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Background: Smoking is responsible for nearly 85% of lung cancer cases and 30% of all cancer-related deaths. Canada has set an ambitious target to reduce tobacco use to 5% by 2035 in alignment with a world-wide tobacco endgame initiative. Aim: We project the impact of achieving a national 5% smoking prevalence rate by 2035 on population-level lung cancer outcomes and costs. Methods: OncoSim-Lung (version 2.5), led by the Canadian Partnership Against Cancer with model development by Statistics Canada, is a microsimulation model that incorporates Canadian demographics, risk factors, registry data, resource utilization and other data to project clinical and economic impacts of cancer control measures. Smoking cessation parameters were modified to reduce the current average national smoking prevalence rate of 18% over time to 5% in 2035. Impacts were compared with those in a reference scenario, which maintained the current prevalence rate. Outputs of interest included lung cancer incidence, mortality, treatment costs, and quality-adjusted life-years (QALYs). Costs and QALYs are undiscounted and reported in 2016 CAD. Results: Achieving a 5% smoking rate by 2035 would result in a 2017-2035 cumulative total of 31,000 fewer lung cancer cases, 21,000 fewer lung cancer-related deaths, and 457,000 additional QALYs compared with projections based on a constant smoking prevalence rate of ∼20%. When stratified by sex, there would be 15,600 and 15,700 fewer lung cancer diagnoses and 11,000 and 10,000 fewer lung cancer-related deaths for males and females respectively. Furthermore, treatment-related costs would be reduced by $680 million dollars. On average there would be 4,500 fewer lung cancer cases, 3,500 fewer deaths, and $35 million in cost savings annually. If a 5% smoking rate is sustained until 2050, then there would be a 15% reduction in lung cancer cases and a 13% reduction in deaths from 2017-2050. Conclusion: Reducing Canada's smoking prevalence to 5% by 2035 could result in a significant reduction in lung cancer cases, deaths and treatment costs. Like Canada, other countries with relatively high smoking prevalence could use averted treatment costs to offset costs of aggressive smoking prevention and cessation programs or redirect them to other healthcare services. [ABSTRACT FROM AUTHOR]

Background: Demonstrated lung cancer mortality reductions through low-dose computed tomography (LDCT) has encouraged some jurisdictions to consider implementing organized LDCT screening. A retrospective analysis of former smokers in the National Lung Screening Trial (NLST) suggested that abstention from smoking coupled with low-dose computed tomography (LDCT) screening realized more mortality benefits than abstinence alone or LDCT alone. Aim: We evaluated the potential costs and cost-effectiveness of lung cancer screening with integrated smoking cessation using OncoSim-Lung (version 2.5), a microsimulation model led by the Canadian Partnership Against Cancer, with model development by Statistics Canada. Methods: We compared organized LDCT screening without smoking cessation to various plausible scenarios of screening with cessation. Assumptions included: annual screening of 55-74 year-old individuals with a 30-pack-yr history; a 42% participation rate reached over 10 years; cessation therapy (nicotine replacement therapy + varenicline + 12 weeks' counseling) at a cost of $490; and up to 10 cessation attempts, with a permanent quit rate of 5% per attempt. Cost-effectiveness was estimated with a lifetime horizon, health system perspective and 1.5% discount rate. Costs are in 2016 CAD. Results: OncoSim-Lung projected that LDCT screening integrated with cessation would cost approximately $76 million annually (undiscounted) from 2017 to 2036 in Canada. About 110 fewer lung cancer (LC) cases and 50 fewer LC deaths would occur annually, compared with screening without cessation. Additionally, many other smoking-related deaths would be prevented. Using a lifetime horizon, smoking cessation would cost $14,000/QALYs gained. In one-way sensitivity analysis, with a 72% participation rate there would be 260 fewer deaths, at $24,000/QALY. With a 10% quit rate, cost-effectiveness would improve to $6,000/QALY. A 50% increase in the cost of the cessation intervention would decrease cost-effectiveness to $22,000/QALY. Conclusion: Robust smoking cessation efforts within a LDCT screening program could save lives and be relatively cost-effective. Cancer control planners should consider integrating smoking cessation when implementing a lung cancer screening initiative. [ABSTRACT FROM AUTHOR]

We present a patient with a so-called disc cyst. Its location in the ventrolateral epidural space and its communication with the herniated disc are clearly shown. The disc cyst developed rapidly and regressed spontaneously. This observation, which has not been reported until now, appears to support focal degeneration with cyst formation as the pathogenesis. [ABSTRACT FROM AUTHOR]

