Multimodal approach utilising a weight management programme prior to bariatric surgery in patients with BMI ≥50 kg/m2: A propensity score matching retrospective cohort study.

We evaluated preoperative weight loss and days from initial consult to surgery in patients with BMI ≥50 kg/m2 who were and were not enrolled in medical weight management (MWM) prior to laparoscopic sleeve gastrectomy. We retrospectively identified patients with BMI ≥50 kg/m2 who had primary sleeve gastrectomy between 2014 and 2019 at two bariatric surgery centres in our healthcare system. Patients presenting after 2017 that received preoperative MWM (n = 28) were compared to a historical cohort of non-MWM patients (n = 118) presenting prior to programme initiation in 2017 on preoperative percent total body weight loss (%TBWL) and days from initial consult to surgery. A total of 151 patients (MWM, 33; non-MWM, 118) met inclusion criteria. BMI was significantly greater in MWM versus non-MWM (p = .018). After propensity score matching, median BMI at initial consult in non-MWM versus MWM no longer differed (p = .922) neither were differences observed on the basis of weight, age, sex, race or ethnicity. After PSM, MWM had significantly lower BMI at surgery (p = .018), lost significantly more weight from consult to surgery (p < .001) and achieved significantly greater median %TBWL from consult to surgery (p < .001). We noted no difference between groups on 6-month weight loss (p = .533). Days from initial consult to surgery did not differ between groups (p < .863). A preoperative MWM programme integrated into multimodal treatment for obesity in patients with a BMI ≥50 kg/m2 resulted in clinically significant weight loss without prolonging time to surgery.

Five-year outcomes of revisional bariatric surgery: gastric band to sleeve gastrectomy or to Roux-en-Y gastric bypass.

BACKGROUND: Revisional bariatric surgery after an index adjustable gastric band (AGB) may be indicated to remedy weight relapse or band-related complications. We examined outcomes five years following revision from AGB to laparoscopic sleeve gastrectomy (AGB-LSG) or to Roux-en-Y gastric bypass (AGB-RYGB). METHODS: We conducted a retrospective review to identify patients (men and women, age 18-80) who underwent one revisional bariatric procedure with AGB as the index procedure at two medical centers in our healthcare system between January 2012 and February 2017. We only included patients with a pre-revision BMI > 30 kg/m2 for whom 5-year follow-up data were available. We compared 5-year weight loss and remission of comorbidities in patients undergoing AGB-LSG and AGB-RYGB conversion. RESULTS: A total of 114 patients met inclusion criteria (65 AGB-LSG, 49 AGB-RYGB). At 5-year post-revision, percent total weight loss (3.4% vs 19.9%; p < 0.001), percent excess weight loss (7.0% vs 50.8%; p < 0.001) and decrease in BMI (1.5 vs 8.8; p < 0.001) was greater in AGB-RYGB vs. AGB-LSG. No significant difference in remission or development of new comorbidities was observed. CONCLUSION: Conversion of AGB to RYGB is associated with superior intermediate-term weight loss compared to conversion of AGB to LSG. Future multicenter studies with larger sample sizes are necessary to further describe the intermediate-term outcomes of revisional bariatric surgery.

Prostate Cancer Detection and Complications of Transperineal Versus Transrectal Magnetic Resonance Imaging-fusion Guided Prostate Biopsies.

OBJECTIVE: To assess the rates of detection of clinically significant prostate cancer (csPCa) and complications associated with transperineal (TP) and transrectal (TR) biopsy approaches to magnetic resonance imaging (MRI)-fusion targeted biopsy. MATERIALS AND METHODS: We retrospectively identified men who underwent TP or TR MRI-targeted biopsy with concurrent systematic random biopsy from August 2020 to August 2021. Primary outcomes were detection rates of csPCa and 30-day complication rates between the 2 MRI-biopsy groups. Data were additionally stratified by prior biopsy status. RESULTS: A total of 361 patients were included in the analysis. No demographic differences were observed. No significant differences were observed between TP and TR approaches on any of the outcomes of interest. TR MRI-targeted biopsies identified csPCa in 47.2% of patients, and TP MRI-targeted biopsies identified csPCa in 48.6% of patients (P = .78). No significant differences were observed in csPCa detection between the 2 approaches for patients on active surveillance (P = .59), patients with prior negative biopsy (P = .34), and patients who were biopsy naïve (P = .19). Complication rates did not vary by approach (P = .45). CONCLUSION: Neither the identification of csPCa by MRI-targeted biopsy nor rates of complications differed significantly based on a TR or TP approach. No differences were seen between MRI-targeted approaches based on prior biopsy or active surveillance status.

