The impact of geriatric-specific variables on long-term outcomes in patients with hepatopancreatobiliary and colorectal cancer selected for resection.

BACKGROUND: Preoperative geriatric-specific variables (GSV) influence short-term morbidity in surgical patients, but their impact on long-term survival in elderly patients with cancer remains undefined. STUDY DESIGN: This observational cohort study included patients ≥65 years who underwent hepatopancreatobiliary or colorectal operations for malignancy between 2014 and 2020. Individual patient data included merged ACS NSQIP data, Procedure Targeted, and Geriatric Surgery Research variables. Patients were stratified by age: 65-74, 75-84, and ≥85 and presence of these GSVs: mobility aid, preoperative falls, surrogate signed consent, and living alone. Bivariable and multivariable analyses were used to evaluate 1-year mortality and postoperative discharge to facility. RESULTS: 577 patients were included: 62.6 % were 65-74 years old, 31.7 % 75-84, and 5.7 % ≥ 85. 96 patients were discharged to a facility with frequency increasing with age group (11.4 % vs 22.4 % vs 42.4 %, respectively, p < 0.001). 73 patients (12.7 %) died during 1-year follow-up, 32.9 % from cancer recurrence. One-year mortality was associated with undergoing hepatopancreatobiliary operations (p = 0.017), discharge to a facility (p = 0.047), and a surrogate signing consent (p = 0.035). Increasing age (p < 0.001), hepatopancreatobiliary resection (p = 0.002), living home alone (p < 0.001), and mobility aid use (p < 0.001) were associated with discharge to a facility. CONCLUSION: Geriatric-specific variables, living alone and use of a mobility aid, were associated with discharge to a facility. A surrogate signing consent and discharge to a facility were associated with 1-year mortality. These findings underscore the importance of preoperative patient selection and optimization, efficacious discharge planning, and informed decision-making in the care of elderly cancer patients.

Missed Monteggia Injuries in Children and Adolescents: A Treatment Algorithm.

Monteggia injuries are rare childhood injuries. In 25-50% of cases, however, they continue to be overlooked, leading to a chronic Monteggia injury. Initially, the chronic Monteggia injury is only characterized by a moderate motion deficit, which is often masked by compensatory movements. Later, however, there is a progressive valgus deformity, neuropathy of the ulnar nerve and a progressive deformity of the radial head ("mushroom deformity") with ultimately painful radiocapitellar arthrosis. In the early stages, when the radial head is not yet deformed and there is no osteoarthritis in the humeroradial joint, these injuries can be treated with reconstruction procedures. This can be achieved either by an osteotomy of the proximal ulna with or without gradual lengthening. If there is already a severe deformity of the radial head and painful osteoarthritis, only rescue procedures such as functional radial head resection or radial head resection with or without hemi-interposition arthroplasty can be used to improve mobility and, above all, to eliminate pain. In this review article, we provide an overview of the current treatment options of chronic Monteggia injury in children and adolescents and present a structured treatment algorithm depending on the chronicity and dysplastic changes.

Association of risk analysis index with 90-day failure to rescue following major abdominal surgery in geriatric patients.

