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Ronald S Chamberlain,1–5 Jaswinder Sond,1 Krishnaraj Mahendraraj,1 Christine SM Lau,1,3 Brianna L Siracuse1 1Department of Surgery, Saint Barnabas Medical Center, Livingston, 2Department of Surgery, Rutgers New Jersey Medical School, Rutgers University, Newark, NJ, USA; 3St. George’s University School of Medicine, Grenada, West Indies; 4Department of Surgery, Banner MD Anderson Cancer Center, Gilbert, AZ, USA; 5Department of Surgery, Valley Cancer Surgical Specialists, Phoenix, AZ, USA Background: Chronic heart failure (CHF), which affects >5 million Americans, accounts for >1 million hospitalizations annually. As a part of the Hospital Readmission Reduction Program, the Affordable Care Act requires that the Centers for Medicare and Medicaid Services reduce payments to hospitals with excess readmissions. This study sought to develop a scale that reliably predicts readmission rates among patients with CHF. Methods: The State Inpatient Database (2006–2011) was utilized, and discharge data including demographic and clinical characteristics on 642,448 patients with CHF from California and New York (derivation cohort) and 365,359 patients with CHF from Florida and Washington (validation cohort) were extracted. The Readmission After Heart Failure (RAHF) scale was developed to predict readmission risk.Results: The 30-day readmission rates were 9.42 and 9.17% (derivation and validation cohorts, respectively). Age 15; 12.04% readmission rate). The relative risk of readmission was 1.67 for the high-risk group compared with the low-risk group. Conclusion: The RAHF scale reliably predicts a patient’s 30-day CHF readmission risk based on demographic and clinical factors present upon initial admission. By risk-stratifying patients, using models such as the RAHF scale, strategies tailored to each patient can be implemented to improve patient outcomes and reduce health care costs. Keywords: heart failure, readmission, risk factors, risk assessment, RAHF scale, hospital readmission reduction program, HRRP, SID database

Lauren S Sparber,1 Christine SM Lau,1,2 Tanya S Vialet,1 Ronald S Chamberlain1–4 1Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA; 2Saint George’s University School of Medicine, Grenada, West Indies; 3Department of Surgery, Banner MD Anderson Cancer Center, Gilbert, AZ, USA; 4Department of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ, USA Introduction: Inguinal and umbilical hernia repairs are among the most common surgical procedures performed in the US. Optimal perioperative pain control regimens remain challenging and opioid analgesics are commonly used. Preoperative nonsteroidal anti-inflammatory drug (NSAID) administration has been shown to reduce postoperative narcotic requirements. This study sought to evaluate the efficacy of perioperative intravenous (IV) ibuprofen on postoperative pain level and narcotic use in patients undergoing open or laparoscopic inguinal and/or umbilical hernia repair.Methods: A single center, randomized, double-blind placebo-controlled trial involving patients ≥18 years undergoing inguinal and/or umbilical hernia repair was performed. Patients were randomized to receive 800 mg of IV ibuprofen or placebo preoperatively. Outcomes assessed included postoperative pain medication required and visual analog scale (VAS) pain scores.Results: Forty-eight adult male patients underwent inguinal and/or umbilical hernia repair. Patients receiving IV ibuprofen used more oxycodone/acetaminophen (32% vs 13%) and IV hydromorphone (12% vs 8.7%), and fewer combinations of pain medications (44% vs 65.2%) in the first two postoperative hours compared to placebo (p=0.556). The IV ibuprofen group had more patients pain free (28% vs 8.7%, p=0.087) and lower VAS scores (3.08±2.14 vs 3.95±1.54, p=0.134) at 2 hours postoperatively, compared to the placebo group, however, this was not statistically significant. Similar pain levels at 1, 3, and 7 days, postoperative and similar use of rescue medications in both groups were observed.Conclusion: Preoperative administration of IV ibuprofen did not significantly reduce postoperative pain among patients undergoing elective hernia repair. Considerable variability in postoperative narcotic analgesic requirement was noted, and larger scale studies are needed to better understand the narcotic analgesic requirements associated with IV ibuprofen in inguinal/umbilical hernia repair patients. Keywords: NSAIDs, ibuprofen, pain, hernia repair, RCT

Christine SM Lau,1,2 Brianna L Siracuse,1 Ronald S Chamberlain1–4 1Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA; 2Saint George’s University School of Medicine, Grenada, West Indies; 3Department of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ, USA; 4Department of Surgery, Banner MD Anderson Cancer Center, Gilbert, AZ, USA Background: COPD affects over 13 million Americans, and accounts for over half a million hospitalizations annually. The Hospital Readmission Reduction Program, established by the Affordable Care Act requires the Centers for Medicare and Medicaid Services to reduce payments to hospitals with excess readmissions for COPD as of 2015. This study sought to develop a predictive readmission scale to identify COPD patients at higher readmission risk. Methods: Demographic and clinical data on 339,389 patients from New York and California (derivation cohort) and 258,113 patients from Washington and Florida (validation cohort) were abstracted from the State Inpatient Database (2006–2011), and the Readmission After COPD Exacerbation (RACE) Scale was developed to predict 30-day readmission risk. Results: Thirty-day COPD readmission rates were 7.54% for the derivation cohort and 6.70% for the validation cohort. Factors including age 40–65 years (odds ratio [OR] 1.17; 95% CI, 1.12–1.21), male gender (OR 1.16; 95% CI, 1.13–1.19), African American (OR 1.11; 95% CI, 1.06–1.16), 1st income quartile (OR 1.10; 95% CI, 1.06–1.15), 2nd income quartile (OR 1.06; 95% CI, 1.02–1.10), Medicaid insured (OR 1.83; 95% CI, 1.73–1.93), Medicare insured (OR 1.45; 95% CI, 1.38–1.52), anemia (OR 1.05; 95% CI, 1.02–1.09), congestive heart failure (OR 1.06; 95% CI, 1.02–1.09), depression (OR 1.18; 95% CI, 1.14–1.23), drug abuse (OR 1.17; 95% CI, 1.09–1.25), and psychoses (OR 1.19; 95% CI, 1.13–1.25) were independently associated with increased readmission rates, P

Christine SM Lau,1,2 Krishnaraj Mahendraraj,1 Ronald S Chamberlain1–4 1Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA; 2Saint George’s University School of Medicine, Grenada, West Indies; 3Department of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ, 4Department of Surgery, Banner MD Anderson Cancer Center, Gilbert, AZ, USA Introduction: Oligodendrogliomas (OGs) account for 4 cm in size. Children typically present with tumors in the temporal lobe, while adults present with tumors in the frontal lobe. Surgical resection confers a survival advantage among all patients, especially pediatric patients. Overall survival (OS) and cancer-specific survival are higher in the pediatric population. Further studies on novel treatment techniques, including bevacizumab and immunotherapy approaches, are required. Keywords: oligodendroglioma, brain cancer, SEER database

Krishnaraj Mahendraraj,1 Sneha Shrestha,1 Christine SM Lau,1,2 Ronald S Chamberlain1–4 1Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA; 2Saint George’s University School of Medicine, Grenada, West Indies; 3Department of Surgery, Banner MD Anderson Cancer Center, Gilbert, AZ, USA; 4Department of Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA Background: Ocular melanoma (OM) comprises

