Does taste preference predict weight regain after bariatric surgery?

BACKGROUND: While bariatric surgery is well established as a means of inducing sustained weight loss, the rate of weight loss typically declines after a year, and weight regain has been observed. Preoperative taste preferences have been suspected to play a role in weight regain, possibly by influencing post-operative dietary practices. We sought to investigate the association between preoperative taste preferences and weight regain following bariatric surgery. METHODS: Patients who underwent bariatric surgery with at least 2 years of follow-up were included. Demographics and weight were collected in follow-up visits; while patient recall of preoperative taste preference was assessed, using a multiple-choice question in the study survey administered at least 6 months post-surgery. Weight regain was calculated as weight at 2 years minus weight at 1 year post-surgery, with weight regain denoted by positive values and weight loss by negative. Linear regression models were utilized to study associations between weight regain and preoperative taste preferences with and without adjusting for demographic factors and surgery type. RESULTS: Patients undergoing RYGB had less weight regain (- 4.5 kg, p = 0.033) compared to patients undergoing VSG. Compared to patients with no preferences, patients with sweet food or salty food preferences had 5.5 kg (p = 0.038) and 6.1 kg (p = 0.048) weight regain, respectively, at 2 years post-surgery. After adjustment, patients with salty food preference had 6.8 kg (p = 0.027) weight regain compared to patients with no preferences. CONCLUSIONS: Preoperative salty taste preference was associated with weight regain at 2 years post-surgery in patients undergoing bariatric surgery. Findings of this project might have implications for predicting long-term weight loss maintenance for patients with known preoperative taste preferences. Our study suggests that patients with preoperative salty taste preference may need further post-operative psychosocial support and resources to prevent weight regain and to ensure healthy and sufficient weight loss.

Sarcomas in the United States: Recent trends and a call for improved staging.

BACKGROUND AND OBJECTIVES: Sarcomas represent a heterogeneous group of tumors, and there is lack of data describing contemporary changes in patterns of care. We evaluated the epidemiology of sarcomas over 12 recent years. METHODS: The Surveillance, Epidemiology and End Results (SEER) database was queried for sarcoma cases from 2002-2014. Patient, tumor and treatment factors, and trends over time were studied overall and by subtype. Univariable and multivariable logistic regression models and 5-year survival and cause-specific mortality (CSM) were summarized. RESULTS: There were 78,527 cases of sarcomas with an overall incidence of 7.1 cases per 100,000 people, increasing from 6.8 in 2002 to 7.7 in 2014. Sarcoma NOS(14.8%) and soft tissue(43.4%) were the most common histology and primary site, respectively. A majority of tumors were high-grade(33.6%) and >5 cm(51.3%). CSM was 28.6% and 5-year survival was 71.4%. Many patients had unknown-grade(42.2%), which associated with 2.6 times increased odds of no surgical intervention. CONCLUSIONS: This comprehensive national study highlights important trends including increasing incidence, changing histologic types, and underestimation of true incidence. A large proportion of sarcomas are inadequately staged (unknown-grade 42.2%) with lack of appropriate surgical treatment. Our study highlights need for standardization of care for sarcomas.

SOSAS Study in Rural India: Using Accredited Social Health Activists as Enumerators.

