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Prior studies of fragmentation of care in pancreatic cancer have not adjusted for indicators of hospital quality such as Commission on Cancer accreditation. The effect of fragmentation of care has not been well defined. We queried the National Cancer Database to identify patients undergoing pancreaticoduodenectomy and distal pancreatectomy with perioperative systemic therapy for clinical stages I–III pancreatic cancer between 2006 and 2019. Patients who received systemic therapy at a center different than the center performing surgery were categorized as having fragmentation of care. Patients having fragmentation of care were further categorized on the basis of whether (fragmentation of care Commission on Cancer) or not (fragmentation of care non-Commission on Cancer) systemic therapy was administered at a facility accredited by the Commission on Cancer. A total of 11,732 patients met inclusion criteria; 5,668 (48.3%) underwent fragmentation of care, and 3,426 (29.2%) fragmentation of care non-Commission on Cancer. Patients undergoing fragmentation of care non-Commission on Cancer were less likely to receive neoadjuvant systemic therapy than those undergoing fragmentation of care Commission on Cancer or non-fragmented care (27.7% vs 40.1% vs 36.8%, P <.001). On Cox analysis, advanced age, comorbid disease, node-positive disease, and facility type were associated with risk of overall survival. Fragmentation of care was not (adjusted hazard ratio = 0.99, 95% confidence interval [0.94–1.06], P =.8). On Kaplan-Meier analysis, there were no significant differences in 5-year overall survival between treatment cohorts. In patients undergoing fragmentation of care for localized pancreatic cancer, those treated with systemic therapy in Commission on Cancer accredited facilities are more likely to be given neoadjuvant therapy but demonstrate no significant improvement in survival relative to those undergoing non-fragmented care or those undergoing fragmentation of care but receiving systemic therapy in nonaccredited facilities. [ABSTRACT FROM AUTHOR]

Increasing regionalization for esophagectomy for cancer may lead patients to travel for surgery at one institution and receive chemotherapy at another closer to home. We explore the effects on survival for care fragmentation, the Commission on Cancer status of secondary institutions providing chemotherapy, and the type of institution performing surgery. We queried the National Cancer Database to identify all patients who underwent esophagectomy for esophageal cancer and received perioperative chemotherapy between 2006 and 2019. Patients were divided into single-center care, fragmented–to–Commission on Cancer care, or fragmented–to–non–Commission on Cancer care. We identified associations using multivariable logistic regression, Kaplan-Meier survival analyses, and Cox proportional hazards models. A total of 18,502 patients met the criteria for inclusion: 8,290 (44.8%) received single-center care; 3,414 (18.5%) fragmented–to–Commission on Cancer care; and 6,798 (36.4%) fragmented–to–non–Commission on Cancer care. Fragmented care was more likely in White patients (adjusted odds ratio = 1.25; P <.001) and in patients nonadjacent to a metropolitan area (adjusted odds ratio = 1.36; P <.001). Overall survival was equivalent between single-center and fragmented care, but undergoing an esophagectomy at an academic center was associated with improved survival (adjusted hazard ratio = 0.82; P =.016). In patients with an esophagectomy at a nonacademic center, overall survival was best if perioperative chemotherapy was administered at Commission on Cancer–accredited facilities compared with chemotherapy at fragmented–to–non–Commission on Cancer centers (P =.022). Most of the esophageal cancer care in the US is fragmented at multiple institutions. When care is fragmented, it is most commonly at non–Commission on Cancer centers for perioperative chemotherapy. Overall survival is best when esophagectomy is performed at an academic center, and perioperative therapy is administered at Commission on Cancer–accredited facilities. [ABSTRACT FROM AUTHOR]

Previous studies have shown that overall survival after lung resection for pulmonary carcinoid tumors is favorable. It is unclear what the prognosis is for observation rather than resection for small carcinoid tumors. We queried the National Cancer Database to identify patients presenting with primary pulmonary carcinoid tumors between 2004 and 2017. We included patients with small (<3 cm) primary pulmonary carcinoids, who were observed or underwent a lung resection. To minimize confounding by indication, we used propensity score matching, while accounting for age, sex, race, insurance type, Charlson-Deyo comorbidity score, typical and atypical histology, tumor size, and year of diagnosis. We used Kaplan-Meier survival analyses to compare 5-year overall survival in the matched cohorts. Of 8435 patients with small pulmonary carcinoids, 783 (9.3%) underwent observation and 7652 (91%) underwent surgical resection. After propensity score matching, surgical resection was associated with improved 5-year overall survival (66% vs 81%, P <.001). No significant difference in overall survival was found between wedge and anatomic resection (88% vs 88%, P =.83). In patients undergoing resection, lymph node sampling at the time of wedge and anatomic resection increased 5-year overall survival (90% vs 86%, P =.0042; 88% vs 82%, P =.04, respectively). Surgical resection of small pulmonary carcinoids is associated with improved survival compared with observation. When surgical resection is performed, wedge and anatomic resection result in similar survival, and lymph node sampling improves survival. [ABSTRACT FROM AUTHOR]

