Current endodontic practice and use of newer technologies in Australia and New Zealand

BACKGROUND

This study investigated endodontic clinical preferences, adoption of newer technologies and information sources among dentists and endodontists.

METHODS

Dental and endodontic society members in Australia and New Zealand were surveyed online regarding their endodontic treatment preferences, armamentarium, information sources and continuing professional education (CPE) attendance.

RESULTS

Complete responses were received from 71 endodontic specialists or postgraduates (Group E) and 139 general dentists (Group D). Most of Group E used dental operating microscopes (95.8%), endodontic cone-beam computed tomography (CBCT; 98.6%) and calcium silicate-based materials (CSBMs; 97.2%), significantly more (P < 0.001) than Group D (86.3% used loupes, <32% used CBCT for endodontics or CSBMs). Most respondents used dental dam always for endodontics (94.3%), electronic apex locators (EAL; 81.0%) and engine-driven nickel-titanium (NiTi) instruments (91.4%); Group E had more experience with engine-driven NiTi (P < 0.001). Endodontic CPE attendance was highest at dental association programs (P < 0.001) while hands-on NiTi training attendance was highest via commercial companies (P < 0.05). Online information sources were commonly used (38.8% of Group D, 59.2% of Group E).

CONCLUSION

Dental dam, EAL and engine-driven NiTi were almost universally used. The endodontic group reported high adoption of newer endodontic technologies. Endodontic CPE and information sources should be further surveyed as online engagement evolves. © 2023 Australian Dental Association.

Dentists' preferences in implant maintenance and hygiene instruction

BACKGROUND

This study investigated the preferences of dentists in Australia in providing professional implant maintenance and implant-specific oral hygiene instructions (OHI).

METHODS

General dentists were surveyed online about their preferences in peri-implant diagnostics, maintenance provision, armamentarium used, and implant OHI techniques and frequency.

RESULTS

Most of the 303 respondents (96%) provided maintenance services; 87.6% reviewed implants regularly while 10.7% only performed diagnostics after detecting clinical signs/symptoms. Supragingival prosthesis cleaning was performed by 77.9% of respondents, 35.0% performed subgingival debridement, 41.9% treated peri-implant mucositis and 18.2% treated peri-implantitis. About 15% did not treat nor refer peri-implant disease, including significantly more non-implant providers and dentists without implant training. Maintenance armamentarium commonly included floss (76.3%), prophylaxis (73.9%), plastic curettes (43.3%) and stainless-steel ultrasonics (38.0%). Brushing (86.5%), flossing (73.9%) and interdental brush use (68.3%) were most commonly recommended. Implant OHI was repeated routinely by 57.4% of dentists who provided it. Dentists with greater implant training and experience were more likely to perform reviews and complex maintenance procedures.

CONCLUSIONS

Peri-implant diagnostics performed, treatments provided and armamentarium varied among dentists. Implant providers and those with higher levels of training had more preventative approaches to implant OHI. Possible shortcomings in disease management and OHI reinforcement were identified.

Reimbursement recommendations for cancer drugs supported by phase II evidence in Canada

Background

Phase ii data are increasingly being used as primary evidence for public reimbursement for oncologic drugs. We compared the frequency of reimbursement recommendations for phase ii and phase iii submissions and assessed for variables associated with a positive or conditional recommendation.

Methods

We identified submissions made to the pan-Canadian Oncology Drug Review's Expert Review Committee (perc), of the Canadian Agency for Drugs and Technologies in Health, July 2011 to July 2019, that were supported only by phase ii data. We identified variables within the perc's deliberative framework, including clinical and economic factors, associated with the final reimbursement recommendation. We conducted a multivariable analysis with logistic regression for these variables: feasibility of phase iii study, hematologic indication, and unmet need.

Results

We identified 139 submissions with a perc final recommendation. In 27 instances (19%), the submission had only phase ii evidence, and a positive recommendation was issued for 63% of them (the positive recommendation rate was 82% for submissions with phase iii evidence). Clinical benefit (p < 0.001), unmet need (p = 0.047), and patient alignment (p = 0.015) were associated with a positive recommendation. If a future phase iii study was deemed feasible for submissions with only phase ii evidence, then in univariable (p = 0.040) and multivariable analysis (p = 0.024), the perc was less likely to recommend reimbursement (odds ratio: 0.132).

Conclusions

Although more than half the oncologic submissions with phase ii data were recommended for public reimbursement, compared with submissions having phase iii data, they were less likely to be recommended. A positive or conditional recommendation was more likely if clinical benefit and alignment with patient values was demonstrated. The perc was less likely to recommend reimbursement for submissions with phase ii evidence if a phase iii trial was deemed possible.

The generation of two specific cancer costing algorithms using Ontario administrative databases

Cancer treatment and management have become increasingly economically burdensome. Consequently, to help with planning health service delivery, it is vital to understand the associated costs. Administrative databases can be used to help understand and generate real-world system-level costs. Using databases to generate costs can take one of two approaches: top-down or bottom-up. Top-down approaches disaggregate the total health care spending from a global health care budget by sector and provider. A bottom-up approach begins with individual-level health care use and its costs, which are then aggregated.

Conditional approval of cancer drugs in Canada: accountability and impact on public funding

Background

We examined how conditional market approval of cancer pharmaceuticals by Health Canada (hc) affects public funding recommendations by the pan-Canadian Oncology Review (pcodr). We were also interested to see how often hc conditions are enforced.

Methods

Health Canada and pcodr databases for 2010-2017 were analyzed for patterns in hc conditional authorization and post-authorization reviews of cancer drugs and for correlation with pcodr reimbursement recommendations.

Results

Between 2010 and 2017, pcodr reviewed 105 unique drug-indication pairings; 21% (n = 22) had conditional hc authorization. In all cases, conditional authorization was given on the basis of preliminary data in a surrogate endpoint and was contingent on further data showing benefit in more robust outcome measures (for example, overall survival). Of those 22 drugs, 36% did not have updated data, 36% had updated data that met hc conditions, and 27% had data that met some, but not all, conditions. During the period considered, hc never revoked conditional authorization for failure to meet conditions. None of the 22 drugs was given an unconditional positive recommendation for public reimbursement by pcodr. A conditional recommendation was given to 11 of the drugs (50%), and reimbursement was not recommended for 6 drugs (27%) because of insufficient evidence.

Conclusions

One fifth of the cancer drugs reviewed for public reimbursement in Canada were conditionally authorized by hc based on preliminary data. Conditional authorization was associated with a recommendation against public funding by pcodr. No drugs had their conditional market authorization revoked for failure to meet conditions, suggesting that a more robust hc reappraisal framework is needed.

