Appendiceal cancer masked as inflammatory appendicitis in the elderly, not an uncommon presentation (Surveillance Epidemiology and End Results (SEER)-Medicare Analysis)

BACKGROUND

The misdiagnosis of appendiceal cancer as inflammatory appendicitis is becoming of greater clinical concern because of the rise of nonoperative management especially in the elder population. To quantify this rate of misdiagnosis, we retrospectively reviewed SEER-Medicare data.

METHODS

The SEER-Medicare database was reviewed from 2000 to 2014. We identified patients older than 65 years old who were diagnosed with appendiceal cancer and then cross-referenced them for a diagnosis of inflammatory appendicitis. Demographic data and oncologic stage were collected.

RESULTS

Our results showed that 28.6% of appendiceal cancer patients received an incorrect initial diagnosis of inflammatory appendicitis. Patients older than 75 years of age were more likely to be misdiagnosed than those between ages 65 and 75 (risk ratio [RR]: 0.81; 95% confidence interval: 0.70-0.93; P = .003). We found that 42% of patients within the misdiagnosis group presented with an earlier stage of disease (stage 1 or 2) compared to 26% of those primarily diagnosed with appendiceal cancer (P < .001).

CONCLUSION

A significant proportion of patients older than 65 years old with appendiceal cancer were initially misdiagnosed with acute appendicitis. We suggest caution when considering a nonoperative approach for appendicitis in the elderly and follow-up imaging or an interval appendectomy should be part of the treatment plan.

Who Undergoes Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy for Appendiceal Cancer? An Analysis of the National Cancer Database

BACKGROUND

We sought to identify patterns of care for patients with appendiceal cancer and identify clinical factors associated with patient selection for multimodality treatment, including cytoreductive surgery and perioperative intraperitoneal chemotherapy (CRS/PIC).

MATERIALS AND METHODS

National Cancer Database (NCDB) data from 2004 to 2014 of all diagnoses of appendiceal cancers were examined. We examined treatment modalities, as well as demographic, tumor-specific, and survival data. A multivariate logistic regression analysis was performed to determine the patient cohort most likely to receive CRS/PIC. Kaplan-Meier was used to estimate survival for all treatment groups. Significance was evaluated at P ≤ 0.05.

RESULTS

We analyzed data on 18,055 patients. Nine thousand nine hundred ninety-two (55.3%) were treated with surgery only, 5848 (32.4%) received surgery and systemic chemotherapy, 1393 (7.71%) received CRS/PIC, 520 (2.88%) received chemotherapy alone, and 302 (1.67%) received neither surgery nor chemotherapy. Significant predictors of receiving CRS/PIC included male sex (OR 1.33, 95% CI: 1.11-1.59), white race (OR 2.00, 95% CI 1.40-2.86), non-Hispanic ethnicity (OR 1.92, 95% CI 1.21-3.05), private insurance (OR 1.52, 95% CI 1.26-1.84), and well-differentiated tumors (OR 4.25, CI: 3.39-5.32) (P < 0.05). Treatment with CRS/PIC was associated with a higher 5-year survival for mucinous malignancies, when compared to surgery alone (65.6% versus 62.4%, P < 0.01). Treatment with CRS/PIC was also associated with higher 5-year survival for well-differentiated malignancies, when compared to all other treatment modalities (74.9% versus 65.4%, P < 0.01).

CONCLUSIONS

Patients were more likely to undergo CRS/PIC if they were male, white, privately insured, and with well-differentiated tumors. CRS/PIC was associated with improved survival in patients with mucinous and low-grade tumors.

Small Bowel and Colorectal Carcinoids

Neuroendocrine tumors, or carcinoid tumors, of both the midgut and hindgut are quite rare, but their incidence is increasing. Surgery is the treatment of choice in patients who can tolerate an operation and have operable disease. Options for the treatment of metastatic disease include cytoreductive surgery, somatostatin analogues, interferon α, local liver therapies (hepatic arterial embolization, ablation), chemotherapy, Peptide-Receptor Radionucleotide Radiotherapy, angiogenesis inhibitors, and mammalian target of rapamycin inhibitors.