The National Lung Screening Trial (NLST) established a role for lung cancer screening. Mortality benefits with screening are predicated on successful treatment with low surgical mortality. Given variations observed in perioperative outcomes after lung cancer resection, it remains unknown whether benefits observed in the NLST are generalizable to a broader population. We sought to determine whether NLST perioperative outcomes are reflective of contemporary practice in a national cohort. We identified patients diagnosed with non-small cell lung cancer who underwent lung resection in the 2014 to 2015 National Cancer Database (NCDB) and the NLST. We compared demographic and cancer characteristics in both datasets. We used hierarchical logistic regression to compare 30-day and 90-day postoperative mortality across facilities in both datasets. In all, 65054 patients in NCDB and 1003 patients in the NLST treated across 1119 NCDB hospitals and 33 NLST hospitals were included. After risk and reliability adjustment, mean 30-day and 90-day mortality were significantly higher among NCDB hospitals (mean 30-day, 2.2 [95% confidence interval (CI), 2.2 to 2.2] vs 1.8 [95% CI, 1.8 to 1.8], P <.001; mean 90-day, 4.2 [95% CI, 4.2 to 4.3] vs 2.9 [95% CI, 2.9 to 2.9], P <.001). Variation in risk- and reliability-adjusted 30-day mortality (95% CI, 1.1% to 4.9%) and 90-day mortality (95% CI, 2.6% to 9.7%) was observed among NCDB hospitals. Adjusted mortality was similar among NLST facilities (30 days, 1.8% to 1.8%; 90 days, 2.9% to 2.9%). Risk- and reliability-adjusted postoperative mortality varies widely in a national cohort compared with outcomes observed in the NLST. Efforts to minimize this variation are needed to ensure that benefits of lung cancer screening are fully realized in the United States. [ABSTRACT FROM AUTHOR]

In December 2013 the US Preventative Services Task Force (USPSTF) recommended annual lung cancer screening for high-risk patients. The Centers for Medicare & Medicaid Services (CMS) later announced coverage in 2015. The impact of these federal decisions at the population level is unknown. Using the Surveillance, Epidemiology, and End Results database, we studied changes in lung cancer incidence by stage and linked to US census data to obtain age-adjusted estimates standardized to the US population. Based on age at diagnosis we stratified patients as age-eligible or age-ineligible for screening. We used difference-in-differences regression to determine the effect of screening on lung cancer incidence by stage. For all age groups the incidence of early-stage lung cancer both before and after the USPSTF guidelines remained relatively stable at 12.8 ± 0.52 and 13.5 ± 0.92 per 100,000 patients, respectively (P =.068). However the difference-in-differences analysis estimated an absolute increase in the age-adjusted incidence by 3.4 per 100,000 persons in the age-eligible group after the announcement of the guidelines (P =.007). The effect was even larger after the CMS decision (4.3/100,000 persons, P <.001). Similarly there was a 14.2 per 100,000 persons absolute reduction in the incidence of advanced-stage lung cancer (P <.001). The 2013 USPSTF lung cancer screening guidelines and CMS coverage decisions were associated with an increased incidence of early-stage lung cancer and decreased incidence of advance-staged lung cancer at the population level. [Display omitted] [ABSTRACT FROM AUTHOR]

A preoperative type and screen (T&S) is traditionally routinely obtained before noncardiac thoracic surgery; however an intraoperative blood transfusion is rare. This practice is overly cautious and expensive. We included adult patients undergoing major thoracic surgery at the Mayo Clinic from 2007 to 2016. Patients receiving a T&S blood test ≤72 hours of surgery was the main exposure. We randomly split the cohort into derivation and validation datasets. We used multiple logistic regression to create a parsimonious nomogram predicting the need for a T&S in relation to the likelihood of intraoperative blood transfusion. We validated the nomogram in terms of discrimination, calibration, and negative predictive value. Of 6280 patients 46.1% had a preoperative T&S, but only 7.1% received intraoperative transfusions. The derivation dataset had 4196 patients. Patients who had a T&S were more likely to have baseline hemoglobin level <10 g/dL (7.9% vs 3.6%, P <.001) and less likely to have minimally invasive operations (36.1% vs 43.5%, P <.001) but were otherwise similar in baseline age and comorbidities. A transfusion threshold of 5% was selected a priori. The nomogram included age, planned operation, approach, body mass index, and preoperative hemoglobin. The nomogram was validated with a c-statistic of 86% and a negative predictive value of 97.9%. Patients who needed a blood transfusion but who did not have a preoperative T&S did not have a higher rate of mortality (P =.121). An intraoperative blood transfusion during major thoracic surgery is a rare event. Patient who required transfusion but did not have a T&S did not have worse outcomes. A simple nomogram can aid in the selective use of T&S orders preoperatively. [Display omitted] [ABSTRACT FROM AUTHOR]

