Impact of Neoadjuvant Therapy for Pancreatic Cancer: Transatlantic Trend and Postoperative Outcomes Analysis

BACKGROUND

The introduction of modern chemotherapy a decade ago has led to increased use of neoadjuvant therapy (NAT) in patients with pancreatic ductal adenocarcinoma (PDAC). A recent North American study demonstrated increased use of NAT and improved operative outcomes in patients with PDAC. The aims of this study were to compare the use of NAT and short-term outcomes in patients with PDAC undergoing pancreatoduodenectomy (PD) among registries from the US and Canada, Germany, the Netherlands, and Sweden.

STUDY DESIGN

Databases from 2 multicenter (voluntary) and 2 nationwide (mandatory) registries were queried from 2018 to 2020. Patients undergoing PD for PDAC were compared based on the use of upfront surgery vs NAT. Adoption of NAT was measured in each country over time. Thirty-day outcomes, including the composite measure (ideal outcomes), were compared by multivariable analyses. Sensitivity analyses of patients undergoing vascular resection were performed.

RESULTS

Overall, 11,402 patients underwent PD for PDAC with 33.7% of patients receiving NAT. The use of NAT increased steadily from 28.3% in 2018 to 38.5% in 2020 (p < 0.0001). However, use of NAT varied widely by country: the US (46.8%), the Netherlands (44.9%), Sweden (11.0%), and Germany (7.8%). On multivariable analysis, NAT was significantly (p < 0.01) associated with reduced rates of serious morbidity, clinically relevant pancreatic fistulae, reoperations, and increased ideal outcomes. These associations remained on sensitivity analysis of patients undergoing vascular resection.

CONCLUSIONS

NAT before PD for pancreatic cancer varied widely among 4 Western audits yet increased by 26% during 3 years. NAT was associated with improved short-term outcomes.

Pancreatectomy for intraductal papillary mucinous neoplasm: has anything changed in North America?

BACKGROUND

Multiple guidelines on the management of intraductal papillary mucinous neoplasm (IPMN) have been published over the past decade. However, practice data are lacking. This study aims to determine whether pancreatectomy procedures, IPMN pathology, or outcomes have changed.

METHODS

ACS-NSQIP Procedure Targeted Pancreatectomy database was queried for patients with IPMN from 2014 to 2019. Cases were stratified by pathology, tumor stage/cyst size and procedure. Pancreatectomies for IPMN by year, 30-day morbidity, and clinically relevant postoperative pancreatic fistula (CR-POPF) were quantified. Mann-Kendall trend tests were performed to assess surgical trends and associated outcomes over time.

RESULTS

3912 patients underwent pancreatectomy for IPMN. 21% demonstrated malignancy and 79% were benign. Morbidity and mortality occurred in 29.7% and 1.5% of cases, respectively. Over time, no change was observed in use of pancreatectomy for IPMN (10%) or in benign/malignant pathology, or cyst size. Robotic approach increased from 9.1% to 16.5% with decreases in laparoscopic (19.5%-15.0%) and open interventions (71.5%-68.1%, p = 0.016). No change was observed over time in morbidity or mortality; however, rates of CR-POPF decreased (18.8%-13.8%, p < 0.001).

CONCLUSIONS

Practice patterns in treatment of IPMN have not changed significantly in North America. More patients are undergoing robotic pancreatectomy, and postoperative pancreatic fistula rates are improving.

Resistant gastroenteropancreatic neuroendocrine tumors: a definition and guideline to medical and surgical management

Gastroenteropancreatic neuroendocrine tumors (NETs), also historically known as carcinoids, are tumors derived of hormone-secreting enteroendocrine cells. Carcinoids may be found in the esophagus, stomach, small intestine, appendix, colon, rectum, or pancreas. The biologic behavior of carcinoids differs based on their location, with gastric and appendiceal NETs among the least aggressive and small intestinal and pancreatic NETs among the most aggressive. Ultimately, however, biologic behavior is most heavily influenced by tumor grade. The incidence of NETs has increased by 6.4 times over the past 40 years. Surgery remains the mainstay for management of most carcinoids. Medical management, however, is a useful adjunct and/or definitive therapy in patients with symptomatic functional carcinoids, in patients with unresectable or incompletely resected carcinoids, in some cases of recurrent carcinoid, and in postoperative patients to prevent recurrence. Functional tumors with persistent symptoms or progressive metastatic carcinoids despite therapy are called "resistant" tumors. In patients with unresectable disease and/or carcinoid syndrome, an array of medical therapies is available, mainly including somatostatin analogues, molecular-targeted therapy, and peptide receptor radionuclide therapy. Active research is ongoing to identify additional targeted therapies for patients with resistant carcinoids.

Radical antegrade modular pancreatosplenectomy (RAMPS): does adrenalectomy alter outcomes?

BACKGROUND

Radical antegrade modular pancreatosplenectomy (RAMPS) has oncologic superiority compared to a standard distal pancreatectomy (DP). For tumors invading into the adrenal gland, a posterior RAMPS takes the left adrenal gland en bloc with the pancreas specimen. The aim of this analysis is to determine whether addition of adrenalectomy alters the outcomes of DP.

METHODS

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Procedure-Targeted Pancreatectomy database was accessed from 2014 to 2019. Patients with pancreatic ductal adenocarcinoma (PDAC) undergoing posterior RAMPS were compared to patients having a standard DP. 30-day outcomes were analyzed using multivariable regression.

RESULTS

3467 PDAC patients underwent DP; 159 (4.6%) also had an adrenalectomy. Posterior RAMPS patients had higher T stage (T3-4 77% vs. 58%, p < 0.01). On multivariable analysis, posterior RAMPS patients had worse perioperative outcomes including more transfusions (OR 2.78, p < 0.01), serious morbidity (OR 1.45, p = 0.04), prolonged hospital stay (OR 1.36, p < 0.05), and less optimal pancreatic surgery (OR 0.61, p < 0.01).

CONCLUSION

Radical antegrade modular pancreatosplenectomy with adrenalectomy (posterior RAMPS) is associated with worse perioperative outcomes compared to a standard distal pancreatectomy. Improved oncologic outcomes must be weighed against higher perioperative morbidity when selecting patients for this more extensive surgical resection.

Chronologic Age, Independent of Frailty, is the Strongest Predictor of Failure-to-Rescue After Surgery for Gastrointestinal Malignancies

BACKGROUND

Prior studies of older cancer patients undergoing large operations have reported similar rates of complications to the general population but higher rates of mortality, suggesting higher rates of failure-to-rescue (FTR) with advanced age. Whether age is a marker for frailty, or an independent predictor of FTR, is not clear.