Effect of interferon alpha and cyclosporine treatment separately and in combination on Middle East Respiratory Syndrome Coronavirus (MERS-CoV) replication in a human in-vitro and ex-vivo culture model

Middle East Respiratory Syndrome Coronavirus (MERS-CoV) has emerged as a coronavirus infection of humans in the past 5 years. Though confined to certain geographical regions of the world, infection has been associated with a case fatality rate of 35%, and this mortality may be higher in ventilated patients. As there are few readily available animal models that accurately mimic human disease, it has been a challenge to ethically determine what optimum treatment strategies can be used for this disease. We used in-vitro and human ex-vivo explant cultures to investigate the effect of two immunomodulatory agents, interferon alpha and cyclosporine, singly and in combination, on MERS-CoV replication. In both culture systems the combined treatment was more effective than either agent used alone in reducing MERS-CoV replication. PCR SuperArray analysis showed that the reduction of virus replication was associated with a greater induction of interferon stimulated genes. As these therapeutic agents are already licensed for clinical use, it may be relevant to investigate their use for therapy of human MERS-CoV infection.

•

The effect of interferon-α and/or cyclosporine on MERS-CoV replication was evaluated with a human ex-vivo culture model.

•

All treatments were able to reduce MERS-CoV replication.

•

The combined treatment was more effective than either agent used alone in reducing MERS-CoV replication.

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The effect of the combined treatment group was associated with a greater induction of interferon stimulated genes.

Examining the medical resource utilization and costs of relapsed and refractory chronic lymphocytic leukemia in Ontario

PURPOSE

The purpose of the present study was to collect medical resource utilization data and costs in Ontario for the management of patients with relapsed or refractory chronic lymphocytic lymphoma (cll) who have undergone at least 1 treatment course and have been stratified by Rai staging.

METHODS

This retrospective longitudinal cohort study, conducted by chart review, analyzed anonymized patient records from two cancer centres in Ontario. Comprehensive records of 86 patients meeting the inclusion criteria were used to obtain resource utilization, which, multiplied by unit costs, were used to determine overall and mean costs. Descriptive statistics are presented for patient demographics, medical resource utilization, and costing data.

RESULTS

The total cost for the cohort was $2.2 million over a mean follow-up period of 4.7 years. The mean total cost per patient (regardless of follow-up) was $25,736. In terms of Rai staging, overall mean costs were highest for stage iv patients. Almost 50% of the total cost was attributable to cll treatments, among which fludarabine-based treatments had the highest utilization.

CONCLUSIONS

For this Canadian cll cohort, medical resource utilization and costs were determined to be $2.2 million, with cll treatments accounting for about half the cost. Costs generally increased with Rai stage.

The experiences of cancer survivors while transitioning from tertiary to primary care

PURPOSE

In current fiscally constrained health care systems, the transition of cancer survivors to primary care from tertiary care settings is becoming more common and necessary. The purpose of our study was to explore the experiences of survivors who are transitioning from tertiary to primary care.

METHODS

One focus group and ten individual telephone interviews were conducted. Data saturation was reached with 13 participants. All sessions were audio-recorded, transcribed verbatim, and analyzed using a qualitative descriptive approach.

RESULTS

Eight categories relating to the main content category of transition readiness were identified in the analysis. Several factors affected participant transition readiness: how the transition was introduced, perceived continuity of care, support from health care providers, clarity of the timeline throughout the transition, and desire for a "roadmap." Although all participants spoke about the effect of their relationships with health care providers (tertiary, transition, and primary care), their relationship with the primary care provider had the most influence on their transition readiness.

CONCLUSIONS

Our study provided insights into survivor experiences during the transition to primary care. Transition readiness of survivors is affected by many factors, with their relationship with the primary care provider being particularly influential. Understanding transition readiness from the survivor perspective could prove useful in ensuring patient-centred care as transitions from tertiary to primary care become commonplace.

Granulocyte colony-stimulating factor in secondary prophylaxis for advanced-stage Hodgkin lymphoma treated with ABVD chemotherapy: a cost-effectiveness analysis

Granulocyte colony-stimulating factor (G-CSF) is commonly administered to patients with Hodgkin lymphoma (HL) with neutropenia. We constructed a decision-analytic model to compare the cost-effectiveness of secondary prophylaxis with G-CSF to a strategy of 'no G-CSF' in response to severe neutropenia for adults with advanced-stage HL treated with ABVD. A Canadian public health payer's perspective was considered and costs were presented in 2013 Canadian dollars. The quality-adjusted life years (QALYs) attained with the G-CSF and 'no G-CSF' strategies were 1.403 and 1.416, respectively. Costs for the strategies with and without G-CSF were $38,971 and $33,982, respectively. In the base case analysis, the 'no G-CSF' strategy was associated with cost savings and improved QALYs; therefore, 'no G-CSF' was the dominant approach. For patients with severe neutropenia during ABVD chemotherapy for advanced-stage HL, a strategy without G-CSF support is associated with improved quality-adjusted outcomes, cost savings, and is the preferred approach.

Impact of country-specific EQ-5D-3L tariffs on the economic value of systemic therapies used in the treatment of metastatic pancreatic cancer

BACKGROUND

Previous Canadian cost-effectiveness analyses in cancer based on the EQ-5D-3L (EuroQoL, Rotterdam, Netherlands) have commonly used U.K. or U.S. tariffs because the Canadian equivalent only just recently became available. The implications of using non-Canadian tariffs to inform decision-making are unclear. We aimed to reevaluate an earlier cost-effectiveness analysis of therapies for metastatic pancreatic cancer (originally performed using U.S. tariffs) with tariffs from Canada and various other countries to determine the impact of using non-country-specific tariffs.

METHODS

We used tariffs from Canada, the United States, the United Kingdom, Denmark, France, Germany, Japan, the Netherlands, and Spain to derive EQ-5D-3L utilities for the 10 health states in the pancreatic cancer model. Quality-adjusted life years (qalys) and incremental cost-effectiveness ratios (icers) were generated, and probabilistic sensitivity analyses (psas) were performed.

RESULTS

Canadian utilities are generally lower than the corresponding U.S. utilities and higher than those for the United Kingdom. Compared with the Canadian-valued scenarios, U.S. and U.K. estimates were statistically different for 3 and 9 scenarios respectively. Overall, 35% of the non-Canadian utilities (28 of 80) were significantly different, clinically, from the Canadian values. Canadian qalys were 6% lower than those for the United States and 6% higher than those for the United Kingdom. When comparing the qalys of each treatment with those of gemcitabine alone, the average percent change was +6.8% for a U.S. scenario and -7.5% for a U.K. scenario compared with a Canadian scenario. Consequently, Canadian icers were approximately 5.4% greater than those for the United States and 8.6% lower than those for the United Kingdom. Based on the psas and compared with the Canadian threshold value, the minimum willingness-to-pay threshold at which the combination chemotherapy regimen of gemcitabine-capecitabine is the most cost-effective is $5,239 less than in the United States and $11,986 more than in the United Kingdom.