Abstract Background Response rate (RR), the most common early means of assessing oncology drugs, is not suitable as the sole endpoint for phase II trials of drugs which induce disease stability but not regression. Time to progression (TTP) may be more sensitive to such agents, but induces recruitment delays in multistage studies. Early progressive disease (EPD) is the earliest signal of time to progression, but is less intuitive to investigators, To study drugs with unknown anti-tumour effect, we designed the Combination Stopping Rule (CSR), which allows investigators to establish a hypothesis using RR and TTP, while the program also employs early progressive disease (EPD) to assess for drug inactivity during the first stage of study accrual. Methods A computer program was created to generate stopping rules based on specified error rates, trial size, and RR and median TTP of interest and disinterest for a two-stage phase II trial. Rules were generated for stage II such that the null hypothesis (Hnul) was rejected if either RR or TTP met desired thresholds, and accepted if both did not. Assuming an exponential distribution for progression, EPD thresholds were determined based on specified TTP values. Stopping rules were generated for stage I such that Hnul was accepted and the study stopped if both RR and EPD were unacceptable. Results Patient thresholds were generated for RR, median TTP, and EPD which achieved specified error rates and which allowed early stopping based on RR and EPD. For smaller proportional differences between interesting and disinteresting values of RR or TTP, larger trials are required to maintain alpha error, and early stopping is more common with a larger first stage. Conclusion Stopping rules are provided for phase II trials for drugs which have either a desirable RR or TTP. In addition, early stopping can be achieved using RR and EPD.

Abstract Background Response rate (RR) alone may be insensitive to drug activity in phase II trials. Early progressive disease (EPD) could improve sensitivity as well as increase stage I stopping rates. This study compares the previously developed dual endpoint stopping rule (DESR), which incorporates both RR and EPD into a two-stage, phase II trial, with rules using only RR. Methods Stopping rules according to the DESR were compared with studies conducted under the Fleming (16 trials) or Gehan (23 trials) designs. The RR hypothesis for the DESR was consistent with the comparison studies (ralt = 0.2, rnul = 0.05). Two parameter sets were used for EPD rates of interest and disinterest respectively (epdalt, epdnul): (0.4, 0.6) and (0.3, 0.5). Results Compared with Fleming, the DESR was more likely to allow stage two of accrual and to reject the null hypothesis (Hnul) after stage two, with rejection being more common with EPD parameters (0.4, 0.6) than (0.3, 0.5). Compared with Gehan, both DESR parameter sets accepted Hnul in 15 trials after stage I compared with 8 trials by Gehan, with consistent conclusions in all 23 trials after stage II. Conclusions The DESR may reject Hnul when EPD rates alone are low, and thereby may improve phase II trial sensitivity to active, cytostatic drugs having limited response rates. Conversely, the DESR may invoke early stopping when response rates are low and EPD rates are high, thus shortening trials when drug activity is unlikely. EPD parameters should be chosen specific to each trial.

Background End-of-life cancer care involves multidisciplinary teams working in various settings. Evaluating the quality of care and the feedback from such processes is an important aspect of health care quality improvement. Our retrospective cohort study reviewed health care use by lung cancer patients at end of life, their reasons for visiting the emergency department (ed), and feedback from regional health care professionals. Methods We assessed 162 Ontario patients with small-cell and relapsed or advanced non-small-cell lung cancer. Demographics, disease characteristics, and resource use were collected, and the consenting caregivers for patients with ed visits were interviewed. Study results were disseminated, and feedback about barriers to care was sought. Results Median patient age was 69 years; 73% of the group had non-small-cell lung cancer; and 39% and 69% had received chemotherapy and radiation therapy respectively. Median overall survival was 5.6 months. In the last 3 months of life, 93% of the study patients had visited an oncologist, 67% had telephoned their oncology team, 86% had received homecare, and 73% had visited the ed. Death occurred for 55% of the patients in hospital; 23%, at home; and 22%, in hospice. Goals of care had been documented for 68% of the patients. Homecare for longer than 3 months was associated with fewer ed visits (80.3% vs. 62.1%, p = 0.022). Key themes from stakeholders included the need for more resources and for effective communication between care teams. Conclusions Use of acute-care services and rates of death in an acute-care facility are both high for lung cancer patients approaching end of life. In our study, interprofessional and patient–provider communication, earlier connection to homecare services, and improved access to community care were highlighted as having the potential to lower the need for acute-care resources. [ABSTRACT FROM AUTHOR]

