Resident memory CD8+ T cells in regional lymph nodes mediate immunity to metastatic melanoma.

The nature of the anti-tumor immune response changes as primary tumors progress and metastasize. We investigated the role of resident memory (Trm) and circulating memory (Tcirm) cells in anti-tumor responses at metastatic locations using a mouse model of melanoma-associated vitiligo. We found that the transcriptional characteristics of tumor-specific CD8+ T cells were defined by the tissue of occupancy. Parabiosis revealed that tumor-specific Trm and Tcirm compartments persisted throughout visceral organs, but Trm cells dominated lymph nodes (LNs). Single-cell RNA-sequencing profiles of Trm cells in LN and skin were distinct, and T cell clonotypes that occupied both tissues were overwhelmingly maintained as Trm in LNs. Whereas Tcirm cells prevented melanoma growth in the lungs, Trm afforded long-lived protection against melanoma seeding in LNs. Expanded Trm populations were also present in melanoma-involved LNs from patients, and their transcriptional signature predicted better survival. Thus, tumor-specific Trm cells persist in LNs, restricting metastatic cancer.

Microevolutionary change in wild stickleback: Using integrative time-series data to infer responses to selection.

A central goal in evolutionary biology is to understand how different evolutionary processes cause trait change in wild populations. However, quantifying evolutionary change in the wild requires linking trait change to shifts in allele frequencies at causal loci. Nevertheless, datasets that allow for such tests are extremely rare and existing theoretical approaches poorly account for the evolutionary dynamics that likely occur in ecological settings. Using a decade-long integrative phenome-to-genome time-series dataset on wild threespine stickleback (Gasterosteus aculeatus), we identified how different modes of selection (directional, episodic, and balancing) drive microevolutionary change in correlated traits over time. Most strikingly, we show that feeding traits changed by as much 25% across 10 generations which was driven by changes in the genetic architecture (i.e., in both genomic breeding values and allele frequencies at genetic loci for feeding traits). Importantly, allele frequencies at genetic loci related to feeding traits changed at a rate greater than expected under drift, suggesting that the observed change was a result of directional selection. Allele frequency dynamics of loci related to swimming traits appeared to be under fluctuating selection evident in periodic population crashes in this system. Our results show that microevolutionary change in a wild population is characterized by different modes of selection acting simultaneously on different traits, which likely has important consequences for the evolution of correlated traits. Our study provides one of the most thorough descriptions to date of how microevolutionary processes result in trait change in a natural population.

Unspoken Truths: Mental Health Among Academic Surgeons.

OBJECTIVE: To characterize the current state of mental health within the surgical workforce in the United States. BACKGROUND: Mental illness and suicide is a growing concern in the medical community; however, the current state is largely unknown. METHODS: Cross-sectional survey of the academic surgery community assessing mental health, medical error, and suicidal ideation. The odds of suicidal ideation adjusting for sex, prior mental health diagnosis, and validated scales screening for depression, anxiety, post-traumatic stress disorder (PTSD), and alcohol use disorder were assessed. RESULTS: Of 622 participating medical students, trainees, and surgeons (estimated response rate=11.4%-14.0%), 26.1% (141/539) reported a previous mental health diagnosis. In all, 15.9% (83/523) of respondents screened positive for current depression, 18.4% (98/533) for anxiety, 11.0% (56/510) for alcohol use disorder, and 17.3% (36/208) for PTSD. Medical error was associated with depression (30.7% vs. 13.3%, P <0.001), anxiety (31.6% vs. 16.2%, P =0.001), PTSD (12.8% vs. 5.6%, P =0.018), and hazardous alcohol consumption (18.7% vs. 9.7%, P =0.022). Overall, 13.2% (73/551) of respondents reported suicidal ideation in the past year and 9.6% (51/533) in the past 2 weeks. On adjusted analysis, a previous history of a mental health disorder (aOR: 1.97, 95% CI: 1.04-3.65, P =0.033) and screening positive for depression (aOR: 4.30, 95% CI: 2.21-8.29, P <0.001) or PTSD (aOR: 3.93, 95% CI: 1.61-9.44, P =0.002) were associated with increased odds of suicidal ideation over the past 12 months. CONCLUSIONS: Nearly 1 in 7 respondents reported suicidal ideation in the past year. Mental illness and suicidal ideation are significant problems among the surgical workforce in the United States.

