Type of Prior Operation Does Not Predict Surgical Intervention for Small Bowel Obstruction.

Background: Patients with prior abdominal surgeries are at higher risk for intra-abdominal adhesive tissue formation and subsequently higher risk for small bowel obstruction (SBO).Purpose: In this study, we investigated whether surgical intervention for SBO was more likely following specific types of abdominal surgeries.Research Design: With retrospective chart review, we pooled data from 799 patients, ages 18 to 89, admitted with SBO between 2012 and 2019. Patients were evaluated based on whether they underwent surgery or were managed conservatively. They were further compared with regard to past surgical history by way of type of abdominal surgery (or surgeries) undergone prior to admission.Results: Of the 799 patients admitted for SBO, 206 underwent surgical intervention while 593 were managed nonoperatively. There was no significant difference in number of prior surgeries (2.07 ± 1.56 vs 2.36 ± 2.11, P = .07) or in number of comorbidities (2.39 ± 1.97 vs 2.65 ± 1.93, P = .09) for surgical vs non-surgical intervention. Additionally, of the operations evaluated, no specific type of abdominal surgery predicted need for surgical intervention in the setting of SBO. However, for both surgical and non-surgical intervention following SBO, pelvic surgery was the most common type of prior abdominal surgery (45% vs 43%). There are significantly more female pelvic surgeries in both the operative (91.4% vs 8.6%, P < .0001) and nonoperative groups (89.9% vs 10.2%, P < .0001).Conclusion: Ultimately, no specific type of prior operation predicted the need for surgical intervention in the setting of SBO.

Indications for Readmission for Small Bowel Obstruction: A Comparison of Medical vs Surgical Service Admission.

Small bowel obstruction (SBO) impacts the health care system and patient quality of life. Previously, we evaluated differences between medical and surgical admissions in the management of SBO. This study investigates indications for readmission based on original admission to medical (MS) or surgical services (SS). A retrospective chart review was performed for 799 patients aged 18 to 89 admitted between 2012 and 2019 with a diagnosis of SBO. Patient characteristics examined included length of stay (LOS), prior abdominal operations, prior SBO, use of small bowel follow through imaging, operative intervention, mortality, and 30-day readmission. There was no difference in readmission rates in patients originally admitted to MS or SS (13.2% vs 12.7%, P = .86). Patients admitted to SS were more likely to be readmitted for recurrent SBO (39% vs 8.6%, P = .006). Patients admitted to MS were more likely to be readmitted for other reasons (73.9% v. 40.2%, P = .004). In the MS cohort, 30.4% (7 patients) had surgery during their initial admission for SBO, and none of those patients were readmitted for recurrent SBO (rSBO). In the SS cohort, 23% had surgery during their initial admission and 31.6% were readmitted for rSBO (P = .002). Patients admitted to SS were more likely to be readmitted for rSBO and to require surgery. Patients admitted to MS were more likely to be readmitted for other reasons. None of the MS patients who had surgery were readmitted for SBO. 31.6% of SS patients who had surgery were readmitted for SBO.

Review of Major Social Determinants of Health in Schizophrenia-Spectrum Psychotic Disorders: I. Clinical Outcomes.

BACKGROUND: Social determinants of health (SDoHs) are receiving growing attention and are particularly relevant to persons with schizophrenia-spectrum psychotic disorders (SSPDs), considering their heightened risk of comorbidities, cognitive and functional decline, and early mortality. Yet, we did not find any comprehensive review of multiple SDoHs in SSPD. STUDY DESIGN: We conducted a scoping review of meta-analyses and systematic reviews of nine major SDoHs in SSPD. STUDY RESULTS: Childhood abuse, parental psychopathology, parental communication problems, bullying, and urban settings with lower socioeconomic status were major risk factors for the greater incidence of SSPD and/or worse health. Social network size was inversely associated with overall psychopathology and negative symptoms. Experiences of racial/ethnic discrimination correlated with the prevalence of psychotic symptoms and experiences. Compared to native populations, the risk of psychosis was higher in immigrants, refugees, and asylees. Social fragmentation was associated with an increased prevalence of schizophrenia. Homeless populations had a 30-fold higher prevalence of schizophrenia than the general population. Seriously mentally ill people were 2.7 times more likely to report food insecurity than controls. The prevalence of non-affective psychosis in prisoners was 2.0%-6.5%, compared to 0.3% in the general population. Certain potentially positive factors like family and community resilience remain poorly studied. CONCLUSIONS: SDoHs are associated with higher rates of and worse outcomes in SSPD. Well-designed longitudinal studies are needed to understand SDoHs' contribution to health in persons with SSPD, to develop interventions, and to implement changes in clinical care and public health policies that would reduce adverse health impacts of SDoHs. Positive SDoHs deserve greater attention.

