How far We Go For Surgery: Distance to Pediatric Surgical Care in Indiana

INTRODUCTION

Despite increasing numbers of pediatric surgery training programs, access to pediatric surgical care remains limited in non-academic and rural settings. We aimed to characterize demographic and patient factors associated with increased distance to selected pediatric surgical procedures in Indiana.

METHODS

This IRB-approved retrospective review analyzed pediatric patients undergoing appendectomy, cholecystectomy, umbilical hernia repair, pyloromyotomy, and video assisted thoracic surgery (VATS) procedures from 2019 through 2021. Data was obtained from an electronic medical record warehouse and the Indiana Hospital Association. Travel distance was calculated as driving distance between patient address and hospital ZIP codes. Statistics were performed in R, with p < 0.05 indicating significance.

RESULTS

There were 6835 operations performed, and half of all operations (46%) were performed at institutions with fellowship-trained pediatric surgeons. The median travel distance for all operations was 13 miles (range 0-182); the shortest was for laparoscopic appendectomy (9 miles, IQR[0-20]). The longest distances were for pyloromyotomy (51 miles, IQR[14-84]) and VATS procedures (57 miles, IQR[13-111]), of which, nearly all were performed at tertiary pediatric care centers (97% and 93%, respectively). There was a significant linear and quadratic effect of age on travel distance (p < 0.001), with younger patients requiring farther travel. On multivariable linear regression, age and procedure type had the largest effect on travel distance (Eta squared 0.03, p < 0.001).

CONCLUSION

Younger age and more specialized procedures, including VATS and pyloromyotomy, were associated with increased travel distance. This highlights regionalization of these procedures to urban areas with pediatric care centers, while others are performed closer to home.

LEVEL OF EVIDENCE

III TYPE OF STUDY: Retrospective comparative study.

Outcomes of Concurrent Ventral Hernia Repair and Cholecystectomy Compared to Ventral Hernia Repair Alone

Introduction It has been suggested that hernia repair with concomitant cholecystectomy increases the risk of postoperative complications due to potential mesh contamination. This study compares postoperative outcomes and complications between patients who underwent ventral hernia repair (VHR) with and without concomitant cholecystectomy (CCY). Methods Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, from 2005 to 2019, we queried patients who underwent ventral hernia repairs using the current procedural terminology (CPT) codes 49652-49657 (laparoscopic) and 49560-49566 (open), with or without cholecystectomy. The ACS NSQIP is a prospective, systematic study of patients who underwent major general surgical procedures aggregating data from over 200 hospitals. Cases involving additional concomitant procedures were excluded. Primary outcomes of interest were 30-day mortality, length of stay, readmission, return to operating room (OR), and postoperative complications. The odds ratio for primary outcomes was calculated using multivariable binomial logistic regression to control for patient risk factors. Results In total, 167586 cases were identified, 165,758 ventral hernia repairs alone, and 1,828 ventral hernia repairs with concomitant cholecystectomy. There was no difference in 30-day mortality, length of stay, readmission, return to the operating room, or postoperative complications between groups. Patients who underwent simultaneous VHR/CCY when compared to those who had VHR alone, had no differences in the rate of surgical site infections (1.86% vs. 1.97%, P = 0.57) or sepsis (0.82% vs. 0.41%, P = 0.10).  Conclusion In a large national sample, there is no significant difference in postoperative outcomes, specifically infection-related complications, when comparing VHR along with concurrent VHR/CCY. Our findings suggest no increased risks for patients undergoing concurrent ventral hernia repair and cholecystectomy. Hence, surgeons might consider this combined approach to offer the best value-based care, especially when it could eliminate the need for a second operation and the risk of infection is low. Prospective studies with more procedural-specific information for hernia repairs and indications for cholecystectomy are needed however it is likely safe to perform both procedures during the same setting in cholecystectomy cases lacking signs of acute infection.