BACKGROUND: Failure to rescue (FTR) is a quality metric defined as mortality after potentially preventable complications after surgery. Predicting patients who are at the highest risk of mortality after a complication may aid in preventing deaths. Thirty-day follow-up period inadequately captures postoperative deaths; alternatively, a 90-day follow-up period has been advocated. This study aimed to examine the association of a validated frailty metric, the risk analysis index (RAI), with 90-day FTR (FTR-90). METHODS: Patients aged ≥65 years who underwent a major abdominal operation between 2014 and 2020 at a quaternary care center were abstracted. Institutional data were merged with the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Geriatric Surgery Research File variables. The association between RAI and FTR-90 was evaluated using multivariable logistic regression. RESULTS: A total of 398 patients with postoperative complications were included. Fifty-two patients (13.1%) died during the 90-day follow-up. The FTR-90 group was older (median age: 76 vs 73 years, respectively; P = .002), had a greater preoperative American Society of Anesthesiologists classification score (P < .001), and had a higher ACS NSQIP estimated risk of morbidity (0.33% vs 0.20%, P < .001) and mortality (0.067% vs 0.012%, P < .001). The FTR-90 group had a greater median RAI score (23 vs 19; P = .002). The RAI score was independently associated with FTR-90 (odds ratio, 1.04; 95% CI, 1.0042-1.0770; P = .028) but not with FTR-30 (P = .13). CONCLUSION: Preoperative frailty, as defined by RAI, is independently associated with FTR at 90-day follow-up. FTR-90 captured nearly 60% more deaths than did FTR-30. Frailty has major implications beyond the typical 30-day follow-up period, and a longer follow-up period must be considered.

Safety of postdischarge extended venous thromboembolism prophylaxis after hepatopancreatobiliary surgery.

BACKGROUND: The risk of venous thromboembolism (VTE) after hepatopancreatobiliary (HPB) surgery is high. Extended postdischarge prophylaxis in this patient population has been controversial. This study aimed to examine the safety of postdischarge extended VTE prophylaxis in patients at high risk of VTE events after HPB surgery. METHODS: Adult patients risk stratified as very high risk of VTE who underwent HPB operations between 2014 and 2020 at a quaternary care center were included. Patients were matched 1:2 extended VTE prophylaxis to the control group (patients who did not receive extended prophylaxis). Analyses compared the proportions of adverse bleeding events between groups. RESULTS: A total of 307 patients were included: 103 in the extended prophylaxis group and 204 in the matched control group. Demographics were similar between groups. More patients in the extended VTE prophylaxis group had a history of VTE (9% vs 3%; P = .045). There was no difference in bleeding events between the extended VTE prophylaxis and the control group (6% vs 2%; P = .091). Of the 6 patients with bleeding events in the VTE prophylaxis group, 5 had gastrointestinal (GI) bleeding, and 1 had hemarthrosis. Of the 4 patients with bleeding events in the control group, 1 had intra-abdominal bleeding, 2 had GI bleeding, and 1 had intra-abdominal and GI bleeding. CONCLUSION: Patients discharged with extended VTE prophylaxis after HPB surgery did not experience more adverse bleeding events compared with a matched control group. Routine postdischarge extended VTE prophylaxis is safe in patients at high risk of postoperative VTE after HPB surgery.

Does a prehospital applied pelvic binder improve patient survival?

INTRODUCTION: Pelvic fractures are serious and oftentimes require immediate medical attention. Pelvic binders have become a critical tool in the management of pelvic injuries, especially in the prehospital setting. Proper application of the pelvic binder is essential to achieve the desired result. This study evaluates the effectiveness of prehospitally applied pelvic binders in improving outcomes for patients with pelvic fractures. METHODS: This retrospective cohort study analyzed 66 patients with unstable pelvic ring fracture classified as AO61B or 61C, who were treated at a Level I hospital in the emergency room between January 2014 and December 2018. The ideal position for a pelvic binder was determined, and patients were divided into three sub-groups based on whether they received a pelvic binder in the ideal position, outside the optimal range, or not at all. The primary outcome measure was the survival rate of the patients. RESULTS: 66 trauma patients with unstable pelvic fractures were enrolled, with a mean age of 53.8 years, who presented to our ER between 2014 and 2018. The mean ISS score was 21.9, with 60.3 % of patients having a moderate to severe injury (ISS > 16 points). Pelvic binder usage did not differ significantly between patients with an ISS < or ≥ 16 points. A total of 9 patients (13.6 %) died during hospitalization, with a mean survival time of 8.1 days. The survival rate did not differ significantly between patients with or without a pelvic binder, or between those with an ideally placed pelvic binder versus those with a binder outside the ideal range. The ISS score, heart rate, blood pressure at admission, and hemoglobin level were significantly different between the group of patients who died and those who survived, indicating their importance in predicting outcomes. CONCLUSION: Our study found that prehospital pelvic binders did not significantly impact patient outcomes for unstable pelvic fractures, with injury severity score (ISS) being the strongest predictor of survival. Assessing injury severity and managing blood loss remain crucial for these patients. While pelvic binders may not impact survival significantly, they still play a role in stabilizing pelvic fractures and managing blood loss.