BACKGROUND: Global estimates show five billion people lack access to safe, quality, and timely surgical care. The wealthiest third of the world's population receives approximately 73.6% of the world's total surgical procedures while the poorest third receives only 3.5%. This pilot study aimed to assess the local burden of surgical disease in a rural region of India through the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey and the feasibility of using Accredited Social Health Activists (ASHAs) as enumerators. MATERIAL AND METHODS: Data were collected in June and July 2015 in Nanakpur, Haryana from 50 households with the support of Indian community health workers, known as ASHAs. The head of household provided demographic data; two household members provided personal surgical histories. Current surgical need was defined as a self-reported surgical problem present at the time of the interview, and unmet surgical need as a surgical problem in which the respondent did not access care. RESULTS: One hundred percent of selected households participated, totaling 93 individuals. Twenty-eight people (30.1%; 95% CI 21.0-40.5) indicated they had a current surgical need in the following body regions: 2 face, 1 chest/breast, 1 back, 3 abdomen, 4 groin/genitalia, and 17 extremities. Six individuals had an unmet surgical need (6.5%; 95% CI 2.45%-13.5%). CONCLUSIONS: This pilot study in Nanakpur is the first implementation of the SOSAS survey in India and suggests a significant burden of surgical disease. The feasibility of employing ASHAs to administer the survey is demonstrated, providing a potential use of the ASHA program for a future countrywide survey. These data are useful preliminary evidence that emphasize the need to further evaluate interventions for strengthening surgical systems in rural India.

Towards diaspora-driven research capacity strengthening in low- and middle-income countries: results from India and Nepal.

BACKGROUND: Biomedical research from high-income countries often informs practice and policy in low- and middle-income countries (LMICs) with vastly different socioeconomic and health systems. Engagement of LMIC-based researchers is integral to setting research priorities in the local context. METHODS: A program, comprising a research seminar and workshop, and utilizing diaspora health professionals to understand research needs and build research capacity in LMICs, was created and pilot-tested at two institutions in India (65 participants) and Nepal (30 participants). Pre- and post-program surveys were instituted to assess participants' attitudes towards research. RESULTS: In the pre-program survey, most participants (India: 76%, Nepal: 100%) perceived research as 'very/extremely important' in their careers. However, a majority felt that finding time (India: 75%, Nepal: 81%) and funding (India: 82%, Nepal: 100%) for research was 'difficult/very difficult'. After the program, 86-91% and 86-100% of participants from India and Nepal, respectively, felt that the various courses were very useful/useful for their research careers. CONCLUSIONS: Research is seen as an integral part of educational training and career advancement in LMICs. However, inadequate training, funding and mentorship remain a challenge. Engagement of diaspora health workers may serve as an important avenue for collaborative biomedical research capacity strengthening in LMICs.

Road traffic injuries: Cross-sectional cluster randomized countrywide population data from 4 low-income countries.

INTRODUCTION: Road traffic injuries (RTI) are a leading cause of morbidity and mortality around the world. The burden is highest in low and middle-income countries (LMICs) and is increasing. We aimed to describe the epidemiology of RTIs in 4 low-income countries using nationally representative survey data. METHODS: The Surgeons Overseas Assessment of Surgical Needs (SOSAS) survey tool was administered in four countries: Sierra Leone, Rwanda, Nepal and Uganda. We performed nationally representative cross-sectional, cluster randomized surveys in each country. Information regarding demographics, injury characteristics, anatomic location of injury, healthcare seeking behavior, and disability from injury was collected. Data were reported with descriptive statistics and evaluated for differences between the four countries using statistical tests where appropriate. RESULTS: A total of 13,765 respondents from 7115 households in the four countries were surveyed. RTIs occurred in 2.2% (2.0-2.5%) of the population and accounted for 12.9% (11.5-14.2%) of all injuries incurred. The mean age was 34 years (standard deviation ±1years); 74% were male. Motorcycle crashes accounted for 44.7% of all RTIs. The body regions most affected included head/face/neck (36.5%) followed by extremity fractures (32.2%). Healthcare was sought by 78% road injured; 14.8% underwent a major procedure (requiring anesthesia). Major disability resulting in limitations of work or daily activity occurred in 38.5% (33.0-43.9%). CONCLUSION: RTIs account for a significant proportion of disability from injury. Younger men are most affected, raising concerns for potential detrimental consequences to local economies. Prevention initiatives are urgently needed to stem this growing burden of disease; additionally, improved access to timely emergency, trauma and surgical care may help alleviate the burden due to RTI in LMICs.