SPCS: a spatial and pattern combined smoothing method for spatial transcriptomic expression

High-dimensional, localized ribonucleic acid (RNA) sequencing is now possible owing to recent developments in spatial transcriptomics (ST). ST is based on highly multiplexed sequence analysis and uses barcodes to match the sequenced reads to their respective tissue locations. ST expression data suffer from high noise and dropout events; however, smoothing techniques have the promise to improve the data interpretability prior to performing downstream analyses. Single-cell RNA sequencing (scRNA-seq) data similarly suffer from these limitations, and smoothing methods developed for scRNA-seq can only utilize associations in transcriptome space (also known as one-factor smoothing methods). Since they do not account for spatial relationships, these one-factor smoothing methods cannot take full advantage of ST data. In this study, we present a novel two-factor smoothing technique, spatial and pattern combined smoothing (SPCS), that employs the k-nearest neighbor (kNN) technique to utilize information from transcriptome and spatial relationships. By performing SPCS on multiple ST slides from pancreatic ductal adenocarcinoma (PDAC), dorsolateral prefrontal cortex (DLPFC) and simulated high-grade serous ovarian cancer (HGSOC) datasets, smoothed ST slides have better separability, partition accuracy and biological interpretability than the ones smoothed by preexisting one-factor methods. Source code of SPCS is provided in Github (https://github.com/Usos/SPCS).

DAPT: A package enabling distributed automated parameter testing

Modern agent-based models (ABM) and other simulation models require evaluation and testing of many different parameters. Managing that testing for large scale parameter sweeps (grid searches), as well as storing simulation data, requires multiple, potentially customizable steps that may vary across simulations. Furthermore, parameter testing, processing, and analysis are slowed if simulation and processing jobs cannot be shared across teammates or computational resources. While high-performance computing (HPC) has become increasingly available, models can often be tested faster with the use of multiple computers and HPC resources. To address these issues, we created the Distributed Automated Parameter Testing (DAPT) Python package. By hosting parameters in an online (and often free) "database", multiple individuals can run parameter sets simultaneously in a distributed fashion, enabling ad hoc crowdsourcing of computational power. Combining this with a flexible, scriptable tool set, teams can evaluate models and assess their underlying hypotheses quickly. Here, we describe DAPT and provide an example demonstrating its use.

Uptake of biosimilars for TNF-α inhibitors adalimumab and etanercept following the best-value biological medicine initiative in Ireland

Background There is over 10 years of clinical experience and evidence to show that biosimilar medicines can be used as safely and effectively in approved therapeutic indications as their originator biological medicines. In Ireland, biosimilar medicine uptake has been very slow, and savings to the health service will only be realised through fostering a competitive biological medicine market. Objective The objective of this study was to investigate the utilisation of biosimilars following a 'best-value biological' medicine initiative for adalimumab and etanercept in the Irish healthcare setting. Methods Data was extracted from the National High Tech claims database and High Tech ordering and management hub for the following drugs; adalimumab (Humira®, Amgevita®, Hulio®, Idacio®, and Imraldi®) and etanercept (Enbrel® and Benepali®). Main outcome measure: uptake of the best-value biological medicines. Results In June 2019, just over 90 patients had been initiated on, or switched to a best-value biological for adalimumab or etanercept. Over the next 12 months this increased to over 8500 patients. With the best-value biologicals accounting for approximately 50 % of market share in June 2020, the combined estimated savings and avoided costs are €22.7 million to date. The gain-share prescribing incentive has raised over €3.6 million for the specialties to invest back into patient care. Conclusion Against the background of a finite healthcare budget, this study shows that increasing use of biosimilars can create the financial savings and space to invest in new innovative therapies for the benefit of many patients.

The logistical management of tertiary urethral disease in the United Kingdom: Implications from an online audit of male reconstructive urethral surgery

Objective:

To determine those patient groupings, based on volume and risk, whose optimal urethral reconstructive management might be provided by a reorganisation of UK reconstructive surgeons.

Methods:

Between 2010 and 2017, ~689 men/year were enrolled onto an online audit platform collecting data about urethral reconstruction in the UK; this accrual was compared against hospital episode statistics (HES). The available workforce, and where this was based, was collected. Individual and institutional incumbent patient volumes, pathology, surgical complexity and outcomes from treatment were collated to stratify volume/risk groups.

Results:

More than 90% of all HES-recorded data were accrued, being provided by 50 surgeons at 39 operative sites. Most reconstructive surgery was provided at 10 centres performing >20 procedures/year. More than 50% of all interventions were of a high-volume low-risk type. Of activity, 32.3% was intermediate volume or moderate risk, and 12.5% of men presented for lower-volume or higher-risk procedures.

Conclusion:

Correlation of detailed volume/outcome data allows the definition of patient populations presenting for urethral reconstruction. Stratification of each group’s management, to optimise the surgical outcome, may be applied to a hierarchical service delivery model based on the complexity of the patient’s presenting urethral pathology.