Disentangling the drivers of decadal body size decline in an insect population.

While climate warming is widely predicted to reduce body size of ectotherms, evidence for this trend is mixed. Body size depends not only on temperature but also on other factors, such as food quality and intraspecific competition. Because temperature trends or other long-term environmental factors may affect population size and food sources, attributing trends in average body size to temperature requires the separation of potentially confounding effects. We evaluated trends in the body size of the midge Tanytarsus gracilentus and potential drivers (water temperature, population size, and food quality) between 1977 and 2015 at Lake Mývatn, Iceland. Although temperatures increased at Mývatn over this period, there was only a slight (non-significant) decrease in midge adult body size, contrary to theoretical expectations. Using a state-space model including multiple predictors, body size was negatively associated with both water temperature and midge population abundance, and it was positively associated with 13 C enrichment of midges (an indicator of favorable food conditions). The magnitude of these effects were similar, such that simultaneous changes in temperature, abundance, and carbon stable isotopic signature could counteract each other in the long-term body size trend. Our results illustrate how multiple factors, all of which could be influenced by global change, interact to affect average ectotherm body size.

Association of Food Desert Residence and 5-Year Mortality in Lung Cancer Patients Undergoing Resection.

INTRODUCTION: Food desert (FD) residence has emerged as a risk factor for poor outcomes in breast, colon and esophageal cancers. The purpose of this retrospective study was to examine FD residence as an associated risk factor in nonsmall cell lung cancer (NSCLC) patients treated with anatomic lung resection (ALR). METHODS: All consecutive ALRs for stage I-III NSCLC from January 2015 to December 2017 at a single institution were reviewed. The primary exposure of interest was FD residence as defined by the United States Department of Agriculture. The primary outcome was 5-y overall mortality. Secondary outcomes were 30-d complications and 1- and 3-y mortality. Cox proportional hazard analysis was used to model factors associated with each outcome, adjusted for covariates. RESULTS: A total of 348 ALRs were included, with 101 (29%) patients residing in an FD. In the unadjusted Cox model, those residing in FD had an associated lower 5-year mortality risk compared to those not residing in an FD (hazard ratio = 0.56, 95% confidence interval (0.33-0.97); P = 0.04). That association was not statistically significant once adjusted for covariates (hazard ratio = 0.59, 95% confidence interval (0.34-1.04); P = 0.07). CONCLUSIONS: In this study, FD residence was not associated with an increase in the risk of 5-y mortality. Selection bias of patients deemed healthy enough to undergo surgery may have mitigated the negative association of FD residence demonstrated in other cancers. Future work will evaluate all NSCLC patients undergoing treatments at our institution to further evaluate FDs as a risk factor for worse outcomes.

Resource use differences of two coexisting chironomid species at localized scales.

Competing species may show positive correlations in abundance through time and space if they rely on a shared resource. Such positive correlations might obscure resource partitioning that facilitates competitor coexistence. Here, we examine the potential for resource partitioning between two ecologically similar midge species (Diptera: Chironomidae) in Lake Mývatn, Iceland. Tanytarsus gracilentus and Chironomus islandicus show large, roughly synchronized population fluctuations, implying potential reliance on a shared fluctuating resource and thereby posing the question of how these species coexist at high larval abundances. We first considered spatial partitioning of larvae. Abundances of both species were positively correlated in space; thus, spatial partitioning across different sites in the lake did not appear to be strong. We then inferred differences in dietary resources with stable carbon isotopes. T. gracilentus larvae had significantly higher δ13C values than C. islandicus, suggesting interspecific differences in resource use. Differences in resource selectivity, tube-building behavior, and feeding styles may facilitate resource partitioning between these species. Relative to surface sediments, T. gracilentus had higher δ13C values, suggesting that they selectively graze on 13C-enriched resources such as productive algae from the surface of their tubes. In contrast, C. islandicus had lower δ13C values than surface sediments, suggesting reliance on 13C-depleted resources that may include detrital organic matter and associated microbes that larvae selectively consume from the sediment surface or within their burrow walls. Overall, our study illustrates that coexisting and ecologically similar species may show positive correlations in space and time while using different resources at fine spatial scales.