Breast Cancer Screening and Social Media: a Content Analysis of Evidence Use and Guideline Opinions on Twitter.

There is ongoing debate regarding the best mammography screening practices. Twitter has become a powerful tool for disseminating medical news and fostering healthcare conversations; however, little work has been done examining these conversations in the context of how users are sharing evidence and discussing current guidelines for breast cancer screening. To characterize the Twitter conversation on mammography and assess the quality of evidence used as well as opinions regarding current screening guidelines, individual tweets using mammography-related hashtags were prospectively pulled from Twitter from 5 November 2015 to 11 December 2015. Content analysis was performed on the tweets by abstracting data related to user demographics, content, evidence use, and guideline opinions. Standard descriptive statistics were used to summarize the results. Comparisons were made by demographics, tweet type (testable claim, advice, personal experience, etc.), and user type (non-healthcare, physician, cancer specialist, etc.). The primary outcomes were how users are tweeting about breast cancer screening, the quality of evidence they are using, and their opinions regarding guidelines. The most frequent user type of the 1345 tweets was "non-healthcare" with 323 tweets (32.5%). Physicians had 1.87 times higher odds (95% CI, 0.69-5.07) of providing explicit support with a reference and 11.70 times higher odds (95% CI, 3.41-40.13) of posting a tweet likely to be supported by the scientific community compared to non-healthcare users. Only 2.9% of guideline tweets approved of the guidelines while 14.6% claimed to be confused by them. Non-healthcare users comprise a significant proportion of participants in mammography conversations, with tweets often containing claims that are false, not explicitly backed by scientific evidence, and in favor of alternative "natural" breast cancer prevention and treatment. Furthermore, users appear to have low approval and confusion regarding screening guidelines. These findings suggest that more efforts are needed to educate and disseminate accurate information to the general public regarding breast cancer prevention modalities, emphasizing the safety of mammography and the harms of replacing conventional prevention and treatment modalities with unsubstantiated alternatives.

Financial Impact of Acute Kidney Injury After Cardiac Operations in the United States.

BACKGROUND: Acute kidney injury (AKI) after major cardiac operations is a potentially avoidable complication associated with increased morbidity, death, and costly long-term treatment. The financial impact of AKI at the population level has not been well defined. We sought to determine the incremental index hospital cost associated with the development of AKI. METHODS: All patients undergoing coronary artery bypass grafting (CABG) or valve replacement operations, or both (clinical classification software codes 43 and 44), between 2008 and 2011 were identified from the Nationwide Inpatient Sample. AKI was identified using International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes (584.xx); patients with chronic renal failure were excluded. Mean total index hospitalization costs were compared between patients with and without AKI. RESULTS: At the population level, 1,078,036 individuals underwent major cardiac procedures from 2008 to 2011, with AKI developing in 105,648 (9.8%). Specifically, AKI developed in 8.0% of CABG, 11.4% of valve replacement, and 17.0% of CABG plus valve replacement patients (p < 0.001). Death was more common among patients with AKI vs those without (13.9% vs 1.3%, p < 0.001). Mean total index hospitalization cost was $77,178 for patients with AKI vs $38,820 for those without (p < 0.001). At the national level, the overall incremental annual index hospitalization cost associated with AKI was $1.01 billion. CONCLUSIONS: AKI developed in 1 in every 10 patients nationwide after a cardiac operation. Achieving a 10% reduction in AKI in this population would likely result in an annual savings of approximately $100,000,000 in index-hospital costs alone. Support for research on mechanisms to detect impending damage and prevent AKI may lead to reduced patient morbidity and death and to substantial health care cost savings.

Association of Parathyroid Hormone Level With Postthyroidectomy Hypocalcemia: A Systematic Review.