CONCLUSIONS

The use of non-country-specific tariffs leads to significant differences in the derived utilities, icers, and psa results. Past Canadian EQ-5D-3L-based cost-effectiveness analyses and related funding decisions might need to be re-visited using Canadian tariffs.

A population-based study of the epidemiology of pancreatic cancer: a brief report

OBJECTIVE

Administrative data are used to describe the pancreatic cancer (pcc) population. The analysis examines demographic details, incidence, site, survival, and factors influencing mortality in a cohort of individuals diagnosed with pcc.

METHODS

Incident cases of pcc diagnosed in Ontario between 1 January 2004 and 31 December 2011 were extracted from the Ontario Cancer Registry. They were linked by encrypted health card number to several administrative databases to obtain demographic and mortality information. Descriptive, bivariate, and survival analyses were conducted.

RESULTS

During the period of interest, 9221 new cases of pcc (4548 in men, 4673 in women) were diagnosed, for an age-adjusted standardized annual incidence in the range of 8.6-9.5 per 100,000 population. Mean age at diagnosis was 70.3 ± 12.5 years (standard deviation). Five-year survival was 7.2% (12.8% for those <60 years of age and 3.6% for those >80 years of age). Survival varied by sex, older age, rural residence, lower income, site of involvement in the pancreas, and presence of comorbidity.

CONCLUSIONS

The mortality rate in pcc is exceptionally high. With an increasing incidence and a mortality positively associated with age, additional support will be needed for this highly fatal disease as demographics in Ontario continue to trend toward a higher proportion of older individuals.

Health system costs for stage-specific breast cancer: a population-based approach

OBJECTIVE

The objective of the present analysis was to determine the publicly funded health care costs associated with the care of breast cancer (bca) patients by disease stage.

METHODS

Incident cases of female invasive bca (2005-2009) were extracted from the Ontario Cancer Registry and linked to administrative datasets from the publicly funded system. The type and use of health care services were stratified by disease stage over the first 2 years after diagnosis. Mean costs and costs by type of clinical resource used in the care of bca patients were compared with costs for a matched control group. The attributable cost for the 2-year time horizon was determined in 2008 Canadian dollars.

RESULTS

This cohort study involved 39,655 patients with bca and 190,520 control subjects. The average age in those groups was 61.1 and 60.9 years respectively. Most bca patients were classified as either stage i (34.4%) or stage ii (31.8%). Of the bca cohort, 8% died within the first 2 years after diagnosis. The overall mean cost per bca case from a public payer perspective in the first 2 years after diagnosis was $41,686. Over the 2-year time horizon, the mean cost increased by stage: i, $29,938; ii, $46,893; iii, $65,369; and iv, $66,627. The attributable cost of bca was $31,732. Cost drivers were cancer clinic visits, physician billings, and hospitalizations.

CONCLUSIONS

Costs of care increased by stage of bca. Cost drivers were cancer clinic visits, physician billings, and hospitalizations. These data will assist planning and decision-making for the use of limited health care resources.

Publication patterns of cancer cost-effectiveness studies presented at major conferences

OBJECTIVE

To be useful to policymakers and stakeholders, cost-effectiveness analyses (ceas) should be published in a timely manner and without bias. The aims of the present study were to examine the time between conference abstract presentation and subsequent publication, to determine the factors associated with time to publication, to evaluate potential publication bias, and to examine discrepancies in the results between abstract and publication.

METHODS

Abstracts of ceas presented at the annual meetings of the American Society of Clinical Oncology (asco), the American Society of Hematology (ash), and the International Society for Pharmacoeconomics and Outcomes Research (ispor) between 1997 and 2007 were reviewed. Time-to-event analysis was performed to assess the timeliness of publication and to examine factors associated with time to publication. Summary statistics were used to assess discrepancies in incremental cost-effectiveness ratios (icers) between abstract and publication.

RESULTS

Of 164 abstracts identified, 65 (39.6%) were subsequently published. The 1-, 2-, 3-, and 5-year publication rates were 12.8%, 25%, 34.2%, and 40.5% respectively. Abstracts were more likely to be published if presented at asco than at ispor (hazard ratio: 1.94; p = 0.038). There was no direct evidence of publication bias for abstracts with favourable icers. Comparing icers between abstracts and publications, the mean absolute difference was 23.8%; 50% of studies had a change in icer exceeding 10%.

CONCLUSIONS

Publication rates for ceas were low, and publication was not timely with respect to informing the decision-making process for funding. Abstract results often differed from publication results and cannot reliably be used in the decision-making process for funding.

Effects of built environment on walking among Hong Kong older adults

1. Reliable and valid interviewer-administered questionnaires were developed to investigate associations of perceived neighbourhood attributes of Hong Kong older adults with their walking for transportation and recreation. 2. Access to and availability of different types of services and destinations, provision of facilities for resting/sitting in the neighbourhood, and easy access to/from residential buildings may help maintain an active lifestyle by facilitating walking for transport in the neighbourhood. 3. Access to services, indoor places for walking, environmental aesthetics, low traffic, and absence of physical barriers may promote recreational walking..

Cost-effectiveness of systemic therapies for metastatic pancreatic cancer

PURPOSE

Gemcitabine and capecitabine (gem-cap), gemcitabine and erlotinib (gem-e), and folfirinox (5-fluorouracil-leucovorin-irinotecan-oxaliplatin) are new treatment options for metastatic pancreatic cancer, but they are also more expensive and potentially more toxic than gemcitabine alone (gem). We conducted a cost-effectiveness analysis of these treatment options compared with gem.

METHODS

A Markov model was constructed to examine costs and outcomes of gem-cap, gem-e, folfirinox, and gem in patients with metastatic pancreatic cancer from the perspective of a government health care plan. Ontario health economic and costing data (2010 Canadian dollars) were used. Efficacy data for the treatments were obtained from the published literature. Resource utilization data were derived from a chart review of consecutive metastatic patients treated for pancreatic cancer at Princess Margaret Hospital, Toronto, Ontario, 2008-2009, and supplemented with data from the literature. Utilities were obtained by surveying medical oncologists across Canada using the EQ-5D. Incremental cost-effectiveness ratios (icers) were calculated.

RESULTS

The icers for gem-cap, gem-e, and folfirinox compared with gem were, respectively, CA$84,299, CA$153,631, and CA$133,184 per quality-adjusted life year (qaly). The model was driven mostly by drug acquisition costs. Given a willingness-to-pay (wtp) threshold greater than CA$130,000/qaly, folfirinox was most cost-effective treatment. When the wtp threshold was less than CA$80,000/qaly, gem alone was most cost-effective. The gem-e option was dominated by the other treatments.

CONCLUSIONS

The most cost-effective treatment for metastatic pancreatic cancer depends on the societal wtp threshold. If the societal wtp threshold were to be relatively high or if drug costs were to be substantially reduced, folfirinox might be cost-effective.