Christine S M Lau,1,2 Amanda Ward,2 Ronald S Chamberlain1–4 1Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA; 2Saint George’s University School of Medicine, Grenada, West Indies; 3Department of Surgery, Banner MD Anderson Cancer Center, Gilbert, AZ, USA; 4Department of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ, USA Introduction: Helicobacter pylori colonization is present in half of the world’s population and can lead to numerous gastrointestinal diseases if left untreated, including peptic ulcer disease and gastric cancer. Although concurrent triple therapy remains the recommended treatment regimen for H. pylori eradication, its success rate and efficacy have been declining. Recent studies have shown that the addition of probiotics can significantly increase eradication rates by up to 50%. This meta-analysis examines the impact of probiotic supplementation on the efficacy of standard triple therapy in eradicating H. pylori. Methods: A comprehensive literature search was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (time of inception to 2016) to identify all published randomized control trials (RCTs) assessing the use of probiotics in addition to triple therapy for the treatment of H. pylori. Searches were conducted using the keywords “probiotics”, “triple therapy”, and “Helicobacter pylori”. RCTs comparing the use of probiotics and standard triple therapy with standard triple therapy alone for any duration in patients of any age diagnosed with H. pylori infection were included. H. pylori eradication rates (detected using urea breath test or stool antigen) were analyzed as-per-protocol (APP) and intention-to-treat (ITT). Results: A total of 30 RCTs involving 4,302 patients APP and 4,515 patients ITT were analyzed. The addition of probiotics significantly increased eradication rates by 12.2% (relative risk [RR] =1.122; 95% confidence interval [CI], 1.091–1.153; P

Krishnaraj Mahendraraj,1 Christine SM Lau,1,2 Injoon Lee,2 Ronald S Chamberlain1–3 1Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA; 2St George’s University School of Medicine, Grenada, West Indies; 3Department of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ, USA Introduction: Uveal melanoma (UM) is the most common primary intraocular malignancy, despite comprising 50 years (OR 4.0, CI =3.4–4.6), distant metastases (OR 8.6, CI =4.7–15), and primary surgical treatment (OR 2.6, CI =2.0–3.3) as independently associated with increased mortality, P

Sudha Arumugam,1 Christine SM Lau,1,2 Ronald S Chamberlain1–3 1Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA; 2Saint George’s University School of Medicine, Grenada, West Indies; 3Department of Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA Objectives: Effective postoperative pain management is crucial in the care of surgical patients. Opioids, which are commonly used in managing postoperative pain, have a potential for tolerance and addiction, along with sedating side effects. Gabapentin’s use as a multimodal analgesic regimen to treat neuropathic pain has been documented as having favorable side effects. This meta-analysis examined the use of preoperative gabapentin and its impact on postoperative opioid consumption.Materials and methods: A comprehensive literature search was conducted to identify randomized control trials that evaluated preoperative gabapentin on postoperative opioid consumption. The outcomes of interest were cumulative opioid consumption following the surgery and the incidence of vomiting, somnolence, and nausea.Results: A total of 1,793 patients involved in 17 randomized control trials formed the final analysis for this study. Postoperative opioid consumption was reduced when using gabapentin within the initial 24 hours following surgery (standard mean difference -1.35, 95% confidence interval [CI]: -1.96 to -0.73; P

Christine SM Lau,1,2 Ronald S Chamberlain1–3 1Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA; 2Saint George's University School of Medicine, Grenada, West Indies; 3Department of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ, USA Introduction: Clostridium difficile infection (CDI) is the leading cause of antibiotic-associated diarrhea. CDI has increased in incidence and severity over the past decade, and is a growing worldwide health problem associated with substantial health care costs and significant morbidity and mortality. This meta-analysis examines the impact of probiotics on the incidence of Clostridium difficile-associated diarrhea (CDAD) among children and adults, in both hospital and outpatient settings. Methods: A comprehensive literature search of all published randomized control trials (RCTs) assessing the use of probiotics in the prevention of CDAD in patients receiving antibiotic therapy was conducted, and the incidence of CDAD was analyzed. Results: Twenty-six RCTs involving 7,957 patients were analyzed. Probiotic use significantly reduced the risk of developing CDAD by 60.5% (relative risk [RR] =0.395; 95% confidence interval [CI], 0.294–0.531; P

Christine SM Lau,1,2 Krishnaraj Mahendraraj,1 Ronald S Chamberlain1–31Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA; 2Saint George's University School of Medicine, Grenada, West Indies; 3Department of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ, USA Introduction: Atypical teratoid rhabdoid tumors (ATRTs) are rare, highly malignant embryonal tumors of the central nervous system (CNS) accounting for 20% of CNS tumors in children under the age of 3. This study examines a large cohort of ATRT patients to determine demographic, clinical, and pathologic factors which impact prognosis and survival. Methods: Demographic and clinical data were abstracted on 174 ATRT patients (171 pediatric patients age 4 cm in male Caucasian children of age

Extrapulmonary small cell carcinoma occurs in nearly all organs except the central nervous system and the liver. We are presenting a case of renal small cell carcinoma (SCC) with two unique characters. A 75-year-old patient was evaluated for back pain with no other complaints. Magnetic Resonance (MR) imaging of the abdomen revealed homogeneous tumor in the left renal pelvis extending beyond the kidney. Metastatic workup was negative. A left nephroureterectomy was performed. Histopathology and immunohistochemistry revealed a small cell carcinoma of the renal pelvis. The patient declined adjuvant therapy and died 2 months after surgery due to unrelated causes. After comprehensive worldwide literature search, we found 13 cases of SCC of the renal pelvis, including the current case. The mean age was 61.6 years (37-83), with a M: F ratio of 1:1.8. The average duration of symptoms was 71.4 days (21-168). Gross hematuria was the most common symptom(69.2%) followed by pain (61.5%). Adjuvant chemotherapy was provided to 4 patients (30.7%), and neoadjuvant to 1 patient. The median survival of patients who did and did not receive chemotherapy was 5.5 months (3-8) and 6 months (2-31), respectively, P<.50. In conclusion, renal SCC (both parenchymal and pelvic SCC) is a rapidly fatal disease with a median survival of ≤ 8 months. [ABSTRACT FROM AUTHOR]

Introduction: Prehabilitation programs or interventions are employed prior to surgery with the aim to optimize the patient before surgery and to improve their physiologic ability to recover from surgery. Components of these programs often include exercise, nutritional supplementation, and psychological interventions. This meta-analysis examines the impact of prehabilitation programs on both surgical and patient outcomes among gastrointestinal (GI) cancer patients undergoing surgery., Methods: A comprehensive literature search was conducted to identify all published randomized control trials (RCT) evaluating the use of prehabilitation programs (with one or more interventions) in GI cancer surgery patients. Outcomes assessed were 6-min walk distance (6MWD), postoperative complications, major complications (as defined as Clavien Dindo grade ≥ 3), surgical site infections (SSI), pneumonia, length of stay (LOS), 30-day readmission, and mortality., Results: Eleven RCTs including 929 patients (475 prehabilitation program and 454 controls) were analyzed. Prehabilitation programs were associated with statistically significant improvements in 6MWD between baseline and immediately prior to surgery (MD = 32.542 m; 95% CI, 10.774-54.310; p = 0.003) and 4-8 weeks after surgery (MD = 48.220 m; 95% CI, 1.532-94.908; p = 0.043) compared with patients who did not receive prehabilitation programs. Similar rates of postoperative complications, major complications, SSI, pneumonia, 30-day readmission, and mortality, as well as LOS, were observed (p > 0.05)., Conclusions: Prehabilitation programs improve exercise capacity both before and after surgery, with no significant difference in LOS, or rates of postoperative complications, 30-day readmission, and mortality. Future studies assessing the different components of prehabilitation programs to identify the most beneficial interventions are required.