METHODS

The ACS-NSQIP database was queried from 2015-19 for patients undergoing surgery for gastrointestinal (GI) malignancy. Patients were divided into age-stratified cohorts: C1 (18-55), C2 (56-65), C3 (66-75), C4 (76-89). Adjusted odds ratios (aOR) were computed to assess the relationship of the FTR rate and age, while controlling for potential confounders. A second analysis was specified with all covariates converted to Z-scores, which generated scaled adjusted odds ratios (saOR) to determine the strongest predictor of FTR.

RESULTS

Multivariable analysis suggests that age is an independent predictor of FTR: C2:C1 aOR = 1.87 (p < 0.001); C3:C1 aOR = 3.33 (p < 0.001); C4:C1 aOR = 5.71 (p < 0.001). The scaled analysis demonstrated that age is the strongest predictor of FTR (saOR = 1.92, p < 0.001); a one standard deviation increase in age was associated with a 92% increased odds of FTR. The saOR for frailty (1.18, p < 0.001) and for number of comorbidities (1.10, p = 0.005) also were statistically significant.

CONCLUSIONS

Chronologic age was independently associated with increased FTR after surgery for GI malignancy and was the strongest predictor of FTR. These results suggest that chronologic age must be carefully considered when evaluating the fitness of a patient for GI cancer surgery.

Disease Control Achieved Using Atezolizumab + Bevacizumab in a Patient With Sarcomatoid Hepatocellular Carcinoma (SHCC), a Rare Variant Excluded From the IMbrave150 Trial

Sarcomatoid hepatocellular carcinoma (SHCC) is a rare variant of liver cancer that lacks treatment options. The IMbrave trail demonstrated the efficacy of atezolizumab and bevacizumab (A + B) in patients with unresectable hepatocellular carcinoma but excluded patients with sarcomatoid variants. Herein, we describe a case of disease control achieved using the IMbrave regimen in a patient with sarcomatoid hepatocellular carcinoma.

Pancreatoduodenectomy: the Metabolic Syndrome is Associated with Preventable Morbidity and Mortality

BACKGROUND

Patients with metabolic syndrome (MS) may have increased perioperative morbidity and mortality. The aim of this analysis was to investigate the association of MS with mortality, serious morbidity, and pancreatectomy-specific outcomes in patients undergoing pancreatoduodenectomy (PD).

METHODS

Patients with MS who underwent PD were selected from the 2014-2018 ACS-NSQIP pancreatectomy-specific database. MS was defined as obesity (BMI ≥ 30 kg/m²), diabetes, and hypertension. Demographics and outcomes were compared by χ² and Mann-Whitney tests, and adjusted odds ratios from multivariable logistic regression assessed the association between MS and primary outcomes.

RESULTS

Of 19,054 patients who underwent PD, 7.3% (n = 1388) had MS. On univariable analysis, patients with MS had significantly worse outcomes (p < 0.05): 30-day mortality (3% vs 1.8%), serious morbidity (26% vs 23%), re-intubation (4.9% vs 3.5%), pulmonary embolism (2.0% vs 1.1%), acute renal failure (1.5% vs 0.9%), cardiac arrest (1.9% vs 1.0%), and delayed gastric emptying (18% vs 16.5%). On multivariable analysis, 30-day mortality was significantly increased in patients with MS (aOR: 1.53, p < 0.01).

CONCLUSION

Metabolic syndrome is associated with increased morbidity and mortality in patients undergoing pancreatoduodenectomy. The association with mortality is a novel observation. Perioperative strategies aimed at reduction and/or mitigation of cardiac, pulmonary, thrombotic, and renal complications should be employed in this population given their increased risk.

Virtual Tumor Board Increases Provider Attendance and Case Presentations

PURPOSE:

Many cancer centers engage in multidisciplinary tumor board meetings to determine the optimal approach to complex cancer care. With the onset of the COVID-19 pandemic, many institutions changed the format of these meetings from in-person to virtual. The aim of this study was to determine if the change to a virtual meeting format had an impact on attendance and cases presented.

METHODS:

Tumor board records were analyzed to obtain attendance and case presentation information at a National Cancer Institute–designated Comprehensive Cancer Center. Twelve-month in-person tumor board data were compared with 12-month virtual tumor board data to assess for difference in attendance and case presentation patterns.

RESULTS:

Seven separate weekly tumor board meetings at the beginning of the study (breast, GI, gynecology, liver, lung, melanoma, and urology) were expanded to nine meetings on the virtual platform (+endocrine and pancreas). Overall attendance increased by 46% on the virtual platform compared with in-person meetings (4,030 virtual attendances v 2,753 in-person, P < .001). Increased attendance was present across all specialties on the virtual platform. In addition, the number of patient cases discussed increased from 2,127 in in-person meeting to 2,656 on the virtual platform (a 20% increase, P < .001).

CONCLUSION:

A significant increase was observed in overall tumor board attendance and in case presentations per meeting, requiring the expansion of additional weekly meetings. Furthermore, in a major cancer center with multiple community affiliates, virtual tumor boards may encourage increased participation from remote sites with the benefit of obtaining expert specialist advice as compared with geographically challenging in-person meetings.

Neoadjuvant Therapy for Pancreatic Cancer: Increased Use and Improved Optimal Outcomes

BACKGROUND

The introduction of more effective chemotherapy a decade ago has led to increased use of neoadjuvant therapy (NAT) in patients with pancreatic ductal adenocarcinoma (PDAC). The aim of this study was to assess the evolving use of NAT in individuals with PDAC undergoing pancreatoduodenectomy (PD) and to compare their outcomes with patients undergoing upfront operation.

STUDY DESIGN

The American College of Surgeons NSQIP Procedure Targeted Pancreatectomy database was queried from 2014 to 2019. Patients undergoing pancreatoduodenectomy were evaluated based on the use of NAT versus upfront operation. Multivariable analysis was performed to determine the effect of NAT on postoperative outcomes, including the composite measure optimal pancreatic surgery (OPS). Mann-Kendall trend tests were performed to assess the use of NAT and associated outcomes over time.

RESULTS

A total of 13,257 patients were identified who underwent PD for PDAC between 2014 and 2019. Overall, 33.6% of patients received NAT. The use of NAT increased steadily from 24.2% in 2014 to 42.7% in 2019 (p < 0.0001). On multivariable analysis, NAT was associated with reduced serious morbidity (odds ratio [OR] 0.83, p < 0.001), clinically relevant pancreatic fistulas (OR 0.52, p < 0.001), organ space infections (OR 0.74, p < 0.001), percutaneous drainage (OR 0.73, p < 0.001), reoperation (OR 0.76, p = 0.005), and prolonged length of stay (OR 0.63, p < 0.001). OPS was achieved more frequently in patients undergoing NAT (OR 1.433, p < 0.001) and improved over time in patients receiving NAT (50.7% to 56.6%, p < 0.001).