Population-based home care services in breast cancer: utilization and costs

OBJECTIVE

To determine utilization and costs of home care services (hcs) for individuals with a diagnosis of breast cancer (bc).

METHODS

Incident cases of invasive bc in women were extracted from the Ontario Cancer Registry (2005-2009) and linked with other Ontario health care administrative databases. Control patients were selected from the population of women never diagnosed with any type of cancer. The types and proportions of hcs used were determined and stratified by disease stage. Attributable home care utilization and costs for bc patients were determined. Factors associated with hcs costs were assessed using regression analysis.

RESULTS

Among the 39,656 bc and 198,280 control patients identified (median age: 61.6 years for both), 75.4% of bc patients used hcs (62.1% stage i; 85.7% stage ii; 94.6% stage iii; 79.1% stage iv) compared with 14.6% of control patients. The number of hcs used per patient-year were significantly higher for the bc patients than for the control patients (14.97 vs. 6.13, p < 0.01), resulting in higher costs per patient-year ($1,210 vs. $325; $885 attributable cost to bc, p < 0.01). The number of hcs utilized and the associated costs increased as the bc stage increased. In contrast, hcs costs decreased as income increased and as previous health care exposure decreased.

INTERPRETATION

Patients with bc used twice as many hcs, resulting in costs that were almost 4 times those observed in a matched control group. Less than an additional $1000 per bc patient per year were spent on hcs utilization in the study population.

Inflammation, organomegaly, and muscle wasting despite hyperphagia in a mouse model of burn cachexia

BACKGROUND

Burn injury results in a chronic inflammatory, hypermetabolic, and hypercatabolic state persisting long after initial injury and wound healing. Burn survivors experience a profound and prolonged loss of lean body mass, fat mass, and bone mineral density, associated with significant morbidity and reduced quality of life. Understanding the mechanisms responsible is essential for developing therapies. A complete characterization of the pathophysiology of burn cachexia in a reproducible mouse model was lacking.

METHODS

Young adult (12-16 weeks of age) male C57BL/6J mice were given full thickness burns using heated brass plates or sham injury. Food and water intake, organ and muscle weights, and muscle fiber diameters were measured. Body composition was determined by Piximus. Plasma analyte levels were determined by bead array assay.

RESULTS

Survival and weight loss were dependent upon burn size. The body weight nadir in burned mice was 14 days, at which time we observed reductions in total body mass, lean carcass mass, individual muscle weights, and muscle fiber cross-sectional area. Muscle loss was associated with increased expression of the muscle ubiquitin ligase, MuRF1. Burned mice also exhibited reduced fat mass and bone mineral density, concomitant with increased liver, spleen, and heart mass. Recovery of initial body weight occurred at 35 days; however, burned mice exhibited hyperphagia and polydipsia out to 80 days. Burned mice had significant increases in serum cytokine, chemokine, and acute phase proteins, consistent with findings in human burn subjects.

CONCLUSIONS

This study describes a mouse model that largely mimics human pathophysiology following severe burn injury. These baseline data provide a framework for mouse-based pharmacological and genetic investigation of burn-injury-associated cachexia.

Primary gastrointestinal tract lymphoma in the pediatric patient: review of 265 patients from the SEER registry

OBJECTIVE

The objective of this study is to determine outcomes of pediatric patients with primary gastrointestinal tract lymphoma (PGTL) and the impact of surgery or radiation on survival.

METHODS

The Surveillance, Epidemiology, and End Result database was queried from 1973 to 2006 for patients younger than 20 years with PGTL.

RESULTS

265 patients with PGTL were identified. Overall 5- and 10-year survivals were 84% and 83%, respectively. Tumors of the stomach (9%) and rectum/anus (2%) had the worst and best 10-year survivals, respectively (59% vs 100%, P = .023). There was no significant difference in 10-year survival for patients younger than 10 years of age who had surgical extirpation (83% vs 85% no surgery, P = .958) or radiotherapy (76% vs 85% no radiotherapy, P = .532). However, there was a significantly decreased 10-year survival in patients 10 years or older who had surgical extirpation (79% vs 100% no surgery, P = .013) or radiotherapy (49% vs 87% no radiotherapy, P = .001). Under multivariate analysis, tumor location was an independent predictor of improved survival (small bowel, HR 0.21, P = .002; large bowel, HR 0.23, P = .004).

CONCLUSION

We found no significant survival advantage for surgical extirpation or radiotherapy in patients younger than 10 years with PGTL, whereas either treatment modality was associated with lower survival in patients 10 years or older.

Percutaneous lavage as primary treatment for infected pancreatic necrosis

BACKGROUND

The classic treatment of infected pancreatic necrosis (IPN) is surgical debridement and drainage. This study reviews our experience with nonoperative percutaneous catheter drainage and serial lavage as primary treatment in patients with IPN.

STUDY DESIGN

Between 1993 and 2009, a prospective nonselected series of 63 consecutive patients with microbiologically confirmed IPN were enrolled with the intent of treating them nonoperatively, and they were retrospectively analyzed. Catheters were placed percutaneously in the interventional radiology (IR) suite, and were used to lavage and debride the necrosis 1-3 times per week. The lavages continued on an outpatient basis by IR, and the catheters were removed with disease resolution.

RESULTS

One patient rapidly became unstable and had to be taken primarily for open debridement. In the remaining 62 patients, 57 survived, for an overall mortality rate of 8%. Fifty patients were treated solely with percutaneous lavage, and 47 survived. Mean hospital length of stay was 61 days, ranging from 6 to 190 days. Mean length of outpatient treatment was 42 days, ranging from 3 to 180 days. Mean number of lavages was 21, ranging from 11 to 75. Eleven patients (18%) deteriorated during percutaneous treatment and required laparotomy, and 9 of these survived. One patient treated percutaneously resolved his sepsis but had a persistent pancreatic fistula and was managed with pancreaticojejunostomy.

CONCLUSIONS

Percutaneous catheter drainage and serial lavage are an effective alternative to open surgical debridement in patients with IPN. Overall survival is excellent, and most patients avoid the morbidity of open debridement. A minority of patients deteriorate, but most of those can be salvaged with open drainage.

Obesity and weight loss at presentation of lung cancer are associated with opposite effects on survival

BACKGROUND

Lung cancer is the second most common neoplasm and the leading cause of cancer deaths in the United States. In cancer, weight loss and obesity are associated with reduced survival. However, the effect of obesity or weight loss at presentation on lung cancer survival has not been well studied.

MATERIALS AND METHODS

Using an extensive cancer dataset, we identified 76,086 patients diagnosed with lung cancer during the period of 1998-2002, of which 14,751 patients presented with obesity and/or weight loss. We examined the relationship between survival and weight loss or obesity at diagnosis using univariate and multivariate analysis.