Introduction: In the United Stated population >70years is likely to double by the year 2050. Elderly population (>70years) are most vulnerable to burns and outcomes following such injuries in this special group is poorly studied. This study aimed to look at outcomes following burns in patients >70years over a period of 17 years., Materials and Methods: Data on 6512 patients admitted to a Level I Burn Center between 1995 and 2011 was analyzed. Age, gender, ethnicity, TBSA, burn etiology, hospital and burn intensive care unit (ICU) length of stay (LOS) and status at discharge were abstracted. Three broad categories were created based on presence or absence of smoke inhalation, No smoke inhalation (Group A), smoke inhalation only (Group B) and smoke inhalation with burn injury (Group C). Differences were analyzed using the student's t-test for continuous variables and Chi-Square test for categorical variables., Results: The study group was comprised of 564 patients, 72.3% in group A, 4.8% in group B and 22.9% in group C formed the study population. The mean age of the patients studied was 80.4±6.7, with female patients being more common (58%). The number of Caucasians (72.9%) was highest in group C compared to other racial groups (p=0.047). Majority of patients in the group B (59.3%) were admitted directly compared to other two groups (group A=24.0%, group B=34.9%, p<0.001). Overall percent total body surface area (% TBSA) and % TBSA third degree burns were higher in group C, whereas % TBSA second degree burns were common in group B (p<0.05). The number ICU admissions, the mean length of ICU stay, mean duration of ventilator support and mean length of hospitalization were all highest in group C patients (p<0.001). The number of discharges to home without home health aide were higher in group A, whereas the number of discharges to nursing home/rehabilitation/extended care facility were higher in group B (p<0.001). The in-hospital mortality (58.1%, p<0.001) and overall burn related mortality (62.8%, p<0.001) were highest in group C. There was no significant difference between the groups for the number of patients converted to hospice care (p=0.21). On multivariate analysis ICU admission (Odds Ratio [OR]=3.7, 95% Confidence Interval [95% CI]=2.1-6.5), ventilator support (OR=7.1, 95% CI=4.1-12.0), and %TBSA >10% (OR=3.1, 95% CI=1.9-5.0) significantly increased mortality. In terms of complications, group C had a significantly higher incidence of pneumonia (18.6%, p<0.001), respiratory failure (17.1%, p=0.001), and sepsis (7.8%, p=0.003)., Conclusions: Patients >70 years constitute small (8.6%) but significant number among burn patients. The overall ICU admissions, number of days on ventilator, ICU stay, in-hospital mortality and overall mortality is higher in this group of population even for low % TBSA burns. Presence of smoke inhalation increases mortality., (Copyright © 2017 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: Graft-versus-host disease (GVHD) is a serious complication of bone marrow transplantation (BMT), requiring higher doses of glucocorticoids or immunosuppressive therapies and further straining transplant recipients. Immunonutrition, such as vitamins and amino acid supplements, increase immunity and decrease inflammation and oxidative stress. This meta-analysis examines the impact of immunonutrition on the incidence of GVHD and postoperative infections among BMT recipients., Methods: A comprehensive literature search for all published randomized controlled trials was conducted with PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2016). Keywords in the search included variations of terms related to immunonutrition, such as "vitamin," "glutamine," and "transplant." Outcomes included incidence of GVHD and infection., Results: Ten randomized controlled trials involving 681 BMT recipients were analyzed: 332 receiving immunonutrition and 349 receiving standard nutrition. Immunonutrition is correlated with a decreased incidence of GVHD by 19% (relative risk [RR] = 0.810, 95% CI: 0.695-0.945, P = .007). There was no significant difference in the incidence of infections with immunonutrition (RR = 1.016, 95% CI: 0.819-1.261, P = .885). Subgroup analysis of glutamine compared with N-acetylcysteine, selenium, and eicosapentaenoic acid showed no significant difference in the incidence of GVHD or infections (RR = 0.913, 95% CI: 0.732-1.139, P = .419; RR = 0.951, 95% CI: 0.732-1.235; P = .708, respectively)., Conclusion: The use of immunonutrition is associated with a reduced risk of GVHD in BMT recipients, potentially as a result of improved immune support and free radical scavenging. Providing immunonutrient supplements is a valuable adjunct in the routine care of BMT recipients, helping to alleviate a common and deadly complication.

Introduction: Primary breast cancer in adolescents is extremely rare and thus is not widely studied. This study aimed to evaluate trends, characteristics, and outcomes among a cohort of adolescents with breast cancer., Patients and Methods: A total of 657,712 female patients with breast cancer from Surveillance Epidemiology and End Results (SEER) database (1973-2009) were analyzed, and 91 adolescents were identified. Three age groups (under 20 years, 20-50 years or premenopausal, and > 50 years or postmenopausal) were compared for tumor size, stage, receptor status, and outcomes. Categorical data were compared by chi-square (Fisher) test and continuous data with Student's t test., Results: Median age was 19 years (range, 10-20 years). A total of 52.7% (n = 48) and 5.5% (n = 5) of patients presented with invasive and in-situ cancers, respectively, and 37.3% (n = 34) with sarcomas. Median tumor size of invasive cancers was 3.2 cm (range, 0.1-12.5 cm). Sixty percent of patients presented with regional disease, and the majority (28%) of those tested were receptor negative. Mortality rates in adolescents were higher than pre- and postmenopausal patients in localized and regional stage. Overall median survival was 106 months., Conclusion: Although rare, breast cancer does occur in adolescent girls and must be considered in differential of breast masses in females under 20, especially with strong breast cancer family history. Prognosis maybe worse than in older patients; however, the sample size is small. Delay in diagnosis, aggressive tumor biology, and negative receptor status may affect prognosis. Routine breast examination in high-risk older adolescents may permit early identification and avoid delay in diagnosis and treatment., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Enhanced recovery after surgery (ERAS) programs have been developed to improve patient outcomes, accelerate recovery after surgery, and reduce healthcare costs. ERAS programs are a multimodal approach, with interventions during all stages of care. This meta-analysis examines the impact of ERAS programs on patient outcomes and recovery., Methods: A comprehensive search of all published randomized control trials (RCTs) assessing the use of ERAS programs in surgical patients was conducted. Outcomes analyzed were length of stay (LOS), overall mortality, 30-day readmission rates, total costs, total complications, time to first flatus, and time to first bowel movement., Results: Forty-two RCTs involving 5241 patients were analyzed. ERAS programs significantly reduced LOS, total complications, and total costs across all types of surgeries (p < 0.001). Return of gastrointestinal (GI) function was also significantly improved, as measured by earlier time to first flatus and time to first bowel movement, p < 0.001. There was no overall difference in mortality or 30-day readmission rates; however, 30-day readmission rates after upper GI surgeries nearly doubled with the use of ERAS programs (RR = 1.922; p = 0.019)., Conclusions: ERAS programs are associated with a significant reduction in LOS, total complications, total costs, as well as earlier return of GI function. Overall mortality and readmission rates remained similar, but there was a significant increase in 30-day readmission rates after upper GI surgeries. ERAS programs are effective and a valuable part in improving patient outcomes and accelerating recovery after surgery.

Malignant melanoma accounts for 75% of all skin cancer deaths and is potentially curable if identified early. Although melanoma is rare in African-Americans (AA), it is associated with a worse prognosis than in Caucasians. This study examines the demographic, pathologic, and clinical factors impacting AA melanoma outcomes.Data for 1106 AA and 212,721 Caucasian cutaneous melanoma patients were abstracted from the Surveillance, Epidemiology, and End Result (SEER) database (1988-2011). Data were grouped on the basis of histological subtypes: "Superficial Spreading" (SS), "Nodular" (NM), "Lentigo Maligna" (LM), "Acral Lentiginous" (AL), and "Not otherwise specified" (NOS).Cutaneous malignant melanoma occurs most commonly in the sixth and seventh decade of life. Caucasian patients presented most commonly with trunk melanomas (34.5%), while lower extremity melanomas were more common in AAs (56.1%), P < 0.001. AAs presented with deeper tumors, more advanced stage of disease, and higher rates of ulceration and lymph node positivity than Caucasians. Cancer-specific mortality was significantly higher, while 5-year cancer-specific survival was significantly lower among AAs for NM and AL subtypes. Multivariate analysis identified male gender, regional and distant stage, NM and AL subtypes as independently associated with increased mortality among both ethnic groups.AAs present most often with AL melanoma on the lower extremities, and with deeper and more advanced stage lesions. AAs have higher cancer-specific mortality for NM and LM than Caucasians. Melanoma education for AA patients and health care providers is needed to increase disease awareness, facilitate early detection, and promote access to effective treatment.

