Intramucosal Extent as a Marker for Advanced Disease and Survival in Gallbladder Adenocarcinoma.

BACKGROUND: Gallbladder cancer (GBC) is the most common biliary tract malignancy and has a poor prognosis. The clinical significance of focal vs diffuse GBC remains unclear. METHODS: A retrospective review was conducted on all patients with non-metastatic GBC at a quaternary care center. Pathology was reviewed, and gallbladder cancer pattern was defined based on the extent of mucosal involvement; "diffuse" if the tumor was multicentric or "focal" if the tumor was only in a single location. Patients undergoing liver resection and portal lymphadenectomy were considered to have definitive surgery. The primary outcome was overall survival and assessed by Kaplan-Meier curves. RESULTS: 63 patients met study criteria with 32 (50.7%) having diffuse cancer. No difference was observed in utilization of definitive surgery between the groups (14 [43.8%] with focal and 12 [38.7%] with diffuse, P = .88). Lymphovascular invasion (P = .04) and higher nodal stage (P = .04) were more common with diffuse GBC. Median overall survival was significantly improved in those with focal cancer (5.1 vs 1.2 years, P = .02). Although not statistically significant, this difference in overall survival persisted in patients who underwent definitive surgery (4.3 vs 2.4 years, P = .70). DISCUSSION: Patients with diffuse involvement of the gallbladder mucosa likely represent a subset with aggressive biology and worse overall survival compared to focal disease. These findings may aid surgeons in subsequent surgical and medical decision-making for patients with GBC.

Gastrointestinal Toxicities of Immune Checkpoint Inhibitors Are Associated With Enhanced Tumor Responsiveness and Improved Survival.

Background: Immune checkpoint inhibitors (ICIs) are increasingly used to treat advanced malignancies. However, they are associated with the development of multiple gastrointestinal immune-related adverse events (GI-irAEs). We aimed to evaluate the types and severity of GI-irAEs associated with ICI therapy, to identify potential risk factors for developing GI-irAEs and to determine the relationship of GI-irAEs development to tumor responsiveness and overall survival. Methods: All patients who received ICIs for advanced malignancies at our center were included. Medical records were reviewed, and data extraction included: baseline demographic characteristics, immunotherapy regimens, development of GI-irAEs, response to treatment, and overall survival. Overall survival was calculated from the date of treatment initiation and estimated by the Kaplan-Meier method. Results: Five hundred sixty-seven patients received ICI therapy for stage IV malignancies. Forty-one (7%) patients experienced at least one GI-irAE. Among those experiencing GI-irAEs, 23 (56%) developed hepatitis, 17 (42%) developed colitis, four (10%) developed pancreatitis, and two (5%) developed gastritis. Patients who developed GI-irAEs experienced a better response to ICI therapy compared to patients who did not develop GI-irAEs (41% vs. 27%, P = 0.003). The 2-year overall survival rate of stage IV cancer patients who developed GI-irAEs was 62% (95% confidence interval (CI): 49 - 79) and 36% for those who did not develop GI-irAEs (95% CI: 32 - 41) (P = 0.002). The median follow-up time of surviving patients was 28 months. Twelve (29%) of the patients receiving dual ICI therapy developed GI-irAEs. Conclusion: Hepatitis, colitis, and pancreatitis were the most commonly encountered GI-irAEs with ICI therapy. Development of these GI-irAEs was associated with superior tumor responsiveness and better overall survival.

Simplified 6-month prediction scores for primary biliary cholangitis patients treated with ursodeoxycholic acid.

OBJECTIVES: To develop a prognostic score evaluating treatment response at 6 months after ursodeoxycholic acid (UDCA) initiation in primary biliary cholangitis (PBC) patients. METHODS: Adult PBC patients who were newly prescribed UDCA at our institution (n = 292) were included. Significant determinants of liver-related adverse events in the multivariable Cox model were used for score development, weighted by ß-coefficients. Discrimination ability was assessed using Harrell's C-statistic. The performance of our model was compared to the previous models. RESULTS: Our model included the following variables evaluated at 6 months: (1) alkaline phosphatase decline of less than 50% from baseline and >upper limit normal (ULN) (2 points); (2) bilirubin >ULN (2 points); (3) albumin

Factors that Minimize Curative Resection for Gallbladder Adenocarcinoma: an Analysis of Clinical Decision-Making and Survival.