IMPORTANCE: There has been an increased interest in measuring parathyroid hormone (PTH) levels as an early predictive marker for the development of hypocalcemia after total thyroidectomy. However, significant variation exists in the timing, type of assay, and thresholds of PTH in the literature. OBJECTIVE: We performed a systematic review to examine the utility of PTH levels in predicting temporary postthyroidectomy hypocalcemia. EVIDENCE REVIEW: A systematic literature review of studies published prior to May 25, 2016 was performed within PubMed, EMBASE, SCOPUS, and Cochrane databases using the following terms and keywords: "thyroidectomy," "parathyroid hormone," and "hypocalcaemia," "calcium," or "calcitriol." Each candidate full-text publication was reviewed by 2 independent reviewers and selected for data extraction if the study examined the prognostic significance of PTH obtained within 24 hours after thyroidectomy to predict hypocalcaemia. Studies were excluded if calcium supplementation was used routinely or based on a PTH level. Study characteristics, PTH parameters used to predict hypocalcemia, and their respective accuracies were summarized. FINDINGS: The initial search yielded 2417 abstracts. Sixty-nine studies, comprising 9163 patients, were included. Overall, for an absolute PTH threshold, the median accuracy, sensitivity, and specificity were 86%, 85%, and 86%, respectively. For a percentage change over time the median accuracy, sensitivity, and specificity were 89%, 88%, and 90%, respectively. CONCLUSIONS AND RELEVANCE: The existing literature regarding PTH levels to predict postthyroidectomy hypocalcemia is extremely heterogeneous. A single PTH threshold is not a reliable measure of hypocalcemia. Additional prospective studies controlled for timing of laboratory draws and a priori defined PTH thresholds need to be performed to ascertain the true prognostic significance of PTH in predicting postthyroidectomy hypocalcaemia.

Validation of the Surgical Apgar Score After Laparotomy at a Tertiary Referral Hospital in Rwanda.

BACKGROUND: The surgical Apgar score (SAS) has demonstrated utility in predicting postoperative outcomes in a variety of surgical disciplines. However, there has not been a study validating the utility of the SAS in surgical patients in low-income countries. We conducted a prospective, observational study of patients undergoing laparotomy at a tertiary referral hospital in Rwanda and determined the ability of SAS to predict inpatient major complications and mortality. METHODS: All adult patients undergoing laparotomy in a tertiary referral hospital in Rwanda from October 2014 to January 2015 were included. Data were collected on patient and operative characteristics. SAS was calculated and patients were divided into four SAS categories. Primary outcomes were in-hospital mortality and major complications. Rates and odds of in-hospital mortality and major complications were examined across the four SAS categories. Logistic regression modeling and calculation of c-statistics was used to determine the discriminative ability of SAS. RESULTS: 218 patients underwent laparotomy during the study period. One hundred and forty-three (65.6%) were male, and the median age was 34 years (IQR 27-51 years). The most common diagnosis was intestinal obstruction (97 [44.5%]). A high proportion of patients (170 [78%]) underwent emergency surgery. Thirty-nine (18.3%) patients died, and 61 (28.6%) patients had a major complication. In-hospital mortality occurred in 25 (50%) patients in the high-risk group, 12 (16%) in the moderate-risk group, 2 (3%) in the mild-risk group and there were no deaths in the low-risk group. Major complications occurred in 32 (64%) patients in the high-risk group, 22 (29%) in the moderate-risk group, 7 (11%) in the mild-risk group and there were no complications in the low-risk group. SAS was a good predictor of postoperative mortality (c-statistic 0.79) and major complications (c-statistic 0.75). CONCLUSIONS: SAS can be used to predict in-hospital mortality and major complications after laparotomy in a Rwandan tertiary referral hospital.

Epidemiology of pediatric surgical needs in low-income countries.