Neonatal respiratory distress syndrome due to surfactant deficiency is associated with high morbidity and mortality in preterm infants, and the use of less invasive surfactant administration (LISA) has been increasingly studied. This meta-analysis found that LISA via thin catheter significantly reduced the need for mechanical ventilation within the first 72 hours (relative risk [RR] = 0.677; P = .021), duration of mechanical ventilation (difference in means [MD] = -39.302 hours; P < .001), duration of supplemental oxygen (MD = -68.874 hours; P < .001), and duration of nasal continuous positive airway pressure (nCPAP; MD = -28.423 hours; P = .010). A trend toward a reduction in the incidence of bronchopulmonary dysplasia was observed (RR = 0.656; P = .141). No significant difference in overall mortality, incidence of pneumothorax, or successful first attempts was observed. LISA via thin catheter significantly reduces the need for mechanical ventilation within the first 72 hours as well as the duration of mechanical ventilation, supplemental oxygen, and nCPAP. LISA via thin catheter appears promising in improving preterm infant outcomes., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Gallbladder carcinoma (GBC) is the most common malignancy of the biliary tract and the third most common gastrointestinal tract malignancy. This study examines a large cohort of GBC patients in the United States in an effort to define demographics, clinical, and pathologic features impacting clinical outcomes., Methods: Demographic and clinical data on 22,343 GBC patients was abstracted from the SEER database (1973-2013)., Results: GBC was presented most often among Caucasian (63.9%) females (70.7%) as poorly or moderately differentiated (42.5% and 38.2%) tumors, with lymph node involvement (88.2%). Surgery alone was the most common treatment modality for GBC patients (55.0%). Combination surgery and radiation (10.6%) achieved significantly longer survival rates compared to surgery alone (4.0 ± 0.2 versus 3.7 ± 0.1 years, p = 0.004). Overall mortality was 87.0% and cancer-specific mortality was 75.4%., Conclusions: GBC is an uncommon malignancy that presents most often among females in their 8th decade of life, with over a third of cases presenting with distant metastasis. The incidence of GBC has doubled in the last decade concurrent with increases in cholecystectomy rates attributable in part to improved histopathological detection, as well as laparoscopic advances and enhanced endoscopic techniques. Surgical resection confers significant survival benefit in GBC patients.

Background: Although burn patients with preexisting mood disorders have been shown to have diminished clinical recovery, acute mental disorders (AMD) are often unrecognized despite a link with post-traumatic stress disorder and social maladjustment later on. This study assessed the clinical profile of a large cohort of burn patients who developed AMD compared to those with chronic mental illness (CMI) and those without mental health problems to assess the impact of AMI on burn outcomes., Methods: Admission data on 96,451 patients with third degree flame burns was abstracted from the Nationwide Inpatient Sample (NIS) Database from 2001 to 2011. AMD was defined as adjustment disorder (ICD-10 codes F43.2-F43.29) and acute stress disorder (F43.0), while CMI was defined as major depressive disorder (F33.0-F33.9) and bipolar disorder (F31.0-F31.9). Data was compared across three subgroups: AMD, CMI, and patients without any mood disorders. Categorical variables were compared using the Chi-square test, and continuous variables were compared using Student t-test and analysis of variance (ANOVA). Multivariate analysis using the "backward Wald" method was performed to calculate odds ratios (OR) and determine independent factors which increased the risk of developing AMD after burn., Results: 979 (1%) burn patients were diagnosed with AMD, compared to 5971 (6.2%) with CMI and 89,501 (92.8%) without mood disorders at the time of the burn. Patients with AMD were significantly younger, predominantly male and Caucasian. Patients with AMD had a higher frequency of multiple third-degree burn sites. AMD patients had a significantly longer length of hospitalization and shorter actuarial survival. More AMD patients lacked social or family support, suffered from alcoholism or illicit drug abuse, and had a history of psychological trauma or self-inflicted injuries compared to other groups. After burn, 4.9% of AMD patients developed burn wound infections, 5.0% had nutritional deficiencies, 1.7% had skin graft failure, 0.7% had acute psychosis, and 3.7% had suicidal ideation, p<0.05. Multivariate analysis identified age 10-39 (OR 4.6), alcoholism (OR 1.4), drug abuse (OR 1.9), psychoses (OR 1.4), and total body surface are (TBSA) 10-39% third degree burns (OR 1.8) as independently associated with developing AMD, p<0.005., Conclusion: The development of AMD in burn patients is associated with poor clinical outcomes including longer hospitalization, decreased survival, and increased complication rates. Premorbid psychopathology, substance abuse and age were associated with a higher incidence AMD after burn than was the severity of the burn wound itself. Routine screening for psychological symptoms of AMD should be performed in all burn patients to avoid increased rates of short and long-term morbidity and mortality., (Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.)

Unintentional burn injury is the third most common cause of death in the U.S. for children age 5 to 9, and accounts for major morbidity in the pediatric population. Pediatric burn admission data from U.S. institutions has not been reported recently. This study assesses all pediatric burn admissions to a State wide Certified Burn Treatment Center to evaluate trends in demographics, burn incidence, and cause across different age groups. Demographic and clinical data were collected on 2273 pediatric burn patients during an 18-year period (1995-2013). Pediatric patients were stratified by age into "age 0 to 6," "age 7 to 12," and "age 13 to 18." Data were obtained from National Trauma Registry of the American College of Surgeons and analyzed using standard statistical methodology. A total of 2273 burn patients under age 18 were treated between 1995 and 2013. A total of 1663 (73.2%) patients were ages 0 to 6, 294 (12.9%) were 7 to 12, and 316 (13.9%) were age 13 to 18. A total of 1400 (61.6%) were male and 873 (38.4%) were female (male:female ratio of 1.6:1). Caucasians had the highest burn incidence across all age groups (40.9%), followed by African-Americans (33.6%), P < .001. Caucasian teenagers formed 62.1% of patients age 13-18, P < .001. A total of 66.3% of all pediatric burns occurred at home, P < .001. Mean TBSA burned was 8.9%, with lower extremity being the most common site (38.5%). Scald burns constituted the majority of cases (71.1%, n = 1617), with 53% attributable to hot liquids related to cooking, including coffee or tea, P < .001. In the teenage group, flame burns were the dominant cause (53.8%). Overall mean length of stay was 10.5 ± 10.8 days for all patients, and15.5 ± 12 for those admitted to the intensive care unit, P < .005. One hundred (4.4%) patients required ventilator support (P = .02), and average duration of mechanical ventilation was 11.9 ± 14.5 days. Skin grafting was performed for 520 (22.9%) patients, P < .001. Overall mortality was 0.9% (n = 20), with mean TBSA involved of 61.5%. The majority of pediatric burn injuries are scald burns that occur at home and primarily affect the lower extremities in Caucasian and African-American males. Among Caucasian teenagers flame burns predominate. Mean length of stay was 10 days, 23% of patients required skin grafting surgery, and mortality was 0.9%. The results of this study highlight the need for primary prevention programs focusing on avoiding home scald injuries in the very young, as well as fire safety training for teenagers.