CONCLUSION

NAT before pancreatoduodenectomy increased more than 3-fold over the past decade and was associated with improved optimal operative outcomes.

Effect of the COVID‐19 pandemic on surgical oncology practice—Results of an SSO survey

Background and Objectives

The COVID‐19 pandemic significantly affected healthcare delivery, shifting focus away from nonurgent care. The aim of this study was to examine the impact of the pandemic on the practice of surgical oncology.

Methods

A web‐based survey of questions about changes in practice during the COVID‐19 pandemic was approved by the Society of Surgical Oncology (SSO) Research and Executive Committees and sent by SSO to its members.

Results

A total of 121 SSO members completed the survey, 77.7% (94/121) of whom were based in the United States. Breast surgeons were more likely than their peers to refer patients to neoadjuvant therapy (p = 0.000171). Head and neck surgeons were more likely to refer patients to definitive nonoperative treatment (p = 0.044), while melanoma surgeons were less likely to do so (p = 0.029). In all, 79.2% (95/120) of respondents are currently using telemedicine. US surgeons were more likely to use telemedicine (p = 0.004). Surgeons believed telemedicine is useful for long‐term/surveillance visits (70.2%, 80/114) but inappropriate (50.4%, 57/113) for new patient visits.

Conclusion

COVID‐19 pandemic resulted in increased use of neoadjuvant therapy, delays in operative procedures, and increased use of telemedicine. Telemedicine is perceived to be most efficacious for long‐term/surveillance visits or postoperative visits.

COVID-19 is Affecting the Presentation and Treatment of Melanoma Patients in the Northeastern United States

Background

Covid-19 significantly affected healthcare delivery over the past year, with a shift in focus away from nonurgent care. Emerging data are showing that screening for breast and colon cancer has dramatically decreased. It is unknown whether the same trend has affected patients with melanoma.

Methods

This is a retrospective cohort study of melanoma patients at two large-volume cancer centers. Patients were compared for 8 months before and after the lockdown. Outcomes focused on delay in treatment and possible resultant upstaging of melanoma.

Results

A total of 375 patients were treated pre-lockdown and 313 patients were treated post-lockdown (17% decrease). Fewer patients presented with in situ disease post-lockdown (15.3% vs. 17.9%), and a higher proportion presented with stage III-IV melanoma (11.2% vs. 9.9%). Comparing patients presenting 2 months before versus 2 months after the lockdown, there was an even more significant increase in Stage III-IV melanoma from 7.1% to 27.5% (p < 0.0001). Finally, in Stage IIIB-IIID patients, there was a decrease in patients receiving adjuvant therapy in the post lockdown period (20.0% vs. 15.2%).

Conclusions

As a result of the recent pandemic, it appears there has been a shift away from melanoma in situ and toward more advanced disease, which may have significant downstream effects on prognosis and could be due to a delay in screening. Significantly patients have presented after the lockdown, and fewer patients are undergoing the recommended adjuvant therapies. Patient outreach efforts are essential to ensure that patients continue to receive preventative medical care and screening as the pandemic continues.

Simultaneous primary invasive breast carcinoma and ipsilateral cutaneous melanoma of the back: Surgical approach and considerations, a case report

INTRODUCTION AND IMPORTANCE

A patient presented with ipsilateral, synchronous primary malignancies of left upper back melanoma and left breast invasive ductal carcinoma. This complex presentation was managed with a multidisciplinary approach.

CASE PRESENTATION

A 61-year-old female presented with multiple cutaneous lesions, revealed to be several foci of melanoma in situ as well as a T4b melanoma of the left upper back. On staging work up, a left breast malignancy was incidentally discovered. Genetic testing did not delineate a relevant mutation to explain the synchronous malignancies. Multidisciplinary surgical planning entailed consideration of the lymphatic drainage patterns of the lesions, with both the upper back melanoma and breast carcinoma expected to drain to the left axilla. Ultimately, simultaneous resections of both malignancies were performed as well as concomitant left sentinel lymph node biopsies utilizing dual tracer technique.

CLINICAL DISCUSSION

Currently, cases of synchronous primary cutaneous melanoma and independent, ipsilateral primary breast carcinoma have not been examined, and thus surgical considerations for axillary staging in this circumstance have not been discussed. The existing literature instead explores the incidence and operative challenges of one malignancy following the other after an interval of time.

CONCLUSION

This case highlights the utility of a multidisciplinary team for complex oncologic presentations and discusses a creative surgical approach to address two simultaneous primary malignancies involving the left breast and ipsilateral skin of the back. This case emphasizes an exceedingly rare presentation and serves as an important example to educate medical professionals on the innovative and team-based approach to treatment.

How to Review a Surgical Scientific Paper: A Guide for Critical Appraisal

It is important for surgeons to participate in the peer-review process of scientific literature. As the number of published manuscripts continues to increase, there is a great need for volunteerism in this arena. However, there is little formal or informal training, which can help surgeons provide unbiased and meaningful reviews. Therefore, it is critical to provide more resources and guidelines to aid surgeons during the review process. The purpose of this paper is to provide a structured guide for a quality review of a surgical paper. This review represents the work of the Association of Women Surgeons Publications Committee.

Perioperative Outcomes Following Combined Versus Isolated Colorectal and Liver Resections: Insights From a Contemporary, National, Propensity Score-Based Analysis

Our objective was to compare outcomes following combined versus isolated resections for metastatic colorectal cancer and/or liver metastases using a large, contemporary national database.

Background

Controversy persists regarding optimal timing of resections in patients with synchronous colorectal liver metastases.

Methods

We analyzed 11,814 patients with disseminated colorectal cancer and/or liver metastases who underwent isolated colon, rectal, or liver resections (CRs, RRs, or LRs) or combined colon/liver or rectal/liver resections (CCLRs or CRLRs) in the National Surgical Quality Improvement Program Participant Use File (2011-2015). We examined associations between resection type and outcomes using univariate/multivariate analyses and used propensity adjustment to account for nonrandom receipt of isolated versus combined resections.

Results

Two thousand four hundred thirty-seven (20.6%); 2108 (17.8%); and 6243 (52.8%) patients underwent isolated CR, RR, or LR; 557 (4.7%) and 469 (4.0%) underwent CCLR or CRLR. Three thousand three hundred ninety-five patients (28.7%) had serious complications (SCs). One hundred forty patients (1.2%) died, of which 113 (80.7%) were failure to rescue (FTR). One thousand three hundred eighty-six (11.7%) patients experienced unplanned readmission. After propensity adjustment and controlling for procedural complexity, wound class, and operation year, CCLR/CRLR was independently associated with increased risk of SC, as well as readmission (compared with LR). CCLR was also independently associated with increased risk of FTR and death (compared with LR).