Level of evidence:

Level IV

Tracking clinical trial accrual strategies and barriers via a Web-based screening tool

6586

Background: The National Cancer Institute Community Cancer Centers Program (NCCCP) has developed a web based tracking tool to monitor screening of patients for clinical trial participation. The system is designed to collect data from multiple research sites throughout the geographically diverse group. The log blindly collects patient demographics, successful trial entry, and reasons for trial enrollment failure. Methods: Seven NCCCP sites utilized the log during the 60 day open accrual period for the Wake Forrest WFU 07–02–03 cancer control trial (chronic lymphocytic leukemia COLD- fX) in Novermber 2008 and December 2008. Results: 327 chronic lymphocytic leukemia patients were screened mostly by chart review. 162 (50%) were eligible for study entry. 45 (14%) entered the trial. 103 (31%) eligible patients declined entry. Of the 103, 72 (70%) did not wish to participate in research, 15 (15%) had travel constraints, 5 (5%) perceived excess toxicity, 9 (9%) gave no reason. 14 (3%) eligible had their physician decline entry. Overall, 28% of eligible patients entered the trial. 165 (50%) were trial ineligible. 82 (50%) for prior therapy, 30 (18%) for co morbid conditions, 10 (6%) missed an entry time requirement, 39 (24%) have incomplete data. Conclusions: The NCCCP trial screening log successfully captures real time clinical trial participation data from a diverse network of clinical trial sites. This data base will allow future analysis of individual clinical trial and site accrual barriers and empower strategies to increase trial participation.

No significant financial relationships to disclose.

Pilonidal sinus of the penis

A pilonidal sinus is a subcutaneous sinus containing hair. It is most commonly found in the natal cleft of hirsute men. Here we describe the unusual finding of a pilonidal sinus arising on the male foreskin.

Spontaneous rupture of kidney with peri-renal haematoma: a conservative approach

Images

Contribution of increased length and intact capping sequences to the conformational preference for helix in a 31-residue peptide from the C terminus of myohemerythrin

In order to examine the effects of chain length on the propensity of short peptides to form helix-like structures in aqueous solution, we have studied a peptide of 31 residues consisting of the C-terminal sequence (residues 88-118) of the four-helix bundle protein myohemerythrin from Themiste zostericola. This peptide, termed MDC, represents the final two elements of secondary structure in the protein, the D-helix and the C-terminal loop sequence, together with a five-residue sequence at the N terminus corresponding to the linker between the C- and D-helices. An N-capping sequence, VDAKNV, immediately precedes the D-helix sequence, and a C-capping sequence, VNHIKGT, corresponding to the alphaL termination motif, occurs at the C-terminal end. The effect of replacement of a cysteine residue in the middle of the sequence with an alanine was explored by the comparison of the MDC peptide and a 16-residue peptide representing the sequence of the D-helix alone, both containing the change Cys99Ala. Significant changes in the NMR and CD spectra were seen for both peptides compared to the wild-type sequence. A comparison of the fluorescence spectra of the wild-type and Cys99Ala peptides indicated that a specific interaction between the side chains of Cys 99 and Trp 102 acts to quench the fluorescence of the tryptophan ring and probably contributes a component that distorts the CD spectrum of the wild-type peptide at approximately 220-235 nm. The effect of an increase in the length of the peptide, with the incorporation of capping sequences derived from the native sequence, was explored by NMR and CD spectroscopy of the 31-residue and 16-residue peptides in aqueous solution and in TFE/water mixtures. Evidence for the formation of a significant population of helical conformers in the region of the MDC peptide corresponding to the D-helix was observed in aqueous solution using CD and NMR spectroscopy. The C-terminal 10 residues of the MDC peptide behave in solution in a manner identical to that of a 10-residue peptide with the same sequence; a highly specific local interaction between an aromatic ring and a glycine amide proton appears to be retained in the longer peptide. Upon addition of trifluoroethanol (TFE), significant shifts are observed in a number of resonances in the NMR spectrum, and both chemical shifts and NOEs provide evidence for a higher population of helix in the D-helix region of the peptide in TFE. However, TFE is unable to promote the propagation of helix beyond the N-cap or alphaL termination motifs, and the specific local interaction observed in the C-terminal sequence is retained in TFE. The CD spectrum in TFE shows an increase in the proportion of helix, to an overall maximum of approximately 55% helix at 50% v/v TFE, corresponding to approximately 100% helix in the D-helix sequence of the peptide, since the N and C termini of the MDC peptide are not helical according to the NMR spectra. The high proportion of helix observed in the D-helix sequence of the longer MDC peptide demonstrates that the presence of intact capping sequences can constrain the peptide conformational ensemble to resemble that seen in the native protein. A compendium of results from this and previous peptide studies has also led to a novel observation, the existence of a correlation between the amide proton chemical shift and temperature coefficient.

