Prehabilitation Programs Improve Exercise Capacity Before and After Surgery in Gastrointestinal Cancer Surgery Patients: A Meta-Analysis

INTRODUCTION

Prehabilitation programs or interventions are employed prior to surgery with the aim to optimize the patient before surgery and to improve their physiologic ability to recover from surgery. Components of these programs often include exercise, nutritional supplementation, and psychological interventions. This meta-analysis examines the impact of prehabilitation programs on both surgical and patient outcomes among gastrointestinal (GI) cancer patients undergoing surgery.

METHODS

A comprehensive literature search was conducted to identify all published randomized control trials (RCT) evaluating the use of prehabilitation programs (with one or more interventions) in GI cancer surgery patients. Outcomes assessed were 6-min walk distance (6MWD), postoperative complications, major complications (as defined as Clavien Dindo grade ≥ 3), surgical site infections (SSI), pneumonia, length of stay (LOS), 30-day readmission, and mortality.

RESULTS

Eleven RCTs including 929 patients (475 prehabilitation program and 454 controls) were analyzed. Prehabilitation programs were associated with statistically significant improvements in 6MWD between baseline and immediately prior to surgery (MD = 32.542 m; 95% CI, 10.774-54.310; p = 0.003) and 4-8 weeks after surgery (MD = 48.220 m; 95% CI, 1.532-94.908; p = 0.043) compared with patients who did not receive prehabilitation programs. Similar rates of postoperative complications, major complications, SSI, pneumonia, 30-day readmission, and mortality, as well as LOS, were observed (p > 0.05).

CONCLUSIONS

Prehabilitation programs improve exercise capacity both before and after surgery, with no significant difference in LOS, or rates of postoperative complications, 30-day readmission, and mortality. Future studies assessing the different components of prehabilitation programs to identify the most beneficial interventions are required.

Determining 30-day readmission risk for heart failure patients: the Readmission After Heart Failure scale

Background

Chronic heart failure (CHF), which affects >5 million Americans, accounts for >1 million hospitalizations annually. As a part of the Hospital Readmission Reduction Program, the Affordable Care Act requires that the Centers for Medicare and Medicaid Services reduce payments to hospitals with excess readmissions. This study sought to develop a scale that reliably predicts readmission rates among patients with CHF.

Methods

The State Inpatient Database (2006–2011) was utilized, and discharge data including demographic and clinical characteristics on 642,448 patients with CHF from California and New York (derivation cohort) and 365,359 patients with CHF from Florida and Washington (validation cohort) were extracted. The Readmission After Heart Failure (RAHF) scale was developed to predict readmission risk.

Results

The 30-day readmission rates were 9.42 and 9.17% (derivation and validation cohorts, respectively). Age <65 years, male gender, first income quartile, African American race, race other than African American or Caucasian, Medicare, Medicaid, self-pay/no insurance, drug abuse, renal failure, chronic pulmonary disorder, diabetes, depression, and fluid and electrolyte disorder were associated with higher readmission risk after hospitalization for CHF. The RAHF scale was created and explained the 95% of readmission variability within the validation cohort. The RAHF scale was then used to define the following three levels of risk for readmission: low (RAHF score <12; 7.58% readmission rate), moderate (RAHF score 12–15; 9.78% readmission rate), and high (RAHF score >15; 12.04% readmission rate). The relative risk of readmission was 1.67 for the high-risk group compared with the low-risk group.

Conclusion

The RAHF scale reliably predicts a patient’s 30-day CHF readmission risk based on demographic and clinical factors present upon initial admission. By risk-stratifying patients, using models such as the RAHF scale, strategies tailored to each patient can be implemented to improve patient outcomes and reduce health care costs.

Preoperative intravenous ibuprofen does not influence postoperative narcotic use in patients undergoing elective hernia repair: a randomized, double-blind, placebo controlled prospective trial

Introduction

Inguinal and umbilical hernia repairs are among the most common surgical procedures performed in the US. Optimal perioperative pain control regimens remain challenging and opioid analgesics are commonly used. Preoperative nonsteroidal anti-inflammatory drug (NSAID) administration has been shown to reduce postoperative narcotic requirements. This study sought to evaluate the efficacy of perioperative intravenous (IV) ibuprofen on postoperative pain level and narcotic use in patients undergoing open or laparoscopic inguinal and/or umbilical hernia repair.

Methods

A single center, randomized, double-blind placebo-controlled trial involving patients ≥18 years undergoing inguinal and/or umbilical hernia repair was performed. Patients were randomized to receive 800 mg of IV ibuprofen or placebo preoperatively. Outcomes assessed included postoperative pain medication required and visual analog scale (VAS) pain scores.

Results

Forty-eight adult male patients underwent inguinal and/or umbilical hernia repair. Patients receiving IV ibuprofen used more oxycodone/acetaminophen (32% vs 13%) and IV hydromorphone (12% vs 8.7%), and fewer combinations of pain medications (44% vs 65.2%) in the first two postoperative hours compared to placebo (p=0.556). The IV ibuprofen group had more patients pain free (28% vs 8.7%, p=0.087) and lower VAS scores (3.08±2.14 vs 3.95±1.54, p=0.134) at 2 hours postoperatively, compared to the placebo group, however, this was not statistically significant. Similar pain levels at 1, 3, and 7 days, postoperative and similar use of rescue medications in both groups were observed.

Conclusion

Preoperative administration of IV ibuprofen did not significantly reduce postoperative pain among patients undergoing elective hernia repair. Considerable variability in postoperative narcotic analgesic requirement was noted, and larger scale studies are needed to better understand the narcotic analgesic requirements associated with IV ibuprofen in inguinal/umbilical hernia repair patients.

Readmission After COPD Exacerbation Scale: determining 30-day readmission risk for COPD patients

BACKGROUND

COPD affects over 13 million Americans, and accounts for over half a million hospitalizations annually. The Hospital Readmission Reduction Program, established by the Affordable Care Act requires the Centers for Medicare and Medicaid Services to reduce payments to hospitals with excess readmissions for COPD as of 2015. This study sought to develop a predictive readmission scale to identify COPD patients at higher readmission risk.