Outcomes after cancer resection are traditionally measured individually. Composite metrics, or textbook outcomes, bundle outcomes into a single value to facilitate assessments of quality. We propose a composite outcome for non-small cell lung cancer resections, examine factors associated with the outcome, and evaluate its effect on overall survival. We queried the National Cancer Database for patients with stage I/II non-small cell lung cancer who underwent sublobar resection, lobectomy, or pneumonectomy from 2010 to 2016. We defined the metric as margin-negative resection, sampling of ≥10 lymph nodes, length of stay <75th percentile, no 30-day mortality, no readmission, and receipt of indicated adjuvant therapy. Multivariable logistic regression, Cox proportional hazards modeling, survival analyses, and propensity score matching were used to identify factors associated with the outcome and overall survival. Of 88,208 patients, 70,149 underwent lobectomy, 14,922 underwent sublobar resection, and 3,137 underwent pneumonectomy. Textbook outcome was achieved in 26.3% of patients. Failure to achieve the outcome was most commonly driven by inadequate nodal assessment. Textbook outcome was more likely after minimally invasive surgical approaches (aOR = 1.47; P< 0.001) relative to open resection and less likely after sublobar resection (aOR = 0.20; P< 0.001) relative to lobectomy. Achievement of textbook outcome was associated with an 9.6% increase in 5-year survival (P< 0.001), was independently associated with improved survival (aHR = 0.72; P < 0.001), and remained strongly associated with survival independent of resection extent after propensity matching. One in 4 patients undergoing non-small cell lung cancer resection achieve textbook outcome. Textbook outcome is associated with improved survival and has value as a quality metric. [ABSTRACT FROM AUTHOR]

Traditionally, neoadjuvant chemoradiation therapy is followed by resection in patients with locally advanced non-small cell lung cancer (NSCLC). The risks and benefits of this approach are not well defined in patients requiring a sleeve lung resection. In this context, we compare the short- and long-term outcomes of neoadjuvant chemotherapy alone vs chemoradiation therapy followed by sleeve lung resection. We used the National Cancer Database to identify locally advanced NSCLC patients who received chemotherapy-alone or chemoradiation therapy in the neoadjuvant setting, followed by a sleeve lung resection, between 2006 and 2017. Our outcomes of interest were 30-day mortality, 90-day mortality, and overall survival. To minimize confounding by indication, we used propensity score adjustment, logistic regression, Kaplan-Meier survival analysis, and Cox proportional hazards models to identify associations. Of 176 patients undergoing sleeve lung resection, 92 (52.3%) received neoadjuvant chemotherapy-alone, and 84 (47.7%) received neoadjuvant chemoradiation therapy. Patients in both groups were well balanced in age, sex, race, Charlson-Deyo comorbidity index, insurance status, median income, and education (all P >.05). Similarly, the groups were well balanced in histology, tumor location, and stage (all P >.05). Patients receiving neoadjuvant chemoradiation therapy had higher 90-day mortality (11.96% vs 2.38%, P =.015), and there was no difference in overall survival between the neoadjuvant chemotherapy-alone vs chemoradiation therapy cohorts (P =.621). In this national study of patients with locally advanced resectable NSCLC requiring a sleeve lung resection, neoadjuvant chemoradiation therapy was associated with a 5-fold increase in 90-day mortality without an overall survival benefit over neoadjuvant chemotherapy-alone. [ABSTRACT FROM AUTHOR]

As the COVID-19 pandemic moves into the survivorship phase, questions regarding long-term lung damage remain unanswered. Previous histopathologic studies are limited to autopsy reports. We studied lung specimens from COVID-19 survivors who underwent elective lung resections to determine whether postacute histopathologic changes are present. This multicenter observational study included 11 adult COVID-19 survivors who had recovered but subsequently underwent unrelated elective lung resection for indeterminate lung nodules or lung cancer. We compared these against an age- and procedure-matched control group who never contracted COVID-19 (n = 5) and an end-stage COVID-19 group (n = 3). A blinded pulmonary pathologist examined the lung parenchyma focusing on 4 compartments: airways, alveoli, interstitium, and vasculature. Elective lung resection was performed in 11 COVID-19 survivors with asymptomatic (n = 4), moderate (n = 4), and severe (n = 3) COVID-19 infections at a median 68.5 days (range 24-142 days) after the COVID-19 diagnosis. The most common operation was lobectomy (75%). Histopathologic examination identified no differences between the lung parenchyma of COVID-19 survivors and controls across all compartments examined. Conversely, patients in the end-stage COVID-19 group showed fibrotic diffuse alveolar damage with intra-alveolar macrophages, organizing pneumonia, and focal interstitial emphysema. In this study to examine the lung parenchyma of COVID-19 survivors, we did not find distinct postacute histopathologic changes to suggest permanent pulmonary damage. These results are reassuring for COVID-19 survivors who recover and become asymptomatic. [ABSTRACT FROM AUTHOR]

Prior studies evaluating the effect of margin status on clinical outcome in patients undergoing resection for intrahepatic and extrahepatic hilar cholangiocarcinoma include small numbers of patients with histologically positive margins. The value of margin negative resection in these cases remains unclear. We queried the National Cancer Database to identify patients undergoing resection for clinical stage I to III intrahepatic and extrahepatic hilar between 2004 and 2015. Patients receiving neoadjuvant therapy and those having <3 lymph nodes examined were excluded. Patients undergoing positive resection were 1:1 propensity matched to those undergoing negative resection. Kaplan-Meier methods were used to compare overall survival for the matched cohorts. In the study, 3,618 patients met the inclusion criteria, and 3,018 (83.4%) underwent negative resection; 600 (16.6%) positive resection. Patients undergoing negative resection had smaller tumors (2.97 ± 0.07 cm vs 3.49 ± 0.15 cm), were less likely to have stage 3 disease (16.7% vs 25.7%) and to receive adjuvant radiation (27.1% vs 45.7%) and chemotherapy (49.4% vs 61.0%) than those undergoing positive resection (all P <.05). On comparison of matched cohorts, patients undergoing negative resection had longer median overall survival (24.5 ± 0.02 vs 19.1 ± 0.02 months) and higher rates of 5-year overall survival (24.5% vs 16.7%) than those undergoing positive resection (P <.01). In patients presenting with resectable intrahepatic and extrahepatic hilar, negative resection is associated with improved overall survival. Extended resections performed in an effort to clear surgical margins are warranted in patients fit for such procedures. [ABSTRACT FROM AUTHOR]