Outcomes over 20 years performing robot-assisted laparoscopic prostatectomy: a single-surgeon experience.

OBJECTIVE: To evaluate a single surgeon's 20-year experience with robotic radical prostatectomy. METHODS: Patients who had undergone robot-assisted laparoscopic prostatectomy by a single surgeon were identified via an IRB approved prospectively maintained prostate cancer database. Patients were divided into 5-year cohorts (cohort A 2001-2005; cohort B 2006-2010; cohort C 2011-2015; cohort D 2016-2021) for analysis. Oncologic and quality of life outcomes were recorded at the time of follow-up visits. Continence was defined as 0-1 pad with occasional dribbling. Potency was defined as intercourse or an erection sufficient for intercourse within the last 4 weeks. RESULTS: Three thousand one hundred fifty-two patients met criteria for inclusion. Clavien ≥ 3 complication rates decreased from 5.9% to 3.2%, p = 0.021. There was considerable Gleason grade group (GG) and stage migration to more advanced disease between cohort A (6.4% GG4 or GG5, 16.2% pT3 or pT4, 1.2% N1) and cohort D (17% GG4 or GG5, 45.5% pT3 or pT4, 14.4% N1; p < 0.001). Consistent with this, an increasing proportion of patients required salvage treatments over time (14.6% of cohort A vs 22.5% of cohort D, p < 0.001). 1-year continence rates improved from 74.8% to greater than 92.4%, p < 0.001. While baseline potency and use of intraoperative nerve spare decreased, for patients potent at baseline, there were no significant differences for potency at one year (p = 0.065). CONCLUSIONS: In this 20-year review of our experience with robotic prostatectomy, complication rates and continence outcomes improved over time, and there was a migration to more advanced disease at the time of surgery.

Incidence of Hiatal Hernia Repair During Primary Bariatric Surgery Conversion: an Analysis of the 2020 MBSAQIP Database.

The rate of hiatal hernia (HH) repair during conversion bariatric surgery is largely unknown. We sought to determine this rate in 12,788 patients undergoing conversion surgery using the 2020 participant use file of the MBSAQIP database. Concurrent HH repair was performed in 24.1% of conversion cases; most commonly during SG to RYGB (33.1%), followed by AGB to SG conversion (20.2%). The remaining conversion pathways had a repair rate around 13%. Only 12.1% of HH repairs were performed using a mesh. GERD was the primary indication for conversion in 65% of the SG to RYGB cases. A much higher proportion of patients with concomitant HH repair reported GERD as the main reason for conversion than those without a HH repair (44.5% vs. 23.7%; p<0.001).

The Effect of a Peritoneal Iliac Flap on Lymphocele Formation After Robotic Radical Prostatectomy: Results From the PLUS Trial.