Demographic Basis of Spatially Structured Fluctuations in a Threespine Stickleback Metapopulation.

AbstractUncovering the demographic basis of population fluctuations is a central goal of population biology. This is particularly challenging for spatially structured populations, which require disentangling synchrony in demographic rates from coupling via movement between locations. In this study, we fit a stage-structured metapopulation model to a 29-year time series of threespine stickleback abundance in the heterogeneous and productive Lake Mývatn, Iceland. The lake comprises two basins (North and South) connected by a channel through which the stickleback disperse. The model includes time-varying demographic rates, allowing us to assess the potential contributions of recruitment and survival, spatial coupling via movement, and demographic transience to the population's large fluctuations in abundance. Our analyses indicate that recruitment was only modestly synchronized between the two basins, whereas survival probabilities of adults were more strongly synchronized, contributing to cyclic fluctuations in the lake-wide population size with a period of approximately 6 years. The analyses further show that the two basins were coupled through movement, with the North Basin subsidizing the South Basin and playing a dominant role in driving the lake-wide dynamics. Our results show that cyclic fluctuations of a metapopulation can be explained in terms of the combined effects of synchronized demographic rates and spatial coupling.

Reasons for Long-term Opioid Prescriptions After Guideline-directed Opioid Prescribing and Excess Opioid Pill Disposal.

OBJECTIVES: The aim of this study was to determine the frequency and reasons for long-term opioid prescriptions (rxs) after surgery in the setting of guideline-directed prescribing and a high rate of excess opioid disposal. BACKGROUND: Although previous studies have demonstrated that 5% to 10% of opioid-naïve patients prescribed opioids after surgery will receive long-term (3-12 months after surgery) opioid rxs, little is known about the reasons why long-term opioids are prescribed. METHODS: We studied 221 opioid-naïve surgical patients enrolled in a previously reported prospective clinical trial which used a patient-centric guideline for discharge opioid prescribing and achieved a high rate of excess opioid disposal. Patients were treated on a wide variety of services; 88% of individuals underwent cancer-related surgery. Long-term opioid rxs were identified using a Prescription Drug Monitoring Program search and reasons for rxs and opioid adverse events were ascertained by medical record review. We used a consensus definition for persistent opioid use: opioid rx 3 to 12 months after surgery and >60day supply. RESULTS: 15.3% (34/221) filled an opioid rx 3 to 12 months after surgery, with 5.4% and 12.2% filling an rx 3 to 6 and 6 to 12 months after surgery, respectively. The median opioid rx days supply per patient was 7, interquartile range 5 to 27, range 1 to 447 days. The reasons for long-term opioid rxs were: 51% new painful medical condition, 40% new surgery, 6% related to the index operation; only 1 patient on 1 occasion was given an opioid rx for a nonspecific reason. Five patients (2.3%) developed persistent opioid use, 2 due to pain from recurrent cancer, 2 for new medical conditions, and 1 for a chronic abscess. CONCLUSIONS: In a group of prospectively studied opioid-naïve surgical patients discharged with guideline-directed opioid rxs and who achieved high rates of excess opioid disposal, no patients became persistent opioid users solely as a result of the opioid rx given after their index surgery. Long-term opioid use did occur for other, well-defined, medical or surgical reasons.

Genome-phenotype-environment associations identify signatures of selection in a panmictic population of threespine stickleback.