METHODS

Demographic and clinical data on 339,389 patients from New York and California (derivation cohort) and 258,113 patients from Washington and Florida (validation cohort) were abstracted from the State Inpatient Database (2006-2011), and the Readmission After COPD Exacerbation (RACE) Scale was developed to predict 30-day readmission risk.

RESULTS

Thirty-day COPD readmission rates were 7.54% for the derivation cohort and 6.70% for the validation cohort. Factors including age 40-65 years (odds ratio [OR] 1.17; 95% CI, 1.12-1.21), male gender (OR 1.16; 95% CI, 1.13-1.19), African American (OR 1.11; 95% CI, 1.06-1.16), 1st income quartile (OR 1.10; 95% CI, 1.06-1.15), 2nd income quartile (OR 1.06; 95% CI, 1.02-1.10), Medicaid insured (OR 1.83; 95% CI, 1.73-1.93), Medicare insured (OR 1.45; 95% CI, 1.38-1.52), anemia (OR 1.05; 95% CI, 1.02-1.09), congestive heart failure (OR 1.06; 95% CI, 1.02-1.09), depression (OR 1.18; 95% CI, 1.14-1.23), drug abuse (OR 1.17; 95% CI, 1.09-1.25), and psychoses (OR 1.19; 95% CI, 1.13-1.25) were independently associated with increased readmission rates, P<0.01. When the devised RACE scale was applied to both cohorts together, it explained 92.3% of readmission variability.

CONCLUSION

The RACE Scale reliably predicts an individual patient's 30-day COPD readmission risk based on specific factors present at initial admission. By identifying these patients at high risk of readmission with the RACE Scale, patient-specific readmission-reduction strategies can be implemented to improve patient care as well as reduce readmissions and health care expenditures.

Oligodendrogliomas in pediatric and adult patients: an outcome-based study from the Surveillance, Epidemiology, and End Result database

Introduction

Oligodendrogliomas (OGs) account for <20% of all intracranial tumors and 25% of gliomas. Despite improvements in imaging techniques allowing for earlier diagnosis, OG is rare among the pediatric population. This study examines a large cohort of OG patients in an effort to define the demographic, clinical, and pathologic factors associated with clinical and survival outcomes.

Methods

Data on 7,001 OG patients were abstracted from the Surveillance, Epidemiology, and End Result (SEER) database (1973–2013). Pediatric patients were defined as ≤19 years old, and adult patients were defined as age ≥20 years.

Results

Among 7,001 OG patients, 6.5% were pediatric (mean age 12 ± 6 years), and 93.5% were adult (mean age 46 ± 15 years). Overall, OGs were more common among males, with a male-to-female ratio of 1.28:1. Overall, OGs were more common among Caucasians (76.9%) and also among the African American (10.8% pediatric vs. 4.0% adult) and Hispanic (12.8% pediatric vs. 11.8% adult). OGs occurred most commonly in the temporal lobe of pediatric patients and the frontal lobes of adults. Surgical resection was the primary treatment modality for both pediatric and adult populations (70.6% and 40.5%), followed by combined surgery and radiation (19.7% and 41.2%). Surgical resection was associated with significantly improved survival in both groups. Pediatric patients had a lower overall mortality (19.8% vs. 48.5%) and lower cancer-specific mortality (17.6% vs. 36.8%).

Conclusion

OGs most often present in Caucasian males in their fifth decade of life with tumors >4 cm in size. Children typically present with tumors in the temporal lobe, while adults present with tumors in the frontal lobe. Surgical resection confers a survival advantage among all patients, especially pediatric patients. Overall survival (OS) and cancer-specific survival are higher in the pediatric population. Further studies on novel treatment techniques, including bevacizumab and immunotherapy approaches, are required.

Disease Severity, Presentation, and Clinical Outcomes Among Adolescents With Malignant Breast Neoplasms: A 20-Year Population-Based Outcomes Study From the SEER Database (1973-2009)

INTRODUCTION

Primary breast cancer in adolescents is extremely rare and thus is not widely studied. This study aimed to evaluate trends, characteristics, and outcomes among a cohort of adolescents with breast cancer.

PATIENTS AND METHODS

A total of 657,712 female patients with breast cancer from Surveillance Epidemiology and End Results (SEER) database (1973-2009) were analyzed, and 91 adolescents were identified. Three age groups (under 20 years, 20-50 years or premenopausal, and > 50 years or postmenopausal) were compared for tumor size, stage, receptor status, and outcomes. Categorical data were compared by chi-square (Fisher) test and continuous data with Student's t test.

RESULTS

Median age was 19 years (range, 10-20 years). A total of 52.7% (n = 48) and 5.5% (n = 5) of patients presented with invasive and in-situ cancers, respectively, and 37.3% (n = 34) with sarcomas. Median tumor size of invasive cancers was 3.2 cm (range, 0.1-12.5 cm). Sixty percent of patients presented with regional disease, and the majority (28%) of those tested were receptor negative. Mortality rates in adolescents were higher than pre- and postmenopausal patients in localized and regional stage. Overall median survival was 106 months.

CONCLUSION

Although rare, breast cancer does occur in adolescent girls and must be considered in differential of breast masses in females under 20, especially with strong breast cancer family history. Prognosis maybe worse than in older patients; however, the sample size is small. Delay in diagnosis, aggressive tumor biology, and negative receptor status may affect prognosis. Routine breast examination in high-risk older adolescents may permit early identification and avoid delay in diagnosis and treatment.