Modulation of gene expression by calreticulin binding to the glucocorticoid receptor

Calreticulin is a multifunctional protein that acts as a major Ca(2+)-binding (storage) protein in the lumen of the endoplasmic reticulum. It is also found in the nucleus, suggesting that it may have a role in transcription regulation. Calreticulin has been reported to bind to the synthetic peptide KLGFFKR, which is almost identical to an amino-acid sequence in the DNA-binding domain of the superfamily of nuclear receptors. Could calreticulin interact with the DNA-binding domain of these receptors and affect their function? Here we report that the amino terminus of calreticulin interacts with the DNA-binding domain of the glucocorticoid receptor and prevents the receptor from binding to its specific glucocorticoid response element. Overexpression of calreticulin in mouse L fibroblasts inhibits glucocorticoid-response-mediated transcriptional activation of a glucocorticoid-sensitive reporter gene and of the endogenous, glucocorticoid-sensitive gene encoding cytochrome P450. Together these results indicate that calreticulin may be important in gene transcription, regulating the glucocorticoid receptor and perhaps other members of the super-family of nuclear receptors.

Cervical cancer in pregnancy: reporting on planned delay in therapy

OBJECTIVE

To report our experience with invasive carcinoma of the cervix during pregnancy, assessing maternal morbidity due to treatment delay and reporting maternal and fetal outcome.

METHODS

Twenty-seven patients with invasive cervical cancer, who were pregnant at the time of diagnosis or treatment, were identified from review of morbidity and mortality statistics between January 1, 1980 and December 31, 1991. All medical records were examined retrospectively.

RESULTS

The incidence of cervical carcinoma in our population was 1.2 cases per 10,000 pregnancies. Most patients had stage I lesions. The predominant histologic cell type was squamous cell carcinoma, followed by adenosquamous carcinoma and adenocarcinoma. Eight patients with stage Ia or Ib cervical cancer postponed therapy to optimize fetal outcome, with a mean diagnosis-to-treatment interval of 144 days (range 53-212). Nineteen patients elected immediate treatment, with a mean diagnosis-to-treatment interval of 17 days (range 2-42). Fetal outcome was uniformly good for the delayed-treatment group. Nine fetal deaths and two neonatal deaths occurred in the immediate-treatment group. All patients who delayed therapy are free of disease after a median follow-up of 23 months.

CONCLUSION

Deliberate delay of therapy to achieve fetal maturity appears to be a reasonable option for patients with stage I cervical cancer complicating pregnancy.

Transcriptional regulation of two cytotoxic T lymphocyte-specific serine protease genes

The expression of two serine proteases is induced by antigenic stimulation in cytotoxic T lymphocytes. Using nuclear run-on analysis the increase in steady state mRNA level has been shown to correspond to transcriptional activation. However, the two genes appear to be sequentially rather than coordinately induced. Both genes were shown to be more sensitive to DNase I digestion than a beta-globin gene in cytotoxic T cells. In addition, for the cytotoxic cell protease 1 gene the 5' region of the gene was more sensitive than the 3' end. Two DNaseI hypersensitive sites were seen in the 5' flanking sequences of both genes. The DNA sequences of the upstream regions of both genes were determined and compared. Although the two flanking sequences are overall quite dissimilar, there are short regions which are shared between the two CTL-protease genes. A number of these have been implicated in regulating the expression of other T cell genes.

Organization of two genes encoding cytotoxic T lymphocyte-specific serine proteases CCPI and CCPII

The genes encoding two recently described cytotoxic T cell proteases, CCPI and CCPII, have been isolated and sequenced. The organizations of the coding and noncoding portions of the two genes are very similar to each other and also to the gene encoding rat mast cell protease type II. Similarly to other serine protease genes, each of the active-site residues is contained on a separate exon; however, two introns were found in particularly interesting positions. One occurs within the postulated activation dipeptide and the other in a position close to the active-site Asp residue. This latter intron interrupts the amino acid sequence in the invariant core region of the protein. We believe that these genes represent a new subfamily of serine protease genes.