Mechanistic insights into radical formation and functionalization in copper/N-fluorobenzenesulfonimide radical-relay reactions.

Copper-catalysed radical-relay reactions that employ N-fluorobenzenesulfonimide (NFSI) as the oxidant have emerged as highly effective methods for C(sp3)-H functionalization. Herein, computational studies are paired with experimental data to investigate a series of key mechanistic features of these reactions, with a focus on issues related to site-selectivity, enantioselectivity, and C-H substrate scope. (1) The full reaction energetics of enantioselective benzylic C-H cyanation are probed, and an adduct between Cu and the N-sulfonimidyl radical (˙NSI) is implicated as the species that promotes hydrogen-atom transfer (HAT) from the C-H substrate. (2) Benzylic versus 3° C-H site-selectivity is compared with different HAT reagents: Cu/˙NSI, ˙OtBu, and Cl˙, and the data provide insights into the high selectivity for benzylic C-H bonds in Cu/NFSI-catalyzed C-H functionalization reactions. (3) The energetics of three radical functionalization pathways are compared, including radical-polar crossover (RPC) to generate a carbocation intermediate, reductive elimination from a formal CuIII organometallic complex, and radical addition to a Cu-bound ligand. The preferred mechanism is shown to depend on the ligands bound to copper. (4) Finally, the energetics of three different pathways that convert benzylic C-H bonds into benzylic cations are compared, including HAT/ET (ET = electron transfer), relevant to the RPC mechanism with Cu/NFSI; hydride transfer, involved in reactions with high-potential quinones; and sequential ET/PT/ET (PT = proton transfer), involved in catalytic photoredox reactions. Collectively, the results provide mechanistic insights that establish a foundation for further advances in radical-relay C-H functionalization reactions.

Outcomes of Injured Patients Before and After the Institution of a Third-Tier Activation at a Level 1 Trauma Center.

BACKGROUND: We hypothesized that the addition of a third-level trauma activation would improve outcomes by formalizing an evaluation process for patients in need of urgent evaluation who did not meet the criteria for full or partial trauma alert activation. METHODS: Admission records for all trauma patients admitted between 2000 and 2021 were obtained. The gamma alert trauma activation was implemented in 2011. A washout period of 6 months was used to account for adjustment to the new protocol. Propensity score matching was performed based on ISS scores, age, injury mechanism, and best-validated comorbidities to create a balanced patient distribution. Patients with missing data were excluded from this study. The association between era and outcomes was determined using logistic and linear regression analyses. RESULTS: The matched cohort was well balanced (SMD <.1, all balanced covariates) and included 18,572 patients. Patients in the gamma alert era had decreased ED dwell time, hospital length of stay, and intensive care unit (ICU) length of stay. Readmission rates and rates of upgrade to ICU status were reduced in the gamma alert era. This era was also associated with lower rates of renal failure, UTI, and pneumonia. There was no significant difference in mortality following implementation of the gamma alert. DISCUSSION: Implementation of the gamma alert was associated with an improvement in ED dwell times, fewer unplanned admissions to the ICU, decreased readmissions, and a reduction in other in-hospital events. We believe that this reflects improved triage of patients to the ICU and more effective care of trauma patients.

Five-Year Sustained Impact of a Thoracic Enhanced Recovery After Surgery Program.