Age-related differences in gene expression in colorectal cancer (CRC)

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Background: Colorectal cancer (CRC) in young patients is increasing in incidence and is associated with worse outcomes than CRC in older patients. While distinct molecular subtypes of CRC have been recently characterized, it is unclear whether there are molecular differences between the tumors of young and old patients. We sought to identify differences in gene expression of CRC between these two groups. Our discovery analysis identified a gene signature of several differentially expressed RNAs, from which we validated PEG10. The PEG10 gene on chromosome 7q21.3 has been implicated in liver, gallbladder, thyroid, and blood cancers, and is thought to play a role in cancer cell survival and regulation of apoptosis. In hepatocellular carcinoma, increased PEG10 expression has been associated with younger patient age. Methods: RNA sequencing data was obtained from The Cancer Genome Atlas (TCGA) and analyzed for differences in gene expression between patients ≤ 45 years old and those ≥ 65 years old. The identified differentially expressed genes were then validated with qPCR using human CRC tissue from patients ≤ 45 years old and those ≥ 65 years old. Results: RNA sequencing data from patients ≤ 45 years old (n = 29) and patients ≥ 65 years old (n = 299) identified seven genes with increased expression in younger patients: ZNF334 (log2 [fold change] = 2.30), DSC3 (1.78), PEG10 (1.67), CACNA1I (1.54), PKIA (1.33), MAP9 (1.27), and EPHX3 (1.17) (p < 0.07). Validation with qPCR for PEG10 was most promising, and was performed on both young (n = 10, mean age = 39) and old patient samples ( n= 8, mean age = 72). Two cancers (20%) in the young group received radiation treatment and five (50%) received chemotherapy. One cancer (12.5%) in the old group received radiation and two (25%) received chemotherapy. PEG10 had increased expression in the young group with log2 [fold change] = 3.16 (p < 0.02). Conclusions: We have identified a potentially unique gene expression signature for CRC in young patients, which includes PEG10. Functional analysis of PEG10 and other genes is underway using in vitro cell culture, archived human tumor tissue, and mouse tumor models.

Colorectal polyposis and inherited colorectal cancer syndromes

The majority of colorectal cancer (CRC) cases are sporadic, with hereditary factors contributing to approximately 35% of CRC cases. Less than 5% of CRC is associated with a known genetic syndrome. Although adenomatous polyposis syndromes, hamartomatous polyposis syndromes, and those previously classified as non-polyposis CRC syndromes are quite rare, it is important for clinicians to know the characteristics of each syndrome and to understand the differences in cancer risks between the different conditions. This information is very important when treatment and surveillance plans are formulated for each individual patient.

Predictive factors for in-stent late loss and coronary lesion progression in patients with type 2 diabetes mellitus randomized to rosiglitazone or placebo

BACKGROUND

Type 2 diabetics (DM2) are at increased risk for restenosis as well as nonculprit coronary artery lesion (NCCL) progression. Rosiglitazone (RSG) favorably modifies many of the altered biologic processes in DM2, although recent reports have questioned its safety. We conducted a double-blind randomized trial to assess the effects of RSG versus placebo on in-stent late lumen loss (LL) and angiographic progression of NCCL.

METHODS

A total of 65 DM2 were randomized to RSG (4 mg/d) (n = 32) or placebo (n = 33) at the time of stenting and underwent clinical and laboratory analysis at 1 and 4 months and 8-month angiography (n = 46 patients). Rapid angiographic progression (RAP) was defined as > or =20% diameter reduction of preexisting NCCL by quantitative coronary angiography, or a new narrowing > or =30%.

RESULTS

Mean LL in RSG (n = 33 lesions) was not different from that of placebo (0.62 +/- 0.59 vs 0.70 +/- 0.67, P = NS). Seven (13.5%) of 52 NCCLs have RAP in RSG versus 9 (16.1%) of 56 in placebo (P = NS). High-sensitivity C-reactive protein (hs-CRP) was the only predictor of RAP. Patients with a 120-day hs-CRP > or =75th percentile had an OR of 7.35 (95% CI 2.35-23) for RAP versus those below. Although RSG treatment also lowered log (hs-CRP) at 4 months (RSG 0.10 +/- 0.37 vs placebo 0.26 +/- 0.49, P = .06), it did not decrease the likelihood of plaque progression while also raising LDL and N-terminal brain naturetic peptide.