Adaptive genetic divergence occurs when selection imposed by the environment causes the genomic component of the phenotype to differentiate. However, genomic signatures of natural selection are usually identified without information on which trait is responding to selection by which selective agent(s). Here, we integrate whole-genome sequencing with phenomics and measures of putative selective agents to assess the extent of adaptive divergence in threespine stickleback occupying the highly heterogeneous lake Mývatn, NE Iceland. We find negligible genome wide divergence, yet multiple traits (body size, gill raker structure and defence traits) were divergent along known ecological gradients (temperature, predatory bird densities and water depth). SNP based heritability of all measured traits was high (h2  = 0.42-0.65), indicating adaptive potential for all traits. Environment-association analyses further identified thousands of loci putatively involved in selection, related to genes linked to, for instance, neuron development and protein phosphorylation. Finally, we found that loci linked to water depth were concurrently associated with pelvic spine length variation - supporting the conclusion that divergence in pelvic spine length occurred in the face of gene flow. Our results suggest that whilst there is substantial genetic variation in the traits measured, phenotypic divergence of Mývatn stickleback is mostly weakly associated with environmental gradients, potentially as a result of substantial gene flow. Our study illustrates the value of integrative studies that combine genomic assays of multivariate trait variation with landscape genomics.

Tumour, whole-blood, plasma and tissue concentrations of metformin in lung cancer patients.

AIM: Metformin is used for the management of type 2 diabetes mellitus (T2DM) and is being tested clinically as an anticancer agent. Metformin concentrations safely achievable in human solid tissues including tumours are unknown. This study was designed to determine metformin concentration in tissue compartments as a function of dose to inform rational dosing in preclinical models and interpretation of clinical results." METHODS: Subjects with solid tumours to be treated by resection and either (A) willingness to take metformin for 7-10 days before surgery or (B) taking metformin for T2DM were eligible. Whole blood, plasma, tumour, tumour-adjacent uninvolved tissue and subcutaneous adipose tissue were obtained for liquid chromatography with tandem mass spectrometry to measure metformin concentrations. RESULTS: All subjects had primary lung tumours. Metformin dose was significantly correlated with drug concentrations in all tissues analysed. Intersubject metformin concentrations varied by over two orders of magnitude. Metformin concentrations were significantly higher in tumour tissues and lower in adipose tissues compared to other tissues. Concentrations in blood and plasma were significantly correlated with concentrations in solid tissues. CONCLUSION: Metformin accumulates in cellular compartments. Concentrations observed in plasma, blood, lung and tumour tissues in subjects treated with US Food and Drug Administration-approved doses for T2DM are lower than those typically used in tissue culture studies. However, such tissue concentrations are in line with those found within cultured cells treated with supra-pharmacological doses of metformin. Given the large intersubject variability in metformin concentrations, it is imperative to determine whether there is an association between tissue metformin concentration and anticancer activity in humans.

Reducing Unnecessary Type and Screens Prior to Thoracic Surgery: A Quality Improvement Initiative.

INTRODUCTION: Previous work identified that routine preoperative type and screen (T&S) testing before elective thoracic surgery is overutilized. We hypothesized that instituting a quality improvement (QI) initiative to change practice would significantly reduce this unnecessary testing, reduce costs, and improve healthcare efficiency. MATERIALS AND METHODS: A QI initiative was developed at a single, academic center to reduce empiric T&S ordering before elective anatomic lung resections. Two interventions were implemented: 1) education based on current institutional data and 2) an electronic medical record order set modification. Utilization of T&S testing, blood transfusion data, and perioperative outcomes were tracked and compared between a preintervention group (2015-2018) and a postintervention group (2020-2021). Cost data were derived from institutional charges and Centers for Medicare & Medicaid Services fee schedules. RESULTS: Of the 553 patients included: 420 were in the preintervention group and 133 were in the postintervention group. The rate of routine T&Ss significantly dropped after implementing the QI initiative (97 versus 20%, P ≤ 0.001). Additionally, no difference in blood transfusion rate was observed (4.3 versus 2.3%, P = 0.29), and there were no differences noted in postoperative complications (P = 0.82), 30-day readmission (P = 0.29), or mortality (P = 0.96). Based on current volumes of ∼200 anatomic lung resections/year, estimated cost savings from reducing T&S testing from 97 to 20% would be at least $40,000 a year. CONCLUSIONS: Our QI initiative significantly reduced the use of routine T&S testing. This practice change was achieved while maintaining excellent outcomes demonstrating routine preoperative T&S testing can be safely reduced in most elective thoracic surgery.