BACKGROUND: Our thoracic enhanced recovery program (ERP) decreased the use of postoperative morphine equivalents and hospital costs 1 year after implementation at our tertiary center. The sustainability and potential increasing benefit of this program were evaluated. METHODS: From 2015 to 2021, we prospectively analyzed the outcomes of patients who underwent elective pleural, pulmonary, or mediastinal operations at our institution. Patients were separated on the basis of the incision (video-assisted thoracoscopic surgery [VATS] or thoracotomy). The ERP protocol was initiated on May 1, 2016, and includes preoperative education, carbohydrate loading, opioid-sparing analgesia, conservative fluid management, protective ventilation, and early ambulation. Outcomes of patients before (2015, pre-VATS and pre-thoracotomy) and after (May 1, 2016, to December 31, 2021, ERP-VATS and ERP-thoracotomy) ERP implementation were compared. RESULTS: The cohort included 1079 patients (pre-ERP era, n = 224 [21%]; ERP era, n = 855 [79%]). There was a median reduction of 1.5 hospital days per patient for ERP-thoracotomy and 1 hospital day per patient for ERP-VATS. Median postoperative morphine equivalents decreased in both groups (125 vs 45 mg, in ERP-thoracotomy; 84 vs 23 mg, ERP-VATS; P < .001), as did total admission cost ($32,118 vs $23,775, ERP-thoracotomy; $17,367 vs $11,560, ERP-VATS; P < .001). Median total fluid balance during the hospital stay decreased significantly. Rates of postoperative atrial fibrillation and urinary retention decreased across both subgroups. CONCLUSIONS: ERP for thoracic surgery is sustainable and has been demonstrated to improve patient outcomes, to decrease opioid use, and to lower hospital costs. Therefore, it has the potential to become the standard of care.

Understanding Antiferromagnetic and Ligand Field Effects on Spin Crossover in a Triple-Decker Dimeric Cr(II) Complex.

Two possible explanations for the temperature dependence of spin-crossover (SCO) behavior in the dimeric triple-decker Cr(II) complex ([(η5-C5Me5)Cr(µ2:η5-P5)Cr(η5-C5Me5)]+) have been offered. One invokes variations in antiferromagnetic interactions between the two Cr(II) ions, whereas the other posits the development of a strong ligand-field effect favoring the low-spin ground state. We perform multireference electronic structure calculations based on the multiconfiguration pair-density functional theory to resolve these effects. We find quintet, triplet, and singlet electronic ground states, respectively, for the experimental geometries at high, intermediate, and low temperatures. The ground-state transition from quintet to triplet at an intermediate temperature derives from increased antiferromagnetic interactions between the two Cr(II) ions. By contrast, the ground-state transition from triplet to singlet at low temperature can be attributed to increased ligand-field effects, which dominate with continued variations in antiferromagnetic coupling. This study provides quantitative detail for the degree to which these two effects can act in concert for the observed SCO behavior in this complex and others subject to temperature-dependent variations in geometry.

Long-term surveillance of branch-duct intraductal papillary mucinous neoplasms without worrisome or high-risk features.

INTRODUCTION: Long-term data evaluating clinical outcomes in patients with branch-duct Intraductal papillary mucinous neoplasms (BD-IPMN) without high-risk stigmata (HRS) or worrisome features (WF) remain limited. METHODS: This observational cohort study included all patients diagnosed with BD-IPMN without HRS or WF between 2003 and 2019 who were enrolled in a prospective surveillance program. Time-to-progression analysis was performed using a cumulative incidence function plot and survival analysis was conducted using Kaplan-Meier. RESULTS: The median follow-up time for the 267 patient cohort was 44.5 months (interquartile range [IQR]: 24.1-72.2). Radiographic cyst growth was observed in 123 (46.1%) patients; 65 (24.3%) patients progressed to WF/HRS. Twenty-six (9.7%) patients were selected for resection during surveillance: 21 (80.8%) WF, 4 (15.4%) HRS; 1 (3.9%) transformed to mixed-duct. Of all the patients who underwent resection, 5 (19.2%) had adenocarcinoma, and 1 (3.8%) had carcinoma-in-situ. The probability of any radiographic progression was 21.3% (5-year) and 51.3% (10-year). For the entire cohort, there was 1.1% mortality secondary to pancreatic adenocarcinoma and 8.2% all-cause mortality. The 5-year overall survival rate was 91.5%, and at 10 years, 81.5%. CONCLUSION: Approximately one in four patients with nonworrisome BD-IPMN have progression to WF/HRS stigmata during surveillance. However, the risk of malignant transformation remains low. Surveillance strategy remains prudent in this patient population.