Malignant Melanoma in African-Americans: A Population-Based Clinical Outcomes Study Involving 1106 African-American Patients from the Surveillance, Epidemiology, and End Result (SEER) Database (1988-2011)

Malignant melanoma accounts for 75% of all skin cancer deaths and is potentially curable if identified early. Although melanoma is rare in African-Americans (AA), it is associated with a worse prognosis than in Caucasians. This study examines the demographic, pathologic, and clinical factors impacting AA melanoma outcomes.Data for 1106 AA and 212,721 Caucasian cutaneous melanoma patients were abstracted from the Surveillance, Epidemiology, and End Result (SEER) database (1988-2011). Data were grouped on the basis of histological subtypes: "Superficial Spreading" (SS), "Nodular" (NM), "Lentigo Maligna" (LM), "Acral Lentiginous" (AL), and "Not otherwise specified" (NOS).Cutaneous malignant melanoma occurs most commonly in the sixth and seventh decade of life. Caucasian patients presented most commonly with trunk melanomas (34.5%), while lower extremity melanomas were more common in AAs (56.1%), P < 0.001. AAs presented with deeper tumors, more advanced stage of disease, and higher rates of ulceration and lymph node positivity than Caucasians. Cancer-specific mortality was significantly higher, while 5-year cancer-specific survival was significantly lower among AAs for NM and AL subtypes. Multivariate analysis identified male gender, regional and distant stage, NM and AL subtypes as independently associated with increased mortality among both ethnic groups.AAs present most often with AL melanoma on the lower extremities, and with deeper and more advanced stage lesions. AAs have higher cancer-specific mortality for NM and LM than Caucasians. Melanoma education for AA patients and health care providers is needed to increase disease awareness, facilitate early detection, and promote access to effective treatment.

Less Invasive Surfactant Administration Reduces the Need for Mechanical Ventilation in Preterm Infants: A Meta-Analysis

Neonatal respiratory distress syndrome due to surfactant deficiency is associated with high morbidity and mortality in preterm infants, and the use of less invasive surfactant administration (LISA) has been increasingly studied. This meta-analysis found that LISA via thin catheter significantly reduced the need for mechanical ventilation within the first 72 hours (relative risk [RR] = 0.677; P = .021), duration of mechanical ventilation (difference in means [MD] = −39.302 hours; P < .001), duration of supplemental oxygen (MD = −68.874 hours; P < .001), and duration of nasal continuous positive airway pressure (nCPAP; MD = −28.423 hours; P = .010). A trend toward a reduction in the incidence of bronchopulmonary dysplasia was observed (RR = 0.656; P = .141). No significant difference in overall mortality, incidence of pneumothorax, or successful first attempts was observed. LISA via thin catheter significantly reduces the need for mechanical ventilation within the first 72 hours as well as the duration of mechanical ventilation, supplemental oxygen, and nCPAP. LISA via thin catheter appears promising in improving preterm infant outcomes.

Ocular melanoma-when you have seen one, you have not seen them all: a clinical outcome study from the Surveillance, Epidemiology and End Results (SEER) database (1973-2012)

BACKGROUND

Ocular melanoma (OM) comprises <5% of all melanomas. Uveal melanoma (UM) is the most common subtype of OM, while conjunctival melanoma (CM) is rare and differs significantly from UM. The purpose of this study is to evaluate a large cohort of OM patients to differentiate demographic, pathologic, and clinical factors between these two neoplasms, which may affect treatment and outcomes.

METHODS

The Surveillance, Epidemiology, and End Results database (1973-2012) was used to extract demographic and clinical data on 8,165 OM patients (92.1% UM and 7.9% CM).

RESULTS

Both CM and UM were most prevalent among Caucasian males in the seventh decade of life. UM patients presented more often with localized disease (90.9% vs 81.2, P<0.01). Surgery (42.8%), radiation (43.0%), or combined surgery and radiation (7.0%) were used in the treatment of UM, while CM was treated almost exclusively with surgery (88.7%). Mean overall survival was longer (15.4 vs 14.6 years; P<0.01) and mortality rates were lower in patients (38.8% vs 46.1%; P<0.01) with CM.

CONCLUSION

Despite presenting with more advanced disease than UM, CM is associated with an increased overall survival. Surgery is the primary therapy for CM, whereas radiotherapy is the primary therapy for UM and is associated with prolonged survival.

Probiotics improve the efficacy of standard triple therapy in the eradication of Helicobacter pylori: a meta-analysis

Introduction

Helicobacter pylori colonization is present in half of the world’s population and can lead to numerous gastrointestinal diseases if left untreated, including peptic ulcer disease and gastric cancer. Although concurrent triple therapy remains the recommended treatment regimen for H. pylori eradication, its success rate and efficacy have been declining. Recent studies have shown that the addition of probiotics can significantly increase eradication rates by up to 50%. This meta-analysis examines the impact of probiotic supplementation on the efficacy of standard triple therapy in eradicating H. pylori.

Methods

A comprehensive literature search was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (time of inception to 2016) to identify all published randomized control trials (RCTs) assessing the use of probiotics in addition to triple therapy for the treatment of H. pylori. Searches were conducted using the keywords “probiotics”, “triple therapy”, and “Helicobacter pylori”. RCTs comparing the use of probiotics and standard triple therapy with standard triple therapy alone for any duration in patients of any age diagnosed with H. pylori infection were included. H. pylori eradication rates (detected using urea breath test or stool antigen) were analyzed as-per-protocol (APP) and intention-to-treat (ITT).

Results

A total of 30 RCTs involving 4,302 patients APP and 4,515 patients ITT were analyzed. The addition of probiotics significantly increased eradication rates by 12.2% (relative risk [RR] =1.122; 95% confidence interval [CI], 1.091–1.153; P<0.001) APP and 14.1% (RR =1.141; 95% CI, 1.106–1.175; P<0.001) ITT. Probiotics were beneficial among children and adults, as well as Asians and non-Asians. No significant difference was observed in efficacy between the various types of probiotics. The risk of diarrhea, nausea, vomiting, and epigastric pain was also reduced.

Conclusion

The addition of probiotics is associated with improved H. pylori eradication rates in both children and adults, as well as Asians and non-Asians. Lactobacillus, Bifidobacterium, Saccharomyces, and mixtures of probiotics appear beneficial in H. pylori eradication. Furthermore, the reduction in antibiotic-associated side effects such as nausea, vomiting, diarrhea, and epigastric pain improves medication tolerance and patient compliance. Given the consequences associated with chronic H. pylori infection, the addition of probiotics to the concurrent triple therapy regimen should be considered in all patients with H. pylori infection. However, further studies are required to identify the optimal probiotic species and dose.