The amount of time surgical trainees spend operating independently has been reduced by work-hour restrictions and shifts in the health care environment that impede autonomy. Few studies evaluate the association between clinical outcome and resident autonomy. The Veterans Affairs Surgical Quality Improvement Program database was queried to identify patients undergoing partial colectomy for neoplasm between 2004 and 2019. Rectal resections, emergency procedures, and those involving postgraduate year 1 and 2 residents were excluded. Records were categorized as performed with the attending scrubbed or not scrubbed. Hierarchical logistic regression was used to identify factors independently associated with operative time, morbidity, and mortality. In total, 7,347 patients met inclusion criteria; 6,890 (93.6%) were categorized as attending scrubbed and 457 (6.4%) as attending not scrubbed. The cohorts were similar in terms of patient demographics, including age, race, body mass index, and American Society of Anesthesiologists class. There were no differences between cohorts in terms of operative time (attending not scrubbed 3.02 hours, attending scrubbed 3.07 hours, P =.42). On hierarchical logistic regression adjusted for age, gender, race, body mass index, functional status, cancer location, facility operative level, wound class, American Society of Anesthesiologists class, length of operation, operative modality (open or minimally invasive), postgraduate year of resident, and year, there were no differences in odds of complications, major morbidity, or mortality based on attending involvement. Colectomies performed by residents with appropriate levels of autonomy are efficient and safe. Our results indicate that attending surgeon judgment regarding resident autonomy is sound and that educational environments can be designed to foster resident independence and preserve clinical quality, safety, and efficiency. [ABSTRACT FROM AUTHOR]

Contemporary data on lung volume reduction surgery (LVRS) is sparse, particularly in regard to utilization and surgical outcomes. In this context, we analyzed the practice patterns and outcomes of LVRS nationally. We identified all patients (n = 1617) undergoing LVRS at 165 hospitals between 2001 and 2017 from The Society of Thoracic Surgeons (STS) General Thoracic Database. Practice patterns were assessed at the hospital and STS regional levels. In addition, we obtained regional chronic obstructive pulmonary disease prevalence data from the Centers for Disease Control. We used hierarchical logistic regression to estimate associations with each outcome of interest and calculate risk- and reliability-adjusted outcome rates. Since 2011, national LVRS utilization has been increasing with decreasing mortality rates (3.1% risk-adjusted mortality in 2016). There is wide regional variation in LVRS average caseload that is not congruent with national chronic obstructive pulmonary disease prevalence (Pearson correlation coefficient −0.11). On multivariable analysis, only older age (adjusted odds ratio 1.05, P <.001), male sex (adjusted odds ratio 1.5, P =.007), underweight body mass index (adjusted odds ratio 1.94, P =.027), and ECOG score of 4 (adjusted odds ratio 5.17, Z-score 3.91, P =.001) were associated with the occurrence of the composite outcome of major morbidity or mortality. At the hospital level, six hospitals performed 40% of all LVRS nationally with adjusted national 30-day mortality rate of 4.3% and composite outcome rate of 15.8%. Despite this, there was minimal variation in adjusted outcome rates. National utilization of LVRS is increasing and it has become safer overall, even at lower volume hospitals. There is regional variation in LVRS use that does not mirror national chronic obstructive pulmonary disease prevalence, suggesting access disparities. The findings have potential policy implications. [ABSTRACT FROM AUTHOR]

The ideal surgical reconstruction of the aortic root in patients with complex endocarditis is controversial. We compared the short- and long-term outcomes between mechanical valves, bioprostheses, and homografts. We identified all patients undergoing an operation for active complex aortic endocarditis at our institution between 2003 and 2017. We grouped patients according to those who received a mechanical valve, bioprosthesis, or homograft. We used multiple logistic regression and proportional hazards models. To minimize confounding by indication, we used marginal risk adjustment to simulate that every patient would undergo (contrary to fact) all 3 operations. Of 159 patients with complex active endocarditis, 48 (30.2%) had a valve plus patch reconstruction, and 85 (53.4%) had a root replacement. Of all, 50 (31.5%) had a mechanical valve, 56 (35.2%) had a bioprosthesis, and 53 (33.3%) had a homograft. The groups were similar in age, sex, body mass index, comorbid conditions, organism, abscess location, and mitral involvement (all P >.05). However, patients receiving mechanical reconstructions were more likely to have native valve endocarditis (46% vs 37.5% vs 17%; P =.005) and less likely to undergo root replacement (32% vs 28.6% vs 100%; P <.001). Marginal risk-adjusted operative mortality was lowest for mechanical valves (4.8%) and highest for homografts (16.9%; P =.041). Long-term survival after root replacement was worse with homografts than with mechanical valve conduits (adjusted hazard ratio, 2.9; P =.045). In patients with complex endocarditis, mechanical valves are associated with similar, if not better, short- and long-term outcomes compared with homografts, even after adjusting for important baseline characteristics and limiting the analysis to root replacements only. [ABSTRACT FROM AUTHOR]

