Citations

BackgroundSynchronous colon cancers, defined as two or more primary colon cancer detected simultaneously at the time of initial diagnosis, account for up to 5% of all colon cancer diagnoses. Management principles and outcomes remain largely undefined.MethodsA retrospective institutional review of patients undergoing curative intent resection for colon adenocarcinoma (Stages I–III) from 1995 to 2007 was performed. Hereditary causes or inflammatory bowel disease were excluded. Matching was performed and Kaplan–Meier analysis was used to compare overall survival.ResultsOf 2,387 patients, 100 (4.2%) had synchronous cancers. Patients with synchronous lesions tended to be older (median 77 vs. 72 years, P < 0.001) with more advanced tumors (41.0% vs. 31.4% Stage III, P = 0.04). After matching, there were no differences in demographics or tumor factors (all P > 0.05). Compared to solitary, synchronous cancers demonstrated an inferior 10‐year overall survival (53.9% vs. 36.5%, P = 0.009). Subset analysis of patients with synchronous cancers showed no difference in overall survival between those with extended versus segmental resections at 120‐months (P = 0.07).ConclusionSynchronous colon cancer is associated with decreased overall survival compared to patients with solitary tumors. Extended resection does not confer a survival benefit in these patients. Further research is needed to determine how to mitigate the poor outcomes. J. Surg. Oncol. 2016;114:80–85. © 2016 Wiley Periodicals, Inc.

Purpose: In the current health care environment, cost effectiveness is critically important in policy setting and care of patients. This study performed a health economic analysis to assess the implications to providers and payers of expanding the use of frozen section margin analysis to minimize reoperations for patients undergoing breast cancer lumpectomy. Methods: A health care economic impact model was built to assess annual costs associated with breast lumpectomy procedures with and without frozen section margin analysis to avoid reoperation. Results: If frozen section margin analysis is used in 20% of breast lumpectomies and under a baseline assumption that 35% of initial lumpectomies without frozen section analysis result in reoperations, the potential annual cost savings are $18.2 million to payers and $0.4 million to providers. Under the same baseline assumption, if 100% of all health care facilities adopted the use of frozen section margin analysis for breast lumpectomy procedures, the potential annual cost savings are $90.9 million to payers and $1.8 million to providers. On the basis of 10,000 simulations, use of intraoperative frozen section margin analysis yields cost saving for payers and is cost neutral to slightly cost saving for providers. Conclusion: This economic analysis indicates that widespread use of frozen section margin evaluation intraoperatively to guide surgical resection in breast lumpectomy cases and minimize reoperations would be beneficial to cost savings not only for the patient but also for payers and, in most cases, for providers.

Photoplethysmography was used to evaluate 14 skin flaps in the pig. Eight skin flaps were 4×12 cm and were based dorsally. Six skin flaps were 4×18 cm and were based ventrally. All flaps were designed to undergo necrosis of the distal end. After elevation of the flap, blood flow to the skin flaps was estimated immediately by means of intravenously administered fluorescein. Photoplethysmography was used to determine blood flow to the skin flaps at 3, 24, 72, and 144 hours after elevation. Surviving length of the skin flaps was measured at nine days. Fluorescein accurately predicted the surviving length of the skin flaps. Photoplethysmography did not show a decrease in blood flow at the level of fluorescein penetration 3 or 48 hours after elevation. However, 72 and 144 hours after elevation, an abrupt decrease in blood flow was noted by photoplethysmography at the level of eventual skin necrosis.

Photoplethysmography was used to evaluate 14 skin flaps in the pig. Eight skin flaps were 4×12 cm and were based dorsally. Six skin flaps were 4×18 cm and were based ventrally. All flaps were designed to undergo necrosis of the distal end. After elevation of the flap, blood flow to the skin flaps was estimated immediately by means of intravenously administered fluorescein. Photoplethysmography was used to determine blood flow to the skin flaps at 3, 24, 72, and 144 hours after elevation. Surviving length of the skin flaps was measured at nine days. Fluorescein accurately predicted the surviving length of the skin flaps. Photoplethysmography did not show a decrease in blood flow at the level of fluorescein penetration 3 or 48 hours after elevation. However, 72 and 144 hours after elevation, an abrupt decrease in blood flow was noted by photoplethysmography at the level of eventual skin necrosis.