OBJECTIVE: According to recent estimates, at least 11% of the total global burden of disease is attributable to surgically-treatable diseases. In children, the burden is even more striking with up to 85% of children in low-income and middle-income countries (LMIC) having a surgically-treatable condition by age 15. Using population data from four countries, we estimated pediatric surgical needs amongst children residing in LMICs. METHODS: A cluster randomized cross-sectional countrywide household survey (Surgeons OverSeas Assessment of Surgical Need) was done in four countries (Rwanda, Sierra Leone, Nepal and Uganda) and included demographics, a verbal head to toe examination, and questions on access to care. Global estimates regarding surgical need among children were derived from combined data, accounting for country-level clustering. RESULTS: A total of 13,806 participants were surveyed and 6,361 (46.1%) were children (0-18 years of age) with median age of 8 (Interquartile range [IQR]: 4-13) years. Overall, 19% (1,181/6,361) of children had a surgical need and 62% (738/1,181) of these children had at least one unmet need. Based on these estimates, the number of children living with a surgical need in these four LMICs is estimated at 3.7 million (95% CI: 3.4, 4.0 million). The highest percentage of unmet surgical conditions included head, face, and neck conditions, followed by conditions in the extremities. Over a third of the untreated conditions were masses while the overwhelming majority of treated conditions in all countries were wounds or burns. CONCLUSION: Surgery has been elevated as an "indivisible, indispensable part of health care" in LMICs and the newly formed 2015 Sustainable Development Goals are noted as unachievable without the provision of surgical care. Given the large burden of pediatric surgical conditions in LMICs, scale-up of services for children is an essential component to improve pediatric health in LMICs.

Computed Tomography in the Management of Adrenal Tumors: Does Size Still Matter?

OBJECTIVE: We sought to evaluate computed tomography (CT) imaging as a predictor of adrenal tumor pathology. METHODS: A retrospective review was conducted of patients who underwent unilateral adrenalectomy for an adrenal mass between January 2005 and July 2015. Tumors were classified as benign, indeterminate, or malignant based on preoperative CT findings. RESULTS: Of 697 patients who underwent unilateral adrenalectomy, 216 met the inclusion criteria. Pathology was benign in 88.4%, indeterminate in 2.3%, and malignant in 9.3%, with a median tumor diameter of 2.7 cm (interquartile range, 1.7-4.1 cm) and 9.5 cm (interquartile range, 7.1-12 cm) in the benign and malignant groups, respectively (P < 0.001). Of the tumors with benign features on CT, 100% (143/143) had benign final pathology. CONCLUSIONS: Imaging characteristics of adrenal tumors on CT scan predict benign pathology 100% of the time. Regardless of size, when interpreted as benign on CT scan, laparoscopic adrenalectomy, if technically feasible, should be the technique used when surgery is offered, or close surveillance may be a safe alternative.

Are There Racial Disparities in Family-Reported Experiences of Care in Inpatient Pediatrics?

Despite increased emphasis on patient satisfaction as a quality measure in health care, little is known about the influence of race in parent-reported experience of care in pediatrics. This study evaluates the association of race with patient satisfaction scores in an inpatient pediatric tertiary care hospital in one year. Risk-adjusted multivariable logistic regression was performed to evaluate the association of minority race with the likelihood to provide a top-box (=5) satisfaction score for 38 individual questions across 8 domains. Of the 904 participants, 269 (29.8%) identified as belonging to a minority race. Parents of minority children reported 30% to 50% lower satisfaction across questions related to well-established themes of interpersonal communication and cultural competency. Overall, minorities also reported lower satisfaction for the domain of nursing care (odds ratio 0.7, P = .016). These findings suggest a need for training and interventions to improve communication and mitigate disparities in how minority patients and their families perceive pediatric care.

Gastric and small intestine gastrointestinal stromal tumors: Do outcomes differ?