Trends in incidence, survival, and management of uveal melanoma: a population-based study of 7,516 patients from the Surveillance, Epidemiology, and End Results database (1973-2012)

Introduction

Uveal melanoma (UM) is the most common primary intraocular malignancy, despite comprising <5% of all melanomas. To date, relatively few case series of UM have been published. Moreover, the factors influencing survival remain largely unknown. This study sought to analyze the impact of demographics, histology, clinical presentation, and treatments on the clinical outcomes of UM in a large modern nationwide patient cohort.

Methods

Demographics and clinical data were abstracted on 277,120 histologically confirmed melanoma patients from the Surveillance, Epidemiology, and End Results database between 1973 and 2012.

Results

A total of 7,516 cases of UM represented 3.2% of all recorded cases of melanoma. The mean age-adjusted incidence was 5.1 per million (95% CI 4.2–6.1) and was higher in males (5.9, CI =4.4–7.6) compared to females (4.5, CI =3.3–5.8), P<0.001. UM occurred most commonly in the sixth decade of life (61.4±15) and among Caucasians (94.7%). A total of 52.3% of cases were reported in the Western US (35.7% in California). The initial diagnoses in 65.2% of cases were by histopathology, followed by clinical diagnosis (18.8%) and radiographic imaging (16.0%). The percentage of UM cases managed by surgery alone decreased by 69.4% between the 1973–1977 and 2006–2012 time periods, concomitant with a 62% increase in primary radiotherapy, P<0.001. The UM mean overall and cancer-specific 5-year relative survival rates were 79.8%±5.8% and 76%±5.3%, respectively. The mean 5-year cancer-specific survival rate (76%) remained stable during the study period between 1973 and 2012. The mean survival for patients treated with primary radiotherapy was significantly improved compared to those treated with surgery alone (15.4±0.4 vs 13.6±0.3, P<0.001). Multivariate analysis identified male sex (odds ratio [OR] 1.1, CI =1.0–1.3), age >50 years (OR 4.0, CI =3.4–4.6), distant metastases (OR 8.6, CI =4.7–15), and primary surgical treatment (OR 2.6, CI =2.0–3.3) as independently associated with increased mortality, P<0.005. Conversely, patients identified as Hispanic (OR 0.6, CI =0.5–0.8) and patients receiving radiation treatment (OR 0.5, CI =0.4–0.7) were independently associated with reduced mortality, P<0.005.

Conclusion

UM remains a rare form of melanoma that occurs primarily in Caucasian patients older than 50 years. More than two-thirds of UM patients are curatively treated with primary radiotherapy as opposed to surgery, which has resulted in a significant improvement in both overall survival and cancer-specific survival. Despite this shift in management strategy, the mean 5-year cancer-specific survival rate remained relatively unchanged during the study period. Male sex, older age, distant disease, and primary surgical therapy rather than radiotherapy are associated with an increased risk of mortality.

Use of preoperative gabapentin significantly reduces postoperative opioid consumption: a meta-analysis

OBJECTIVES

Effective postoperative pain management is crucial in the care of surgical patients. Opioids, which are commonly used in managing postoperative pain, have a potential for tolerance and addiction, along with sedating side effects. Gabapentin's use as a multimodal analgesic regimen to treat neuropathic pain has been documented as having favorable side effects. This meta-analysis examined the use of preoperative gabapentin and its impact on postoperative opioid consumption.

MATERIALS AND METHODS

A comprehensive literature search was conducted to identify randomized control trials that evaluated preoperative gabapentin on postoperative opioid consumption. The outcomes of interest were cumulative opioid consumption following the surgery and the incidence of vomiting, somnolence, and nausea.

RESULTS

A total of 1,793 patients involved in 17 randomized control trials formed the final analysis for this study. Postoperative opioid consumption was reduced when using gabapentin within the initial 24 hours following surgery (standard mean difference -1.35, 95% confidence interval [CI]: -1.96 to -0.73; P<0.001). There was a significant reduction in morphine, fentanyl, and tramadol consumption (P<0.05). While a significant increase in postoperative somnolence incidence was observed (relative risk 1.30, 95% CI: 1.10-1.54, P<0.05), there were no significant effects on postoperative vomiting and nausea.

CONCLUSION

The administration of preoperative gabapentin reduced the consumption of opioids during the initial 24 hours following surgery. The reduction in postoperative opioids with preoperative gabapentin increased postoperative somnolence, but no significant differences were observed in nausea and vomiting incidences. The results from this study demonstrate that gabapentin is more beneficial in mastectomy and spinal, abdominal, and thyroid surgeries. Gabapentin is an effective analgesic adjunct, and clinicians should consider its use in multimodal treatment plans among patients undergoing elective surgery.

Sequential (as Opposed to Simultaneous) Antibiotic Therapy Improves Helicobacter pylori Eradication in the Pediatric Population: A Meta-Analysis

Helicobacter pylori is a common infection associated with many gastrointestinal diseases. Triple or quadruple therapy is the current recommendation for H pylori eradication in children but is associated with success rates as low as 50%. Recent studies have demonstrated that a 10-day sequential therapy regimen, rather than simultaneous antibiotic administration, achieved eradication rates of nearly 95%. This meta-analysis found that sequential therapy increased eradication rates by 14.2% (relative risk [RR] = 1.142; 95% confidence interval [CI] = 1.082-1.207; P < .001). Ten-day sequential therapy significantly improved H pylori eradication rates compared to the 7-day standard therapy (RR = 1.182; 95% CI = 1.102-1.269; p < .001) and 10-day standard therapy (RR = 1.179; 95% CI = 1.074-1.295; P = .001), but had lower eradication rates compared to 14-day standard therapy (RR = 0.926; 95% CI = 0.811-1.059; P = .261). The use of sequential therapy is associated with increased H pylori eradication rates in children compared to standard therapy of equal or shorter duration.