Disturbance of the normal relationship between the caudal border of the upper lateral cartilage and the cephalic margin of the lobular cartilage—the so‐called “cul‐de‐sac” area—can result in alar collapse and nasal airway obstruction. This may be caused by either the aging process or trauma, both surgical and nonsurgical. Rhinolift is a surgical procedure that was developed for the treatment of the aging ptotic nasal tip. We have applied this technique to patients with nasal airway obstruction resulting from alar collapse. Elevation of the cephalic margin of the lobular cartilage to a position superficial to the upper lateral cartilage restores the normal relationship between these two structures. The upper lateral cartilage then assists in stenting the vestibule open, and thereby improves nasal breathing. Over the past 10 years, 20 patients have had rhinolifts at our institution for the relief of nasal airway obstruction. Concomitant surgery included nasal septal reconstruction in 12 patients, polypectomy in one patient, and placement of a silicone rubber septal prosthesis for closure of a large septal perforation in three patients. Rhinolift was the sole procedure used for the correction of valvular pathology in 10 patients. The other 10 patients had modifications made in their upper lateral cartilage along with the rhinolift. Five patients described restoration of normal nasal breathing, while 14 patients showed partial symptomatic improvement. One patient reported no improvement in nasal breathing. Rhinolift is a safe effective surgical technique for functional improvement of nasal breathing in patients with alar collapse resulting from inadequate cartilaginous support.

A new computerized technique for the assessment of human nasal ciliary beat frequency is described. Thirty normal volunteers underwent nasal cytologic brushing to obtain ciliary samples. In each subject, 150 ciliary beats were analyzed from each of 50 separate ciliated cell clusters. The ciliary beat frequency for each area was determined with fast Fourier transformation. The results were plotted on a histogram to determine the ciliary beat distribution. The mean frequency for these samples was 11.29 Hz, with a standard deviation of 0.96 Hz. The median frequency for these samples was 11.25 Hz. These results show a marked improvement over hand‐counting microphotometry techniques because of the much larger sampling size and elimination of much human error. We believe this method of ciliary analysis represents a significant advancement in the evaluation of ciliary function and should assist in the diagnosis of patients with congenital and acquired forms of ciliary dysmotility.

Objectives To identify distinct frailty trajectories (clusters of individuals following a similar progression of frailty over time) in an aging population and to estimate associations between frailty trajectories and emergency department visits, hospitalizations, and all‐cause mortality. Design Population‐based cohort study. Setting Olmsted County, Minnesota. Participants Olmsted County, Minnesota residents aged 60–89 in 2005. Measurements Longitudinal changes in frailty between 2005 and 2012 were measured by constructing a yearly Rockwood frailty index incorporating body mass index, 17 comorbidities, and 14 activities of daily living. The frailty index measures variation in health status as the proportion of deficits present of the 32 considered (range 0–1). Results Of the 16,443 Olmsted County residents aged 60–89 in 2005, 12,270 (74.6%) had at least 3 years of frailty index measures and were retained for analysis. The median baseline frailty index increased with age (0.11 for 60–69, 0.14 for 70–79, 0.19 for 80–89). Three distinct frailty trajectories were identified in individuals aged 60–69 at baseline and two trajectories in those aged 70–79 and 80–89. Within each decade of age, increasing frailty trajectories were associated with greater risks of emergency department visits, hospitalization, and all‐cause mortality, even after adjustment for baseline frailty index. Conclusion The number of frailty trajectories differed according to age. Within each age group, those in the highest frailty trajectory had greater healthcare use and worse survival. Frailty trajectories may offer a way to target aging individuals at high risk of hospitalization or death for therapeutic or preventive interventions.