Vaccine attributes and vaccine uptake in Hungary: evidence from a conjoint experiment.

BACKGROUND: In an ongoing public health crisis, the question of why some people are unwilling to take vaccines with particular attributes is an especially pertinent one, since low rates of vaccination mean that it will take longer for many nations to exit the coronavirus disease 2019 (COVID-19) pandemic. METHODS: In this article, we conduct a pre-registered conjoint experiment in Hungary (N = 2512), where respondents were asked about their attitudes towards hypothetical COVID-19 vaccines whose characteristics varied across a number of attributes. RESULTS: Results indicate that vaccine attributes matter for the likelihood of uptake when it comes to the prevalence of severe side effects, efficacy and country of origin. Moreover, we find that our pre-treatment measure of institutional trust moderates the effect of our treatment, as differences in vaccine attributes are larger for those with robust levels of institutional trust compared to those with weaker levels. CONCLUSION: Our findings suggest that institutional trust matters when it comes to understanding the relationship between vaccine attributes and likelihood of uptake.

Double trouble: How sectarian and national narcissism relate differently to collective violence beliefs in Lebanon.

Collective narcissism is a belief in ingroup greatness which is contingent on external validation. A lack of research on collective narcissism amongst non-Western contexts and minority groups remains a challenge for the field. However, here we test two types of collective narcissism (sectarian and national) as differential predictors of two dimensions of collective violence beliefs (against outgroup members and leaders) in a large, diverse, community sample from Lebanon (N = 778). We found that sectarian narcissism (narcissism related to smaller political and religious ingroup identity) predicted support for collective violence against members of different sects, while national narcissism predicted opposition to such collective violence. Neither form of collective narcissism had any significant relationship with collective violence against outgroup leaders. We controlled for both sectarian and national identification and found no significant effects in predicting either one of the two dimensions of collective violence beliefs. In this non-Western context, in which a coherent national identity is undermined by sectarianism, national narcissism seems to be a progressive motivator for unity and social change, while sectarian narcissism is rather associated with extreme attitudes, such as support for collective violence.

Lung Cancer Screening in a Surgical Lung Cancer Population: Analysis of a Rural, Quaternary, Academic Experience.

BACKGROUND: Rural populations face many health disadvantages including higher rates of tobacco use and lung cancer than more populated areas. Given this, we specifically sought to understand the current screening landscape in a cohort of patients with resected lung cancer to help direct improvements in the screening process. MATERIALS AND METHODS: We retrospectively reviewed our prospective database at a rural, quaternary, academic institution from January 2015 to June 2018. All patients who underwent resection for primary lung cancer were studied to assess the frequency of preoperative low-dose chest computed tomography per accepted guidelines. The intent was to evaluate participant demographics, clinical stage, frequency, and distribution of Lung-RADS reporting. RESULTS: About 446 patients underwent primary resection, of which 252 were deemed screening-eligible. About 57 (22.6%) underwent low-dose chest computed tomography screening and 195 (77.4%) did not. No significant demographic differences were identified between groups. However, 82.5% (47/57) of the screened patients presented with clinical stage IA disease, compared with 67.1% (131/195) of the nonscreened patients (P = 0.03). Among those screened, 36.8% (21/57) did not have a Lung-RADS score documented despite 52.3% (11/21) of those coming from accredited programs. CONCLUSIONS: Our screening completion rate was only 22.6% of eligible patients and 36.8% of those patients did not have a documented Lung-RADS score. These findings, in combination with the increased rate of diagnosis of stage IA disease, provide compelling reasons to further investigate factors designed to improve access and screening practices at rural institutions.

Patient-Reported Outcomes in Surgical Oncology: An Overview of Instruments and Scores.

Traditional measures of quality and effectiveness in surgical oncology have focused on morbidity, mortality, and when available, recurrence rates. Measuring patient-reported outcomes (PROs) has become more widely accepted during the last decade. This article reviews instruments commonly used in the surgical treatment of cancer patients to evaluate PROs. In addition, it discusses the linkage of PROs and health-related quality of life measures with traditional surgical complications and highlights future directions related to the expanding use of PROs in the surgical care of cancer patients.