Background: Leukocyte filtration has been hypothesized to reduce the risk of postoperative infections by alleviating the immunosuppressive effect of whole blood. However, the literature regarding the clinical efficacy of leukocyte filtration remains conflicted. This meta-analysis investigates the impact of allogeneic and autologous leukocyte-filtered blood transfusions on the incidence of postoperative infections in adult surgical patients., Methods: A comprehensive literature search of PubMed, Google Scholar, and Cochrane Central Registry of Controlled trials (1966-2016) was completed for all published randomized controlled trials. Postoperative infections under "as-per-protocol" (APP) and "intention-to-treat" (ITT), length of stay, and mortality were analyzed., Results: Sixteen randomized controlled trials involving 6586 randomized (ITT) patients (4615 APP patients) in various clinical settings were evaluated. The leukocyte-filtered blood group demonstrated an overall 26% risk reduction in postoperative infections when analyzed by APP (relative risk [RR] = 0.74; 95% confidence interval [CI, 0.60-0.92]; P = 0.007) and a 22% risk reduction when analyzed by ITT (RR = 0.78; 95% CI [0.65-0.94]; P = 0.009). Leukocyte-filtered blood was also associated with a significant reduction in length of stay (standardized difference of mean [SDM] = -0.74; 95% CI [-1.32 to -0.15]; P = 0.014) and all-cause mortality (RR = 0.74; 95% CI [0.57-0.95]; P = 0.018)., Conclusions: Leukocyte-filtered blood transfusions are associated with significantly lower postoperative infection rates in both the APP and ITT populations. Leukocyte filtration also shortens length of stay and decreases all-cause mortality in surgical patients and should be considered in all surgical patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Real-time ultrasound (US) guidance for central venous catheter (CVC) insertion has been shown to increase cannulation success rates and reduce complications in adults. Literature regarding US-guided CVC placement in children remains limited and conflicting. This meta-analysis examines the efficacy and safety of US-guided CVC placement among pediatric patients., Methods: A comprehensive literature search of all published randomized control trials (RCTs) comparing the use of real-time US-guided CVC insertion with anatomic landmark (LM)-guided CVC insertion in pediatric patients <18 y of age was conducted. Outcomes analyzed were cannulation success rate, number of attempts required, incidence of accidental arterial puncture, and time to cannulation., Results: Eight RCTs involving 760 patients were analyzed. US-guided CVC insertion significantly increased success rates by 31.8% and decreased the mean number of attempts required. A trend toward a decrease in the risk of accidental arterial puncture with the use of US-guided CVC insertion was also observed. US-guided CVC insertion was not associated with a significant difference in time required for CVC placement., Conclusion: US-guided CVC placement is associated with significantly higher success rates and decreased mean number of attempts required for cannulation. US-guided CVC insertion improves success rates, and should be utilized in pediatric patients.

Importance: Total hip replacement is a commonly performed orthopedic procedure for the treatment of painful arthritis, osteonecrosis, or fracture., Objective: To develop and verify a scale for predicting readmission rates for total hip replacement patients and allow for the development and implementation of readmission risk-reduction strategies., Design, Setting, and Participants: Discharge data on 268 518 patients from New York and California (derivation cohort) and 153 560 patients from Florida and Washington (validation cohort) were collected from the State Inpatient Database, a part of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality (2006-2011). Analysis of the derivation cohort was performed in July 2013 and analysis of the validation cohort was performed in August 2014. Demographic and clinical characteristics of patients undergoing total hip replacement were abstracted. The Readmission After Total Hip Replacement Risk Scale was developed to predict readmission risk., Main Outcome and Measure: Readmission rate., Results: Of the 268 518 patients from New York and California (derivation cohort), 151 009 (56.2%) were women and 216 477 (80.6%) were white. Of the 153 560 patients from Florida and Washington (validation cohort), 86 534 (56.3%) were women and 120 591 (78.5%) were white. Overall 30-day readmission rate was 5.89% for the derivation cohort and 5.82% for the validation cohort. Readmission rates for men and women were 5.79% and 6.08% for the derivation cohort (odds ratio [OR], 1.05; 95% CI, 1.02-1.09) and 5.80% and 5.84% for the validation cohort (OR, 0.99; 95% CI, 0.95-1.04), respectively. The following were all determined to be associated with increased risk of readmission after total hip replacement: being older than 71 years (OR, 1.83; 95% CI, 1.77-1.89), African American (OR, 1.23; 95% CI, 1.15-1.31), and in the lowest income quartile (OR, 1.18; 95% CI, 1.12-1.24); revision replacement (OR, 1.82, 95% CI, 1.75-1.90); liver disease (OR, 1.57; 95% CI, 1.39-1.77); congestive heart failure (OR, 1.49; 95% CI, 1.38-1.61); chronic pulmonary disease (OR, 1.33; 95% CI, 1.27-1.39); renal failure (OR, 1.26; 95% CI, 1.18-1.36); diabetes (OR, 1.21; 95% CI, 1.16-1.27); fluid and electrolyte disorder (OR, 1.21; 95% CI, 1.14-1.27); anemia (OR, 1.19; 95% CI, 1.15-1.25); rheumatoid arthritis (OR, 1.19; 95% CI, 1.10-1.29); coagulopathy (OR, 1.19; 95% CI, 1.08-1.32); hypertension (OR, 1.17; 95% CI, 1.12-1.21); and obesity (OR, 1.15; 95% CI 1.09-1.21). They were used to create the Readmission After Total Hip Replacement Risk Scale, which was applied to the validation cohort and explained 89.1% of readmission variability in that cohort., Conclusions and Relevance: Data derived from patients in the New York and California State Inpatient Database were reliably able to explain readmission variability for patients in the Florida and Washington State Inpatient Database at a rate of 89.1% based on known preoperative risk factors. Risk-stratification models, such as the Readmission After Total Hip Replacement Risk Scale, can identify high-risk patients for readmission and permit implementation of patient-specific readmission-reduction strategies to reduce readmissions and health care expenditures.

Background: The health benefits of probiotics and synbiotics are well established in healthy adults, but their role in preventing postoperative sepsis remains controversial. This meta-analysis assesses the impact of probiotics and synbiotics on the incidence of postoperative sepsis in gastrointestinal (GI) surgical patients., Methods: A comprehensive literature search of all published randomized control trials (RCTs) was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2015). Inclusion criteria included RCTs comparing the use of any strain or dose of a specified probiotic/synbiotic with placebo or a "no treatment" control group. The incidence of postoperative sepsis (within 1 month of surgery) and postoperative mortality were analyzed., Results: Fifteen RCTs involving 1201 patients (192 receiving probiotics, 413 receiving synbiotics, and 596 receiving placebo) were analyzed. Overall, probiotic and synbiotic uses significantly reduced the risk of developing postoperative sepsis by 38 % (relative risk (RR) = 0.62, 95 % confidence interval (CI) 0.52-0.74, p < 0.001)., Conclusions: The use of probiotic/synbiotic supplementation is associated with a significant reduction in the risk of developing postoperative sepsis in patients undergoing elective GI surgery. Probiotic/synbiotic supplementation is a valuable adjunct in the care of patients undergoing GI surgery. Additional studies are required to determine the optimal dose and strain of probiotic/synbiotic.

Helicobacter pylori is a common infection associated with many gastrointestinal diseases. Triple or quadruple therapy is the current recommendation for H pylori eradication in children but is associated with success rates as low as 50%. Recent studies have demonstrated that a 10-day sequential therapy regimen, rather than simultaneous antibiotic administration, achieved eradication rates of nearly 95%. This meta-analysis found that sequential therapy increased eradication rates by 14.2% (relative risk [RR] = 1.142; 95% confidence interval [CI] = 1.082-1.207; P < .001). Ten-day sequential therapy significantly improved H pylori eradication rates compared to the 7-day standard therapy (RR = 1.182; 95% CI = 1.102-1.269; p < .001) and 10-day standard therapy (RR = 1.179; 95% CI = 1.074-1.295; P = .001), but had lower eradication rates compared to 14-day standard therapy (RR = 0.926; 95% CI = 0.811-1.059; P = .261). The use of sequential therapy is associated with increased H pylori eradication rates in children compared to standard therapy of equal or shorter duration., (© The Author(s) 2015.)