Background Patients with limited-stage (ls) or extensive-stage (es) small-cell lung cancer (sclc) are commonly given platinum-based chemotherapy as first-line treatment. Standard chemotherapy for patients with ls sclc includes a platinum agent such as cisplatin combined with the non-platinum agent etoposide. The objective of the present systematic review was to investigate the efficacy of adding radiotherapy to chemotherapy in patients with ES SCLC and to determine the appropriate timing, dose, and schedule of chemotherapy or radiation for patients with SCLC. Methods The medline and embase databases were searched for randomized controlled trials (rcts) comparing treatment with radiotherapy plus chemotherapy against treatment with chemotherapy alone in patients with es sclc. Identified rcts were also included if they compared various timings, doses, and schedules of treatment for patients with es SCLC or LS SCLC. Results Sixty-four rcts were included. In patients with LS SCLC, overall survival was greatest with platinum-etoposide compared with other chemotherapy regimens. In patients with es sclc, overall survival was greatest with chemotherapy containing platinum-irinotecan than with chemotherapy containing platinum-etoposide (hazard ratio: 0.84; 95% confidence interval: 0.74 to 0.95; p = 0.006). The addition of radiation to chemotherapy for patients with es sclc showed mixed results. There was no conclusive evidence that the timing, dose, or schedule of thoracic radiation affected treatment outcomes in SCLC. Conclusions In patients with LS SCLC, cisplatin-etoposide plus radiotherapy should remain the standard therapy. In patients with es sclc, the evidence is insufficient to recommend the addition of radiotherapy to chemotherapy as standard practice to improve overall survival. However, on a case-by-case basis, radiotherapy might be added to reduce local recurrence. The most commonly used chemotherapy is platinum-etoposide; however, platinum-irinotecan can be considered. [ABSTRACT FROM AUTHOR]

Oesophageal perforation related to anterior cervical surgery is an uncommon but well recognised and potentially life-threatening complication with an incidence of 0–3.4%. Our experience with this complication and a review of the literature are presented. We retrospectively reviewed our clinical experience over 10 years and found four patients in whom an oesophageal perforation was recognised after anterior surgery for cervical spine trauma. In three patients the perforation was noticed in the early post-operative period and the other had a delayed presentation. In all patients, the hardware was removed, long-term intravenous antibiotics were administered and parenteral nutrition was instituted. In two patients a primary suture of the perforation was performed and in one of these an additional sternocleidomastoid myoplasty was carried out as well. One patient had conservative treatment and one died before closure of the perforation could be performed. The two patients, in whom surgical repair of the perforation was performed, recovered well with residual neurological deficits as expected due to the cervical trauma. In the patient in whom conservative treatment was instituted, healing of the perforation occurred. One patient died due to systemic complications, indirectly related to the perforation. Although not very frequent and sometimes difficult to diagnose, oesophageal perforations after anterior cervical surgery constitute a potentially life-threatening complication. Diagnosis is made by imaging or endoscopic studies, but clinical suspicion is most important. Basic treatment consists of surgery with removal of hardware, drainage of abscesses, primary closure of the perforation if possible, parenteral nutrition and antibiotic therapy. Residual instability should be recognised in time and may be anticipated in patients in whom there has been little time for solid bony fusion. Successful management depends on early diagnosis and immediate institution of treatment. [ABSTRACT FROM AUTHOR]

Abstract: Skull fracture is a frequently observed type of severe head injury. Historically, a variety of impact test set-ups and techniques have been used for investigating skull fracture. The most frequently used are the free-fall technique, the guided fall or drop tower set-up and the piston-driven impactor set-up. This document proposes a new type of set-up for cadaver head impact testing which combines the strengths of the most frequently used techniques and devices. The set-up consists of two pendulums, which allow for a 1 degree of freedom rotational motion. The first pendulum is the impactor and is used to strike the blow. The head is attached to the second pendulum using a polyester resin. Local skull deformation and impact force are measured with a sample frequency of 65kHz. From these data, absorbed energy until skull fracture is calculated. A set-up evaluation consisting of 14 frontal skull and head impact tests shows an accurate measurement of both force and local skull deformation until fracture of the skull. Simplified mechanical models are used to analyse the different impacting techniques from literature as well as the new proposed set-up. It is concluded that the proposed test set-up is able to accurately calculate the energy absorbed by the skull until fracture with an uncertainty interval of 10%. Second, it is concluded that skull fracture caused by blunt impact occurs before any significant motion of the head. The two-pendulum set-up is the first head impact device to allow a well-controlled measurement environment without altering the skull stress distribution. [Copyright &y& Elsevier]