CONCLUSIONS

Rosiglitazone appears not to lower LL or reduce angiographic progression of NCCL in DM2 and had complex effects on markers of cardiac risk.

Counterfactual thinking about actions and failures to act

When people think counterfactually about how a situation could have turned out differently, they mentally undo events in regular ways (e.g., they focus on actions not failures to act). Four experiments examine the recent discovery that the focus on actions in the short term switches to inactions in the long term. The experiments show that this temporal switch occurs only for particular sorts of situations. Experiment 1 showed no temporal pattern to the agency effect when 112 participants judged emotional impact and frequency of "if-only" thoughts from both short- and long-term perspectives for an investment scenario. Experiment 2 showed no temporal pattern when 190 participants considered a college choice scenario with a good outcome. Experiment 3 showed no temporal pattern when 131 participants considered an investment scenario even when the situation for the actor and nonactor was bad from the outset. Experiment 4, with 113 participants, showed a focus on actions even when the investment loss was equal for both the actor and nonactor. The implications of the results are discussed in terms of what is explicitly available in the mental representation of actions and inactions.

Counterfactual thinking about actions and failures to act

When people think counterfactually about how a situation could have turned out differently, they mentally undo events in regular ways (e.g., they focus on actions not failures to act). Four experiments examine the recent discovery that the focus on actions in the short term switches to inactions in the long term. The experiments show that this temporal switch occurs only for particular sorts of situations. Experiment 1 showed no temporal pattern to the agency effect when 112 participants judged emotional impact and frequency of "if-only" thoughts from both short- and long-term perspectives for an investment scenario. Experiment 2 showed no temporal pattern when 190 participants considered a college choice scenario with a good outcome. Experiment 3 showed no temporal pattern when 131 participants considered an investment scenario even when the situation for the actor and nonactor was bad from the outset. Experiment 4, with 113 participants, showed a focus on actions even when the investment loss was equal for both the actor and nonactor. The implications of the results are discussed in terms of what is explicitly available in the mental representation of actions and inactions.

Counterfactual thinking about controllable events

When people think about what might have been, they mentally undo controllable rather than uncontrollable events. We report the results of two experiments in which we examined this controllability effect in counterfactual thinking. The experiments show that the mutability of controllable events is influenced by the perceived appropriateness or inappropriateness of the events. The first experiment shows that people change inappropriate controllable actions more than appropriate controllable ones. The second experiment shows that people mutate inappropriate controllable events whether the outcome is exceptional or normal with respect to intrapersonal habitual norms, and whether the outcome is positive or negative. We discuss the implications for alternative theories of counterfactual thinking.

The temporality effect in counterfactual thinking about what might have been

When people think about what might have been, they undo an outcome by changing events in regular ways. Suppose two contestants could win 1,000 Pounds if they picked the same color card; the first picks black, the second red, and they lose. The temporality effect refers to the tendency to think they would have won if the second player had picked black. Individuals also think that the second player will experience more guilt and be blamed more by the first. We report the results of five experiments that examine the nature of this effect. The first three experiments examine the temporality effect in scenarios in which the game is stopped after the first contestant's card selection because of a technical hitch, and then is restarted. When the first player picks a different card, the temporality effect is eliminated, for scenarios based on implicit and explicit negation and for good outcomes. When the first player picks the same card, the temporality effect occurs in each of these situations. The second two experiments show that it depends on the order of events in the world, not their descriptive order. It occurs for scenarios without preconceptions about normal descriptive order; it occurs whether the second event is mentioned in second place or first. The results are consistent with the idea that the temporality effect arises because the first event is presupposed and so it is immutable; and the elimination of the temporality effect arises because the availability of a counterfactual alternative to the first event creates an opposing tendency to mutate it. We sketch a putative account of these effects based on characteristics of the mental models people construct when they think counterfactually.