BACKGROUND AND OBJECTIVES: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Previous literature has suggested that small intestine GISTs are more aggressive than gastric GISTs. Our primary objective was to compare the outcomes of gastric and small intestine GISTs in the decade after approval of imatinib for treatment. METHODS: The SEER database was queried for cases of gastric and small intestine GIST between the years 2002 and 2012, using the ICD-O-3 histology code 8936. Survival analysis was performed using generalized gamma models for time to cause-specific mortality (CSM). RESULTS: CSM was 14.0% for the 3,759 gastric GIST patients and 14.3% for the 1,848 small intestine GIST patients. Five-year survival was 82.2% and 83.3% for gastric and small intestine patients, respectively. The number of diagnosed cases of GIST increased over the course of this study, especially for tumors <5 cm in size and in patients over age 50 years. CONCLUSIONS: In this large nation-wide study, we found that patients with gastric and small intestine GISTs had similar outcomes, in contrast to previous reports. The diagnosis of GIST has significantly increased in the last decade, which may reflect the increased recognition of this entity and frequent use of imaging. J. Surg. Oncol. 2017;115:351-357. © 2016 Wiley Periodicals, Inc.

Predictors of improved survival for patients with retroperitoneal sarcoma.

BACKGROUND: Retroperitoneal sarcomas are rare tumors that can be locally aggressive with high rates of recurrence. Given that data on survival in patients with retroperitoneal sarcomas are conflicting, we sought to use a nationwide cancer database to identify factors associated with survival in patients with retroperitoneal sarcomas. METHODS: The Surveillance, Epidemiology, and End Results database was utilized to identify patients with retroperitoneal sarcomas from 2002 to 2012. Univariable and multivariable survival analysis was performed using a generalized gamma parametric survival function. RESULTS: A total of 2,920 patients were included; overall 5- and 10-year survivals were 58.4% and 45.3%, respectively. On multivariable survival analysis, age, histologic type, grade, size, local extension, lymph node, and distant metastasis were associated with decreased survival (all P < .05). Patients undergoing operative resection survived 2.5 times longer (95% confidence interval: 2.0-3.0, P < .001) and those receiving radiation therapy 1.3 times longer (95% confidence interval: 1.1-1.6, P = .001), respectively. CONCLUSION: During the past decade, retroperitoneal sarcoma patients treated with radiation demonstrate longer survival compared with patients who did not receive radiation. Further study is needed to fully elucidate the mechanisms that underlie the radiation-related survival benefit observed in this study.

Musculoskeletal disease in Nepal: A countrywide cross-sectional survey on burden and surgical access.

INTRODUCTION: Musculoskeletal disease (MSD) is a major cause of disability in the global burden of disease, yet data regarding the magnitude of this burden in low and middle-income countries (LMICs) are lacking. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey was designed to measure incidence and prevalence of surgically treatable conditions, including MSD, in patients in LMICs. METHODS: A countrywide survey was done in Nepal using SOSAS in May-June 2014. Clusters were chosen based on population weighted random sampling. Chi squared tests and multivariate logistic regression assessed associations between demographic variables and MSD. RESULTS: Self-reported MSDs were seen in 14.8% of survey respondents with an unmet need of 60%. The majority of MSDs (73.9%) occurred between 1 and 12 months prior to the survey. Female sex (OR = 0.6; p < 0.000), access to motorized transport (for secondary facility, OR = 0.714; p < 0.012), and access to a tertiary health facility (OR = 0.512; p < 0.008) were associated with lower odds of MSD. DISCUSSION: Based on this study, there are approximately 2.35 million people living with MSDs in Nepal. As the study identified non-availability, lack of money, and fear and/or lack of trust as the major barriers to orthopedic care in Nepal, future work should consider interventions to address these barriers. CONCLUSION: There is a need to increase surgical capacity in LMICs; in particular, there is a need to bolster trauma and orthopedic care. Previous studies have suggested ways to allocate resources to build capacity. We recommend targeting the alleviation of these identified barriers in parallel with capacity building.

Assessing access to surgical care in Nepal via a cross-sectional, countrywide survey.