The Neural Signature of Impaired Dual-Tasking in Idiopathic Rapid Eye Movement Sleep Behavior Disorder Patients.

Dual-task gait can be a useful biomarker for cognitive decline and a sensitive predictor of future neurodegeneration in certain clinical populations, such as patients with idiopathic rapid eye movement sleep behavior disorder. OBJECTIVES: The objective of this cross-sectional study was to determine the neural signature of dual-tasking deficits in idiopathic rapid eye movement sleep behavior disorder using a validated gait paradigm. METHODS: Fifty-eight participants (28 controls; 30 idiopathic rapid eye movement sleep behavior disorder patients) were recruited; 52 participants had functional MRI scans as they performed a validated dual-task virtual reality gait paradigm using foot pedals. Forty-one participants completed single- and dual-task "overground walking" on a pressure sensor carpet. RESULTS: Idiopathic rapid eye movement sleep behavior disorder patients showed deficits in dual-tasking (i.e., greater mean step time) compared to controls during "overground walking." Functional MRI revealed that idiopathic rapid eye movement sleep behavior disorder patients had reduced blood-oxygen-level-dependent signal change in the dorsal caudate nucleus, and significantly different corticostriatal functional connectivity patterns from controls, when dual-tasking in high versus low cognitive load. While controls showed greater connectivity between frontoparietal and motor networks, idiopathic rapid eye movement sleep behavior disorder patients exhibited less change in this connectivity as a function of cognitive load. CONCLUSIONS: These findings demonstrate evidence of dual-task gait deficits in idiopathic rapid eye movement sleep behavior disorder patients, underpinned by disrupted corticostriatal connectivity. Minimal differences in the level of functional connectivity between dual-tasking conditions of high and low cognitive load suggest that idiopathic rapid eye movement sleep behavior disorder patients recruit cognitive networks to control gait even when the cognitive demands are low. This may indicate a compensatory strategy for early cognitive decline in idiopathic rapid eye movement sleep behavior disorder. © 2020 International Parkinson and Movement Disorder Society.

Routine Chest X-Rays After Thoracic Surgery Are Unnecessary.

BACKGROUND: Routine chest x-rays (CXRs) ordered on thoracic surgery inpatients are common, costly, and of unclear clinical utility. We sought to investigate CXR ordering practices and their impact on clinical care. MATERIALS AND METHODS: A single-center, retrospective cohort study of adult patients admitted after undergoing thoracic surgery with an intraoperative chest tube (CT) placed was performed over a 1-y period. Our primary outcome was a CXR-driven change in care. We evaluated routine CXR orders immediately after surgery in the postanesthesia care unit (PACU) and after final CT removal. "Routine" was defined as not ordered during a workup for a clinical concern. Patients were excluded if they underwent pleurodesis, were discharged with a CT, or had an immediate post-CT removal clinical change prompting intervention. RESULTS: A total of 241 patients met inclusion. All patients received a routine PACU CXR, and 48% (117) had abnormal radiographic findings (e.g., pneumothorax, consolidation, effusion, etc). Secondary to this CXR, one patient (0.4%) experienced a change in care: a repeat CXR only. All patients received a routine final CT removal CXR, and 58% (140) had abnormal radiographic findings. After this CXR, 33 patients (14%) experienced a change in care: 32 underwent repeat CXR and one was clinically observed. Overall, no patients experienced a procedural intervention. CONCLUSIONS: Routine post-thoracic surgery CXRs in the PACU and after CT removal have limited clinical impact. Quality initiatives should be pursued to decrease empiric CXR use and reserve ordering for specific clinical concerns.

Long-Term Outcomes of a Preoperative Lung Resection Smoking Cessation Program.