OBJECTIVE: To assess the effectiveness of a peritoneal flap on the formation of lymphoceles after robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection. METHODS: We conducted a single surgeon, assessor blinded prospective randomized controlled trial (the Prospective Lymphocele Ultrasound Study) in men undergoing robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection. At the conclusion of the node dissection, patients were block randomized 1:1 to either standard of care (no bladder peritoneal flap) or to the creation of a bladder peritoneal flap. Lymphocele formation was assessed by pelvic ultrasound postoperatively. The primary outcome was lymphocele formation. Rates of lymphocele formation and complications were analyzed using chi-square. Other outcomes, including length of stay, number of lymph nodes removed, lymphocele volume, and quality of life measures, were analyzed by t-tests or Wilcoxon Ranked Sum Tests, as appropriate. An a priori power calculation was performed using O'Brien-Fleming alpha sharing for the interim analyses. Two preplanned interim analyses were performed when 45 and 90 patients per group had follow-up ultrasounds. RESULTS: A statistically significant difference in lymphocele formation was seen on the second interim analysis for 183 patients (4.3% vs. 15.6%, p = .011) stopping enrollment; this remained significant in the final analysis of 216 patients (3.6% vs 14.2%, p = .006). No other significant differences were observed. CONCLUSION: This prospective randomized trial supports the implementation of this simple modification for robotic assisted radical prostatectomy with bilateral extended pelvic lymph node dissection.

Enhanced Recovery After Surgery Is Associated With Reduced Hospital Length of Stay after Urgent or Emergency Isolated Coronary Artery Bypass Surgery at an Urban, Tertiary Care Teaching Hospital: An Interrupted Time Series Analysis With Propensity Score Matching.

OBJECTIVE: To evaluate whether enhanced recovery after surgery (ERAS) was associated with reduced length of stay (LOS) after urgent or emergency coronary artery bypass graft surgery (CABG). DESIGN: A retrospective analysis of an institutional database for urgent or emergency isolated CABG before versus after ERAS. Propensity matching identified comparable subpopulations pre- versus post-ERAS. Interrupted time series analysis was used to evaluate LOS. SETTING: At a tertiary care teaching hospital. PARTICIPANTS: A total of 1,012 patients undergoing urgent or emergent CABG-346 from 2016 to 2017 (pre-ERAS), and 666 from 2018 to 2020 (post-ERAS). Emergent CABG was performed within 24 hours, and urgent CABG was performed during the same hospitalization to reduce clinical risk. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Propensity-matched post-ERAS (n = 565) versus pre-ERAS patients (n = 330) demonstrated reduced LOS (9 [8-13] v (10 [8-14] days p = 0.015), increased likelihood of extubation within 6 hours (46.0% v 35.8%, p = 0.003), shorter ventilation time (6.3 [5.1-10.2] v (7.2 [5.4-12.2] hours, p = 0.003), reduced morphine milligram equivalent use on postoperative days 1 and 2 (69.6 ± 62.2 v 99.0 ± 61.6, p < 0.001), and increased intraoperative ketamine use (58.8% v 35.2%, p < 0.001). There were no differences regarding reintubation, intensive care unit readmission, or 30-day morbidity. Adjusted segmental regression (n = 1,012) for LOS demonstrated reduced mean LOS of approximately 2 days after ERAS (ß2 coefficient -1.943 [-3.766 to -0.121], p = 0.037), with stable trends for mean LOS and no change in slope throughout the pre-ERAS and post-ERAS time periods. CONCLUSIONS: Enhanced recovery after surgery was associated with reduced LOS after urgent or emergency CABG without adverse effects on prolonged ventilation, reintubation, intensive care unit readmission, or 30-day outcomes.

What is the most effective way to ensure that patients successfully undergo germline testing for prostate cancer?

INTRODUCTION: We sought to identify the most effective way to refer patients with prostate cancer to germline testing. METHODS: After IRB approval, we queried the electronic medical records (EMR) to identify patients (ages 18-89) with prostate cancer who were referred for or offered germline testing for prostate cancer from May 1, 2019 to February 24, 2021 through either telephone referral, EMR referral or in-office testing. The 3 cohorts were compared on receipt of testing and time to testing. Multivariate logistic regression and Cox regression evaluated the influence of referral cohort and reason for testing on receipt of testing and time to testing, respectively. RESULTS: A total of 184 patients met study inclusion criteria; 47 were referred for germline testing via telephone, 70 were referred through the EMR and 67 were offered testing in the office. No significant demographic or clinical differences were observed. Telephone referral yielded the lowest response (17%; P < 0.001) with the longest time interval between referral and testing (103 days; P < 0.001); in-office testing yielded the highest response (66%). More patients were referred because of both family history and high risk characteristics in the EMR and in-office testing cohorts (21.4% and 25.4% respectively). Referral method was significantly (P < 0.001) associated with receipt of test, while reason for testing was not. Referral method was also independently related to time to testing (P < 0.001) while reason for referral was not. CONCLUSIONS: Urologists should offer germline testing in the office for the most effective and expedient results.