BACKGROUND: Adequate surgical care is lacking in many low- and middle-income countries because of diverse barriers preventing patients from reaching providers. We sought to assess perceived difficulties to accessing surgical care in Nepal using the Surgeons OverSeas Assessment of Surgical Need tool. METHODS: Fifteen of 75 Nepali districts were selected proportionate to the population, with 1,350 households surveyed. Household heads answered questions regarding access to health facilities, and 2 household members were interviewed for medical history. Continuous and categorical variables were analyzed via Wilcoxon rank sum test and Pearson χ(2) test. Multivariable logistic regressions for independent predictors of care access were performed controlling for age, sex, location, and literacy. RESULTS: Of respondents with a surgical condition (n = 1,342), 650 (48.4%) accessed care and 237 (17.7%) did not. Unadjusted analyses showed greater median travel times to all facilities (P < .001) and median transport costs to secondary and tertiary centers (P < .001) for those who did not access care versus those who did. Literate respondents were more likely to access care across all facilities and access variables in adjusted models (odds ratio 1.66-1.80, P < .01). Those without transport money were less likely to access care at any facility in all analyses (P < .01). CONCLUSION: The data project that at least 2.4 million individuals lack access to needed surgical care in Nepal during their lifetimes, with those not accessing health facilities having lower literacy rates and fewer transport resources. Promoting education, outreach programs, and transportation access could lessen barriers but will require further exploration.

Long-term outcomes in treatment of retroperitoneal sarcomas: A 15 year single-institution evaluation of prognostic features.

BACKGROUND: Retroperitoneal sarcomas are connective tissue tumors arising in the retroperitoneum. Surgical resection is the mainstay of treatment. Debate has arisen over extent of resection, changes in histological classification/grading, and interest in incorporating radiotherapy. Therefore, we reviewed our institution's experience to evaluate prognostic factors. METHODS: Retrospective chart review of all primary RPS patients at Johns Hopkins Hospital from 1994 to 2010. Histologic diagnosis and grading were re-evaluated with current criteria. Prognostic factors for survival, and recurrence were assessed. RESULTS: One hundred thirty-one primary RPS patients met inclusion criteria. Median survival for patients who undergo en-bloc resection to negative margins (R0/R1) is 81.7 months. Surgical margins and grade were the most important factors for survival along with age, gender, presence of metastases and resection of ≥5 organs. Five-year survival for R0/R1 resection was 60%, similar to compartmental resection. Radiotherapy significantly decreased local recurrence (P = 0.026) on multivariate analysis. Grade in leiomyosarcomas and dedifferentiation in liposarcomas dictated patterns of local versus distal recurrence. CONCLUSIONS: En bloc surgical resection to R0/R1 margins remains the cornerstone of therapy and provides comparable outcomes to compartmental resections. Grade remains important for prognosis, and histology dictates recurrence patterns. Radiotherapy appears promising for local control and warrants further investigation. J. Surg. Oncol. 2016;114:56-64. © 2016 Wiley Periodicals, Inc.

"Halo effect" in trauma centers: does it extend to emergent colectomy?

BACKGROUND: Trauma centers (TCs) have been demonstrated to improve outcomes for some nontrauma surgical conditions, such as appendicitis, but it remains unclear if this extends to all emergency general surgery procedures. Using emergent colectomy in patients with diverticulitis as index condition, this study compared outcomes between TCs and nontrauma centers (NTCs). MATERIALS AND METHODS: The Nationwide Emergency Department Sample (2006-2011) was queried for patients ≥16 y with diverticulitis who underwent emergency surgical intervention. Outcomes included mortality, total charges, and length of stay (LOS). Mortality in TC and NTC was compared using logistic regression, controlling for patient, procedure, and hospital-level characteristics. Adjusted total charges and LOS were analyzed using generalized linear models with gamma and Poisson distributions, respectively. RESULTS: A total of 25,396 patients were included, 5189 (20.4%) were treated at TC and 20,207 (79.6%) at NTC. Median age and sex distribution were similar. Unadjusted proportional in-hospital mortality did not differ between TC and NTC; median charges and LOS were greater in TC. After adjusting, the odds of mortality were significantly higher in TC (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.02-1.51; P = 0.003) as were mean charges and LOS (P < 0.001). CONCLUSIONS: The improved outcomes reported for other nontrauma conditions in TC were not observed for patients undergoing an emergent colectomy for diverticulitis after accounting for patient, procedure, and hospital-level characteristics. Future research is needed to assess differences in case mix between TC versus NTC and possible case-mix effects on outcomes to elucidate potential benefit of surgical care in a TC across the breadth of emergency general surgery conditions.