Risk of Metabolic Complications in Patients with Solid Tumors Treated with mTOR inhibitors: Meta-analysis

BACKGROUND/AIM

Numerous trials have described a wide variation of metabolic complications associated with the mammalian target of rapamycin inhibitors (mTORi). This analysis aimed to report and critically analyze the risks of mTORi-associated metabolic complications.

MATERIALS AND METHODS

A comprehensive search of all published phase II or III randomized controlled trials were investigated. Outcomes included were adverse effect profiles of hyperglycemia (HGC), hypertriglyceridemia (HTG), and hypercholesterolemia (HCE).

RESULTS

Sixteen phase II/III clinical trials were identified. The overall incidence of all-grade (AG) and high-grade (HG) metabolic complications associated with mTORi were 39.7% and 4.1% respectively. mTORi use was associated with an increased risk of AG (2.97 [2.25-3.92]) and HG HGC (4.08 [2.71-6.14]), AG (2.22 [1.70-2.89]) and HG HTG (1.88 [1.10-3.20]), and AG (2.48 [1.83-3.36]) and HG HCE (4.26 [2.30-7.90]).

CONCLUSION

mTORi are associated with a significantly increased risk of AG and HG HGC, HTG, and HCE. Clinicians should be aware of these risks, perform regular monitoring, and consider alternative anti-neoplastic treatments or adjunctive pharmacological intervention if necessary.

Probiotics are effective at preventing Clostridium difficile-associated diarrhea: a systematic review and meta-analysis

INTRODUCTION

Clostridium difficile infection (CDI) is the leading cause of antibiotic-associated diarrhea. CDI has increased in incidence and severity over the past decade, and is a growing worldwide health problem associated with substantial health care costs and significant morbidity and mortality. This meta-analysis examines the impact of probiotics on the incidence of Clostridium difficile-associated diarrhea (CDAD) among children and adults, in both hospital and outpatient settings.

METHODS

A comprehensive literature search of all published randomized control trials (RCTs) assessing the use of probiotics in the prevention of CDAD in patients receiving antibiotic therapy was conducted, and the incidence of CDAD was analyzed.

RESULTS

Twenty-six RCTs involving 7,957 patients were analyzed. Probiotic use significantly reduced the risk of developing CDAD by 60.5% (relative risk [RR] =0.395; 95% confidence interval [CI], 0.294-0.531; P<0.001). Probiotics proved beneficial in both adults and children (59.5% and 65.9% reduction), especially among hospitalized patients. Lactobacillus, Saccharomyces, and a mixture of probiotics were all beneficial in reducing the risk of developing CDAD (63.7%, 58.5%, and 58.2% reduction).

CONCLUSION

Probiotic supplementation is associated with a significant reduction in the risk of developing CDAD in patients receiving antibiotics. Additional studies are required to determine the optimal dose and strain of probiotic.

Pediatric Chordomas: A Population-Based Clinical Outcome Study Involving 86 Patients from the Surveillance, Epidemiology, and End Result (SEER) Database (1973-2011)

BACKGROUND/AIMS

Primary chordomas, rare cancers arising from the notochord remnants, are extremely rare in the pediatric population. This study examined a large cohort of primary chordoma patients to determine factors impacting prognosis and survival.

METHODS

Demographic and clinical data on 1,358 primary chordoma patients (86 pediatric patients ≤19 years of age and 1,272 adult patients ≥20 years of age) were abstracted from the Surveillance, Epidemiology, and End Result (SEER) database (1973-2011).

RESULTS

Pediatric primary chordomas present most often as small tumors <4 cm in the cranium of male Caucasians. Despite the majority of primary chordomas presenting with locoregional involvement (90.4%), pediatric patients had more distant disease (14.8 vs. 9.2%, p < 0.05). Survival among pediatric patients having surgery only was significantly longer than for adults (22.5 vs. 14.3 years, p < 0.001). Overall survival was longer (17.2 vs. 12.6 years) and overall mortality was lower in pediatric patients (38.4 vs. 49.8%), but cancer-specific mortality was higher (37.2 vs. 28.6%, p < 0.005).

CONCLUSIONS

Pediatric primary chordomas present most often as small tumors <4 cm in the cranium of male Caucasians. Despite having a higher rate of metastasis, they have prolonged survival compared to adults. Surgical resection significantly improves survival in pediatric primary chordoma patients, and should be considered as first-line therapy in all eligible children.

Atypical teratoid rhabdoid tumors: a population-based clinical outcomes study involving 174 patients from the Surveillance, Epidemiology, and End Results database (1973-2010)

Introduction

Atypical teratoid rhabdoid tumors (ATRTs) are rare, highly malignant embryonal tumors of the central nervous system (CNS) accounting for 20% of CNS tumors in children under the age of 3. This study examines a large cohort of ATRT patients to determine demographic, clinical, and pathologic factors which impact prognosis and survival.

Methods

Demographic and clinical data were abstracted on 174 ATRT patients (171 pediatric patients age <20 and 3 adult patients age ≥20) from the Surveillance, Epidemiology, and End Results database (1973–2010). Standard statistical methodology was used.

Results

A total of 174 ATRT cases (mean age of 2.84 years) were identified. ATRT had a higher incidence in males (56.3%), Caucasians (59.1%), and children <3 years of age (80.5%), P<0.001. The most common primary sites were the cerebellum (17.8%), ventricles (16.1%), and frontal lobe (12.6%). Mean overall survival was 3.2±0.4 years, while overall and cancer-specific mortality were 63.2% and 56.3%, respectively, P=0.005. Most ATRT cases were treated with surgery alone (58.0%), followed by a combination of surgery and radiation (34.3%), no treatment (6.5%), and radiation alone (1.2%). The use of combination therapy has increased significantly (16.1%) since 2005 (P<0.001), while primary surgical resection and radiation therapy rates remain relatively unchanged. The longest survival was observed among ATRT patients receiving combination therapy (5.9±0.7 years), followed by radiation alone (2.8±1.2 years), and surgery alone (1.9±0.4 years), P<0.001. Multivariable analysis identified only distant metastases (OR =4.6) as independently associated with increased mortality, whereas combination therapy (OR =0.4) was associated with reduced mortality, P<0.005.