Background/aim: Numerous trials have described a wide variation of metabolic complications associated with the mammalian target of rapamycin inhibitors (mTORi). This analysis aimed to report and critically analyze the risks of mTORi-associated metabolic complications., Materials and Methods: A comprehensive search of all published phase II or III randomized controlled trials were investigated. Outcomes included were adverse effect profiles of hyperglycemia (HGC), hypertriglyceridemia (HTG), and hypercholesterolemia (HCE)., Results: Sixteen phase II/III clinical trials were identified. The overall incidence of all-grade (AG) and high-grade (HG) metabolic complications associated with mTORi were 39.7% and 4.1% respectively. mTORi use was associated with an increased risk of AG (2.97 [2.25-3.92]) and HG HGC (4.08 [2.71-6.14]), AG (2.22 [1.70-2.89]) and HG HTG (1.88 [1.10-3.20]), and AG (2.48 [1.83-3.36]) and HG HCE (4.26 [2.30-7.90])., Conclusion: mTORi are associated with a significantly increased risk of AG and HG HGC, HTG, and HCE. Clinicians should be aware of these risks, perform regular monitoring, and consider alternative anti-neoplastic treatments or adjunctive pharmacological intervention if necessary., (Copyright© 2016 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Background/aims: Primary chordomas, rare cancers arising from the notochord remnants, are extremely rare in the pediatric population. This study examined a large cohort of primary chordoma patients to determine factors impacting prognosis and survival., Methods: Demographic and clinical data on 1,358 primary chordoma patients (86 pediatric patients ≤19 years of age and 1,272 adult patients ≥20 years of age) were abstracted from the Surveillance, Epidemiology, and End Result (SEER) database (1973-2011)., Results: Pediatric primary chordomas present most often as small tumors <4 cm in the cranium of male Caucasians. Despite the majority of primary chordomas presenting with locoregional involvement (90.4%), pediatric patients had more distant disease (14.8 vs. 9.2%, p < 0.05). Survival among pediatric patients having surgery only was significantly longer than for adults (22.5 vs. 14.3 years, p < 0.001). Overall survival was longer (17.2 vs. 12.6 years) and overall mortality was lower in pediatric patients (38.4 vs. 49.8%), but cancer-specific mortality was higher (37.2 vs. 28.6%, p < 0.005)., Conclusions: Pediatric primary chordomas present most often as small tumors <4 cm in the cranium of male Caucasians. Despite having a higher rate of metastasis, they have prolonged survival compared to adults. Surgical resection significantly improves survival in pediatric primary chordoma patients, and should be considered as first-line therapy in all eligible children., (© 2016 S. Karger AG, Basel.)

Initial conservative therapy is applied to all cases of chylothorax (CTx) with expected excellent outcomes. The indication for aggressive surgical treatment of early CTx remains uncertain and requires rigorous scientific scrutiny. Lymphangiography and lymphoscintigraphy are useful to localize the leak and assess thoracic duct patency as well as to differentiate partial from complete thoracic duct transection. The aetiology of the CTx, flow rate and patient condition dictate the preferred management. Octreotide/somatostatin and etilefrine therapy is highly efficacious in the conservative management of CTx. For patients in whom conservative management fails, those who are good surgical candidates, and those in whom the site of the leak is well identified, surgical repair and/or ligation using minimally invasive techniques is highly successful with limited adverse outcomes. Similarly, if the site of the chylous effusion cannot be well visualized, a thoracic duct ligation via video-assisted thoracic surgery is the gold standard approach. A pleuroperitoneal or less often a pleurovenous shunt is a final option and may be curative in some patients., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Purpose: Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in preterm infants, affecting ~6-7% of very-low-birth-weight (VLBW) infants. Early intervention and aggressive treatment has improved clinical outcomes, but considerable morbidity continues to accrue to NEC survivors. This meta-analysis examines the impact of probiotics on the incidence of NEC and complications among VLBW infants., Methods: A comprehensive literature search for all published randomized control trials (RCTs) assessing the use of probiotics to prevent NEC in VLBW infants was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2014). The incidences of NEC, sepsis, overall mortality, and time to reach full enteral feeds were analyzed., Results: 20 RCTs involving 5982 preterm VLBW infants were analyzed. Risk of NEC was reduced by 49.1% (RR=0.509; 95% CI, 0.385-0.672; p<0.001), and overall mortality by 26.9% among infants receiving probiotics (RR=0.731; 95% CI, 0.577-0.926; p=0.009). An 8.1% reduction in sepsis was also observed in infants receiving probiotics (RR=0.919; 95% CI, 0.823-1.027; p=0.137). Time to reach full enteral feeds was reduced by 1.2 days among infants receiving probiotics (MD: -1.217; 95% CI, -2.151 to -0.283; p=0.011)., Conclusion: The use of probiotic supplementation in preterm VLBW infants is associated with a significant reduction in the risk of NEC and overall mortality. Additional studies are required to determine the optimal genus, species, and dose of probiotic., (Copyright © 2015 Elsevier Inc. All rights reserved.)

This is the last of five manuscripts reviewing the historical origins of some of the more commonly used surgical instruments and takes "time out" to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

This is the fourth of five manuscripts reviewing the historical origins of some of the more commonly used surgical instruments and takes "time out" to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

Articular heterotopic ossification (HO) and subsequent bony ankylosis (BA) are infrequent yet devastating complications of severe burn injuries. These conditions are diagnosed clinically and confirmed by imaging. Patients then begin active physical therapy until cleared for surgery, which remains the standard of care. This study critically reviews the existing literature on the diagnosis, treatment, and surgical outcomes of HO/BA in severely burned patients and provides an evidence-based treatment algorithm. A comprehensive search for all the studies addressing HO and BA after burn injury was conducted using PubMed and Google Scholar from 1957 to 2013. Fifty-one studies on postburn HO/BA have been published, reporting incidences from 0.1 to 35.3%. Most patients suffered from third-degree, thermal burns, with a mean TBSA of 49 ± 14%. The mean time from burn until diagnosis was 7 ± 11 months. Seventy-nine percent of the affected joints were elbows and 84% had adjacent and/or overlying burns. Ninety-one percent of joints had solely extra-articular HO. Ninety percent of HO/BA cases were treated with anatomic excision, and all achieved appreciable increases in range of motion with infrequent recurrence. Perioperative radiotherapy was used infrequently. Surgical articular reconstruction is the standard of care for postburn HO/BA severe enough to limit joint movement and/or function. Early detection and initiation of physical therapy are paramount in preventing progression to complete BA. Increased awareness and more rapid means of detecting postburn articular changes may permit earlier discontinuation of passive range of motion exercises, thereby halting the initiation and progression of HO.

Introduction. Hepatocellular carcinoma (HCC) is a rare pediatric cancer accounting for 0.5% of all pediatric malignancies. This study examines a large cohort of HCC patients in an effort to define the factors impacting clinical outcomes in pediatric HCC patients compared to adults. Methods. Demographic and clinical data on 63,771 HCC patients (257 pediatric patients ≤ 19 and 63,514 adult patients age ≥ 20) were abstracted from the SEER database (1973-2011). Results. HCC was more common among males (59.5% pediatric and 75.1% adults) and Caucasians (50.4% and 50.5%), p < 0.05. Children more often presented with fibrolamellar variant HCC (24.1% versus 0.3%, p = 0.71) and advanced HCC, including distant disease (33.1% versus 20.8%, p < 0.001), and tumors > 4 cm in size (79.6% versus 62.0%, p = 0.02). Pediatric HCC patients undergoing surgery (13.107 versus 8.324 years, p < 0.001) had longer survival than adult HCC patients. Overall mortality was lower (65.8% versus 82.0%, p < 0.001) in the pediatric HCC group. Conclusion. HCC is a rare pediatric malignancy that presents most often as an advanced tumor, >4 cm in Caucasian males. Children with HCC achieve significantly longer mean overall survival compared to adults with HCC, primarily attributable to the more favorable fibrolamellar histologic variant, and more aggressive surgical intervention, which significantly improves survival.