To assess the prevalence and characteristics of neuropathic pain (NP) at diagnosis of head and neck squamous cell carcinoma (HNSCC) and its impact on nutritional status and treatment tolerance. Patients treated for HNSCC between January 1, 2018 and January 30, 2019 were included. Pain was assessed prospectively on the DN2 and NSPI scales. Epidemiological characteristics, nutritional status and treatment tolerance were collected. Two groups were distinguished according to absence or presence of neuropathic pain (NP-, NP +). Sixty patients were included. NP prevalence at diagnosis was 54%, mainly involving locally advanced oral cavity and oropharyngeal tumors. There was a significant intergroup difference in nutritional status, with 62% malnutrition in NP+ versus 32% in NP− (p = 0.0321). There was no such difference in tolerance. NP is frequent at diagnosis of HNSCC. Early diagnosis on a simple validated score can help improve quality of life and nutritional status. [ABSTRACT FROM AUTHOR]

Extracts of different medicinal plants had been used to control several diseases in both traditional medicine and modern drugs. In the current study, we aimed to examine the changes in chemical composition of Zilla spinosa Forssk. plants collected from different habitats in Saudi Arabia in response to spatial and seasonal variations. Z. spinosa samples were collected from two different sites in Riyadh and Eastern regions in Saudi Arabia to examine the spatial variations effects on the studied parameters. Samples were collected from both sites at two different times (3:00 PM and 3:00 AM) to examine the effect of light on the chemical content and composition of these plants. Samples was, also, collected from the same sites at two different seasons (on start of January 2018 "winter season" and end of May 2018 "summer season") to examine the effect of temperature changes (seasonal variations) on the chemical content and composition of the different studied plants. In Z. spinosa plants collected from Riyadh region, squalene was found to be the major constitute of 3 samples; however, surprisingly, the sample collected in Winter at 3:00 AM showed the presence of mome inositol and (Z)-5-(formylmethylene)-4-methoxy-2(5 h)-furanone as the dominant components. Similarly, chemical compositions of essential oils extracted from Z. spinosa samples collected from Eastern region in the Summer season was dominated by squalene. Z. spinosa plants showed that all collected samples had high carbohydrate and protein contents with very low content of fats. [ABSTRACT FROM AUTHOR]

Data on failure to rescue (FTR) after esophagectomy are sparse. We sought to better understand the patient factors associated with FTR and to assess whether FTR is associated with hospital volume. We identified all patients undergoing esophagectomy between 2010 and 2014 from the Agency for Healthcare Research and Quality Nationwide Readmission Database. We defined FTR as mortality after a major complication. Multiple logistic regression was used to identify patient factors and hospital–volume associations with FTR. Of 26,820 patients undergoing an esophagectomy, 7130 (26.6%) experienced a major complication. Of those, 1321 did not survive the index hospitalization (FTR rate, 18.5%). Risk factors for FTR included increasing age (adjusted odds ratio [aOR], 1.06; P <.001), congestive heart failure (aOR, 2.07; P <.001), bleeding disorders (aOR, 2.9; P <.001), liver disease (aOR, 2.37; P =.001), and renal failure (aOR, 2.37; P =.002). At the hospital level there was wide variation in FTR rates across hospital volume quintiles, with 21.2% of patients suffering a complication not surviving to discharge at low-volume hospitals compared with 13.4% at high-volume hospitals (P <.001). At low-volume hospitals the highest FTR rates were acute renal failure (35.3%), postoperative hemorrhage (31.9%), and pulmonary failure (28.1%). One in 5 esophagectomy patients suffering a complication at low-volume hospitals do not survive to discharge. Several patient factors are associated with death after a major complication. Strategies to improve the recognition and management of complications in at-risk patients may be essential to improve outcomes at low-volume hospitals. [ABSTRACT FROM AUTHOR]

Reversible addition-fragmentation chain transfer polymerization of chloroprene on the surface of silica nanoparticles was performed to obtain polychloroprene-grafted-silica nanoparticles (PCP- g -SiO 2 NPs). These particles were dispersed in a commercial polychloroprene matrix to obtain PCP nanocomposites with different silica core loadings (1, 5, 10, and 25 wt%). Two different chain graft densities were studied ("low," 0.022 ch/nm2 and "high," 0.21 ch/nm2) as a function of the grafted polymer molecular mass. The cured samples showed significant improvement in the mechanical properties of the PCP rubber nanocomposites as compared to the unfilled PCP as measured by standard tensile and dynamic mechanical analysis even with low silica content. The mechanical properties of the nanocomposites were notably enhanced when the graft density was low and grafted molecular masses were high. Transmission electron microscopy (TEM) and Small-Angle X-ray Scattering (SAXS) were used to analyze the dispersion states of the grafted nanoparticles which confirmed the correlation between high grafted chain lengths and improved dispersion states and mechanical properties. Image 1 • Polychloroprene grafted nanoparticles were prepared with precise control of graft density, molar mass and dispersity. • Correlations were made between dispersion state in an industrial rubber andmechanical properties. • High molar mass grafts and low chain density provided the best dispersion and largest improvements in mechanical properties. [ABSTRACT FROM AUTHOR]