Review of Major Social Determinants of Health in Schizophrenia-Spectrum Disorders: II. Assessments.

BACKGROUND AND AIMS: Social determinants of health (SDoHs) impact the development and course of schizophrenia-spectrum psychotic disorders (SSPDs). Yet, we found no published scholarly reviews of psychometric properties and pragmatic utility of SDoH assessments among people with SSPDs. We aim to review those aspects of SDoH assessments. STUDY DESIGN: PsychInfo, PubMed, and Google Scholar databases were examined to obtain data on reliability, validity, administration process, strengths, and limitations of the measures for SDoHs identified in a paired scoping review. STUDY RESULTS: SDoHs were assessed using different approaches including self-reports, interviews, rating scales, and review of public databases. Of the major SDoHs, early-life adversities, social disconnection, racism, social fragmentation, and food insecurity had measures with satisfactory psychometric properties. Internal consistency reliabilities-evaluated in the general population for 13 measures of early-life adversities, social disconnection, racism, social fragmentation, and food insecurity-ranged from poor to excellent (0.68-0.96). The number of items varied from 1 to more than 100 and administration time ranged from less than 5 minutes to over an hour. Measures of urbanicity, low socioeconomic status, immigration status, homelessness/housing instability, and incarceration were based on public records or targeted sampling. CONCLUSIONS: Although the reported assessments of SDoHs show promise, there is a need to develop and test brief but validated screening measures suitable for clinical application. Novel assessment tools, including objective assessments at individual and community levels utilizing new technology, and sophisticated psychometric evaluations for reliability, validity, and sensitivity to change with effective interventions are recommended, and suggestions for training curricula are offered.

Risk Factors for Brain Health in Agricultural Work: A Systematic Review.

Certain exposures related to agricultural work have been associated with neurological disorders. To date, few studies have included brain health measurements to link specific risk factors with possible neural mechanisms. Moreover, a synthesis of agricultural risk factors associated with poorer brain health outcomes is missing. In this systematic review, we identified 106 articles using keywords related to agriculture, occupational exposure, and the brain. We identified seven major risk factors: non-specific factors that are associated with agricultural work itself, toluene, pesticides, heavy metal or dust exposure, work with farm animals, and nicotine exposure from plants. Of these, pesticides are the most highly studied. The majority of qualifying studies were epidemiological studies. Nigral striatal regions were the most well studied brain area impacted. Of the three human neuroimaging studies we found, two focused on functional networks and the third focused on gray matter. We identified two major directions for future studies that will help inform preventative strategies for brain health in vulnerable agricultural workers: (1) the effects of moderators such as type of work, sex, migrant status, race, and age; and (2) more comprehensive brain imaging studies, both observational and experimental, involving several imaging techniques.

Multidisciplinary Management of Angiosarcoma - A Review.

Angiosarcomas (AS) are a diverse group of soft tissue sarcomas, arising from blood and lymphatic vessels. They frequently present in the elderly, and in patients with previous radiation or lymphedema. A wide range of genetic derangements contribute to their development, and AS histology is often high-grade in keeping with aggressive disease biology. The clinical presentation, while often innocuous, is marked by its infiltrative and aggressive nature, with a proclivity for metastatic spread, and outcomes are often poor. Surgery is performed for localized, resectable cases. A multidisciplinary approach, appropriately employing surgery, radiation, chemotherapy, or potentially recently approved immune-oncology agents, can result in positive outcomes.

An Appreciative Inquiry Approach to the Core Competencies: Taking it From Theory to Practice.

OBJECTIVE: To operationalize the surgical core competencies by using a qualitative inquiry strategy to explore how surgical competence is behaviorally demonstrated by faculty. DESIGN: Categorical general and vascular surgery residents completed a survey soliciting opinions regarding which faculty were deemed most representative of each core competency. The surveys served as a theoretical sample, as surgeons selected were then interviewed, and interviews transcribed. A qualitative research approach using grounded theory coding methods was used for transcript analysis. Iterative coding was performed, and emergent themes were then extracted from transcript analysis. SETTING: Southern Illinois University School of Medicine, Department of Surgery in Springfield, IL, a tertiary academic center. PARTICIPANTS: Fourteen of 19 residents completed the survey (74% response rate). Two surgeons were selected for each competency. A total of 7 interviews were performed, with 4 surgeons being chosen for 2 competencies. RESULTS: Emergent themes revealed that competent surgeons shared qualities that drove their development and execution of each competency. These qualities included self-awareness, a selfless character, responsibility and ownership, context awareness, reliance on relationships and community, and a pattern of habit formation and discipline. Additionally, the competencies were noted to be pursued in an interrelated and interdependent fashion. CONCLUSIONS: Surgeons deemed competent in any core domain shared common qualities. Further study exploring how each of these is identified, developed and taught is warranted. The competencies are an inter-related matrix whose development and execution correlates with foundational personal disciplines.