A randomized controlled trial of an enhanced recovery after surgery protocol in patients undergoing laparoscopic sleeve gastrectomy.

BACKGROUND: The purpose of this study was to evaluate the effect of an enhanced recovery after surgery (ERAS) protocol on opioid and anti-emetic use, length of stay and safety after laparoscopic sleeve gastrectomy (LSG). METHODS: Patients who underwent LSG between March 2018 and January 2019 at our accredited, high-volume bariatric surgery center were randomized to either standard of care (SOC) or ERAS. ERAS included a pre- and post-surgical medication regimen designed to reduce postoperative nausea, vomiting and pain. Outcomes included post-operative symptom scores, opioid use, anti-emetic use, time to achieve readiness for discharge (RFD) and inpatient and 30-day adverse events, readmissions and emergency department visits. RESULTS: The final analysis included 130 patients, (SOC 65; ERAS 65). Groups did not differ on demographics or comorbidities. Relative to SOC, fewer ERAS patients utilized opioids in the hospital ward (72.3% vs. 95.4%; p < .001), peak pain scores were significantly lower, and median time to achieve RFD was shorter (28.0 h vs. 44.4 h; p = 0.001). More ERAS patients were discharged on post-operative day 1 (38.5% vs. 15.4%; p < .05). The overall use of rescue anti-emetic medications was not different between groups. Rates of postoperative 30-day events, readmissions, and emergency department visits did not differ between groups. CONCLUSION: Relative to SOC, ERAS was associated with earlier discharge, lower pain scores, less frequent use of opioids and use in lower amounts after LSG with no differences in 30 day safety outcomes.

Food cue reactivity in successful laparoscopic gastric banding: A sham-deflation-controlled pilot study.

Laparoscopic adjustable gastric banding (LAGB) offers a unique opportunity to examine the underlying neuronal mechanisms of surgically assisted weight loss due to its instant, non-invasive, adjustable nature. Six participants with stable excess weight loss (%EWL ≥ 45) completed 2 days of fMRI scanning 1.5-5 years after LAGB surgery. In a within-subject randomized sham-controlled design, participants underwent (sham) removal of ∼ 50% of the band's fluid. Compared to sham-deflation (i.e., normal band constriction) of the band, in the deflation condition (i.e., decreasing restriction) participants showed significantly lower activation in the anterior (para)cingulate, angular gyrus, lateral occipital cortex, and frontal cortex in response to food images (p < 0.05, whole brain TFCE-based FWE corrected). Higher activation in the deflation condition was seen in the fusiform gyrus, inferior temporal gyrus, lingual gyrus, lateral occipital cortex. The findings of this within-subject randomized controlled pilot study suggest that constriction of the stomach through LAGB may indirectly alter brain activation in response to food cues. These neuronal changes may underlie changes in food craving and food preference that support sustained post-surgical weight-loss. Despite the small sample size, this is in agreement with and adds to the growing literature of post-bariatric surgery changes in behavior and control regions.

Enhanced Recovery After Surgery Is Associated With Improved Outcomes and Reduced Racial and Ethnic Disparities After Isolated Coronary Artery Bypass Surgery: A Retrospective Analysis With Propensity-Score Matching.