Conclusion

ATRT is a rare and highly aggressive embryonal malignancy of the CNS that presents more often as locoregional tumors >4 cm in male Caucasian children of age <3 years, involving the cerebellum, ventricles, or frontal lobe. Combination therapy significantly improves survival, and its use has been increasing since 2005.

The changing management of chylothorax in the modern era

Initial conservative therapy is applied to all cases of chylothorax (CTx) with expected excellent outcomes. The indication for aggressive surgical treatment of early CTx remains uncertain and requires rigorous scientific scrutiny. Lymphangiography and lymphoscintigraphy are useful to localize the leak and assess thoracic duct patency as well as to differentiate partial from complete thoracic duct transection. The aetiology of the CTx, flow rate and patient condition dictate the preferred management. Octreotide/somatostatin and etilefrine therapy is highly efficacious in the conservative management of CTx. For patients in whom conservative management fails, those who are good surgical candidates, and those in whom the site of the leak is well identified, surgical repair and/or ligation using minimally invasive techniques is highly successful with limited adverse outcomes. Similarly, if the site of the chylous effusion cannot be well visualized, a thoracic duct ligation via video-assisted thoracic surgery is the gold standard approach. A pleuroperitoneal or less often a pleurovenous shunt is a final option and may be curative in some patients.

Surgeons and their tools: a history of surgical instruments and their innovators. Part V: pass me the hemostat/clamp

This is the last of five manuscripts reviewing the historical origins of some of the more commonly used surgical instruments and takes "time out" to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

Surgeons and Their Tools: A History of Surgical Instruments and Their Innovators. Part V: Pass Me the Hemostat/Clamp

This is the last of five manuscripts reviewing the historical origins of some of the more commonly used surgical instruments and takes “time out” to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

Surgeons and their tools: a history of surgical instruments and their innovators. Part IV: pass me the forceps

This is the fourth of five manuscripts reviewing the historical origins of some of the more commonly used surgical instruments and takes "time out" to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

Surgeons and Their Tools: A History of Surgical Instruments and their Innovators. Part III: The Medical Student's Best Friend—Retractors

This is the third of five manuscripts reviewing the historical origins of some of the more commonly used surgical instruments and takes “time out” to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

Surgeons and their tools: a history of surgical instruments and their innovators. Part III: the medical student's best friend—retractors

This is the third of five manuscripts reviewing the historical origins of some of the more commonly used surgical instruments and takes "time out" to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

Surgeons and Their Tools: A History of Surgical Instruments and Their Innovators—Part II: The Surgeon's Wand—Evolution from Knife to Scalpel to Electrocautery

This is the second of five articles reviewing the historical origins of some of the more commonly used surgical instruments and takes “time out” to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

Surgeons and their tools: a history of surgical instruments and their innovators--Part II: The surgeon's wand-evolution from knife to scalpel to electrocautery

This is the second of five articles reviewing the historical origins of some of the more commonly used surgical instruments and takes "time out" to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

Surgeons and their tools: a history of surgical instruments and their innovators--part I: place the scissors on the Mayo stand

This is the first of five articles reviewing the historical origins of some of the more commonly used surgical instruments and takes "time out" to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

Surgeons and Their Tools: A History of Surgical Instruments and Their Innovators—Part I: Place the Scissors on the Mayo Stand

This is the first of five articles reviewing the historical origins of some of the more commonly used surgical instruments and takes “time out” to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

Biomarkers for pancreatic cancer: promising new markers and options beyond CA 19-9

Pancreatic adenocarcinoma accounts for nearly 90-95% of exocrine malignant tumors of the pancreas. Traditionally, overexpressed proteins/epitopes such as CA 19-9, CA-50, CEA, and many others were being used as pancreatic cancer tumor markers. The main utility of these biomarkers was in the diagnosis of pancreatic cancer as well as to assess response to chemotherapy and to determine prognosis and to predict tumor recurrence. However, these markers had significant limitations such as lack of sensitivity, false-negative results in certain blood groups, as well as false-positive elevation in the presence of obstructive jaundice. To circumvent these limitations, an extraordinary amount of research is being performed to identify an accurate tumor marker or a panel of markers that could aid in the management of the pancreatic cancer. Although this research has identified a large number and different variety of biomarkers, few hold future promise as a preferred marker for pancreatic cancer. This review provides an insight into exciting new areas of pancreatic biomarker research such as salivary, pancreatic juice, and stool markers that can be used as a noninvasive test to identify pancreatic cancer. This manuscript also provides a discussion on newer biomarkers, the role of microRNAs, and pancreatic cancer proteomics, which have the potential to identify a preferred tumor marker for pancreatic adenocarcinoma. This review further elaborates on important genetic changes associated with the development and progression of pancreatic cancer that holds the key for the identification of a sensitive biomarker and which could also serve as a therapeutic target.

The efficacy of procalcitonin as a biomarker in the management of sepsis: slaying dragons or tilting at windmills?

BACKGROUND

Sepsis is defined as systemic inflammatory response syndrome (SIRS) in the context of an underlying infectious process, and is associated with high rates of morbidity and mortality, particularly when initial therapy is delayed. Numerous biomarkers, including but not limited to cytokines (interleukins-2 and -6 [IL-2, IL-6] and tumor necrosis factor-α [TNF-α]), leukotrienes, acute-phase proteins (C-reactive protein [CRP]), and adhesion molecules, have been evaluated and rejected as unsuitable for the diagnosis of sepsis, predicting its severity, and guiding its treatment. Most recently, procalcitonin (PCT) has been suggested as a novel biomarker that may be useful in guiding therapeutic decision making in the management of sepsis. This article assesses critically the published literature on the clinical utility of PCT concentrations for guiding the treatment of sepsis in adult patients.