RESULTS

Median survival time (MST) for all lung cancer patients was 8.7 mo. Patients presenting with weight loss (15.8%) had shorter MST versus those who did not (6.4 versus 9.2 mo, P < 0.001) and patients with weight loss had significantly shortened MST for all stages and histologic subtypes. In contrast, obese patients at presentation (5.4%) had longer MST relative to non-obese patients (13.0 versus 8.6 mo, P < 0.001), which was significant across all stages and histologic subtypes. Multivariate analysis revealed that the absence of weight loss was an independent, positive predictor of improved survival (HR = 0.087, P < 0.001), while the absence of obesity was an independent predictor of worsened survival in lung cancer (HR = 1.16, P < 0.001).

CONCLUSIONS

Our results demonstrate an inverse relationship between survival and weight loss at presentation and a potentially protective effect of obesity in lung cancer survival, which could be due to greater physiologic reserves, thereby prolonging life by slowing the progress of cancer cachexia.

Rhabdomyosarcoma in children: a SEER population based study

OBJECTIVE

To examine incidence and outcomes for pediatric rhabdomyosarcoma (RMS).

METHODS

The SEER registry was examined for patients with RMS < 20 y old.

RESULTS

Overall, 1544 patients were identified for an incidence of 0.4414/100,000 per year. Males outnumbered females 3:2. Tumors were classified as embryonal (67%), alveolar (32%), and pleomorphic (1%). Alveolar and pleomorphic RMS were more common in adolescents, whereas embryonal type was more common in younger children (P = 0.0001). Pleomorphic (47%) and alveolar (39%) RMS commonly presented with distant disease, in contrast to embryonal (25%). Most patients had surgical resection (81%) and radiotherapy (63%). Overall, 5- and 10-y survival was 60% and 57%, respectively. Univariate analysis identified higher survival for age < 10 y, local stage, favorable site, embryonal type, <5 cm tumor size, and surgical resection. Multivariate analysis identified non-embryonal type (HR 1.451), non-favorable site (HR 1.570), no surgery (HR 1.726), age ≥ 10 y (HR 1.734), 1973-1978 diagnosis year (HR 1.730), and distant disease (HR 3.456) as independent predictors of mortality.

CONCLUSIONS

Embryonal histology, the most common type of pediatric RMS, presents in young children and has better prognosis than alveolar or pleomorphic types. Patients with embryonal tumors, favorable tumor location, age < 10 y, localized disease, and surgical resection have improved survival.

Does Children's Oncology Group hospital membership improve survival for patients with neuroblastoma or Wilms tumor?

PURPOSE

To determine prognostic significance of hospital surgical volume and Children's Oncology Group (COG) membership on neuroblastoma (NBL) and Wilms tumor (WT) survival.

METHODS

The Florida Cancer Data System was queried from 1981 to 2004.

RESULTS

Of 869 NBL patients, 463 were treated at COG/HVC, 246 at COG/LVC, and 160 at non-COG/LVC. COG hospitals treated a larger proportion of patients <1 year of age (P = 0.002) and relatively more patients with adrenal and mediastinal tumors (P = 0.005). COG centers more frequently administered chemotherapy (72% vs. 51%, P < 0.001). Five- and 10-year survival rates were higher at COG/HVC (70.6%, 67.7%) and COG/LVC (75.8%, 72.6%) than non-COG/LVC (59.5%, 54.4%, P < 0.05). Of 790 WT patients, 395 were treated at COG/HVC, 210 at COG/LVC, and 185 at non-COG/LVC. COG hospitals treated younger patients and lower staged tumors (P < 0.05). COG centers more frequently administered chemotherapy (88% vs. 59%, P < 0.001). Five- and 10-year survival rates were higher at COG/HVC (91.3%, 89.9%) and COG/LVC (96.7%, 94.7%) than non-COG/LVC (82.4%, 81.7%, P < 0.05). Multivariate analysis demonstrated WT patients treated at non-COG hospitals, but not NBL patients, had worse survival (HR 3.107, P = 0.01).

CONCLUSION

Children treated at COG hospitals had higher overall use of chemotherapy. This translated into a significantly improved survival benefit for WT.

Do all patients with carcinoma of the esophagus benefit from treatment at teaching facilities?

BACKGROUND

We sought to determine whether patients with esophageal carcinoma benefit from regionalization of care.

METHODS

The Florida Cancer Data System (FCDS) and the Agency for Health Care Administration data sets (1998-2002) were merged and queried.

RESULTS

A total of 5,041 patients (87.6% Caucasian vs. 11.1% African American (AA)) demonstrated a median survival time of 9.8 months overall and 23.4 months following surgical resection (P < 0.001). Adenocarcinoma arose predominantly in Caucasian patients (98.1%). Patients with adenocarcinoma (n = 2,248) derived a treatment benefit at a TF (HR = 1.35, P = 0.003), including an improved 90-day mortality following surgery (2.1% vs. 4.0%, P < 0.001). Squamous cell carcinoma (SCC) arose predominantly in AA patients (91.6%). No overall survival benefit at TF was observed (HR = 1.01, P = 0.915), however a trend for reduced 90-day surgical mortality was observed at TF (1.9% vs. 5.2%, P = 0.062). Multivariate analysis for adenocarcinoma demonstrates that poverty, lack of chemotherapy or surgery, and failure to provide treatment at a TF are independent predictors of worse survival. For SCC patients, AA race was a significant predictor of poorer survival while TF and poverty level were not.

CONCLUSIONS

These data suggest no benefit from potential regionalized care for patients with squamous histology, which disproportionately affects AA.

Survival disparities in newborns with congenital diaphragmatic hernia: a national perspective

PURPOSE

The aim of the study was to examine national outcomes for congenital diaphragmatic hernia (CDH).

METHODS

We analyzed the Kids' Inpatient Database for patients admitted at less than 8 days of age.

RESULTS

Overall, 2774 hospitalizations were identified. Most patients were white and had private insurance. Most patients were treated at urban (96%), teaching (75%), and not identified as children's hospital (NIACH) (50%). Birth was the most common admission source at NIACH (91%) and children's unit in general hospital (CUGH) (59%), compared to hospital transfer at children's general hospital (CGH) (81%). Most CDH were repaired through the abdomen (81%), and 25% required extracorporeal membrane oxygenation (ECMO). Most NIACH patients were transferred to another hospital, whereas most at CGH and CUGH were discharged home. Survival to discharge was 66% after excluding hospital transfers. Univariate analysis revealed higher survival for males, birth weight (BW) of 3 kg or more, whites, patients with private insurance, and those in the highest median household income quartile. Survival was 86% after CDH repair but 46% for ECMO. Multivariate analysis identified black race (hazard ratio [HR], 1.536; P = .03) and other race (HR, 1.515; P = .03) as independent predictors of mortality.

CONCLUSIONS

Hospital survival for CDH is related to sex, BW, race, and socioeconomic status. Blacks and other non-Hispanic minorities have higher mortality rates.