This is the third of five manuscripts reviewing the historical origins of some of the more commonly used surgical instruments and takes "time out" to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

This is the second of five articles reviewing the historical origins of some of the more commonly used surgical instruments and takes "time out" to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

This is the first of five articles reviewing the historical origins of some of the more commonly used surgical instruments and takes "time out" to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

Elderly patients in the USA account for 26-50% of all intensive care unit (ICU) admissions. The applicability of validated ICU scoring systems to predict outcomes in the "Oldest Old" is poorly documented. We evaluated the utility of three commonly used ICU scoring systems (SAPS II, SAPS III, and APACHE II) to predict clinical outcomes in patients > 90 years. 1,189 surgical procedures performed upon 951 patients > 90 years (between 2000 and 2010) were analyzed. SAPS II, SAPS III, and Acute APACHE II were calculated for all patients admitted to the SICU. Differences between survivors and nonsurvivors were analyzed using the Student's t-test and binary logistic regression analysis. A receiver operating characteristic (ROC) curve was constructed for each scoring system studied. The area under the ROC curve (aROC) for the SAPS III was 0.81 at a cut-off value of 57, whereas the aROC for SAPS II was 0.75 at a cut-off score of 44 and the aROC for APACHE II was 0.74 at a cut-off score of 13. The SAPS III ROC curve for prediction of hospital mortality exhibited the greatest sensitivity (84%) and specificity (66%) with a score of 57 for the "Oldest Old" population.

Background: Sepsis is defined as systemic inflammatory response syndrome (SIRS) in the context of an underlying infectious process, and is associated with high rates of morbidity and mortality, particularly when initial therapy is delayed. Numerous biomarkers, including but not limited to cytokines (interleukins-2 and -6 [IL-2, IL-6] and tumor necrosis factor-α [TNF-α]), leukotrienes, acute-phase proteins (C-reactive protein [CRP]), and adhesion molecules, have been evaluated and rejected as unsuitable for the diagnosis of sepsis, predicting its severity, and guiding its treatment. Most recently, procalcitonin (PCT) has been suggested as a novel biomarker that may be useful in guiding therapeutic decision making in the management of sepsis. This article assesses critically the published literature on the clinical utility of PCT concentrations for guiding the treatment of sepsis in adult patients., Methods: A comprehensive search of all published studies of the use of serum concentrations of PCT to guide the treatment of sepsis in adult patients (1996 to 2011) was conducted with PubMed and Google Scholar. The search focused on the value of PCT concentrations to guide the diagnosis, prognosis, monitoring, and escalation and de-escalation of antbiotic therapy in these patients. Keywords searched included "procalcitonin," "sepsis," "sepsis biomarker," "sepsis diagnosis," "sepsis prognosis," "sepsis mortality," "antibiotic escalation," "antibiotic de-escalation," "antibiotic duration," and "antimicrobial stewardship.", Results: Forty-six trials evaluating the efficacy of PCT concentrations in diagnosing sepsis have been published, with 39 of these trials yielding positive results and 7 yielding negative results. Wanner et al. published the largest study (n=405) demonstrating that peak PCT concentrations occur early after injury in both patients with sepsis and those with multiple organ dysfunction syndrome (MODS). Among 17 trials assessing the prognostic value of PCT concentrations with regard to clinical outcome and morbidity, 12 trials yielded positive results and five showed negative or equivocal results. Reith et al. published the largest study of the prognostic use of PCT concentrations (n=246), demonstrating that median PCT values on post-operative days (POD) one, four, and 10 were predictive of mortality in patients with abdominal sepsis (p<0.01). Among 14 trials of the utility of PCT concentrations for establishing an infectious cause of sepsis, 13 yielded positive results and only one yielded negative results. The largest study of this use of PCT concentrations, conducted by Baykut et al. (n=400), evaluated these concentrations in post-operative patients with infection, and demonstrated that concentrations of PCT remained elevated until POD 4, with a second increase observed between POD 4 and POD 6. In uninfected patients, PCT concentrations began to decrease on POD 2. Only a single study has assessed the utility of PCT concentrations in guiding the escalation of antibiotic therapy, and its results were negative. Specifically, Jensen et al. (n=1,200) compared a PCT-guided antibiotic escalation strategy with the standard of care for sepsis and found no difference in outcomes. They also found that the PCT group had a longer average stay in the intensive care unit (ICU), greater rates of mechanical ventilation, and a decreased estimated glomerular filtration rate (eGFR). Among four trials focusing on PCT concentrations and antibiotic de-escalation, all showed positive results with the measurement of PCT concentrations. The largest such study, by Bouadma et al. (n=621), demonstrated a four-day decrease in antibiotic duration when PCT concentrations were used to guide therapy relative to the study arm given the standard of care, with no increase in mortality (p=0.003)., Conclusions: The diagnostic value of serum PCT concentrations for discriminating among SIRS, sepsis, severe sepsis, and septic shock remains to be established. Although higher PCT concentrations suggest a systemic bacterial infection as opposed to a viral, fungal, or inflammatory etiology of sepsis, serum PCT concentrations do not correlate with the severity of sepsis or with mortality. At present, PCT concentrations are solely investigational with regard to determining the timing and appropriateness of escalation of antimicrobial therapy in sepsis. Nevertheless, serum PCT concentrations have established utility in monitoring the clinical response to medical and surgical therapy for sepsis, and in surveillance for the development of sepsis in burn and ICU patients, and may have a role in guiding the de-escalation of antibiotic therapy.

Pancreatic adenocarcinoma accounts for nearly 90-95% of exocrine malignant tumors of the pancreas. Traditionally, overexpressed proteins/epitopes such as CA 19-9, CA-50, CEA, and many others were being used as pancreatic cancer tumor markers. The main utility of these biomarkers was in the diagnosis of pancreatic cancer as well as to assess response to chemotherapy and to determine prognosis and to predict tumor recurrence. However, these markers had significant limitations such as lack of sensitivity, false-negative results in certain blood groups, as well as false-positive elevation in the presence of obstructive jaundice. To circumvent these limitations, an extraordinary amount of research is being performed to identify an accurate tumor marker or a panel of markers that could aid in the management of the pancreatic cancer. Although this research has identified a large number and different variety of biomarkers, few hold future promise as a preferred marker for pancreatic cancer. This review provides an insight into exciting new areas of pancreatic biomarker research such as salivary, pancreatic juice, and stool markers that can be used as a noninvasive test to identify pancreatic cancer. This manuscript also provides a discussion on newer biomarkers, the role of microRNAs, and pancreatic cancer proteomics, which have the potential to identify a preferred tumor marker for pancreatic adenocarcinoma. This review further elaborates on important genetic changes associated with the development and progression of pancreatic cancer that holds the key for the identification of a sensitive biomarker and which could also serve as a therapeutic target.

Although diabetes mellitus (DM) and pancreatic cancer (PC) are intricately linked, a comprehensive review addressing the impact of DM on PC prognosis and surgical outcomes is lacking. PubMed search was performed (1980-2012) using keywords "pancreatic cancer", "diabetes mellitus", "glucose intolerance", "pancreatic resection", "prognosis", and "post-operative outcomes". The search results were analyzed to determine the strength of association between DM and PC and to assess the impact of DM on PC prognosis and postoperative outcomes. Thirty-one studies involving 38,777 patients were identified. Patients with non-insulin-dependent DM have 1.5-2 fold increased relative risk of developing PC. Non-insulin-dependent DM is identified in 25.7% of patients with PC compared to 10.4% age-matched controls (95% confidence interval, 1.5-4.7; P < 0.0001). Patients with PC are more likely to have a diagnosis of new-onset DM than age-matched controls (14.7% vs 2.7%; P < 0.0001). Patients with PC with DM have a significantly lower overall survival than those without DM (14.4 vs 21.7 months; P < 0.001). The presence of DM significantly increases overall postoperative complication rates (45.6% vs 35.6%; P < 0.008). Patients with new-onset non-insulin-dependent DM are at a higher risk of developing PC and have a worse long-term survival and a higher rate of postoperative complications.