Reproductive health care and family planning among women in Nepal.

OBJECTIVE: To describe findings from a validated survey examining access to care, contraceptive needs, access to surgical care, menstruation-related healthcare needs, and barriers to receiving reproductive health care in Nepal. METHODS: An analysis was undertaken using data obtained through a two-part population-based, cross-sectional, cluster-randomized survey corroborated by a visual physical examination performed nationwide between May 25 and June 12, 2014. Women aged 12-50years were included. The odds of delivering exclusively in a health facility, having a cesarean delivery, and using contraception were modeled using logistic regression. RESULTS: Overall, 876 female interviewees were of reproductive age (12-50years). Only 237 (27.1%) women were using contraception. Maternal education was the strongest predictor of delivering exclusively in a healthcare facility (odds ratio [OR] 7.57, 95% confidence interval [CI] 4.48-12.79; P<0.001). The odds of having a cesarean delivery were doubled by urban living (OR 2.20, 95% CI 1.09-4.13; P<0.001). On multivariable analysis, a predictor of using contraception was a history of having given birth (OR 9.61, 95% CI 4.62-20.01; P<0.001). CONCLUSION: In Nepal, reproductive healthcare disparities for women are manifold. Education for women appears to be a significant determinant of accessing reproductive health care.

Program Death 1 Immune Checkpoint and Tumor Microenvironment: Implications for Patients With Intrahepatic Cholangiocarcinoma.

BACKGROUND: Program death 1 (PD-1) and its ligand (PD-L1) have been identified as potential therapeutic targets for solid and hematologic malignancies. The current study aimed to assess PD-L1 expression in intrahepatic cholangiocarcinoma (ICC) and relate clinical outcomes to its expression. METHODS: Formalin-fixed, paraffin-embedded tumor specimens were obtained for patients undergoing surgery at Johns Hopkins Hospital between 1991 and 2011. Immunohistochemistry was used to assess PD-L1 expression in tumor-associated macrophages (TAMs) and within the tumor front (TF). RESULTS: Of 54 tumor samples analyzed, 34 stained positive for PD-L1 expression on TAMs (TAMs+), and 39 stained positive for PD-L1 expression on cells within the tumor front (TF+). The TF+ patients were less likely to present with metastatic lymph nodes (N1 patients: 26.7 vs 7.7 %; p = 0.011), whereas all tumors with intrahepatic metastasis failed to demonstrate staining for PD-L1 around the tumor front (p = 0.020). Patients with tumors shown to be TAMs+ were less likely to present with multiple lesions (35.0 vs 8.8 %; p = 0.017). Patients with tumors exhibiting PD-L1 expression around the tumor front demonstrated a worse overall survival than TF patients (p = 0.008). Multivariable analysis showed that patients with tumors staining for PD-L1 in the tumor front had a 59.5 % reduced survival (TF- vs TF+: time ratio, 0.405; 95 % confidence interval, 0.215-0.761; p = 0.005). CONCLUSION: Expression of PD-L1 was noted among a majority of patients, and PD-L1 expression within the tumor front was associated with a 60 % decreased survival. Future clinical trials are necessary to assess the safety and efficacy of anti-PD-L1 therapies among patients with ICC.