Osteosarcoma: improvement in survival limited to high-grade patients only

BACKGROUND

We sought to identify the significant prognostic parameters of patients with osteosarcoma over the past three decades using a population-based registry.

METHODS

A total of 3765 patients with osteosarcoma were identified in the SEER database. Information regarding patient demographics, clinical and treatment characteristics, cause of death and survival were extracted. Kaplan-Meier, Log-Rank, and Cox regression were used for analysis.

RESULTS

On multivariate analysis only age group '<25 years', 'local' stage and 'low' grade, 'appendicular skeleton' and employment of 'surgical resection' showed a disease-specific survival benefit with a P value < 0.001. The long-term survival improved in the interval from 1973 to 1985 from approximately 55 to 65% but subsequent improvement has been limited only to patients with high-grade disease.

CONCLUSION

When comparing survival rates by decade of diagnosis, it appears that improvement in survival since 1985 is limited to patients with high-grade disease only.

LEVEL OF EVIDENCE

The level of evidence for this article is 2.

Do racial or socioeconomic disparities exist in lung cancer treatment?

BACKGROUND

Determine the effects of race, socioeconomic status, and treatment on outcomes for patients diagnosed with lung cancer.

METHODS

The Florida cancer registry and inpatient and ambulatory data were queried for patients diagnosed from 1998-2002.

RESULTS

A total 76,086 of lung cancer patients were identified. Overall, 55.6% were male and 44.4% were female. The demographic distribution of patients was 92.7% Caucasian, 6.7% African American, and 5.7% Hispanic. The mean age of diagnosis was 70 years old. African American patients presented at a younger age, with more advanced disease, and were less likely to undergo surgical therapy than their Caucasian counterparts. Median survival time (MST) for the entire cohort was 8.7 months, while MST for African American patients was 7.5 months. Patients who received surgery, chemotherapy, or radiation therapy demonstrated significantly improved outcomes. Stepwise multivariate analysis revealed that African American race was no longer a statistically significant predictor of worse outcomes once corrections were made for demographics and comorbid conditions, suggesting that the originally reported disparities in lung cancer outcomes and race may be in part because of poor pretreatment performance status. In contrast, patients of the lowest socioeconomic status continue to have a slightly worse overall prognosis than their affluent counterparts (hazard ratio = 1.05, P = .001).

CONCLUSIONS

Lung cancer continues to carry a poor prognosis for all patients. Once comorbidities are corrected for, African American patients carry equivalently poor outcomes. Nonetheless, emphasis must be placed on improving pretreatment performance status among African American patients and efforts for earlier diagnosis among the impoverished patients must be made.

Incidence and outcomes of extremity soft-tissue sarcomas in children

BACKGROUND

We studied the outcomes of pediatric extremity tumors on a population scale.

METHODS

The Surveillance, Epidemiology, and End Results database (1973-2006) was queried for all patients under 20 y of age.

RESULTS

Overall, 1175 patients were identified. The median age at diagnosis was 12 y, but most patients were ≥10 y of age (72%, n = 842). Most tumors were non-rhabdomyosarcoma soft tissue sarcomas (NRSTS) (79%, n = 879). The most common tissue of origin was muscle (43%, n = 474). Most rhabdomyosarcoma (RMS) (n = 220) were alveolar type (n = 140). Most patients presented with local disease (64%, n = 699), and underwent surgical intervention (88%, n = 1027), but did not have radiotherapy (62%, n = 710). RMS was more likely to present in younger children (P < 0.001) and with distant disease (P < 0.001). Older patients were more likely to receive radiotherapy than infants (P < 0.001). Overall 5-y survival was 79%. RMS had significantly worse 5-y survival (56% versus 85% for NRSTS, P < 0.001). Surgical intervention was associated with higher 5-y survival (84% versus 48%, P < 0.001). Radiotherapy was associated with worse 5-y survival (74% versus 83%, P = 0.002). Multivariate analysis identified RMS (HR 2.20, P < 0.001), nerve and muscle (not synovial sarcoma) tissue of origin (HR 2.26, P = 0.002, and HR 1.59, P = 0.036), regional or distant disease (HR 1.65, P = 0.011, and HR 5.96, P < 0.001, respectively), and lack of surgical intervention (HR 2.20, P < 0.001) as independent predictors of poor outcome.

CONCLUSIONS

Extremity sarcomas are most common in older children. RMS is more common in younger children, but is associated with lower survival, and is an independent prognostic indicator of mortality.

Pediatric non-Wilms renal tumors: subtypes, survival, and prognostic indicators

BACKGROUND

To determine the outcomes and predictors of survival for pediatric non-Wilms renal tumors (NWRT).

METHODS

The SEER database (1973-2005) was queried for all patients < 20 y of age.

RESULTS

Overall, 349 cases of NWRT were identified. The major histologic groups included renal cell carcinoma (RCC) (44%), clear cell sarcoma of the kidney (CCSK) (17%), and malignant rhabdoid tumor (MRT) (12%). A bimodal age distribution was observed, with tumors commonly presenting in patients ≤4 y of age and ≥15 y of age. More than 50% of RCC presented at ≥15 y of age, whereas ≥80% of CCSK or MRT patients were ≤4 y of age. Most RCC (57%) and CCSK (53%) were locally staged while most MRT presented with distant disease (51%, P < 0.001). Overall 10-y survival was 63% with improved survival observed in patients with CCSK (79%) and RCC (70%) versus MRT (29%, P < 0.001). By univariate analysis, surgical resection was associated with improved overall 10-y survival (68% versus 30%, P < 0.001), while no benefit was observed for radiotherapy (60% versus 63%, P = 0.8). By multivariate analysis, worse overall survival was observed for patients ≥ 10 y old (HR 4.01, P = 0.013) and those with advanced disease (HR = 12.78, P < 0.001). Patients with MRT (HR = 11.61, P < 0.001) and CCSK (HR = 3.68, P = 0.038) had significantly worse prognosis compared with those with RCC. Surgical resection improved overall survival (HR = 0.36, P = 0.001).

CONCLUSION

For pediatric NWRT, younger patients and those with RCC have improved survival, while a diagnosis of MRT portends a worse prognosis. Surgical extirpation significantly improves survival for all patients.

Perspective: PhD scientists completing medical school in two years: looking at the Miami PhD-to-MD program alumni twenty years later

Producing and retaining physician-scientists remains a major challenge in advancing innovation, knowledge, and patient care across all medical disciplines. Various programs during medical school, including MD-PhD programs, have been instituted to address the need for continued production of physician-scientists. From 1971 through 1989, 508 students with a prior PhD in the sciences, mathematics, or engineering graduated in two years from an accelerated MD program at the University of Miami School of Medicine. The program, designed to address potential clinical physician shortages rather than physician-scientist shortages, quickly attracted many top-notch scientists to medicine. Many program graduates went to top-tier residencies, pursued research careers in academic medicine, and became academic leaders in their respective fields. A retrospective examination of graduates conducted in 2008-2009 demonstrated that approximately 59% took positions in academic university medical departments, 3% worked for governmental agencies, 5% entered industry as researchers or executives, and 33% opted for private practice. Graduates' positions included 85 full professors, 11 university directors or division heads, 14 academic chairs, 2 medical school deans, and 1 astronaut. Overall, 30% of graduates had obtained National Institutes of Health funding after completing the program. These results suggest that accelerated medical training for accomplished scientists can produce a large number of successful physician-scientists and other leaders in medicine. Furthermore, these results suggest that shortening the medical portion of combined MD-PhD programs might also be considered.