Several members of the green algae possess the ability to produce lipids and/or high value compounds in significant quantities. While for several of these green algal species induction of increased lipid production has been shown, and cultivation of species for high value molecules occurs at production scale, the molecular mechanisms governing over-accumulation of molecules synthesized from isoprenoid precursors, carotenoids, for example, have received far less attention. Here, we present a calculation of the required ATP equivalencies per carbon atom and reducing power equivalencies as NADH/NADPH (NAD(P)H) per carbon atom for the isoprenoid molecules β-carotene (C 40 ), astaxanthin (C 40 ), and squalene (C 30 ). We compared energetic requirements of carbohydrates, triacylglycerol, and isoprenoid molecules under a gradient of conditions of cellular stress. Our calculations revealed slightly less ATP and NAD(P)H equivalency per carbon atom between triacylglycerol and the three isoprenoid molecules. Based on our results, we propose that the driving force for differences in accumulation patterns of carotenoids vs. triacylglycerols in algal cells under stress is largely dependent on the presence and regulation of bypass mechanisms at metabolic junction bottlenecks, like pyruvate dehydrogenase (PDH), within particular species. We provide a discussion of several molecular mechanisms that may influence carbon partitioning within different groups of green algae, including metabolic inhibition through accumulation of specific substrates related to ATP and reducing equivalent production (NAD(P)H) as well as cellular compartmentalization. This work contributes to the ongoing discussion of cellular homeostatic regulation during stress, as well as the potential mechanisms driving long-term carbon storage as it relates to energy and redox states within the algal cell. [ABSTRACT FROM AUTHOR]

Background Malignant pleural mesothelioma (MPM) remains an aggressive malignancy that is difficult to cure. However, the treatment paradigm of MPM has evolved, and the national practice patterns are unknown. This study examined the national trends in the epidemiology, national treatment patterns, and survival of patients with this disease. Methods We identified all patients (n = 19,134) with MPM from the National Cancer Data Base from 2004 to 2013. We analyzed patient, tumor characteristics, and treatment patterns using descriptive statistics and used Kaplan-Meier and Cox proportional hazards models to estimate survival stratified by the type of therapy administered. Results Four histologic subtypes were represented in the National Cancer Data Base, these included sarcomatoid (n = 2,355 [12.3%]), epithelioid (n = 6,858 [35.8%]), biphasic (n = 13,617 [11%]), and not otherwise specified (n = 8,560 [44.7%]). Across all subtypes, the prevalence of mesothelioma was highest among white men. Sarcomatoid had the worst survival (adjusted hazard ratio, 2.2; p < 0.001). Most patients did not receive any specific modality of treatment (40.2%). Chemotherapy alone was the most common treatment used (31.8%). Trimodality treatment with chemotherapy, surgical resection, and radiation therapy was associated with the best survival (adjusted hazard ratio, 0.43; p < 0.001), followed by combination chemotherapy and resection (adjusted hazard ratio, 0.49; p < 0.001). Conclusions This is the first publication to date to analyze the mesothelioma National Cancer Data Base. Although survival remains poor, multimodality therapy with surgical resection is associated with the best survival for MPM. Further research is needed to improve survival and overall patient outcomes. [ABSTRACT FROM AUTHOR]

RAFT polymerization and surface-initiated RAFT polymerization (SI-RAFT) of chloroprene was studied. The SI-RAFT polymerization rate of chloroprene was found to be slower than free solution RAFT polymerization, and further regulated by the graft density of grafted polymers. The resulting polychloroprene-grafted silica nanoparticles were directly crosslinked to obtain matrix-free polychloroprene nanocomposites that showed good nanoparticle dispersion and superior mechanical properties compared with unfilled polychloroprene rubber. [ABSTRACT FROM AUTHOR]