Conclusions

Combined resection uniformly confers increased risk of SC and increased risk of mortality after CCLR; addition of colorectal to LR increases risk of readmission. Combined resections are less safe, and potentially more costly, than isolated resections. Effective strategies to prevent SC after combined resections are warranted.

"Optimization of Surgical Resident Safety and Education During the COVID-19 Pandemic - Lessons Learned"

The COVID-19 pandemic has engendered rapid and significant changes in patient care. Within the realm of surgical training, the resultant reduction in clinical exposure and case volume jeopardizes the quality of surgical training. Thus, our general surgery residency program proceeded to develop a tailored approach to training that mitigates impact on resident surgical education and optimizes clinical exposure without compromising safety. Residents were engaged directly in planning efforts to craft a response to the pandemic. Following the elimination of elective cases, the in-house resident complement was effectively decreased to reduce unnecessary exposure, with a back-up pool to address unanticipated absences and needs. Personal protective equipment availability and supply, the greatest concern to residents, has remained adequate, while being utilized according to current guidelines. Interested residents were given the opportunity to work in designated COVID ICUs on a volunteer basis. With the decrease in operative volume and clinical duties, we shifted our educational focus to an intensive didactic schedule using a teleconferencing platform and targeted areas of weakness on prior in-service exams. We also highlighted critical COVID-19 literature in a weekly journal club to better understand this novel disease and its effect on surgical practice. The long-term impact of the COVID-19 pandemic on resident education remains to be seen. Success may be achieved with commitment to constant needs assessment in the changing landscape of healthcare with the goal of producing a skilled surgical workforce for public service.

Comparison of laparoscopy versus mini-laparotomy for jejunostomy placement in patients with gastric adenocarcinoma

BACKGROUND

Optimal nutrition is challenging for patients with gastric and gastroesophageal adenocarcinoma and often requires feeding tube placement prior to preoperative therapy. Feeding jejunostomy (FJ) placement via mini-laparotomy is technically easier to perform than laparoscopic FJ. The purpose of this study was to compare outcomes in patients with gastric adenocarcinoma undergoing laparoscopic versus mini-laparotomy FJ placement.

METHODS

A retrospective cohort study was performed of patients with gastric adenocarcinoma receiving laparoscopic versus mini-laparotomy FJ at a single tertiary referral center from 2000 to 2018. 30-day outcomes included complications, conversion to laparotomy, reoperation, length of stay, and readmission.

RESULTS

A total of 656 patients met the inclusion criteria and were studied. The majority of patients were male (68.1%) with a mean age of 60.6 years. The difference in surgical approach remained relatively stable over time. Overall, 82 (12.5%) patients experienced complications, and three (0.5%) patients died postoperatively. While readmission and conversion to open laparotomy did not differ between groups, overall complications (10.5% vs. 20.8%, p = 0.002), Clavien-Dindo ≥ 3 complications (4.0% vs. 8.9%, p = 0.021), length of stay (4.1 vs. 5.6 days, p < 0.001), and reoperation (0.9% vs. 4.0%, p = 0.002) favored the laparoscopic over mini-laparotomy group.

CONCLUSION

The current study helps clarify the risk of FJ placement in patients with gastric adenocarcinoma requiring nutritional support. Laparoscopic FJ placement has lower overall morbidity and length of stay compared to mini-laparotomy. However, caution is needed in preventing and identifying the rare causes of postoperative mortality that may be associated with laparoscopic FJ placement.

Management and outcomes of ruptured, perforated or fistulized tumors of mesenchymal origin

BACKGROUND

Patients with ruptured, perforated or fistulized (RPF) sarcomas commonly have issues such as sepsis and malnutrition and are usually unsuitable for oncologic resection in the emergency setting. We present our approach for managing a series of patients and the outcomes which were achieved with multidisciplinary care.

METHODS

We reviewed records of patients referred to the section of sarcoma surgical oncology. Clinicopathologic factors, preoperative and operative interventions as well as short-term oncologic outcomes were assessed.

RESULTS

Sixteen patients were identified between 1 January 1998 to 31 December 2018. Median age was 42.8 years. Histologies were; Gastrointestinal stromal tumors (7), desmoid (4), spindle cell tumor (2), dedifferentiated liposarcoma (2), and nonseminomatous germ cell tumor (1). Five patients had preoperative sepsis, 8 received antimicrobials, and 50% required hospitalization with a median stay of 21 days. Total parenteral nutrition was administered to 5 (31.3%) patients. Median tumor size and estimated blood loss were 13.1 cm and 350 mL respectively. No perioperative mortality occurred. Two patients have expired at a median follow-up of 16.1 months.

CONCLUSION

Preoperative optimization, including the use of percutaneous drains, and antibiotics to control sepsis, where necessary, can lead to eventual oncologic resection with acceptable morbidity and no short-term mortality for patients with RPF sarcomas.

Detours on the Road to Recovery: What Factors Delay Readiness to Return to Intended Oncologic Therapy (RIOT) After Liver Resection for Malignancy?

BACKGROUND

Poor recovery after oncologic hepatic resection delays Return to Intended Oncologic Therapy (RIOT) and shortens survival. In order to identify at-risk patients, this study was designed to determine which psychosocial and perioperative factors are associated with delayed RIOT readiness.

METHODS

A prospectively maintained database was queried to identify consecutive patients undergoing hepatectomy for malignancy from 2015 to 2017. Perioperative factors were compared between patients with early (≤ 28 postoperative days) vs. delayed (> 28 postoperative days) clearance to RIOT. Univariate analysis and multivariable logistic regression were performed.

RESULTS

Of 114 patients, 76 patients (67%) had an open surgical approach, 32 (28%) had a major hepatectomy, and 6 (5%) had a major complication, with no mortalities. Eighty-two patients (72%) had early and 32 patients (28%) had delayed RIOT readiness. Patients with high preoperative symptom burden were more likely to have delayed RIOT readiness (OR 3.1, 95% CI 1.1-8.4, p = 0.024). On multivariable analysis, open surgical approach (OR 6.9, 95% CI 1.4-34.7, p = 0.018), length of stay > 5 days (OR 3.6, 95% CI 1.4-9.4, p = 0.010), and any complication (OR 3.4, 95% CI 1.1-10.7, p = 0.033) were associated with delayed RIOT readiness. Postoperative factors associated with delayed RIOT readiness included nutritional and wound-healing parameters.

