.6 ± 6.3) or robotic (6.8 ± 6.4) RCR (P < 0.0001). Although there was an increased likelihood of positive surgical margins with open RCR (OR 1.3, 95% CI [1.09, 1.66]; P < 0.0001), there was no difference in robotic and laparoscopic techniques. Younger insured patients at academic/research affiliated hospitals have a higher likelihood of receiving robotic RCR. Compared with open RCR, robotic RCR have a lower likelihood of positive surgical margins and shorter LOS.

In the Modern Era of CT, Do Blunt Trauma Patients with Markers for Blunt Bowel or Mesenteric Injury Still Require Exploratory Laparotomy?

After blunt trauma, certain CT markers, such as free intraperitoneal air, strongly suggest bowel perforation, whereas other markers, including free intraperitoneal fluid without solid organ injury, may be merely suspicious for acute injury. The present study aims to delineate the safety of nonoperative management for markers of blunt bowel or mesenteric injury (BBMI) that are suspicious for significant bowel injury after blunt trauma. This was a retrospective review of adult blunt trauma patients with abdominopelvic CT scans on admission to a Level I trauma center between 2012 and 2014. Patients with CT evidence of acute BBMI without solid organ injury were included. The CT markers for BBMI included free intraperitoneal fluid, bowel hematoma, bowel wall thickening, mesenteric edema, hematoma and stranding. Two thousand blunt trauma cases were reviewed, and 94 patients (4.7%) met inclusion criteria. The average Injury Severity Score was 13.6 ± 10.1 and the median hospital stay was four days. The most common finding was free fluid (74 patients, 78.7%). The majority of patients (92, 97.9%) remained asymptomatic or clinically improved without abdominal surgery. After a change in abdominal examination, two patients (2.1%) underwent laparotomy with bowel perforation found in only one patient. Thus, 93 patients did not have a surgically significant injury, indicating that these markers demonstrate 1.1 per cent positive predictive value for bowel perforation. The presence of these markers after blunt trauma does not mandate laparotomy, though it should prompt thorough and continued vigilance toward the abdomen.

The Effect of Interhospital Transfers on the Outcome of Rural Trauma.

Urban areas house the majority of the population in the United States but trauma deaths occur more commonly in rural areas. In this study, we aimed to investigate if direct patient admission to a Level I trauma center improves outcomes in rural trauma. We retrospectively reviewed data in our trauma database from January 2008 to the end of December 2012 to compare the overall outcomes between direct admissions (DAs) and interhospital transfers (IHTs). Of the 6118 patients who met the inclusion criteria, 59.5 per cent were in the DA group and 40.5 per cent in the IHT group. Injury severity score was similar between the two groups but severe traumatic brain injury was more common (P = 0.001) in the DA group. Hospital length of stay, complication rate, and in-hospital mortality were not different between the two groups (all P> 0.2). In multivariate analysis, there was no difference in survival between the two modes of admission (odds ratio, 95% confidence interval: 0.91, 0.69-1.20, P = 0.51). We concluded that rural trauma IHTs had no detrimental impact on the outcome. Prospective studies would better elucidate factors associated with patient outcomes in rural trauma.