Background: This study aimed to assess the radiographic proximal humerus bony adaptations to stress shielding and associated clinical outcomes following stemless total shoulder arthroplasty., Methods: A retrospective review of all patients who underwent stemless total shoulder arthroplasty surgery at our centre from 2010 to 2020 was performed., Results: In total, 115 stemless total shoulder arthroplasty utilising a single implant design with a minimum one-year follow-up were identified over a 10-year period. The median follow-up was 3.5 years (range: 1-8.9 years). Evidence of stress shielding was observed in 20 cases (17%), (9 mild (8%), 0 moderate (0%), 11 severe (9%). No significant differences were seen between stress shielding and gender, body mass index, post-operative range-of-motion, patient satisfaction, or Oxford shoulder score. No significant differences were seen between the operative technique and stress shielding. No cases had evidence of humeral lucency. In total, 24 cases (21%) had evidence of glenoid lucency of Lazarus grade 0-3. No cases had Lazarus grades 4 or 5. There was no association between stress shielding and humeral lucency, glenoid lucency, or revision procedure., Discussion: Stress shielding in this study occurred at lower rates than anticipated following stemless total shoulder arthroplasty and was not associated with radiographic evidence of lucency, revision procedures, or adverse effect on clinical outcome measures., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Failed fixation of intracapsular hip fractures in young patients is associated with high morbidity and cost. Accordingly, we set out to determine the association between unsatisfactory post-operative imaging (judged by two fellowship-trained trauma consultants and a senior trainee) and the risk of subsequent reoperation, including adjustment for potential confounding variables. Ninety-four (94) patients aged <60 were included in the study from a single major trauma centre. Exhausted patients (19%) required further surgery, with the most common reason being avascular necrosis (n=10) followed by non-union (n=6). Univariate analysis found only smokers and unsatisfactory fracture reduction to be predictive of failure (p < 0.05). Other demographics and recognised scoring systems from the literature were poor predictors of failure apart from the Haiduewych classification system, utilised to assess the quality of reduction, which showed a trend towards significance (p0.053). Multivariate analysis showed smoking and unsatisfactory fracture reduction to be strong predictors of failure (p<0.05). In those with unsatisfactory fracture reduction, 50% required reoperation compared to 17.5% of those with satisfactory reduction. This study highlights the key principles of ensuring adequate intraoperative reduction and fixation, in keeping with GIRFT principles. Avoiding secondary reoperation is crucial to prevent long-term negative outcomes for this typically high functional demand group of patients. We recommend regular, consultant peer review of post-operative imaging as a method of identifying substandard fracture fixations and those at risk of failure. This will allow opportunities for teaching, clinical improvement, and multidisciplinary team (MDT) discussions of at-risk patients., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. North of Scotland Research Ethics Service issued approval NA. Research ethics was sought from the North of Scotland Research Ethics service. Using the HRA decision tool, it was deemed unnecessary and was classed by the NHS as a service evaluation. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Whittaker et al.)

This paper describes a modification of the traditional fascial tongue surgical approach to the distal humerus. In particular, we describe the reflection and utilisation of radial and ulnar triceps bundles to allow complete visualisation of the distal humerus. This extensile technique allows access to the entirety of the distal humerus and provides excellent visualisation to the operating surgeon. Indications for the surgical approach include open reduction with internal fixation of fractures (both intra- and extra-articular) and total elbow replacement. Whilst standard approaches to the distal humerus are well described, this modification describes a new surgical approach that improves access and visualisation of the traditional fascial tongue technique. Alternative approaches to improve visualisation include an olecranon osteotomy; the triceps bundle modification allows excellent exposure to the distal humerus whilst avoiding complications associated with an olecranon osteotomy. The surgical technique is illustrated with intra-operative photographs, which aim to aid in guiding the surgeon in undertaking critical steps of this approach., How to Cite This Article: Rankin IA, Dixon J, Goffin J, et al. A Modified Surgical Approach to the Distal Humerus: The Triceps Bundle Technique. Strategies Trauma Limb Reconstr 2024;19(2):99-103., Competing Interests: Source of support: Nil Conflict of interest: NoneConflict of interest: None, (Copyright © 2024; The Author(s).)