Deductive reasoning with factual, possible, and counterfactual conditionals

We compared reasoners' inferences from conditionals based on possibilities in the present or the past (e.g., "If Linda had been in Dublin then Cathy would have been in Galway") with their inferences based on facts in the present or the past (e.g., "If Linda was in Dublin then Cathy was in Galway"). We propose that people construct a richer representation of conditionals that deal with possibilities rather than facts: Their models make explicit not only the suppositional case, in which Linda is in Dublin and Cathy is in Galway, but also the presupposed case, in which Linda is not in Dublin and Cathy is not in Galway. We report the results of four experiments that corroborate this model theory. The experiments show that reasoners make more inferences from conditionals based on possibilities rather than on facts when the inferences depend on the presupposed case. The results also show that reasoners generate different situations to verify and falsify conditionals based on possibilities and facts.

Reasoning strategies for suppositional deductions

Deductive reasoning shares with other forms of thinking a reliance on strategies, as shown by the results of three experiments on the nature and development of control strategies to solve suppositional deductions. These puzzles are based on assertors who may or may not be telling the truth, and their assertions about their status as truthtellers and liars. The first experiment shows that reasoners make backward inferences as well as forward inferences, to short-cut their way through the alternatives, and the generation of suppositions is a source of difficulty. The second experiment establishes that the elimination of the suppositional status of an individual does not render problems easier. The third experiment shows that reasoners can improve their reasoning accuracy and speed spontaneously, without feedback, and it clarifies the transfer of strategies and their development. We discuss the implications of these data for alternative theories of suppositional deduction and for the relationship between reasoning and other forms of thinking such as problem solving.

Modal reasoning, models, and Manktelow and Over

Manktelow and Over (1991) argue that their studies of Wason's selection task favor explanations of deontic reasoning based on mental models, but that such theories need to incorporate utilities. This theoretical note proposes a simpler explanation of the phenomena: subjects in the selection task consider only those cards that are explicitly represented in their models of the conditional, and so insight into the task depends on constructing fully explicit models. Such models for modal conditionals of the form, If p occurs then q may occur are: [formula: see text] Each line denotes a separate model, and the models represent either what is possible, or, in the deontic interpretation, what is permissible. A deontic rule is accordingly violated by the contingency: [symbol: see text] p and q, for example the rule, "If you spend more than 100 pounds, then you may take a free gift" is violated by taking the free gift (q) but not spending more than 100 pounds ([symbol: see text] p). If the rule is interpreted as a bi-conditional, then the second of the models, p and [symbol: see text] q, is also now a violation, for example spending more than 100 pounds (p) but not getting the free gift ([symbol: see text] q). Manktelow and Over's instructions lead subjects to focus on one or other of the two sorts of violations of the rule. There is accordingly no need to introduce utilities into models in order to explain the phenomena.

Propositional reasoning by model

This article describes a new theory of propositional reasoning, that is, deductions depending on if, or, and, and not. The theory proposes that reasoning is a semantic process based on mental models. It assumes that people are able to maintain models of only a limited number of alternative states of affairs, and they accordingly use models representing as much information as possible in an implicit way. They represent a disjunctive proposition, such as "There is a circle or there is a triangle," by imagining initially 2 alternative possibilities: one in which there is a circle and the other in which there is a triangle. This representation can, if necessary, be fleshed out to yield an explicit representation of an exclusive or an inclusive disjunction. The theory elucidates all the robust phenomena of propositional reasoning. It also makes several novel predictions, which were corroborated by the results of 4 experiments.

Suppressing valid inferences with conditionals

Three experiments are reported which show that in certain contexts subjects reject instances of the valid modus ponens and modus tollens inference form in conditional arguments. For example, when a conditional premise, such as: If she meets her friend then she will go to a play, is accompanied by a conditional containing an additional requirement: If she has enough money then she will go to a play, subjects reject the inference from the categorical premise: She meets her friend, to the conclusion: She will go to a play. Other contexts suppress the conditional fallacies. The first experiment demonstrates the effects of context on conditional reasoning. The second experiment shows that the inference suppression disappears when the categorical premise refers to both of the antecedents, such as: She meets her friend and she has enough money. In this case, subjects make both the valid inferences and the fallacies, regardless of the contextual information. The third experiment establishes that when subjects are given general information about the duration of a situation in which a conditional inducement was uttered, such as: If you shout then I will shoot you, they reject both the valid inferences and the fallacies. The results suggest that the interpretation of premises plays an even more central role in reasoning than has previously been admitted.