CONCLUSIONS

This study highlights the previously under-described importance of preoperative patient symptom burden on delayed postoperative recovery. As a cancer patient's return to oncologic therapy after hepatectomy has a substantial impact on survival, it is critical to adhere to enhanced recovery principles and address all other modifiable factors that delay recovery.

Severe Preoperative Symptoms Delay Readiness to Return to Intended Oncologic Therapy (RIOT) After Liver Resection

BACKGROUND

Symptom burden, as measured by patient-reported outcome (PRO) metrics, may have prognostic value in various cancer populations, but remains underreported. The aim of this project was to determine the predictive impact of preoperative patient-reported symptom burden on readiness to return to intended oncologic therapy (RIOT) after oncologic liver resection.

METHODS

Preoperative factors, including anthropometric analysis of sarcopenia, were collected for patients undergoing oncologic liver resection from 2015 to 2018. All patients reported their preoperative symptom burden using the MD Anderson Symptom Inventory, Gastrointestinal version (MDASI-GI). Time to RIOT readiness was compared using standard statistics.

RESULTS

Preoperative symptom burden was measured in 107 consecutive patients; 52% had at least one moderate symptom score and 21% reported at least one severe score. Highest rated symptoms were fatigue, disturbed sleep, and distress. For patients reporting a severe preoperative symptom burden, the median time to RIOT readiness was 35 days (interquartile range [IQR] 28-42), compared with 21 days (IQR 21-28) for those without severe symptoms (p < 0.001). On multivariable analysis, severe preoperative symptom burden was independently associated with longer time to RIOT readiness (estimate +7.5 days, 95% confidence interval 2.6-12.3; p = 0.002).

CONCLUSIONS

Preoperative symptom burden has a substantial impact on time to RIOT readiness, leading to, on average, a 7-day delay in RIOT readiness compared with patients without severe preoperative symptoms. Identifying and targeting severe preoperative symptoms may hasten recovery and improve time to necessary adjuvant therapies.

Enhanced recovery in liver surgery decreases postoperative outpatient use of opioids

BACKGROUND

Pathways of enhanced recovery in liver surgery decrease inpatient opioid use; however, little data exist regarding their effect on discharge prescriptions and post-discharge opioid intake.

METHODS

For consecutive patients undergoing liver resection from 2011-2018, clinicopathologic factors were compared between patients exposed to enhanced recovery vs. traditional care pathways. Multivariable analysis was used to determine factors predictive for traditional opioid use at the first postoperative follow-up. The enhanced recovery in liver surgery protocol included opioid-sparing analgesia, goal-directed fluid therapy, early postoperative feeding, and early ambulation.

RESULTS

Of 244 cases, 147 enhanced recovery patients were compared with 97 traditional pathway patients. Enhanced recovery patients were older (median 57 years vs 52 years, P = .031) and more frequently had minimally invasive operations (37% vs 16%, P < .001), with fewer major complications (2% vs 9%, P = .011). Enhanced recovery patients were less likely to be discharged with a prescription for traditional opioids (26% vs 79%, P < .001) and less likely to require opioids at their first postoperative visit (19% vs 61%, P < .001) despite similarly low patient-reported pain scores (median 2/10 both groups, P = .500). On multivariable analysis, the traditional recovery pathway was independently associated with traditional opioid use at the first follow-up (odds ratio 6.4, 95% confidence interval 3.5-12.1; P < .001).

CONCLUSION

The implementation of an enhanced recovery in liver surgery pathway with opioid-sparing techniques was associated with decreased postoperative discharge prescriptions for opioids and outpatient opioid use after oncologic liver surgery, while achieving the same level of pain control. For this and other populations at risk of persistent opioid use, enhanced recovery strategies can eliminate excess availability of opioids.

Contemporary analysis of complications associated with biliary stents during neoadjuvant therapy for pancreatic adenocarcinoma

BACKGROUND

With the increasing use of biliary stents for neoadjuvant therapy (NT) for pancreatic adenocarcinoma (PDAC), the risk of post-pancreaticoduodenectomy (PD) infection remains relevant. This study documents the contemporary incidence of stent-related complications (SRC) during NT and to analyze their impact on surgical infections.

METHODS

Consecutive patients from a single institution (2011-15) with resected PDAC treated with biliary decompression, NT, and PD were analyzed. Stent-related complications (SRC) were compared among patients with/without prospectively documented composite pre- and post-operative infections (surgical site infection [SSI], organ space infection [OSI], and cholangitis).

RESULTS

Of 114 total patients, (median 164 days, initial stent to surgery), 95% had initial endoscopic (vs. percutaneous) stenting. Initial stents were often plastic (80/114, 70%), with 43/114 (38%) undergoing routine exchange to metal stent before NT. Fifteen (13%) patients had stent cholangitis during NT requiring antibiotics and/or stent exchange. There were 33/114 (29%) patients with SRC, requiring 66 exchanges. Post-PD rates of SSI, OSI, and cholangitis were 23%, 5%, and 4%, respectively [composite rate 30%]. On multivariate analysis, SRC were not associated with composite surgical infections (p > 0.05).

CONCLUSIONS

Although SRC occurred in almost one-third of PDAC patients during NT, with appropriate intervention, there was no association with increased surgical infections.

Trends and Outcomes for Minimally Invasive Surgery for Inflammatory Bowel Disease

BACKGROUND

The relapsing and remitting nature of inflammatory bowel disease (IBD) predisposes patients to the development of fibrotic strictures, which must often be managed surgically. Laparoscopy provides the potential for enhanced perioperative care. Previous studies comparing morbidity and trends of open versus laparoscopic resection have been constrained by length of study and sample size.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, patients with primary diagnosis of IBD undergoing surgical resection from 2005 to 2015 were identified. Morbidity and mortality rates were then compared between open and laparoscopic resections using multiple logistic regression analyses.

RESULTS

A total of 10,699 resections were performed on IBD patients; 4816 (45.0%) of which were performed laparoscopically. The use of laparoscopy increased annually from 20.9% in 2005 to 55.4% in 2015. Comparing laparoscopic versus open, all 30-d outcomes tended to favor laparoscopy with the exception of operating room time, which was equal between the two groups. The difference in 30-d outcomes was statistically significant in laparoscopy versus open technique for pneumonia (1.0% versus 2.0%), ventilator use >48 h (0.6% versus 1.9%), acute renal failure (0.1% versus 0.4%), renal insufficiency (0.2% versus 0.6%), superficial surgical site infection (4.6% versus 7.7%), deep incisional surgical site infection (1.1% versus 1.8%), organ space infection (5.4% versus 7.3%), urinary tract infection (1.3% versus 2.2%), death (0.2% versus 0.7%), and length of hospital stay (6.4 versus 9.4 d).