Breast cancer is a diverse disease that requires a fully integrated multidisciplinary approach. Breast surgery has undergone a revolutionary change leading us from the conventional radical mastectomy of the Halstedian era to the current motion of nipple sparing mastectomy (NSM). Despite the lack of randomized controlled trials, the technique of NSM continues to gain popularity as a prophylactic procedure in high risk patients. The current indications for NSM, if any, in the treatment of early invasive breast cancer remains uncertain and requires rigorous scientific scrutiny. This article aims to critically review the indications and limitations of NSM, discuss evidence based intra-operative protocols and to discuss ways in which radiation therapy may be incorporated in treatment planning following NSM. A comprehensive search of the scientific literature was carried out using PubMed to access all publications related to nipple sparing mastectomy. The search focused specifically on technique, current management, safety, and complications of these procedures. Keywords searched included "Nipple sparing mastectomy,""breast conserving surgery,""Nipple areola complex preservation" and "skin sparing mastectomy." NSM offers an opportunity to preserve native breast envelope without mutilation of nipple-areola complex (NAC), and avoids multiple surgical procedures required for reconstruction. NSM may be a reasonable alternative for prophylactic and select breast cancer patients without NAC involvement; however, oncological safety of NSM has not yet been fully demonstrated. Best available evidence suggests that patients should be selected based on study of breast duct anatomy by breast Magnetic Resonance Imaging, mammographic distance between tumor and nipple and obligatory intra-operative frozen section from retro-areolar tissue. Additional factors such as tumor size, axillary lymph node status, lymphovascular invasion and degree of intraductal component are also being used to either include or exclude NSM candidates based on institutional protocols. Heterogeneity of patients selected for NSM is great and the lack of standardization of preoperative investigations, intra-operative technique and pathologic sampling of retro-areola tissues mandates a multi-institutional prospective study to define and validate a role for NSM in invasive breast cancer and DCIS. Nipple necrosis or sloughing is an important problem after NSM which can be greatly reduced using alternative skin incisions. Even if the nipple survives, an insensate nipple and lack of sexual function is common and requires preoperative counseling and discussion. Finally the relation and timing of intra-operative versus adjuvant breast radiation and tailoring of dosage and delivery methods has not been fully explored. Although NSM reduces the psychological trauma associated with nipple loss, the oncologic safety as well as functional and aesthetic outcomes needs additional investigation., (© 2011 Wiley Periodicals, Inc.)

Background: Intraoperative frozen section (IFS) examination of sentinel lymph nodes (SLN) is useful in selecting patients with invasive breast cancer for immediate axillary lymph node dissection. However, whether IFS evaluation of the SLNs in ductal carcinoma in situ (DCIS) of the breast has any value has not been previously assessed., Methods: Clinicopathologic data from patients with DCIS who underwent resection with SLN biopsy (2004-2010) were collected to assess the sensitivity, specificity, and accuracy of IFS, and its impact on axillary management., Results: A total of 267 patients with DCIS underwent resection with SLN biopsy and IFS evaluation. Preoperative pathology was DCIS (n = 231), DCIS with microinvasion (n = 24), and DCIS with other lesions (n = 12). Fifty-two (19.5%) patients had invasive breast cancer on final pathology. SLN metastases were identified in 13 (4.8%) patients; however, only 4 (1.5%) were IFS positive. IFS examination was negative in 263 (98.5%) patients. Among patients with SLN metastases, the most common pattern of metastases was either micrometastasis (n = 6) or immunohistochemistry-positive individual tumor cells (n = 4), whereas 3 patients had a macrometastasis. IFS examination was falsely negative in 9 of these 13 patients for a false-negative rate of 69.3%, and a sensitivity and specificity of 31% and 100% respectively. Nine of the 13 patients underwent axillary lymph node dissection and only 1 patient had further axillary metastasis., Conclusions: SLN metastases in DCIS is rare and most commonly involves SLN micrometastasis or immunohistochemistry-positive individual tumor cells. SLN IFS evaluation in DCIS has a low yield and sensitivity, and can be safely omitted to reduce operative duration and cost., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: High-risk prognostic factors for adults with well-differentiated thyroid cancer (WDTC) have been well established, but the same is not true for pediatric patients. This study sought to determine whether validated adult prognostic systems are applicable to pediatric patients and to develop a novel prognostic scale that may better reflect outcomes in pediatric subgroups., Methods: We queried 62,007 cases of WDTC from the Surveillance, Epidemiology, and End Results (SEER) database (1973-2009) to identify 895 patients <20 years of age with WDTC. Data abstracted included age, gender, race, histology type, primary tumor size, cancer stage, and mortality. Odds ratio and 95% confidence intervals were set and data were analyzed with SAS version 9.2., Results: Among 895 pediatric WDTC patients, the overall cause-specific mortality was 0.8%. The presence of distant metastasis was associated with the worst prognosis (P = .0045) followed by larger primary tumor size (P = .0135) and male gender (P = .0162). When classified into low-, moderate-, and high-risk categories according to the distant metastasis (Me), larger primary tumor size (S), and male sex (S) (MeSS) algorithm, mortality rates were 0%, 2.7%, and 23%, respectively., Conclusion: Commonly used prognostic indices for WDTC in adults do not reliably predict poor outcomes among pediatric patients. Rather, a system based on MeSS is more applicable to pediatric patients. Patients who exhibit a high MeSS score have a significantly worse overall survival than those who do not express any MeSS characteristics., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Introduction: Prophylactic mastectomy (PM) rates in the United States are rising due to determination of increased Gail risk, moderate-high risk lesions, a strong family history, and gene mutation carriers. The role of sentinel lymph node biopsy (SLNB) in PM remains controversial. This report sought to examine clinical utility of SLNB in PM., Methods: A total of 292 patients underwent bilateral or contralateral PM (1999-2011). SLNB was performed on the PM side in 195 (66.7%) patients with standard techniques. Clinicopathologic data were analyzed for the incidence of occult cancer in prophylactic breast and/or axilla. Univariate analysis was used to determine factors that predict SLN positivity., Results: The median patient age was 49 years (range, 19-79 years). Contralateral invasive breast cancer (64.7%) was the most common indication for PM. A total of 209 (71.5%) invasive breast cancer and 49 (16.7%) in situ cancers (n = 38 ductal carcinoma in situ, n = 10 lobular carcinoma in situ) were identified on the therapeutic mastectomy side, with a median tumor size of 1.5 cm. 58.6% were estrogen receptor positive and 4.7% were multicentric. Three (1%) ductal carcinoma in situ, 4 (1.3%) lobular carcinoma in situ, and 5 (1.7%) atypical ductal, and 1 (0.3%) lobular hyperplasia were identified in PM breast. No invasive breast cancer or positive SLN was identified in PM breast and/or axilla., Conclusion: Although a minimally invasive procedure, the utility of SLNB in patients with absent or contralateral early disease is limited. Advanced T stage, multicentricity, or receptor status on the therapeutic side or a finding of in situ or atypical hyperplasia in prophylactic breast specimen yielded no positive SLN. Routine SLNB in pure bilateral PM can safely be omitted, which reduces axillary morbidity and operative time and/or cost. Selective use of SLNB for contralateral recurrent and/or locally advanced cancers warrants further investigation., (Copyright © 2013 Elsevier Inc. All rights reserved.)