METHODS

A comprehensive search of all published studies of the use of serum concentrations of PCT to guide the treatment of sepsis in adult patients (1996 to 2011) was conducted with PubMed and Google Scholar. The search focused on the value of PCT concentrations to guide the diagnosis, prognosis, monitoring, and escalation and de-escalation of antbiotic therapy in these patients. Keywords searched included "procalcitonin," "sepsis," "sepsis biomarker," "sepsis diagnosis," "sepsis prognosis," "sepsis mortality," "antibiotic escalation," "antibiotic de-escalation," "antibiotic duration," and "antimicrobial stewardship."

RESULTS

Forty-six trials evaluating the efficacy of PCT concentrations in diagnosing sepsis have been published, with 39 of these trials yielding positive results and 7 yielding negative results. Wanner et al. published the largest study (n=405) demonstrating that peak PCT concentrations occur early after injury in both patients with sepsis and those with multiple organ dysfunction syndrome (MODS). Among 17 trials assessing the prognostic value of PCT concentrations with regard to clinical outcome and morbidity, 12 trials yielded positive results and five showed negative or equivocal results. Reith et al. published the largest study of the prognostic use of PCT concentrations (n=246), demonstrating that median PCT values on post-operative days (POD) one, four, and 10 were predictive of mortality in patients with abdominal sepsis (p<0.01). Among 14 trials of the utility of PCT concentrations for establishing an infectious cause of sepsis, 13 yielded positive results and only one yielded negative results. The largest study of this use of PCT concentrations, conducted by Baykut et al. (n=400), evaluated these concentrations in post-operative patients with infection, and demonstrated that concentrations of PCT remained elevated until POD 4, with a second increase observed between POD 4 and POD 6. In uninfected patients, PCT concentrations began to decrease on POD 2. Only a single study has assessed the utility of PCT concentrations in guiding the escalation of antibiotic therapy, and its results were negative. Specifically, Jensen et al. (n=1,200) compared a PCT-guided antibiotic escalation strategy with the standard of care for sepsis and found no difference in outcomes. They also found that the PCT group had a longer average stay in the intensive care unit (ICU), greater rates of mechanical ventilation, and a decreased estimated glomerular filtration rate (eGFR). Among four trials focusing on PCT concentrations and antibiotic de-escalation, all showed positive results with the measurement of PCT concentrations. The largest such study, by Bouadma et al. (n=621), demonstrated a four-day decrease in antibiotic duration when PCT concentrations were used to guide therapy relative to the study arm given the standard of care, with no increase in mortality (p=0.003).

CONCLUSIONS

The diagnostic value of serum PCT concentrations for discriminating among SIRS, sepsis, severe sepsis, and septic shock remains to be established. Although higher PCT concentrations suggest a systemic bacterial infection as opposed to a viral, fungal, or inflammatory etiology of sepsis, serum PCT concentrations do not correlate with the severity of sepsis or with mortality. At present, PCT concentrations are solely investigational with regard to determining the timing and appropriateness of escalation of antimicrobial therapy in sepsis. Nevertheless, serum PCT concentrations have established utility in monitoring the clinical response to medical and surgical therapy for sepsis, and in surveillance for the development of sepsis in burn and ICU patients, and may have a role in guiding the de-escalation of antibiotic therapy.

Utility of intraoperative frozen section examination of sentinel lymph nodes in ductal carcinoma in situ of the breast

BACKGROUND

Intraoperative frozen section (IFS) examination of sentinel lymph nodes (SLN) is useful in selecting patients with invasive breast cancer for immediate axillary lymph node dissection. However, whether IFS evaluation of the SLNs in ductal carcinoma in situ (DCIS) of the breast has any value has not been previously assessed.

METHODS

Clinicopathologic data from patients with DCIS who underwent resection with SLN biopsy (2004-2010) were collected to assess the sensitivity, specificity, and accuracy of IFS, and its impact on axillary management.

RESULTS

A total of 267 patients with DCIS underwent resection with SLN biopsy and IFS evaluation. Preoperative pathology was DCIS (n = 231), DCIS with microinvasion (n = 24), and DCIS with other lesions (n = 12). Fifty-two (19.5%) patients had invasive breast cancer on final pathology. SLN metastases were identified in 13 (4.8%) patients; however, only 4 (1.5%) were IFS positive. IFS examination was negative in 263 (98.5%) patients. Among patients with SLN metastases, the most common pattern of metastases was either micrometastasis (n = 6) or immunohistochemistry-positive individual tumor cells (n = 4), whereas 3 patients had a macrometastasis. IFS examination was falsely negative in 9 of these 13 patients for a false-negative rate of 69.3%, and a sensitivity and specificity of 31% and 100% respectively. Nine of the 13 patients underwent axillary lymph node dissection and only 1 patient had further axillary metastasis.

CONCLUSIONS

SLN metastases in DCIS is rare and most commonly involves SLN micrometastasis or immunohistochemistry-positive individual tumor cells. SLN IFS evaluation in DCIS has a low yield and sensitivity, and can be safely omitted to reduce operative duration and cost.

Extranodal Rosai-Dorfman disease: a rare soft tissue neoplasm masquerading as a sarcoma

Introduction

Rosai–Dorfman disease (RDD) is a rare proliferative histiocytic disorder of unknown etiology. RDD typically presents with generalized lymphadenopathy and polymorphic histiocytic infiltration of the lymph node sinuses; however, occurrences of extranodal soft tissue RDD may rarely occur when masquerading as a soft tissue sarcoma.

Materials and methods

A comprehensive search of all published cases of soft tissue RDD without associated lymphadenopathy was conducted using PubMed and Google Scholar for the years 1988 to 2011. Ophthalmic RDD was excluded.

Results

Thirty-six cases of extranodal soft tissue RDD, including the current one, have been reported since 1988. Anatomical distribution varied among patients. Four (11.1%) patients presented with bilateral lesions in the same anatomic region. Pain was the most common symptom in six (16.8%) patients. Sixteen (41.6%) patients were managed surgically, of which one (2.8%) case experienced recurrence of disease.