CONCLUSIONS

These data not only display trends that indicate that the number of laparoscopic resections for IBD have increased over time but are associated with favorable complication rates, operating time, and length of hospital stay, suggesting that laparoscopy may be a safer option for treatment of fibrotic strictures associated with IBD.

Reviewing the review: a qualitative assessment of the peer review process in surgical journals

BACKGROUND

Despite rapid growth of the scientific literature, no consensus guidelines have emerged to define the optimal criteria for editors to grade submitted manuscripts. The purpose of this project was to assess the peer reviewer metrics currently used in the surgical literature to evaluate original manuscript submissions.

METHODS

Manuscript grading forms for 14 of the highest circulation general surgery-related journals were evaluated for content, including the type and number of quantitative and qualitative questions asked of peer reviewers. Reviewer grading forms for the seven surgical journals with the higher impact factors were compared to the seven surgical journals with lower impact factors using Fisher's exact tests.

RESULTS

Impact factors of the studied journals ranged from 1.73 to 8.57, with a median impact factor of 4.26 in the higher group and 2.81 in the lower group. The content of the grading forms was found to vary considerably. Relatively few journals asked reviewers to grade specific components of a manuscript. Higher impact factor journal manuscript grading forms more frequently addressed statistical analysis, ethical considerations, and conflict of interest. In contrast, lower impact factor journals more commonly requested reviewers to make qualitative assessments of novelty/originality, scientific validity, and scientific importance.

CONCLUSION

Substantial variation exists in the grading criteria used to evaluate original manuscripts submitted to the surgical literature for peer review, with differential emphasis placed on certain criteria correlated to journal impact factors.

A proactive outreach intervention that decreases readmission after hepatectomy

BACKGROUND

After hepatectomy, 7%-19% of patients are readmitted within 30 days, accounting for substantial cost and poor patient experience. The purpose of this study was to analyze the impact of a proactive outreach intervention on readmissions.

METHODS

Consecutive patients undergoing hepatectomy by a single surgeon 2012-2016 were identified in a prospectively maintained database. In August 2013 a postoperative intervention was implemented; an advanced practice provider called each patient within 72 hours of discharge. Readmission rates were compared pre- and postintervention using standard statistics.

RESULTS

Two hundred thirty-one patients met the inclusion criteria and major hepatectomy was performed in 45.5% of patients. Although the complication rate was similar (25.0% preintervention and 19.4% postintervention, P = .324), readmissions within 30 days of operation decreased from 14.5% pre- to 6.5% postintervention (P = .046). Approximately 30% of outreach interactions required outpatient intervention. Factors associated with readmission on univariate analysis included increased operative time (P = .007), major hepatectomy (P = .012), hemi or extended hepatectomy (P = .032), second stage operation (P = .031), bile leak (P = 0.022), and any complication/modified Accordion complication ≥ 3 within 30 days (P <.0001). On multivariate analysis, lack of post-discharge intervention (P = .012) and bile leak (P = .031) were independently associated with readmission.

CONCLUSION

These data demonstrate the efficacy of a proactive communication intervention after discharge to decrease readmissions after hepatectomy. The additional work created by the intervention is likely offset by decreased inpatient care needs and costs. Identification of high-risk populations and application of technology are likely to lead to further improvements.

Trends in laparoscopic colorectal surgery over time from 2005-2014 using the NSQIP database

BACKGROUND

Laparoscopy, originally pioneered by gynecologists, was first adopted by general surgeons in the late 1980s. Since then, laparoscopy has been adopted in the surgical specialties and colorectal surgery for treatment of benign and malignant disease. Formal laparoscopic training became a required component of surgery residency programs as validated by the Fundamentals of Laparoscopic Surgery curriculum; however, some surgeons may be more apprehensive of widespread adoption of minimally invasive techniques. Although an overall increase in the use of laparoscopy in colorectal surgery is anticipated over a 10-year period, it is unknown if a similar increase will be seen in higher risk or more acutely ill patients.

METHODS

Using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2005-2014, colorectal procedures were identified by Current Procedural Terminology codes and categorized to open or laparoscopic surgery. The proportion of colorectal surgeries performed laparoscopically was calculated for each year. Separate descriptive statistics was performed and categorized by age and body mass index (BMI). American Society of Anesthesiology (ASA) classification and emergency case status variables were added to the project to help assess complexity of cases.

RESULTS

During the 10-year study period, the number of colorectal cases increased from 3114 in 2005 to 51,611 in 2014 as more hospitals joined NSQIP. A total of 277,376 colorectal cases were identified; of which, 114,359 (41.2%) were performed laparoscopically. The use of laparoscopy gradually increased each year, from 22.7% in 2005 to 49.8% in 2014. Laparoscopic procedures were most commonly performed in the youngest age group (18-49 years), overweight and obese patients (BMI 25-34.9), and in ASA class 1-2 patients. Over the 10-year period, there was a noted increase in the use of laparoscopy in every age, BMI, and ASA category, except ASA 5. The percent of emergency cases receiving laparoscopic surgery also doubled from 5.5% in 2005 to 11.5% in 2014.

CONCLUSIONS

Over a 10-year period, there was a gradual increase in the use of laparoscopy in colorectal surgery. Further, there was a consistent increase of laparoscopic surgery in all age groups, including the elderly, in all BMI classes, including the obese and morbidly obese, and in most ASA classes, including ASA 3-4, as well as in emergency surgeries. These trends suggest that minimally invasive colorectal surgery appears to be widely adopted and performed on more complex or higher risk patients.

Extended pharmacologic thromboprophylaxis in oncologic liver surgery is safe and effective

Essentials The risk for venous thromboembolism after liver surgery remains high in the modern era. We evaluated the safety/efficacy of extended anticoagulation in liver surgery. This protocol reports zero venous thromboembolism events in 124 liver surgery patients. Extended anticoagulation after oncologic liver surgery is safe and effective.