Are patients of low socioeconomic status receiving suboptimal management for pancreatic adenocarcinoma?

BACKGROUND

The objective of this study was to define the effects of socioeconomic status (SES) and other demographic variables on outcomes for patients with pancreatic adenocarcinoma.

METHODS

Florida cancer registry and inpatient hospital data were queried for pancreatic adenocarcinoma diagnosed from 1998 to 2002.

RESULTS

In total, 16,104 patients were identified. Low SES (LSES) patients were younger at diagnosis (P < .001) but presented with similar disease stage and tumor grade. LSES patients were less likely to receive surgical extirpation (16.5% vs 19.8%; P < .001), chemotherapy (30.7% vs 36.4%; P < .001), or radiotherapy (14.3% vs 16.9%; P = .003). Among surgical patients, 30-day mortality was significantly higher (5.1% vs 3.7%; P < .001) and overall median survival was significantly worse (5.0 months vs 6.2 months; P < .001) in the LSES cohorts. Although surgical patients who were treated at teaching facilities (TF) did significantly better; an increased 30-day surgical mortality (2.2% vs 1.3%; P < .001) and decreased median survival (5 months for poverty level >15% vs 6.2 months for poverty level <5%; P < .001) also were observed for patients of LSES. In a multivariate analysis that corrected for patient comorbidities, significant independent predictors of a poorer prognosis included LSES (hazard ratio [HR], 1.09); treatment at a non-TF (HR, 1.09); and failure to receive surgical extirpation (HR, 1.92), chemotherapy (HR 1.41), or radiation (HR 1.25).

CONCLUSIONS

Patients of LSES were less likely to receive surgical extirpation, chemotherapy, or radiation and had significantly higher perioperative and long-term mortality rates. A greater understanding of the barriers to providing optimal care and identifying means for improving successful delivery of therapies to the poor with pancreatic cancer are needed.

A comprehensive analysis of parotid and salivary gland cancer: worse outcomes for male gender

BACKGROUND

To determine the effects of patient demographics, socioeconomic status (SES) and clinical variables on outcomes for patients with salivary and parotid gland tumors.

METHODS

Florida cancer registry and inpatient hospital data were queried for cancer of the salivary glands diagnosed between 1998-2002.

RESULTS

A total of 1573 patients were identified. Women were diagnosed at a younger age (median age (years): women 60.8 versus men 64.3, P=0.003). Men were more often diagnosed with high grade tumors (65.1% versus 41.9% for women, P<0.001) and advanced disease stage (>stage III: 60.2 versus 49.4%, P<0.001), but underwent surgical extirpation and received radiation at equal rates compared with women. Overall 5-year survival rates was superior in women (67.4% versus 55.6%, P=0.001). By multivariate analysis, adjusted for patient comorbidities, age over 65 (HR 3.43 P=0.008), advanced disease stage (HR 8.05 P<0.001), and high tumor grade (HR 2.33, P<0.001) were independent predictors of worse prognosis. Improved outcomes were observed for female gender (HR 0.68, P=0.011). Tumors located in the parotid gland (HR 0.631 P=0.003) and receiving both surgical extirpation and radiation were predictors of improved survival.

CONCLUSION

Salivary gland tumors carry a worse prognosis than tumors of the parotid. Male patients have worse outcomes.

Does chemoradiotherapy improve outcomes for surgically resected adenocarcinoma of the stomach or esophagus?

BACKGROUND

To use a population-based registry to evaluate the effect of chemotherapy or radiation on survival for patients undergoing curative-intent surgery for adenocarcinoma of the esophagus or stomach.

METHODS

A linked data set between the Florida Cancer Data System and the Florida Agency for Health Care Administration from 1998 to 2003 was queried.

RESULTS

Overall, 3,378 patients underwent surgical extirpation with curative intent, 636 patients had esophageal adenocarcinoma (EAC), and 2,742 patients had gastric adenocarcinoma (GAC). Outcomes were adjusted for patient comorbidities and hospital teaching status. Overall, no benefit was observed for adjuvant therapies for EAC patients. A small improvement in survival was observed with adjuvant therapies for GAC. For localized EAC or GAC there was no additional survival benefit associated with adjuvant therapies. For patients with regional EAC, chemotherapy (20.0 vs. 13.0 months, P < .001) and radiation (18.6 vs. 13.5 months, P = .007) were associated with a statistically significant survival benefit. In multivariate analysis, independent predictors of improved survival for regional EAC include chemotherapy (hazard ratio [HR] .535, P < .001) and radiotherapy (HR .656, P = .01). For GAC, patients with regional disease showed an improved median survival with chemotherapy (21.1 vs. 11.2 months, P < .001) and radiotherapy (22.6 vs. 12.3 months, P < .001). In multivariate analysis, independent predictors of improved survival for regional GAC include chemotherapy (HR .629, P < .001) and radiation (HR .603, P < .001).

CONCLUSIONS

Patients with regional adenocarcinoma of the esophagus or stomach, but not those with localized disease, derive a statistically significant survival benefit from the addition of chemotherapy and radiation to surgical resection.

Ewing sarcoma demonstrates racial disparities in incidence-related and sex-related differences in outcome: an analysis of 1631 cases from the SEER database, 1973-2005

BACKGROUND

Previous reports of Ewing sarcoma cohorts suggested that there is a difference in incidence according to racial origin. However, to the authors' knowledge, this finding has never been tested in a population-based database, and the impact of race on clinical outcome and the significance of known risk factors stratified to racial groups have not been reported.

METHODS

Patients who had Ewing sarcoma diagnosed between 1973 and 2005 were identified in the Surveillance, Epidemiology, and End Results database. Patient demographic and clinical characteristics; incidence; year of diagnosis; tumor location, tumor size, and disease stage at diagnosis; treatment(s); cause of death; and survival were extracted. Kaplan-Meier, log-rank, and Cox regressions were used to analyze the significance of prognostic factors.

RESULTS

Race-specific incidence indicated that Caucasians have the highest incidence (0.155), followed by Asians/Pacific Islanders (0.082), and African Americans (0.017). The difference in incidence between Caucasians and African Americans was 9-fold and significant (P<.001). The incidence of Ewing sarcoma increased over the past 3 decades among Caucasians (P<.05). Survival was not impacted by race. Local disease stage, primary tumor location in the appendicular skeleton, and tumor size<or=8 cm conferred a significant survival benefit. Women demonstrated improved survival among the Caucasian patients (P<.03).