OBJECTIVES: To evaluate whether enhanced recovery after surgery (ERAS) protocol implementation was associated with improved outcomes and decreased racial and ethnic outcome disparities after isolated coronary artery bypass graft (CABG) surgery. DESIGN: A retrospective analysis of an institutional CABG database with propensity-score matching. SETTING: At a single tertiary care teaching hospital. PARTICIPANTS: One thousand seven hundred thirty-five patients undergoing isolated CABG: 656 patients from 2016 to 2017 (pre-ERAS) and 1,079 patients from 2018 to 2020 (post-ERAS). Each patient cohort was divided into a White subgroup and a racial and ethnic minorities (Minorities) subgroup. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Propensity-matched post-ERAS patients (n = 584) compared to pre-ERAS patients (n = 584) demonstrated reductions in total length of stay (LOS) (median [interquartile range]): (7 [5-10] v 8 [6-11.5] days, p = .006), postoperative LOS (5 [4-7] v 5 [4-7] days, p = .001), total ventilation time (6.1 [4.8-9.5] v 6.6 [5.2-10.9] hours, p = .004), postoperative morphine milligram equivalents (mean ± standard deviation: 68.6 ± 57.5 v 100.0 ± 59.4, p < .001), and increased likelihood of early extubation (48.8% v 42.3%, p = .026); the Minorities subgroup demonstrated reductions in likelihood of intensive care unit (ICU) readmission (1.3% v 8.1%, p = .012) and postoperative morphine milligram equivalents (73.6 ± 64.0 v 107.8 ± 71.9, p < .001). Logistic regression models demonstrated that disparities in ICU readmission and postoperative LOS between White and Minorities patients were eliminated post-ERAS. CONCLUSIONS: ERAS for isolated CABG surgery was associated with reduced total and postoperative LOS, reduced total ventilation time, and increased early extubation for all patients, as well as reduced ICU readmission for the Minorities subgroup. ERAS implementation was associated with reduced disparities between White and racial and ethnic minority patients for ICU readmission and postoperative LOS.

Outcomes of MRI fusion-guided versus systematic standard prostate biopsies.

INTRODUCTION: The current utility of MRI-fusion targeted biopsy as either an adjunct to or replacement for systematic template biopsy for the detection of clinically significant prostate cancer is disputed. The purpose of this study is to assess the current effectiveness of MRI-targeted versus systematic template prostate biopsies at two institutions and to consider possible underlying factors that could impact variability between detection rates in our patient population compared to others. MATERIALS AND METHODS: A retrospective review from our prospectively maintained prostate cancer databases was conducted. Patients with prostate MRI lesions (PI-RADSv2) receiving concurrent systematic 12-core and MRI-fusion targeted biopsies were reviewed. Clinically significant cancer was considered to be Grade Group ≥ 2. RESULTS: A total of 457 patients were included in the analysis; 255 patients received their biopsy at Institution A and 202 at Institution B. Overall cancer detection rate was 68%; the clinically significant cancer detection rate was 34%. Both MRI-targeted and systematic biopsies identified unique cases of clinically significant prostate cancer that the other modality missed. Out of 157 cases of clinically significant prostate cancer, MRI-targeted biopsy identified 29/157 cases (18%) missed by systematic biopsy, while systematic biopsy identified 37/157 cases (24%) missed by MRI-targeted biopsy (p = .39). Individual biopsy performance was similar when stratified by active surveillance or prior biopsy status, PI-RADSv2 score, and institution. CONCLUSIONS: MRI-fusion targeted and systematic biopsy each identified unique cases of clinically significant prostate cancer. Both biopsy modalities should be utilized in order to provide the greatest sensitivity for the detection of clinically significant prostate cancer.

Utility of a Novel Scale to Assess Readiness for Discharge After Bariatric Surgery.