Survival Implications of Increased Utilization of Local Excision for cT1N0 Esophageal Cancer.

OBJECTIVE: We hypothesized that patients with cT1N0 esophageal cancer undergoing local excision would have lower survival compared with esophagectomy due to potential discordant staging. BACKGROUND: Local excision has become an attractive alternative for management of early esophageal cancer, avoiding the morbidity of esophagectomy. It is uncertain if occult nodal metastasis impacts survival. METHODS: An observational study was conducted using the National Cancer Database (1998-2012) for patients with clinical T1N0 esophageal cancer who underwent local excision (n = 1625) or esophagectomy (n = 3255). RESULTS: The proportion of patients undergoing local excision increased from 12% in 1998 to 50% in 2012 (P < 0.001). After esophagectomy, 61% of cT1N0 cancers had concordant clinical and pathological staging, with 5.2% having positive nodal disease; 37% were staged concordant after local excision, with excess missing data (60%). Ninety-day mortality was 7.4% after esophagectomy compared with 2.8% after local excision (P < 0.001). While no significant difference was seen in unadjusted survival, adjusted Cox regression analysis indicated worse survival after esophagectomy compared with local excision for all cases [hazard ratio (HR) 1.57, 95% confidence interval (CI) 1.27-1.95] and for patients with concordant staging (HR 1.68, 95% CI 1.23-2.28). CONCLUSIONS: Local excision for cT1N0 esophageal cancer has increased over time. Contrary to our hypothesis, despite incomplete nodal staging, patients undergoing local excision have favorable survival, particularly in the adenocarcinoma subgroup. This may reflect early differences in mortality due to differences in procedure-related complications and/or selection bias. As this study has limited power to compare outcomes between T1a and T1b cancers, further analysis is warranted.

Obesity increases malignant risk in patients with branch-duct intraductal papillary mucinous neoplasm.

BACKGROUND: Obesity is an established risk factor for pancreatic adenocarcinoma. No study has examined specifically the influence of obesity on malignant risk in patients with intraductal papillary mucinous neoplasm (IPMN), a group at substantial risk of pancreatic adenocarcinoma. We hypothesize that obesity is associated with a greater frequency of malignancy in IPMN. METHODS: Data on patients undergoing resection for IPMN between 1992 and 2012 at a high-volume university institution were collected prospectively. Clinicopathologic and demographic parameters were reviewed. Patients were classified according to World Health Organization categories of body mass index (BMI). Malignancy was defined as high-grade dysplastic or invasive IPMN. RESULTS: We collected data on 357 patients who underwent resection for IPMN. Of these, 274 had complete data for calculation of preoperative BMI and 31% had malignant IPMN. Of 254 patients with a BMI of <35 kg/m(2), 30% had malignant IPMN versus 50% in patients with BMI of ≥35 (P = .08). In branch-duct IPMN, patients with a BMI of <35 had 12% of malignant IPMN compared with 46% in severely obese patients (P = .01). Alternatively, in main-duct IPMN, no difference was found in the malignancy rate (48% vs 56%; P = .74). CONCLUSION: These findings suggest that obesity is associated with an increased frequency of malignancy in branch-duct IPMN. Obesity is a potentially modifiable risk factor that may influence oncologic risk stratification, patient counseling, and surveillance strategy.

Comparative evaluation of disodium edetate and diethylenetriaminepentaacetic acid as iron chelators to prevent metal-catalyzed destabilization of a therapeutic monoclonal antibody.

Understanding the effect of metal chelators with respect to their ability to inhibit metal-catalyzed degradation in biologic products is a critical component for solution formulation development. Two metal chelators, disodium edetate (Na(2)EDTA) and diethylenetriaminepentaacetic acid (DTPA), were evaluated for their ability to stabilize IgG2 mAb in solution formulations spiked with various levels of iron. Real-time stability attributes such as oxidation, soluble aggregate formation, deamidation, and fragmentation demonstrated that DTPA was equivalent to Na(2)EDTA with respect to inhibiting iron-induced degradation over the range of iron concentrations studied. When sufficient chelator was present to stoichiometrically complex trace iron contamination, both Na(2)EDTA and DTPA exhibited the capacity to reduce protein degradation. However, substoichiometric ratios of both chelators were unable to inhibit the degradation induced by free iron ions, which were found to bind weakly to the mAb. This bound iron did not measurably alter the secondary or the tertiary structure of the mAb but appeared to decrease its intrinsic thermodynamic stability, probably by causing subtle perturbations in the tertiary structure. These destabilization effects were not observed when the chelators were present at stoichiometric ratios highlighting the feasibility of using DTPA as an alternate trace metal chelator to Na(2)EDTA in biologic protein formulations.