Introduction: The aim of this study was to evaluate noise exposure to the operating room staff consisting of the surgeon, assistant, anaesthetist and Mako Product Specialist (MPS) during Mako robotic-arm assisted total knee arthroplasty (TKA) and total hip arthroplasty (THA). We aimed to determine whether employees were exposed to noise at or above a lower exposure action value (LEAV) set out by the Noise at Work Regulations 2005, Health and Safety Executive (HSE), UK., Materials and Methods: We prospectively recorded intra-operative noise levels in Mako robotic-arm assisted TKA and THA over a period of two months using the MicW i436 connected to an iOS device (Apple), using the Sound Level Meter App (iOS) by the National Institute for Occupation Safety and Health (NIOSH). Data obtained was then used to calculate "worst case" daily exposure value to assess if sound levels were compliant with UK guidelines. Comparison between operating room staff groups was performed with ANOVA testing., Results: A total of 19 TKA and 11 THA operations were recorded. During TKA, for the primary surgeon and the assistant, the equivalent continuous sound pressure level (L Aeq ) was over 80 dB, exceeding the LEAV set out by the Noise at Work Regulations by HSE. During THA, the average L Aeq and peak sound pressure levels did not exceed the LEAV. The calculated daily exposure for the primary surgeon in TKA was 82 dB. A Tukey post hoc test revealed that L Aeq was statistically significantly lower in the anaesthetist and MPS (p < .001) compared to the primary surgeon and assistant in both TKA and THA., Conclusions: Operating room staff, particularly the primary surgeon and assistant are exposed to significant levels of noise during Mako robotic-arm assisted TKA and THA. Formal assessments should be performed to further assess the risk of noise induced hearing loss in robotic-arm assisted arthroplasty., (© 2024. The Author(s).)

Background: This study aimed to assess the outcomes of patients with complex rib fractures undergoing operative or nonoperative management at our major trauma center., Methods: A retrospective review of all patients who were considered for surgical stabilization of rib fractures (SSRF) at a single major trauma center from May 2016 to September 2022 was performed., Results: In total, 352 patients with complex rib fractures were identified. Thirty-seven patients (11%) fulfilled the criteria for surgical management and underwent SSRF. The SSRF group had a significantly higher proportion of patients with flail chest (32 [86%] vs. 94 [27%], p<0.001) or Injury Severity Score (ISS) >15 (37 [100%] vs. 129 [41%], p<0.001). No significant differences were seen between groups for 1-year mortality. Patients who underwent SSRF within 72 hours were 6 times less likely to develop pneumonia than those in whom SSRF was delayed for over 72 hours (2 [18%] vs. 15 [58%]; odds ratio, 0.163; 95% confidence interval, 0.029-0.909; p=0.036). Prompt SSRF showed non-significant associations with shorter intensive care unit length of stay (6 days vs. 10 days, p=0.140) and duration of mechanical ventilation (5 days vs. 8 days, p=0.177). SSRF was associated with a longer hospital length of stay compared to nonoperative patients with flail chest and/or ISS >15 (19 days vs. 13 days, p=0.012), whilst SSRF within 72 hours was not., Conclusion: Surgical fixation of complex rib fractures improves outcomes in selected patient groups. Delayed surgical fixation was associated with increased rates of pneumonia and a longer hospital length of stay.

This multicenter phase Ib study aimed to establish a recommended phase II dose for durvalumab (Du) ± tremelimumab (Tr) in combination with standard platinum-doublet chemotherapy. Eligible patients were enrolled into one of six dose levels (DL) of Du ± Tr which included concomitant treatment with standard platinum-doublet regimens; (pemetrexed, gemcitabine, etoposide, (each with cisplatin or carboplatin) or nab-paclitaxel (with carboplatin)). Dose escalation was according to a Rolling Six type design. Both weight-based and fixed dosing of Du and Tr were explored. Du was continued until progression. Tr dosing was finite (up to 6 doses) with increasing dose and/or frequency by DL. 136 patients were enrolled. The majority of drug-related adverse events (AEs) were ≤ grade 2 and attributable to chemotherapy. AEs considered related to immunotherapy were mainly ≤ grade 2; the most frequent (occurring ≥10 %) were colitis/diarrhea, skin, and thyroid dysfunction. Seven patients had DLTs including pneumonitis, myocarditis, diarrhea, encephalitis, motor neuropathy, and enterocolitis. There were 2 treatment-related deaths. Tr and Du exposures did not appear affected by chemotherapy. Among the 73 non-small cell lung cancer (NSCLC) patients treated, the objective response rate was 51 % (95 %CI = 38.7-62.6 %) with a median progression-free and overall survival of 6.5 months (95 % CI = 5.5-9.4 months) and 19.8 months (95 % CI = 14.8 months - not yet reached) respectively. Anti-tumour activity was observed across PD-L1 subtypes. Du 1500 mg q3w and Tr 75 mg q3wx5 can be safely combined with platinum-doublet chemotherapy. Efficacy among NSCLC patients appears comparable to results from other immunotherapy and chemotherapy combination trials. NCT02537418., (Copyright © 2020 Elsevier B.V. All rights reserved.)