BACKGROUND: The safe release of a patient from hospital care after bariatric surgery depends upon the achievement of satisfactory health status. Here, we describe a new objective scale (the Readiness for Discharge, RFD Scale) to measure the patient's suitability for hospital discharge after bariatric surgery. METHODS: We conducted a retrospective, observational analysis of data collected in a randomized clinical trial of an enhanced recovery after surgery protocol for laparoscopic sleeve gastrectomy from 3/15/2018 to 1/12/2019. Nursing staff assessed 122 patients every 4-8 h after surgery using a checklist to document 5 components: ambulation, vital signs, pain, nausea, and oral intake of clear fluid. Satisfaction of each component was scored as "1" (satisfactory) or "0" (not satisfactory). Scores were summed and analyzed for patterns. RFD = 5 marked the patient as ready for discharge. RESULTS: Sufficient intake of clear liquid was the last RFD component satisfied in 87% of patients. Two overall response patterns emerged: "Steady Progressors" (n = 51) whose RFD score rose steadily from 0 to 5 without reversion to a lower score; and "Oscillators" (n = 71) who had at least one temporary decrease in RFD score on the way to attaining 5, or showed a simultaneous oscillation of components without change in RFD. CONCLUSIONS: The RFD checklist allows objective scoring of medical readiness for discharge after LSG and has the potential to improve clinical communication.

Fundamental Movement Skills and Physical Activity of 3-4-Year-Old Children within Early Childhood Centers in New Zealand.

We sought to describe and explore relationships between fundamental movement skills (FMS) and level of physical activity (PA; light-, medium-, vigorous, and kCal/hour) in preschool children, aged 3-4-years-old, across four early childhood education (ECE) settings. Children's FMS were assessed using the Test for Gross Motor Development-2 (TGMD-2; n = 81) and PA via accelerometers (S = 53). Eighty-four children participated, with 50 in both assessments. The TGMD-2 showed as the children got older, their locomotor skills (p < 0.001, r = 0.512) and object control motor skills (p < 0.001, r = 0.383) improved. Accelerometry showed children were primarily inactive at ECE (78.3% of the time). There were significant correlations between kCal/hour and light (p < 0.001, r = -0.688), moderate (p < 0.001, r = 0.599) and vigorous (p < 0.001, rs = 0.707) activity, and between gross motor quotient and locomotor (p < 0.001, r = 0.798) and object control (p < 0.001, r = 0.367) skills. No correlation was observed between gross motor quotient and kCal/hour. To conclude, children in this cohort were primarily inactive during ECE center hours. Moreover, gross motor quotient was significantly correlated to locomotor and object control skills.

The Effect of a 10-Week Physical Activity Programme on Fundamental Movement Skills in 3-4-Year-Old Children within Early Childhood Education Centres.

The objective of this study was to examine the effect of a 10-week physical activity (PA) programme, in early childhood education (ECE) settings, on 3 and 4-year-old children's fundamental movement skills (FMS). A further aim was to examine FMS three-months post-intervention. The PA instructors delivered one 45 min session/week over 10 weeks, to 3- and 4-year-old children (n = 46), across four ECE centres. These sessions involved participation from ECE teachers. Children in the control group (CON; n = 20) received no PA classes and completed pre- and post-intervention assessments only. Locomotor (e.g., running/hopping) and object-control (e.g., kicking/throwing) skills were assessed using the Test for Gross Motor Development-2 (TGMD-2), before and after the intervention and, for the intervention group (EXP), at 3 months. Locomotor and object-control skills significantly improved in the EXP group, with typically no change in the CON group. The EXP group's locomotor and object-control skills were maintained at 3 months. The 10-week PA intervention successfully improved 3- and 4-year-old children's FMS.

A COVID-19 Pivot Plan to Resume Elective Surgeries at the Hartford Healthcare Connecticut Orthopaedic Institute.