BACKGROUND: Gallbladder adenocarcinoma has a poor prognosis as it is often diagnosed incidentally, and patients have a high risk for residual and occult metastatic disease. Expert guidelines recommend definitive surgery for ≥T1b tumors; however, surgical management is inconsistent. This study evaluates the factors that affect the completion of radical resection with portal lymphadenectomy and its impact on survival. METHODS: A retrospective review of patients who underwent surgery for gallbladder cancer from 2008 to 2017 at an academic institution was performed. Patients were analyzed based on whether they underwent definitive surgical resection. Patient factors and clinical decision-making were analyzed; overall survival was compared using Kaplan-Meier analysis. RESULTS: Seventy-five patients with ≥T1b tumors were identified, of who 32 (42.7%) underwent definitive resection. Fifty-four (72%) patients had gallbladder cancer identified as an incidental diagnosis following laparoscopic cholecystectomy. Among patients who did not undergo definitive resection, the underlying factors were varied. Only 24 (55.8%) patients in the non-definitive resection group were seen by surgical oncology. Among patients who underwent re-operation for definitive resection, 12 (38.7%) were upstaged on final pathology. Of the 43 patients who did not undergo definitive resection, 4 (9.3%) had metastatic disease identified during attempted re-resection. Patients who underwent definitive resection had a significantly longer median overall survival compared to those who did not (4.3 v. 1.9 years, p = 0.02). CONCLUSIONS: Patients undergoing definitive resection have a significantly improved survival, including as part of a re-operative strategy. Universal referral to a surgical specialist is a modifiable factor resulting in increased definitive resection rates.

Transaminases are Potential Biomarkers of Disease Severity in COVID-19 Patients: A Single-Center Experience.

BACKGROUND: Considering the rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), the clinical implications of gastrointestinal (GI) and hepatic manifestations of coronavirus disease 2019 (COVID-19) in the U.S. population require analysis. METHODS: We retrospectively reviewed all adult patients with COVID-19 admitted to our facility. Patients were divided into two groups based on the presence of GI symptoms and transaminitis at presentation. Univariable analysis was performed to assess the differences between study groups. Kruskal-Wallis and Pearson's chi-square tests were used to compare the median of continuous and categorical variables, respectively. Multivariate logistic regression analysis was performed to identify predictors of mechanical ventilation, cytokine release syndrome (CRS), and mortality after adjusting for baseline variables. RESULTS: A total of 84 patients were analyzed. After adjusting for baseline comorbidities, presence of GI symptoms (aOR, adjusted odds ratio 4.2, 95% CI, 1.17-15.60, p=0.03) and transaminitis on admission (aOR 5.69, 95% CI, 1.47-21.99, p=0.01) were associated with CRS. Transaminitis on admission and elevated total bilirubin during hospitalization were associated with an increased need for mechanical ventilation (aOR 6.17, 95% CI, 1.49-25.44, p=0.02 and aOR 7.29, 95% CI, 1.73-30.75, p=0.007, respectively). An elevated aspartate aminotransferase (AST) on admission (aOR 13.41, 95% CI, 1.08-165.69, p=0.04) and elevated total bilirubin during hospitalization (aOR 82.68, 95% CI, 1.67-4074.8, p=0.02) were independently associated with an increased risk of mortality in COVID-19 patients. CONCLUSION: COVID-19 patients with transaminitis on admission had a higher risk of requiring mechanical ventilation and developing CRS. Patients with elevated AST on admission and elevated total bilirubin had higher mortality. Patients with GI symptoms did not have worse outcomes.

Improving Physician-patient and Physician-nurse Communication and Overall Satisfaction Rates: A Quality Improvement Project.

Introduction Communication between healthcare providers and patients is a key component associated with the quality of healthcare and patient satisfaction. Often, simple communication skills may be insufficient to sustain a successful provider-patient relationship. The aim of this project was to assess and improve patient and nurse satisfaction with physicians via improvement in physician-patient and physician-nurse communication to a level greater than 90%. Methods Initial surveys were given to the patients and nurses on admission to the regular nursing floor to assess current satisfaction rates. Afterward, visual handouts were given that provided details about the current medical team members and the role of each team member. which were updated daily along with the medical plan. Surveys were then handed out to the patients and their nurses at the time of discharge. All surveys were conducted anonymously. Results A total of 26 surveys (n = 13 patients, n = 13 nurses) were collected and analyzed for a preliminary assessment. Surveys concluded that 68.8% of patients were satisfied with the patient-provider communication; similarly, 74.4% of the nurses were satisfied with the nurse-provider communication. In the next six weeks, visual handouts were implemented. During this period, surveys involving a total of 40 patients and 40 nurses were collected. The results after the intervention revealed that 93.3% of patients were satisfied with the patient-provider communication, and 94.7% of nurses were satisfied with the nurse-provider communication. Post-intervention, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) displayed an improvement in physician communication, reaching the expected goal of 84.4%. Conclusion Ineffective communication often goes undetected in many healthcare settings, causing serious effects on the health and safety of patients, and may ultimately jeopardize overall satisfaction. Literature has shown a positive correlation between patient satisfaction and improved clinical outcomes. Using visual aids and updating medical care plans on a daily basis are simple yet effective tools to improve communication. Written materials should be created in a patient-friendly manner to enhance communication, clarity, and understanding.