For unresectable intrahepatic cholangiocarcinoma (ICC), we previously showed that pre-therapy CT volumetric enhancement (VE) associates with biological (e.g., degree of stromal infiltration and necrosis, genetic mutations, and infiltrating lymphocytes) and clinical outcomes. Further, we showed that a change in VE following radiotherapy (RT) is prognostic. Here, we integrated these baseline and post-treatment imaging features to appraise their joint prognostic value. We retrospectively identified 112 patients (54% female, median age 63 years) who received definitive RT (78% photon, 22% proton; median biologically effective [BED 10 ] dose 86 Gy, interquartile range [IQR] 75-98 Gy) with triple phase CT imaging at diagnosis, prior to RT, and following RT. A technology company's multimodality tumor tracking software was used to quantify tumor VE ≥1 standard deviation of that of healthy parenchyma on each scan. Based on prior work, each patient was stratified into (1) low/high VE at baseline (cutpoint: 32% VE) and (2) VE-based response/non-response to RT (cutpoint: 26% decrease in VE). Overall survival (OS) and local failure-free survival (LFFS) following RT were assessed using the Kaplan-Meier method. Cox analyses were performed to include the 2 radiomic markers and traditional covariates of survival. Concordance indices (C-index) were used to evaluate model performance. At a median follow up of 74 months, 46% failed locally and 85% died. The 2-year OS and LFFS were 40% (95% confidence interval [CI], 30-49%) and 26% (CI, 18-34%), respectively. At baseline, median VE was 25% (IQR 14-45%); VE was categorized as low in 43% and high in 57%. Following RT, median change in VE was +3% (IQR -7% to +176%); change was categorized as non-response for 56% and response in 44%. On multivariable analysis for OS, Stage IV disease (hazard ratio [HR] 2.11, CI 1.35-3.31; P =0.001) was associated with poorer survival. High VE (HR 0.38, CI 0.24-0.59; P <0.001) and VE-based response to RT (HR 0.19, CI 0.12-0.32; P <0.001) were each independently associated with longer survival (C-index 0.77). For LFFS, Stage IV disease (HR 1.61, CI 1.03-2.52; P =0.036) was associated with shorter latency to local failure/death, while high VE (0.40, 95% CI 0.26-0.62; P <0.001) and VE-based response to RT (HR 0.29, CI 0.18-0.46; P <0.001) were associated with longer latency (C-index 0.74). Median OS stratified by cohort is shown in Table 1. For ICC patients treated with definitive RT, VE measured on pre-therapy imaging and pre/post-RT imaging each independently had greater predictive value than conventional patient and disease factors. These metrics, with their biological and clinical associations, may help personalize therapeutic approaches for ICC. External model validation is warranted. [ABSTRACT FROM AUTHOR]

Context: Testicular germ-cell tumors (GCT) are highly curable. A multidisciplinary approach, including cisplatin-based chemotherapy has resulted in cure in the majority of patients with GCT. Thus, the life expectancy of survivors will extend to many decades post-diagnosis. Late treatment toxicities associated with cisplatin-based chemotherapy may impact their future health. Objective: To systematically evaluate evidence regarding the long-term toxicity of cisplatin in GCT survivors. Evidence acquisition: We carried out a critical review of PubMed/Medline in February 2017 according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Identified reports were reviewed according to the Consolidated Standards of Reporting Trials (CONSORT) criteria. Eighty-three publications were selected for inclusion in this analysis. Evidence synthesis: Included reports evaluated long-term toxicities of cisplatin-based chemotherapy in GCT survivors. Studies reporting neuro- and ototoxicity, secondary malignancies, cardiovascular, renal and pulmonary toxicities, hypogonadism and infertility were found. Seven studies (8%) reported genetic underpinnings of long-term toxicities and 3 (4%) and 14 (19%) studies correlated long-term toxicities with circulating platinum levels and cumulative dose of cisplatin, respectively. Significant risks for long-term toxicities associated with cisplatin and platinum-based regimens were reported. The cumulative dose of cisplatin and circulating platinum were reported as risk factors. Several single-nucleotide polymorphisms identified patients susceptible to cisplatin compared with wild-type individuals. Conclusions: GCT survivors cured with cisplatin-based chemotherapy are at risk for long-term side-effects. Detection of single-nucleotide polymorphisms could be a valuable tool for predicting long-term toxicities. Patient summary: Herein, this article summarizes the available evidence of long-term toxicity of cisplatin-based chemotherapy in GCT survivors and provide insights from Indiana University. [ABSTRACT FROM AUTHOR]

Background The current national trends, practice patterns, and outcomes after sleeve resection compared with pneumonectomy in the United States are not known. In addition, whether hospital sleeve-to-pneumonectomy (S:P) ratios are a valid marker of hospital quality is unclear. We describe practice patterns and evaluate the utility of the S:P ratio. Methods We identified all patients (N = 23,964) undergoing sleeve resection (n = 1,713) or pneumonectomy (n = 22,251) in the National Cancer Data Base between 1998 and 2012 at 644 hospitals. We used propensity score matching to compare short-term outcomes and overall survival between pneumonectomy and sleeve resection. We grouped hospitals into S:P ratio quintiles and used multilevel modeling to analyze hospital-level outcomes. Results There has been a 1% yearly increase in sleeve resection rates, with wide variation in hospital S:P ratios (middle quintile, 1:12; range, 1:38 to 1:3). After propensity score matching, differences in age, clinical T and N stage, and the incidence of main bronchus tumors were negligible among other variables. Sleeve resections were associated with lower 30-day (1.6% vs 5.9%; p < 0.001) and 90-day mortality (4% vs 9.4%; p < 0.001) and improved overall survival. Hospitals with higher S:P ratios were not associated with better risk-adjusted 30-day (7.2% vs 7.4%; p = 0.244) or 90-day mortality (11.9% vs 12.2%; p = 0.308) or same-hospital readmission rates (3.7% vs 4.3%; p = 0.523). Conclusions Compared with pneumonectomy, sleeve resections are associated with improved short-term outcomes and improved overall survival. However, hospital S:P ratios were not associated with better risk-adjusted outcomes and thus may not be a valid quality measure. [ABSTRACT FROM AUTHOR]