Radical ring-opening polymerization of sustainably-derived thionoisochromanone.

We present the synthesis, characterization and radical ring-opening polymerization (rROP) capabilities of thionoisochromanone (TIC), a fungi-derivable thionolactone. TIC is the first reported six-membered thionolactone to readily homopolymerize under free radical conditions without the presence of a dormant comonomer or repeated initiation. Even more, the resulting polymer is fully degradable under mild, basic conditions. Computations providing molecular-level insights into the mechanistic and energetic details of polymerization identified a unique S,S,O-orthoester intermediate that leads to a sustained chain-end. This sustained chain-end allowed for the synthesis of a block copolymer of TIC and styrene under entirely free radical conditions without explicit radical control methods such as reversible addition-fragmentation chain transfer polymerization (RAFT). We also report the statistical copolymerization of ring-retained TIC and styrene, confirmed by elemental analysis and energy-dispersive X-ray spectroscopy (EDX). Computations into the energetic details of copolymerization indicate kinetic drivers for ring-retaining behavior. This work provides the first example of a sustainable feedstock for rROP and provides the field with the first six-membered monomer susceptible to rROP, expanding the monomer scope to aid our fundamental understanding of thionolactone rROP behavior.

Correction: Radical ring-opening polymerization of sustainably-derived thionoisochromanone.

[This corrects the article DOI: 10.1039/D2SC06040J.].

Metal-Carbodithioate-Based 3D Semiconducting Metal-Organic Framework: Porous Optoelectronic Material for Energy Conversion.

Solar energy conversion requires the working compositions to generate photoinduced charges with high potential and the ability to deliver charges to the catalytic sites and/or external electrode. These two properties are typically at odds with each other and call for new molecular materials with sufficient conjugation to improve charge conductivity but not as much conjugation as to overly compromise the optical band gap. In this work, we developed a semiconducting metal-organic framework (MOF) prepared explicitly through metal-carbodithioate "(-CS2)nM" linkage chemistry, entailing augmented metal-linker electronic communication. The stronger ligand field and higher covalent character of metal-carbodithioate linkages─when combined with spirofluorene-derived organic struts and nickel(II) ion-based nodes─provided a stable, semiconducting 3D-porous MOF, Spiro-CS2Ni. This MOF lacks long-range ordering and is defined by a flexible structure with non-aggregated building units, as suggested by reverse Monte Carlo simulations of the pair distribution function obtained from total scattering experiments. The solvent-removed "closed pore" material recorded a Brunauer-Emmett-Teller area of ∼400 m2/g, where the "open pore" form possesses 90 wt % solvent-accessible porosity. Electrochemical measurements suggest that Spiro-CS2Ni possesses a band gap of 1.57 eV (σ = 10-7 S/cm at -1.3 V bias potential), which can be further improved by manipulating the d-electron configuration through an axial coordination (ligand/substrate), the latter of which indicates usefulness as an electrocatalyst and/or a photoelectrocatalyst (upon substrate binding). Transient-absorption spectroscopy reveals a long-lived photo-generated charge-transfer state (τCR = 6.5 µs) capable of chemical transformation under a biased voltage. Spiro-CS2Ni can endure a compelling range of pH (1-12 for weeks) and hours of electrochemical and photoelectrochemical conditions in the presence of water and organic acids. We believe this work provides crucial design principles for low-density, porous, light-energy-conversion materials.

Long term employment following heart transplantation in the United States.