SUMMARY

Background The incidence of venous thromboembolism (VTE) after liver surgery remains high. Objective To evaluate the safety and efficacy of extended pharmacologic thromboprophylaxis after liver surgery for the prevention of VTE. Patient/Methods From August 2013 to April 2015, 124 patients who underwent liver resection for malignancy were placed on an extended pharmacologic thromboprophylaxis protocol. Intraoperative VTE prophylaxis included thromboembolic deterrent hoses and sequential compression devices. Once hemostasis had been ensured following hepatectomy, daily anticoagulant VTE prophylaxis was initiated for the duration of hospitalization. After hospital discharge, the large majority of patients (114, 91.9%) continued to receive anticoagulant thromboprophylaxis (enoxaparin) to complete a total course of 14 days after minor/minimally invasive hepatectomy or 28 days after major hepatectomy or a history of VTE. Results The cohort included 39 (31.2%) major hepatectomies and 38 (31.5%) minor/minimally invasive approaches. The intraoperative, postoperative and overall transfusion rates were 5.6%, 8.1%, and 10.5%, respectively. Pharmacologic thromboprophylaxis was started on postoperative day (POD) 0 for 40 (32.3%) patients and on POD 1 for 84 (67.7%) patients. During 90 days of follow-up, no postoperative symptomatic deep vein thrombosis or pulmonary embolic events were diagnosed. Standard-protocol computed tomography scans of the chest, abdomen and pelvis that were obtained for 112 (90.3%) study patients showed no pulmonary emboli, or other thoracic, splanchnic or ileofemoral vein thromboses. Two (1.6%) patients had minor bleeding events that resolved after discontinuation of enoxaparin, requiring neither blood transfusion nor reoperation. The severe complication rate was 5.6%, with no 90-day mortalities. Conclusions These preliminary data suggest that extended pharmacologic thromboprophylaxis for liver surgery patients is safe and effective.

Multi-Institution Analysis of Infection Control Practices Identifies the Subset Associated with Best Surgical Site Infection Performance: A Texas Alliance for Surgical Quality Collaborative Project

BACKGROUND

In an effort to reduce surgical site infection (SSI) rates, a large number of infection control practices (ICPs), including operating room attire policies, have been recommended. However, few have proven benefits and many are costly, time-consuming, and detrimental to provider morale. The goal of this multi-institution study was to determine which ICPs are associated with lower postoperative SSI rates.

STUDY DESIGN

Twenty American College of Surgeons NSQIP and Texas Alliance for Surgical Quality-affiliated hospitals completed this Quality Improvement Assessment Board-approved study. Surgeon champions at each hospital ranked current surgery, anesthesia, and nursing adherence to 38 separate ICPs in 6 categories (attire, preoperative, intraoperative, preoperative, intraoperative, antibiotics, postoperative, and reporting) on 4-point scales for general surgery cases. These data were compared with the risk-adjusted general surgery SSI odds ratios contained in the July 2016 American College of Surgeons NSQIP hospital-level, risk-adjusted reports. Compliance rates were compared between the 7 best (median SSI odds ratio, 0.64; range, 0.56 to 0.70) and 7 worst (median SSI odds ratio, 1.16; range, 0.94 to 1.65) performers using ANOVA.

RESULTS

Nearly all hospitals reported maximal adherence to hair removal with clippers (Surgical Care Improvement Project measure Inf-6) and to best-practice prophylactic antibiotic metrics (Surgical Care Improvement Project measure Inf-1-3). Variable adherence was identified across many ICPs and more frequent compliance with 8 ICPs correlated with lower SSI odds ratios, including preoperative shower; skin preparation technique; using clean instruments, gowns, and gloves for wound closure and dressing changes; and transparent internal reporting of SSI data. Operating room attire ICPs, including coverage of nonscrubbed provider head and arm hair, did not correlate with SSI rates.

CONCLUSIONS

This analysis suggests that the subset of ICPs that focus on perioperative patient skin and wound hygiene and transparent display of SSI data, not operating room attire policies, correlated with SSI rates. Implementation of this subset of evidence-based ICPs may improve SSI rates at lower-performing hospitals.

Using MRI to non-invasively and accurately quantify preoperative hepatic steatosis

BACKGROUND

The obesity epidemic has significantly increased the incidence and severity of hepatic steatosis in liver surgery patients and liver donors, potentially impacting postoperative liver regeneration and function. Development of a non-invasive means to quantify hepatic steatosis would facilitate selection of candidates for liver resection and transplant donation.

METHODS

An IRB-approved protocol prospectively enrolled 28 patients with liver tumors requiring hepatic resection. In all patients, fast dual-echo gradient-echo MR images were acquired using 2-Point Dixon technique in 2D and 3D. The degree of steatosis was quantified by percent fat fraction (%FF) from in- and out-of-phase, and water-only and fat-only images. The technique-specific %FFs were compared to intraoperative and histopathological findings.

RESULTS

For patients with >30% steatosis by histology, the mean %FF was 22% (SD ± 5.2%) compared to a mean %FF of 5.0% (SD ± 2.1%, p = 0.0001) in patients with <30% steatosis. Using scaled values for the MR-calculated %FF, all patients with >30% pathologic steatosis could be identified preoperatively.

CONCLUSIONS

Quantitative MRI identified patients with clinically-relevant steatosis with 100% accuracy. These findings could have significant impact on the management of liver resection patients and transplant donors.

Protein disulfide isomerase, a component of the estrogen receptor complex, is associated with Chlamydia trachomatis serovar E attached to human endometrial epithelial cells

Chlamydia trachomatis serovar E, the leading bacterial agent responsible for sexually transmitted diseases, is required to invade genital epithelial cells for its growth and survival, yet little is known about the adhesin-receptor interactions promoting its entry. In contrast, much has been published on the heparan sulfate receptor for binding C. trachomatis L2 elementary bodies (EBs) prior to entry into HeLa cells. Using a different experimental approach in which a biotinylated apical membrane protein receptor(s) attached to EB at 4 degrees C was stripped off the surface of polarized HEC-1B cells and immunoprecipitated with polyclonal anti-EB antibodies, an approximately 55-kDa protein was reproducibly detected by enhanced chemiluminescence and two-dimensional gel electrophoresis. Matrix-assisted laser desorption ionization mass-spectrometry sequence analysis revealed the 55-kDa protein to be protein disulfide isomerase (PDI), a member of the estrogen receptor complex which carries out thiol-disulfide exchange reactions at infected host cell surfaces. Exposure of HEC-1B cells during EB attachment (1.5 to 2 h) to three different inhibitors of PDI reductive reactions--(i) the thiol-alkylating reagent DTNB (5,5'-dithiobis[2-nitrobenzoic acid]), (ii) bacitracin, and (iii) anti-PDI antibodies--resulted in reduced chlamydial infectivity. Since (i) C. trachomatis serovar E attachment to estrogen-dominant primary human endometrial epithelial cells is dramatically enhanced and (ii) productive entry into and infectivity of EB in host cells is dependent on reduction of EB cross-linked outer membrane proteins at the host cell surface, these data provide some preliminary evidence for an intriguing new potential receptor candidate for further analysis of luminal C. trachomatis serovar E entry.

Elevation change of the southern greenland ice sheet

Seasat and Geosat satellite altimeter measurements for the Greenland ice sheet (south of 72 degreesN latitude) show that surface elevations above 2000 meters increased at an average rate of only 1. 5 +/- 0.5 centimeters per year from 1978 to 1988. In contrast, elevation changes varied regionally from -15 to +18 centimeters per year, seasonally by +/-15 centimeters, and interannually by +/-8 centimeters. The average growth rate is too small to determine if the Greenland ice sheet is undergoing a long-term change due to a warmer polar climate.