Isolation of two cDNA sequences which encode cytotoxic cell proteases

Two cDNAs which cross-hybridized with cytotoxic cell protease genes were identified in a library generated from a cytotoxic T cell line. Sequence analysis revealed that the two new members of the family contained the three catalytic triad residues which characterize the active sites of serine proteases. A comparison of the protein sequences revealed not only a high degree of homology but also the conservation of some unusual structural features. These include the lack of a disulphide bond which spans the active site serine, the presence of a signal sequence and the inference of a dipeptide activation sequence.

Biochemical evidence for osteomalacia with carbamazepine therapy

Many anticonvulsants are known to cause osteomalacia, however, carbamazepine has not previously been studied in this regard. We studied 31 patients on carbamazepine (mean dose 758 mg +/- s.d. 468 mg per day), as a single drug for epilepsy for a duration of 20.5 +/- 10 months. Three patients (10%) had hypocalcaemia, and serum calcium was significantly lower (P less than 0.01), and serum alkaline phosphatase significantly higher (P less than 0.05) than matched control subjects. Serum phosphorus was significantly inversely correlated and serum alkaline phosphatase was positively correlated with both dose and duration, but not blood levels of carbamazepine. These findings are consistent with mild biochemical changes of osteomalacia. None of the patients were symptomatic. Serum bilirubin (mean 2.6 +/- 1.4 mumol/l) was very significantly lower (P less than 0.01) than in controls. Both the calcium and bilirubin disturbances are probably due to carbamazepine causing hepatic microsomal enzyme induction.

Phenobarbitone in previously untreated epilepsy

In a prospective study we used phenobarbitone to treat 13 new patients with epilepsy (eight adults and five children). Full seizure control was achieved in 11 patients and poor compliance was documented in one of the remaining two patients (in both of whom seizures were reduced by over 50%). Doses sufficient to give mean steady state plasma levels of more than 43 mumol/l (10 microgram/ml) appeared to be associated with better seizure control than lower doses. No serious side effects were observed.

Carbamazepine as a single drug in the treatment of epilepsy. A prospective study of serum levels and seizure control

Serum levels and seizure control were investigated in a prospective study when carbamazepine was given as a single drug to 32 patients with a variety of seizures. The patients included 13 previously untreated patients (group 1), and 19 who were unresponsive to other anticonvulsant drugs used in different combinations or as a single treatment (group 2). Thirteen patients (10 from group 1, and three from group 2) became seizure-free, and a greater than 50% reduction in seizure frequency occurred in 10 patients (nine from group 2, and one from group 1). Less than 50% reduction in seizure frequency occurred in five patients from group 2. As a wide range of serum levels was associated with complete freedom from seizures, or a greater than 50% reduction in seizure frequency, it was not possible to define a therapeutic range for carbamazepine. Side effects occurred at the start of treatment or after a dose increase. A wide range of serum levels was associated with side effects, and some patients could not tolerate levels greater than 42 mumol/l.

The effects of toxic and non-toxic serum phenytoin levels on carbohydrate tolerance and insulin levels

The effect of toxic and non-toxic phenytoin levels on carobhydrate tolerance and insulin levels was studied in 18 patients with epilepsy and 17 control subjects. Toxic levels were defined as a serum level greater than 20 microgram/ml. Toxic levels occurred in 11 patients and nontoxic levels in seven patients. Blood glucose and insulin levels were measured at 30-min intervals for a period of 3 h following the ingestion of 50 g glucose. Blood glucose levels were measured by the ferricyanide method, and serum insulin levels by immunoassay of insulin with insulin antibody precipitate. Serum phenytoin levels were measured by gas liquid chromatography. The insulin profiles were the same for all three groups, but there was a significant delay in reaching peak glucose concentrations in patients with toxic levels of phenytoin. It was therefore confirmed that non-toxic levels of phenytoin do not affect carbohydrate tolerance or insulin levels when phenytoin is used in the routine treatement of epilepsy, and it has also been shown that toxic levels of phenytoin do not affect carbohydrate tolerance when the high levels are detected at an early stage.