BACKGROUND: Employment is an important metric of post-transplant functional status and the quality of life yet remains poorly described after heart transplant. We sought to characterize the prevalence of employment following heart transplantation and identify patients at risk for post-transplant unemployment. METHODS: Adults undergoing single-organ heart transplantation (2007-2016) were evaluated using the UNOS database. Univariable analysis was performed after stratifying by employment status at 1-year post-transplant. Fine-Gray competing risk regression was used for risk adjustment. Cox regression evaluated employment status at 1 year with mortality. RESULTS: Of 10,132 heart transplant recipients who survived to 1 year and had follow-up, 22.0% were employed 1-year post-transplant. Employment rate of survivors increased to 32.9% by year 2. Employed individuals were more likely white (70.8% vs 60.4%, p < 0.01), male (79.6% vs 70.7% p < 0.01), held a job at listing/transplant (37.6% vs 7.6%, p < 0.01), and had private insurance (79.1% vs 49.5%, p < 0.01). Several characteristics were independently associated with employment including age, employment status at time of listing or transplant, race and ethnicity, gender, insurance status, education, and postoperative complications. Of 1,657 (14.0%) patients employed pretransplant, 58% were working at 1-year. Employment at 1year was independently associated with mortality with employed individuals having a 26% decreased risk of mortality. CONCLUSION: Over 20% of heart transplant patients were employed at 1 year and over 30% at 2 years, while 58% of those working pretransplant had returned to work by 1-year. While the major predictor of post-transplant employment is preoperative employment status, our study highlights the impact of social determinants of health.

Influence of Fracture Reduction on the Functional Outcome after Intramedullary Nail Osteosynthesis in Proximal Humerus Fractures.

Background: Optimal treatment of proximal humeral fractures (PHF) is still controversial. Therefore, we aim to investigate the influence of fracture reduction after intramedullary nailing of a PHF on the clinical outcome. Methods: Patients treated with intramedullary nail for PHF from 2013−2018, (minimum follow-up 12 months) were retrospectively included. Constant Score (CS), DASH and Simple Shoulder Test (SST) were collected. Postoperative radiographs were used to determine head-shaft-alignment (HSA), head-shaft-displacement (HSD), integrity of the medial hinge and the cranialization of the greater tuberosity (CGT). The results of fracture reduction were categorized as either "anatomical", "acceptable" or as "malreduction". Malreduction exists when at least one of the following parameters are present: HSA > 150/< 110°, HSD >5 mm, CTM > 5 mm or lack of integrity of the medial hinge. Results: 42 patients (mean age 65.5 ± 14.1 years, 15 male, 27 female) with a mean follow-up time of 43 months were included. The average CS was 60 ± 30, DASH 49.8 ± 24.3 and SST 62.9 ± 26.9. There was an "anatomic" reduction in 9 (21.4%), "acceptable" in 7 (16.6%) and a "malreduction" in 26 (62%) patients. Comparing the combined "anatomical" and "acceptable" reduction group with the "malreduction" group, worse scores were observed in the "malreduction" group (CS 67.2 vs. 55.2, DASH 45.2 vs. 51.9, SST: 69.3 vs. 58.6) without statistical significance (CS: p = 0.095, DASH: p = 0.307, SST: p = 0.400). By means of multiple logistic regression analyses no statistically significant risk factors were identified for lower DASH, CS and SST scores. Conclusions: Anatomical fracture reduction using intramedullary nails has a positive effect on postoperative outcome for the 3 scores recorded, without reaching statistical significance.

Localized Active Space-State Interaction: a Multireference Method for Chemical Insight.