BACKGROUND: Smoking cessation programs for patients with cancer suggest 6-mo quit rates between 22% and 40%, and 1-y rates of 33%. We sought to investigate the long-term outcomes of an intensive, preoperative smoking cessation program in patients undergoing lung resection. MATERIAL AND METHODS: A retrospective analysis of an IRB-approved, prospective database was performed. Elective lung resections between January 1, 2015 and June 30, 2017 were identified. Demographics, smoking status, pack years, occurrence of smoking cessation counseling, complications, and quit date were obtained. Smoking cessation included face-to-face motivational interviewing, choice of nicotine replacement therapy, discussion that surgery may be canceled or delayed without cessation, and follow-up as needed. RESULTS: A total of 340 patients underwent lung resection. Of these, 82 patients were classified as current smokers. All were advised to quit and encouraged to meet with a certified tobacco treatment specialist. Sixty-three patients met with a tobacco treatment specialist and 19 did not. Overall, 60 patients (73%) were able to quit before surgery. At 2 y postoperatively, 15 (18%) were lost to follow-up and 9 (11%) had died. Excluding deaths and censoring those lost to follow-up, cessation rates at 6, 12, and 24 mo postoperatively were 55.3%, 55.6%, and 51.7%, respectively. CONCLUSIONS: Implementation of an intensive smoking cessation program in the preoperative period demonstrated high initial, mid-term, and long-term success rates. The preoperative period, particularly one centered around lung cancer, is an effective time for smoking cessation intervention and can lead to a high rate of cessation up to 2 y after surgery.

Preoperative Type and Screen is Unnecessary in Elective Anatomic Lung Resection and Esophagectomy.

BACKGROUND: Preoperative type and screen (TS) is routinely performed before elective thoracic surgery. We sought to evaluate the utility of this practice by examining our institutional data related to intraoperative and postoperative transfusions for two common, complex procedures. MATERIALS AND METHODS: A single-center, retrospective review of a prospective thoracic surgery database was performed. Patients who underwent consecutive elective anatomic lung resection (ALR) and esophagectomy from January 2015 to April 2018 were included. Perioperative characteristics between patients who received transfusion of packed red blood cells and those who did not were compared. The rates of emergent and nonemergent transfusions were evaluated. Cost data were derived from institutional charges and Centers for Medicare & Medicaid Services fee schedules. RESULTS: Of 370 patients, 16 (4.3%) received a transfusion and four (1.1%) were deemed emergent by the surgeons and 0 (0%) by blood bank criteria. For ALR (n = 321), 13 (4.0%) received a transfusion, and four (1.2%) were emergent. For esophagectomies (n = 49), three (6.1%) received a transfusion, and none were emergent. Patients who underwent ALR requiring a transfusion had a lower preoperative hemoglobin (11.7 versus 13.4 gm/dL, P = 0.001), higher estimated blood loss (1325 versus 196 mL, P < 0.001), and longer operative time (291 versus 217 min, P = 0.003) than nontransfused patients. Based on current volumes, eliminating TS in these patients would save at least an estimated $60,100 per year. CONCLUSIONS: Emergent transfusion in ALR and esophagectomy is rare. Routine preoperative TS is most likely unnecessary for these cases. These results will be used in a quality improvement initiative to change practice at our institution.

Evaluating the Sustained Attention Response Task to Quantify Cognitive Fluctuations in Dementia With Lewy Bodies.

Cognitive fluctuations (CFs) are a core diagnostic feature of dementia with Lewy bodies (DLB). Detection of CF is still mostly based on subjective reports from the patient or informant; more quantitative measures are likely to improve the accuracy for the diagnosis of DLB. The purpose of the current study is to test whether performance on the Sustained Attention Response Task (SART) could distinguish those patients with DLB with and without CF. Twenty-four patients with DLB were tested on the SART and performance was related to scores on the Clinical Assessment of Fluctuations (CAFs) and One Day Fluctuation Assessment Scale (ODFAS). The number of "misses" made was a significant predictor of their fluctuation severity, attentional performance, disorganized thinking, and language production ratings on the ODFAS. However, measures on the SART did not correlate with measures on the CAF scale. In conclusion, these findings suggest that SART is a feasible measure of sustained attention in this population and has clinical and diagnostic relevance to the measurement of CF, particularly those aspects measured by the ODFAS.