CONCLUSIONS

To the authors' knowledge, this is the first report focusing on racial disparity in incidence of Ewing sarcoma. Caucasians were affected more frequently, although outcomes were similar between races. It is noteworthy that being a woman constituted a survival benefit only among the Caucasian patients. Further studies will need to clarify the reasons for racial disparities in incidence and for sex differences in survival.

Surgery does not adversely affect survival in primary gastrointestinal lymphoma

OBJECTIVE

To evaluate the impact of surgery on gastrointestinal lymphoma.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried from 1973 to 2005.

RESULTS

A total of 17,222 cases of PGIL were identified. The overall incidence of PGIL was approximately 1.505 cases per 100,000. A significantly increasing incidence for PGIL was observed (APC = +4.67, P < 0.05). In the cases for which treatment data was available, resection occurred in roughly half of the patients. In univariate analysis, surgical extirpation did not improve survival (47 months vs. 76 months, P < 0.001), while radiation treatment improved median survival (77 months vs. 59 months, P < 0.001). Multivariate analysis revealed increasing age and male gender as independent predictors of decreased overall survival. Tumor location also was a significant predictor of outcome. Large B-cell lymphoma type PGIL had a poorer prognosis than marginal zone B-cell lymphoma. By multivariate analysis, surgery was not found to increase the risk of death (HR = 0.99).

CONCLUSIONS

No associated survival benefit for surgery in the treatment in gastrointestinal lymphoma was observed. Determination of lymphoma should preclude surgical resection. Nonetheless, inadvertent extirpative surgery or in association with perforation does not appear to increase mortality.

Outcomes of malignant CNS ependymomas: an examination of 2408 cases through the Surveillance, Epidemiology, and End Results (SEER) database (1973-2005)

BACKGROUND

Determine the role of surgery and radiation therapy for patients with malignant CNS ependymomas.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database (1973-2005) was queried.

RESULTS

Overall, a total of 2408 cases of malignant ependymomas were identified. Of these, 2132 cases (88.5%) were identified as WHO grade II ependymomas and 276 cases (11.5%) as WHO grade III (anaplastic) ependymomas. The annual incidence of ependymomas was approximately 1.97 cases per million in 2005. Overall median survival for all patients was 230 mo, with a significant difference between women and men (262 mo versus196 mo, respectively) (P=0.004). Median age at diagnosis was 37 y among females and 34 y in males. Patients who successfully underwent surgical resection had a considerably longer median survival (237 mo versus 215 mo, P<0.001) as well as a significantly improved five-year survival (72.4% versus 52.6%, P<0.001). Univariate analysis demonstrated that age, gender, ethnicity, primary tumor site, WHO grade and surgical resection were significant predictors of improved survival for ependymoma patients. Multivariate analysis identified that a WHO grade III tumor, male gender, patient age, intracranial tumor locations and failure to undergo surgical resection were independent predictors of poorer outcomes. Multivariate analysis of partially resection cases revealed that lack of radiation was a sign of poor prognosis (HR 1.748, P=0.024).

CONCLUSION

Surgical extirpation of ependymomas is associated with significantly improved patient survival. For partially resected tumors, radiation therapy provides significant survival benefit.

Pediatric FAST and elevated liver transaminases: An effective screening tool in blunt abdominal trauma

BACKGROUND

The current standard for the evaluation of children with blunt abdominal trauma (BAT) consists of physical examination, screening lab values, and computed tomography (CT) scan. We sought to determine if the focused assessment with sonography for trauma (FAST) combined with elevated liver transaminases (AST/ALT) could be used as a screening tool for intra-abdominal injury (IAI) in pediatric patients with BAT.

METHODS

Registry data at a level 1 trauma center was retrospectively reviewed from 1991-2007. Data collected on BAT patients under the age of 16 y included demographics, injury mechanism, ISS, GCS, imaging studies, serum ALT and AST levels, and disposition. AST and ALT were considered positive if either one was >100 IU/L.

RESULTS

Overall, 3171 cases were identified. A total of 1008 (31.8%) patients received CT scan, 1148 (36.2%) had FAST, and 497 (15.7%) patients received both. Of the 497 patients, 400 (87.1%) also had AST and ALT measured. FAST was 50% sensitive, 91% specific, with a positive predictive value (PPV) of 68%, negative predictive value (NPV) of 83%, and accuracy of 80%. Combining FAST with elevated AST or ALT resulted in a statistically significant increase in all measures (sensitivity 88%, specificity 98%, PPV 94%, NPV 96%, accuracy 96%).

CONCLUSIONS

FAST combined with AST or ALT > 100 IU/L is an effective screening tool for IAI in children following BAT. Pediatric patients with a negative FAST and liver transaminases < 100 IU/L should be observed rather than subjected to the radiation risk of CT.

Thrombotic cutaneous gangrene with autoamputation of the penis: a rare extracolonic manifestation of ulcerative colitis in a child

We present a pediatric patient with ulcerative colitis who developed thrombotic cutaneous gangrene involving skin of the lower chest, abdomen, back, bilateral buttocks, bilateral thighs, perineum, and genitalia, ultimately resulting in autoamputation of the glans penis. After an extensive review of the literature, we describe the diagnosis and management of this devastating condition.

African-American and low-socioeconomic status patients have a worse prognosis for invasive ductal and lobular breast carcinoma: do screening criteria need to change?

BACKGROUND

Determine the effect of race, socioeconomic status (SES) and other demographic variables on outcomes of patients with invasive ductal and lobular breast cancer.

STUDY DESIGN

Florida cancer registry and inpatient hospital data were queried for patients diagnosed with invasive breast cancer from 1998 to 2002.

RESULTS

A total of 63,472 patients with breast cancer were identified. Overall, 90.5% of patients were Caucasian, 7.6% African American, and 8.7% Hispanic. African-American patients presented at a younger age and with more-advanced disease, 10.5% presented with breast cancer before the age of 40 years, and 22.4% before 45 years of age. African-American patients were less likely to undergo operations. Similarly, low-SES patients were less likely to have operations and presented more often with larger tumors. Stepwise multivariate analysis revealed a substantial drop in the hazard ratio for African-American patients once correction for stage of presentation was made, suggesting that disparities in breast cancer outcomes are, in part, a result of advanced stage at presentation. Race and low SES were independent predictors of worse prognosis when controlling for patient comorbidities and treatment.

CONCLUSIONS

Dramatic disparities by patient race and SES exist in breast cancer. Our study integrates previous smaller studies, providing comprehensive insight into African-American patients and their outcomes for breast cancer. Earlier screening programs and greater access to cancer care for the poor and African Americans are needed. Successful institution of such programs will not completely erase disparities in outcomes for breast cancer in African-American patients.