Multireference electronic structure methods, like the complete active space (CAS) self-consistent field model, have long been used to characterize chemically interesting processes. Important work has been done in recent years to develop modifications having a lower computational cost than CAS, but typically these methods offer no more chemical insight than that from the CAS solution being approximated. In this paper, we present the localized active space-state interaction (LASSI) method that can be used not only to lower the intrinsic cost of the multireference calculation but also to improve interpretability. The localized active space (LAS) approach utilizes the local nature of the electron-electron correlation to express a composite wave function as an antisymmetrized product of unentangled wave functions in local active subspaces. LASSI then uses these LAS states as a basis from which to express complete molecular wave functions. This not only makes the molecular wave function more compact but also permits flexibility in choosing those states to be included in the basis. Such selective inclusion of states translates to the selective inclusion of specific types of interactions, thereby allowing a quantitative analysis of these interactions. We demonstrate the use of LASSI to study charge migration and spin-flip excitations in multireference organic molecules. We also compute the J coupling parameter for a bimetallic compound using various LAS bases to construct the Hamiltonian to provide insights into the coupling mechanism.

Evaluating the Impact of Preoperative Geriatric-Specific Variables and Modified Frailty Index on Postoperative Outcomes After Elective Pancreatic Surgery.

BACKGROUND: Pursuing pancreatic resection in elderly patients is often complex and limited by concern for functional status and postoperative risk. This study examines the associations between two different preoperative functional status metrics with postoperative outcomes in the geriatric population. METHODS: Patients who participated in the ACS NSQIP Geriatric Surgery Research File pilot program (2014-2018) undergoing elective pancreatic operations were included. Two clinically meaningful functional status scores were calculated: the presence of one or more geriatric-specific variable (GSV) and a 5-factor modified frailty index (mFI-5). Multivariable logistic regression adjusting for ACS NSQIP-estimated risk was performed to evaluate associations between preoperative GSV, mFI-5 and 30-day outcome measures. RESULTS: A total of 1266 patients were included: 808 (64%) age 65-74, 302 (24%) age 75-80, and 156 (12%) age ≥ 81; 843 (67%) patients underwent pancreatoduodenectomy. Operations were performed for pancreatic adenocarcinoma in 712 (56%) patients. Older patients had greater likelihood of postoperative morbidity (35% vs 31% vs 47%, by age group, p = 0.004) and discharge to a facility (12% vs 23% vs 48%, by age group, p < 0.001). Adjusting for ACS NSQIP predicted risk, patients with a preoperative GSV were more likely to require reoperation and discharge to a facility (OR 1.81 [95% CI 1.03-3.16] and 3.95 [95% CI 2.91-5.38], respectively). The mFI-5 was not associated with postoperative outcomes (all p ≥ 0.18). CONCLUSION: The presence of a preoperative GSV is associated with reoperation and discharge to a skilled facility following elective pancreatic resection. Geriatric-specific variables should be considered in joint preoperative decision making to optimize care.

Subcostal lymph nodes: An unusual sentinel lymph node basin in cutaneous melanoma.

BACKGROUND AND OBJECTIVES: Lymphatic drainage from subcostal nodes, along the costal groove, have not previously been characterized as sites for melanoma drainage and metastasis. This study reports a series of patients with subcostal nodes draining primary melanomas, with characterization of the sites of primary melanomas that drain to these nodes. METHODS: Patients who presented to our institution between 2005 and 2020 with documented cutaneous melanoma and sentinel lymph node biopsy of a subcostal node (sentinel = S), or metastases to subcostal nodes later in clinical management (recurrent = R) were included. Patient demographics, melanoma pathology, nodal features, imaging information, surgical approaches, and outcomes data were collected. RESULTS: Six patients had subcostal sentinel nodes (SNs). Primary sites included the posterior trunk and lateral chest wall. Subcostal nodes were found under ribs 10-12. Subcostal SNs had at least one dimension measuring 3 mm or less. There were no surgical complications related to removing the subcostal SN. CONCLUSIONS: Melanoma can metastasize to subcostal lymph nodes and be found at the time of SN biopsy or identified at recurrence. These small nodes are fed by lymphatic channels that run in the neurovascular bundle under the ribs. When lymphatic mapping identifies a subcostal SN, it should be excised.