Study Design Retrospective clinical study of a prospectively collected, national database. Objective Determine the 30-day incidence, timing, and risk factors for venous thromboembolism (VTE) following thoracolumbar spine surgery. Methods The American College of Surgeons National Surgical Quality Improvement Program Participant Use File identified 43,777 patients who underwent thoracolumbar surgery from 2005 to 2012. Multiple patient characteristics were identified. The incidence and timing (in days) of deep vein thrombosis (DVT) and pulmonary embolus (PE) were determined. Multivariable regression analysis was performed to identify significant risk factors. Results Of the 43,777 patients identified as having had thoracolumbar surgery, 202 cases of PE (0.5%) and 311 cases of DVT (0.7%) were identified. VTE rates were highest in patients undergoing corpectomy, with a 1.7% PE rate and a 3.8% DVT rate. Independent risk factors for VTE included length of stay (LOS) ≥ 6 days (odds ratio [OR] 4.07), disseminated cancer (OR 1.77), white blood cell count > 12 (OR 1.76), paraplegia (OR 1.75), albumin < 3 (OR 1.73), American Society of Anesthesiologists class 4 or greater (OR 1.54), body mass index > 40 (OR 1.49), and operative time > 193 minutes (OR 1.43). LOS < 3 days was protective (OR 0.427). Conclusions We report an overall 30-day PE rate of 0.5% and DVT rate of 0.7% following thoracolumbar spine surgery. Patients undergoing corpectomy were at highest risk for VTE. Multiple VTE risk factors were identified. Further studies are needed to develop algorithms to stratify VTE risk and direct prophylaxis accordingly.

OBJECTIVE Malignant peripheral nerve sheath tumors (MPNSTs) of the eighth cranial nerve (CN) are exceedingly rare. To date the literature has focused on MPNSTs occurring after radiation therapy for presumed benign vestibular schwannomas (VSs), while MPNSTs arising without prior irradiation have received little attention. The objectives of the current study are to characterize the epidemiology, clinical presentation, disease course, and outcome using a large national cancer registry database and a systematic review of the English literature. Additionally, a previously unreported case is presented. METHODS The authors conducted an analysis of the Surveillance, Epidemiology, and End Results (SEER) database, a systematic review of the literature, and present a case report. Data from all patients identified in the SEER database with a diagnosis of MPNST involving the eighth CN, without a history of prior radiation, were analyzed. Additionally, all cases reported in the English literature between January 1980 and March 2015 were reviewed. Finally, 1 previously unreported case is presented. RESULTS The SEER registries identified 30 cases between 1992 and 2012. The average incidence was 0.017 per 1 million persons per year (range 0.000–0.0687 per year). The median age at diagnosis was 55 years, and 16 (53%) were women. Thirteen cases were diagnosed upon autopsy. Of the 17 cases diagnosed while alive, the median follow-up was 118 days, with 3 deaths (18%) observed. When compared with the incidence of benign VS, 1041 VSs present for every 1 MPNST arising from the eighth CN. Including a previously unreported case from the authors' center, a systematic review of the English literature yielded 24 reports. The median age at diagnosis was 44 years, 50% were women, and the median tumor size at diagnosis was 3 cm. Eleven patients (46%) reported isolated audiovestibular complaints typical for VS while 13 (54%) exhibited facial paresis or other signs of a more aggressive process. Treatment included microsurgery alone, microsurgery with adjuvant radiation, or microsurgery with chemoradiation. Sixty-one percent of patients receiving treatment experienced recurrence, 22% of which were diagnosed with drop metastases to the spine. Ultimately, 13 patients (54%) died of progressive disease at a median of 3 months following diagnosis. The ability to achieve gross-total resection was the only feature that was associated with improved disease-specific survival. CONCLUSIONS MPNSTs of the eighth CN are extremely rare and portend a poor prognosis. Nearly half of patients initially present with findings consistent with a benign VS, often making an early diagnosis challenging. In light of these data, early radiological and clinical follow-up should be considered in those who elect nonoperative treatment, particularly in patients with a short duration of symptoms or atypical presentation. These data also provide a baseline rate of malignancy that should be considered when estimating the risk of malignant transformation following stereotactic radiosurgery for VS.