Conclusion

RDD is a rare inflammatory non-neoplastic process that should be considered in the differential diagnosis of a soft tissue tumor. Thus, differentiation of extranodal RDD from more common soft tissue tumors such as soft tissue sarcoma or inflammatory myofibroblastic tumor is often difficult and typically requires definitive surgical excision with histopathological examination. While the optimal treatment for extranodal RDD remains ill-defined and controversial, surgical excision is typically curative.

An evidence-based review of the current treatment of congenital diaphragmatic hernia

Congenital diaphragmatic hernia is a rare but severe condition affecting 1 in 2000 to 3000 newborns with a survival rate of 67%. Although regular antenatal screening allows prenatal diagnosis in many cases, traditionally treatment has been based on postnatal surgical repair. Recent literature has pointed out the survival benefits of initial stabilization and the use of gentle ventilation strategies prior to definitive treatment, shifting the trend from immediate to delayed surgical repair. Advances in fetal intervention have allowed the introduction of fetal endoscopic tracheal occlusion as a method to hasten lung development before birth in order to minimize postnatal morbidity. Despite appropriate treatment, the long-term outcomes of these patients are plagued with numerous complications, associated with the primary pathology and also aggressive therapeutic measures. International centers of excellence have recently come together in an effort to standardize the care of such patients in hopes of maximizing their outcomes.

Prophylactic mastectomy in patients at high risk: is there a role for sentinel lymph node biopsy?

INTRODUCTION

Prophylactic mastectomy (PM) rates in the United States are rising due to determination of increased Gail risk, moderate-high risk lesions, a strong family history, and gene mutation carriers. The role of sentinel lymph node biopsy (SLNB) in PM remains controversial. This report sought to examine clinical utility of SLNB in PM.

METHODS

A total of 292 patients underwent bilateral or contralateral PM (1999-2011). SLNB was performed on the PM side in 195 (66.7%) patients with standard techniques. Clinicopathologic data were analyzed for the incidence of occult cancer in prophylactic breast and/or axilla. Univariate analysis was used to determine factors that predict SLN positivity.

RESULTS

The median patient age was 49 years (range, 19-79 years). Contralateral invasive breast cancer (64.7%) was the most common indication for PM. A total of 209 (71.5%) invasive breast cancer and 49 (16.7%) in situ cancers (n = 38 ductal carcinoma in situ, n = 10 lobular carcinoma in situ) were identified on the therapeutic mastectomy side, with a median tumor size of 1.5 cm. 58.6% were estrogen receptor positive and 4.7% were multicentric. Three (1%) ductal carcinoma in situ, 4 (1.3%) lobular carcinoma in situ, and 5 (1.7%) atypical ductal, and 1 (0.3%) lobular hyperplasia were identified in PM breast. No invasive breast cancer or positive SLN was identified in PM breast and/or axilla.

CONCLUSION

Although a minimally invasive procedure, the utility of SLNB in patients with absent or contralateral early disease is limited. Advanced T stage, multicentricity, or receptor status on the therapeutic side or a finding of in situ or atypical hyperplasia in prophylactic breast specimen yielded no positive SLN. Routine SLNB in pure bilateral PM can safely be omitted, which reduces axillary morbidity and operative time and/or cost. Selective use of SLNB for contralateral recurrent and/or locally advanced cancers warrants further investigation.

The Role for Prophylaxis Inferior Vena Cava Filters in Patients Undergoing Bariatric Surgery: Replacing Anecdote with Evidence

The number of patients choosing surgical alternatives for weight reduction continues to increase. Despite common thromboembolic preventive methods, which include perioperative subcutaneous heparin injections, early mobilization, and sequential compression devices, postoperative deep vein thrombosis/pulmonary embolism remains a devastating complication after bariatric surgery. The role prophylactic inferior vena cava (IVC) filters may play in bariatric surgery remains controversial, and this article aims to address the risks and benefits of prophylactic IVC filters in high-risk bariatric patients and suggest an evidence-based algorithm for their use.

The role for prophylaxis inferior vena cava filters in patients undergoing bariatric surgery: replacing anecdote with evidence

The number of patients choosing surgical alternatives for weight reduction continues to increase. Despite common thromboembolic preventive methods, which include perioperative subcutaneous heparin injections, early mobilization, and sequential compression devices, postoperative deep vein thrombosis/pulmonary embolism remains a devastating complication after bariatric surgery. The role prophylactic inferior vena cava (IVC) filters may play in bariatric surgery remains controversial, and this article aims to address the risks and benefits of prophylactic IVC filters in high-risk bariatric patients and suggest an evidence-based algorithm for their use.

Nipple-sparing mastectomy in modern breast practice

Breast cancer management has evolved from the conventional radical Halsted to a fully integrated multidisciplinary approach. Nipple sparing mastectomy (NSM) is an innovative technique that preserves native breast envelope without mutilation of nipple-areola complex (NAC), thus providing a reasonable alternative for early cancers without NAC involvement and prophylactic high risk patients and avoids multiple surgical procedures required for reconstruction. This article aims to critically review indications, intra-operative protocols, radiotherapy planning and limitations of NSM. Patient selection should be based on study of breast duct anatomy by Magnetic Resonance Imaging, mammographic tumor-nipple distance and obligatory intra-operative frozen section from retro-areolar tissue. Tumor size, axillary lymph node status, lymphovascular invasion and/or degree of intraductal component are factors used to include NSM candidates based on institutional practice. Given the heterogeneity of patients and lack of standardization of preoperative investigations, surgical technique and pathologic sampling of retro-areola tissue so far, mandates a multi-institutional prospective study to define and validate a role for NSM in invasive breast cancer and DCIS. Nipple necrosis is an important NSM complication which can be greatly reduced using alternative skin incisions. Even if the nipple survives, an insensate nipple and lack of sexual function is common and requires preoperative counseling and discussion. Finally the relation and timing of intra-operative versus adjuvant breast radiation and tailoring of dosage and delivery methods has not been fully explored. Although NSM reduces psychological trauma associated with nipple loss, the oncologic safety as well as functional and aesthetic outcomes needs additional investigation.