Differences in the association of Chlamydia trachomatis serovar E and serovar L2 with epithelial cells in vitro may reflect biological differences in vivo

Chlamydia trachomatis serovar E is one of the most common bacterial sexually transmitted pathogens. Since it is an obligate intracellular bacterium, efficient colonization of genital mucosal epithelial cells is crucial to the infectious process. Serovar E elementary bodies (EB) metabolically radiolabeled with 35S-Cys-Met and harvested from microcarrier bead cultures, which significantly improves the infectious EB-to-particle ratio, provided a more accurate picture of the parameters of attachment of EB to human endometrial epithelial cells (HEC-1B) than did less infectious 14C-EB harvested from flask cultures. Binding of serovar E EB was (i) equivalent at 35 and 4 degrees C, (ii) decreased by preexposure of EB to heat or the topical microbicide C31G, (iii) comparable among common eukaryotic cell lines (HeLa, McCoy), and (iv) significantly increased to the apical surfaces of polarized cells versus nonpolarized cells. In parallel experiments with C. trachomatis serovar L2, serovar E attachment was not affected by heparin or heparan sulfate whereas these glucosaminoglycans dramatically reduced serovar L2 attachment. These data were confirmed by competitive inhibition of serovar E binding and infectivity by excess unlabeled live and UV-inactivated serovar E EB but not by excess serovar L2 EB. The noninvasive serovar E strains in the lumen of the genital tract enter and exit the apical domains of target columnar epithelial cells to spread canalicularly in an ascending fashion from the lower to the upper genital tract. In contrast, the invasive serovar L2 strains are primarily submucosal pathogens and likely use the glucosaminoglycans concentrated in the extracellular matrix to colonize the basolateral domains of mucosal epithelia to perpetuate the infectious process.

The microbicidal agent C31G inhibits Chlamydia trachomatis infectivity in vitro

Safe and effective vaginal microbicidal compounds are being sought to offer women an independent method for protection against transmission of sexually acquired pathogens. The purpose of this study was to examine the efficacy of two formulations of one such compound, C31G, against Chlamydia trachomatis serovar E alone, its host epithelial cell (HEC-1B) alone, and against chlamydiae-infected HEC-1B cells. Preexposure of isolated, purified infectious chlamydial elementary bodies (EB) to C31G, at pHs 7.2 and 5.7, for 1 h at 4 degrees C resulted in reduced infectivity of EB for HEC-1B cells. Examination of the C31G-exposed 35S-EB on sodium dodecyl sulfate-polyacrylamide gel electrophoresis autoradiographs and by Western blotting revealed a C31G concentration-dependent and pH-dependent destabilization of the chlamydial envelope, resulting in the release of chlamydial lipopolysaccharide and proteins. Interestingly, when the host human genital columnar epithelial cells were infected with chlamydiae and then exposed to dilute concentrations of C31G which did not alter epithelial cell viability, chlamydial infectivity was also markedly reduced. C31G gained access to the developing chlamydial inclusion causing damage to or destruction of metabolically active reticulate bodies as well as apparent alteration of the inclusion membrane, which resulted in premature escape of chlamydial antigen to the infected epithelial surface. These studies show that the broad-spectrum antiviral and antibacterial microbicide C31G also has antichlamydial activity.

Profiles of functional recovery in fifty traumatically brain-injured patients after acute rehabilitation

Research to demonstrate the efficacy of head injury rehabilitation is important at a time when cost-containment efforts are intensifying. A useful tool that would predict the functional improvement during hospitalization and length of stay (LOS) of persons with traumatic brain injury would be of benefit to patients and their families, insurance carriers, and rehabilitation specialists. This study examines functional improvements made by 50 traumatic brain-injured patients admitted to the rehabilitation unit at the University of California, Davis, Medical Center (UCDMC) as measured by the UCDMC Davis Functional Status Measure (DFSM), which was adapted from the Functional Independence Measure (FIM). The DFSM incorporates additional items to provide a more thorough measure of skills to be rehabilitated. The purpose of this study was to compare scores and profiles on the DFSM items obtained by patients with LOS greater than and less than and equal to the median rehabilitation LOS (23 days). Relationships were explored among admission DFSM scores, LOS for rehabilitation, discharge destination, and functional outcome. Results indicate that patients admitted to the rehabilitation unit attained a similar profile or level of function by discharge, regardless of admission Glasgow Coma Scale scores or admission DFSM scores. There were no significant differences in admission Glasgow Coma Scale score, age, acute LOS, or discharge disposition between the LOS groups. There was a significant difference in median admission DFSM score in 26 of 31 categories between the LOS groups. There was a significant difference in median DFSM change (admission to discharge) in 24 of 31 categories between the LOS groups. The admission DFSM total score was inversely proportional to the length of stay, with a correlation coefficient of 0.78. DFSM change and admission to discharge was linearly correlated with LOS (R = 0.66). The DFSM documents functional outcome and measures gains during inpatient rehabilitation. The DFSM profile is helpful in predicting the LOS needed to achieve those gains.

The late chlamydial inclusion membrane is not derived from the endocytic pathway and is relatively deficient in host proteins

Chlamydiae are obligate intracellular parasites which multiply within infected cells in a membrane-bound structure termed an inclusion. Newly internalized bacteria are surrounded by host plasma membrane; however, the source of membrane for the expansion of the inclusion is unknown. To determine if the membrane for the mature inclusion was derived by fusion with cellular organelles, we stained infected cells with fluorescent or electron-dense markers specific for organelles and examined inclusions for those markers. We observed no evidence for the presence of endoplasmic reticulum, Golgi, late endosomal, or lysosomal proteins in the inclusion. These data suggest that the expansion of the inclusion membrane, beginning 24 h postinoculation, does not occur by the addition of host proteins resulting from either de novo host synthesis or by fusion with preexisting membranes. To determine the source of the expanding inclusion membrane, antibodies were produced against isolated membranes from Chlamydia-infected mouse cells. The antibodies were demonstrated to be solely against Chlamydia-specified proteins by both immunoprecipitation of [35S]methionine-labeled extracts and Western blotting (immunoblotting). Techniques were used to semipermeabilize Chlamydia-infected cells without disrupting the permeability of the inclusion, allowing antibodies access to the outer surface of the inclusion membrane. Immunofluorescent staining demonstrated a ring-like fluorescence around inclusions in semipermeabilized cells, whereas Triton X-100-permeabilized cells showed staining throughout the inclusion. These studies demonstrate that the inclusion membrane is made up, in part, of Chlamydia-specified proteins and not of existing host membrane proteins.