Background The Connecticut Orthopaedic Institute (COI) conceptualized a Pivot Plan during an elective surgery moratorium at the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic with the goal of planning and executing orthopedic procedures safely. With the resumption of elective surgeries and the continued planning of surgical recovery over the months (and possibly years) to follow, facilities must brace themselves for repeat waves of COVID-19. Thereby, herein we share the Pivot Plan, its implementation process, evaluation of patient safety, and program performance during a pandemic. This could inform the efforts of other institutions seeking to restart non-emergent surgeries during similarly trying times in the future.  Methods The COI formed a multidisciplinary team of leaders that met weekly to design a Pivot Plan and a dashboard to guide the resumption of surgeries and assess the performance of the Pivot Plan. The plan revolved around four domains: safety, space, staff, and supplies. It was implemented in two COI-affiliated facilities: MidState Medical Center (MMC) and St. Vincent's Medical Center (SVMC). Monthly metrics from May to November 2020 were compared to the six-month averages for the pre-pandemic baseline period from September 2019 to February 2020. Results The total number (N) of elective orthopaedic cases prior to the pandemic pre-COVID averaged 372 cases per month for MMC and 197 cases for SVMC. During the pandemic post-COVID, N averaging at 361 for MMC and 243 for SVMC illustrates COI was able to perform elective surgeries amid a worsening pandemic. Same-day (SD) discharge rates for total joint arthroplasty (TJA) pre-COVID averaged 8% for MMC and 3% for SVMC. Post-COVID, the SD average was 16.7% for MMC and 11.4% for SVMC. This data indicates that orthopaedic providers were cognizant of length of stay in order to reduce the risk of in-hospital exposure to COVID-19. The 30-day readmission (30R) rate for TJA pre-COVID averaged 1.4% for MMC and 2.7% for SVMC. A high level of care and follow-up is reflected in a lower average 30R post-COVID, 1.1% for both MMC and SVMC. Transitions for TJA patients to their home settings after surgery also reflect the quality of care and the efficiency of the patient throughput process with necessary precautions in place. Post-COVID, the patient transition to home (T) averaged 98.1% for MMC and 97.5% for SVMC compared to T = 96.8% for MMC and 88% for SVMC pre-COVID. No patients experienced deep vein thrombosis or pulmonary embolism during the time period of the project. Positive COVID-19 diagnosis 23 days after discharge was 0% at MMC and 0.2% at SVMC. Conclusion The COI Pivot Plan was successfully implemented at two different hospitals offering elective orthopaedic surgeries to a varied patient population. The precautions taken by COI were effective in controlling the spread of the SARS-CoV-2 virus while returning to elective orthopaedic surgery. Furthermore, data collected before and after the onset of the COVID-19 pandemic indicated that program performance and quality improved.

Identification of a five gene signature to predict time to biochemical recurrence after radical prostatectomy.

BACKGROUND: Identification of novel biomarkers associated with high-risk prostate cancer or biochemical recurrence can drive improvement in detection, prognosis, and treatment. However, studies can be limited by small sample sizes and sparse clinical follow-up data. We utilized a large sample of prostate specimens to identify a predictive model of biochemical recurrence following radical prostatectomy and we validated this model in two external data sets. METHODS: We analyzed prostate specimens from patients undergoing radical prostatectomy at Hartford Hospital between 2008 and 2011. RNA isolated from formalin-fixed paraffin-embedded prostates was hybridized to a custom Affymetrix microarray. Regularized (least absolute shrinkage and selection operator [Lasso]) Cox regression was performed with cross-validation to identify a model that incorporated gene expression and clinical factors to predict biochemical recurrence, defined as postoperative prostate-specific antigen (PSA) > 0.2 ng/ml or receipt of triggered salvage treatment. Model performance was assessed using time-dependent receiver operating curve (ROC) curves and survival plots. RESULTS: A total of 606 prostate specimens with gene expression and both pre- and postoperative PSA data were available for analysis. We identified a model that included Gleason grade and stage as well as five genes (CNRIP1, endoplasmic reticulum protein 44 [ERP44], metaxin-2 [MTX2], Ras homolog family member U [RHOU], and OXR1). Using the Lasso method, we determined that the five gene model independently predicted biochemical recurrence better than a model that included Gleason grade and tumor stage alone. The time-dependent ROCAUC for the five gene signature including Gleason grade and tumor stage was 0.868 compared to an AUC of 0.767 when Gleason grade and tumor stage were included alone. Low and high-risk groups displayed significant differences in their recurrence-free survival curves. The predictive model was subsequently validated on two independent data sets identified through the Gene Expression Omnibus. The model included genes (RHOU, MTX2, and ERP44) that have previously been implicated in prostate cancer biology. CONCLUSIONS: Expression of a small number of genes is associated with an increased risk of biochemical recurrence independent of classical pathological hallmarks.

Harvesting strategies as evidence for 4000 years of camas (Camassia quamash) management in the North American Columbia Plateau.

One of the greatest archaeological enigmas is in understanding the role of decision-making, intentionality and interventions in plant life cycles by foraging peoples in transitions to and from low-level food production practices. We bring together archaeological, palaeoclimatological and botanical data to explore relationships over the past 4000 years between people and camas (Camassia quamash), a perennial geophyte with an edible bulb common across the North American Pacific Northwest. In this region throughout the late Holocene, people began experimenting with selective harvesting practices through targeting sexually mature bulbs by 3500 cal BP, with bulb harvesting practices akin to ethnographic descriptions firmly established by 1000 cal BP. While we find no evidence that such interventions lead to a selection for larger bulbs or a reduction in time to maturity, archaeological bulbs do exhibit several other domestication syndrome traits. This establishes considerable continuity to human intervention into camas life cycles, but these dynamic relationships did not result in unequivocal morphological indications of domestication. This approach to tracking forager plant management practices offers an alternative explanatory framework to conventional management studies, supplements oral histories of Indigenous traditional resource management and can be applied to other vegetatively propagated species.

Does post prostatectomy decipher score predict biochemical recurrence and impact care?

PURPOSE: To examine the ability of the Decipher test to predict early biochemical recurrence after radical prostatectomy and to impact clinical decisions in advance of metastasis and death. METHODS: We identified Decipher tests ordered after radical prostatectomy for adverse pathology in men treated for prostate cancer between 1/1/14 and 8/31/18. Biochemical recurrence was defined as prostate-specific antigen > 0.02 ng/mL. Decipher score is reported as lower risk (< 0.6) and higher risk ≥ 0.60). Kaplan-Meier analysis was used to examine the relationship between Decipher score and time to biochemical recurrence (months). Cox regression was used to analyze the relationship between Decipher score and time to biochemical recurrence while controlling for a number of clinical characteristics. Secondary analyses focused on a subset of men with prostate-specific antigen > 0.02 and < 0.20 ng/mL to determine if high-risk Decipher scores were associated with receipt of salvage treatment. RESULTS: A total of 203 cases were analyzed: 37.9% and 62.1% had lower and higher risk Decipher scores respectively, and 56.2% had a biochemical recurrence. Median (inter-quartile range) follow-up was 20 (13.5, 25.3) months. Decipher score was significantly associated with time to biochemical recurrence (p = 0.027) while in the secondary analyses, high-risk Decipher scores (≥ 0.60) were associated with salvage treatment (p = 0.018). Stage category and Decipher score were significant predictors of time from elevated PSA to salvage treatment in the secondary analyses. CONCLUSION: While it might not contribute statistically, Decipher score can be clinically useful in helping patients reach treatment decisions.

C Peptide Fails to Improve the Utility of the DiaRem Algorithm in Predicting Remission of Type II Diabetes After Bariatric Surgery.

We evaluated the utility of C peptide as an addition to the DiaRem score for predicting type 2 diabetes (T2D) remission 1 year after bariatric surgery in 175 patients. DiaRem score was significantly correlated with C peptide (r = - .43; p < .001). Both DiaRem and C peptide were significant predictors of remission of T2D (OR (95% CI) = .81 (.75-.86); p < 0001 and OR (95% CI) = 1.35 (1.15-1.60); p < .001, respectively). ROC analysis indicated that DiaRem was a significantly stronger predictor than C peptide (p < .001). Hierarchical regression indicated that C peptide failed to significantly improve the prediction of diabetes remission after accounting for DiaRem (OR (95% CI) = 1.079 (.87-1.26); p = .406). This study does not support the inclusion of C peptide in the DiaRem algorithm.