Background This study examined the variation in the adoption of video-assisted thoracoscopic surgery (VATS) for lobectomy across United States hospitals from a population-based national database. Methods We used the National Cancer Data Base to identify patients undergoing lobectomy between 2010 and 2012 and used hierarchical regression to estimate case-mix–adjusted VATS lobectomy rates using patient and tumor characteristics. We stratified hospitals into quintiles by adjusted VATS lobectomy rates. To account for lack of equipment to perform minimally invasive thoracoscopic operations, we also obtained data on VATS wedge resections. Results Of 55,972 cancer lobectomies performed at 905 hospitals, 17,072 (30.5%) were VATS. Crude hospital VATS use varied widely (mean was 25.5% of all lobectomies per hospital; interquartile range, 4.4% to 42.3%). Variation persisted after case-mix adjustment. For example, VATS rates at the highest and lowest quintiles were 76% vs 0.6%, respectively. Differences in patient and tumor characteristics across quintiles were negligible, and there was no indication that those hospitals lacked VATS equipment. The risk-adjusted same-hospital readmission (6.7% vs 7%; p > 0.2), 30-day mortality (1.5% vs 1.5%; p > 0.2), and 90-day mortality (2.9% vs 2.7%; p = 0.038) rates were similar between the highest and lowest quintiles. Length of stay was shorter at hospitals in the highest VATS quintile (6.6 vs 7.4 days; p < 0.001). Conclusions Adoption of VATS lobectomy varies widely across United States hospitals. This variation cannot be explained by patient or tumor characteristics or by a shortage of VATS equipment. Efforts to reduce this variation will require the dissemination and implementation of novel training techniques and learning opportunities for surgeons. [ABSTRACT FROM AUTHOR]

Background: Small bowel obstruction (SBO) is a common diagnosis; however, outcomes of and risk factors for SBO and malignant bowel obstruction (MBO) surgery are not well understood. We sought to characterize outcomes and risk factors for surgery for SBO and MBO.Methods: A retrospective cohort study was performed utilizing prospectively collected data from the Michigan Surgical Quality Collaborative (7/2012-3/2015). Cases included those with ICD9 diagnosis code of bowel obstruction and CPT codes for lysis of adhesions, intestinal bypass, and small bowel resection. Cases were stratified by disseminated malignancy (MBO). Factors associated with complications and 30-day mortality were evaluated.Results: Two thousand two hundred thirty-three patients underwent surgery for bowel obstruction, including 86 patients (3.9 %) with MBO. MBO patients had an adjusted mortality rate of 14.5 % (benign 5.0 %); the adjusted complication rate was 32.2 % (benign 27.0 %). Factors independently associated with mortality included disseminated cancer, older age, American Society of Anesthesiologists IV/V, cirrhosis, ascites, urinary tract infection, sepsis, albumin <3.5, hematocrit <30, and bowel resection.Conclusions: Surgery for bowel obstruction carries a relatively high risk for morbidity and mortality, particularly in patients with malignant bowel obstruction. Considering the identified risk factors for mortality may help clinicians make recommendations regarding surgery in the setting of MBO. [ABSTRACT FROM AUTHOR]

Guillain-Barré syndrome (GBS) has been described to be associated with HIV infection. It is commonly present at seroconversion, wherein there is high viral load along with low CD4 count. It has also been reported rarely as immune reconstitution inflammatory syndrome (IRIS) associated with antiretroviral therapy (ART). A 21-year-old gentleman with vertically transmitted HIV was switched to second line anti-retroviral therapy 3 weeks prior to presentation (Baseline CD4: 8 cells/mm3, HIV-1 viral load: 820,265 copies/ml). He presented with 1 week history of progressive lower limbs weakness associated with reduced sensation, gradually ascended to involve upper limbs, with difficulty in swallowing. There was areflexia, loss of sensation in glove and stocking distribution, nasal speech and dysautonomia. Brain and spine magnetic resonance imaging showed no focal intracranial or intraspinal lesion. Cerebrospinal fluid examination (CSF) showed nil cell count with protein 0.83g/L, globulin positive, and a csf/serum glucose ratio of 0.46. Nerve conduction study showed prolonged F wave with sacral sparing and prolonged latency suggestive of demyelinating neuropathy. Patient diagnosed as GBS and received a 5-day course of intravenous immunoglobulin (IVIG). He had respiratory failure that required mechanical ventilation, which gradually improved and extubated. CSF was negative for HSV, VZV, CMV, Zika virus, cryptocococcus, mycobacterium and anti-GQ1b antibodies. Repeated HIV-1 viral load: 995 copies/ml. The occurence of GBS is thought to be due to an autoimmune response against myelin sheath due to dysregulation triggered by HIV primary infection, which can also occur during IRIS. Risk factors for developing IRIS in our patient are HIV infection at younger age, rapid decline in HIV viral load, and low CD4 counts at baseline. It is crucial to differentiate GBS from other infectious causes of neuro-IRIS, thus appropriate treatment such as IVIG and plasma exchange can be administered early to prevent further disease progression and hasten recovery. [ABSTRACT FROM AUTHOR]

[Display omitted] • A simple synthesis method of Cu 2 O@MIP nanocomposite for the development of an electrochemical biosensor for the detection of creatinine at a nanomolar scale. • Experimental design (DoE) was used for the optimization of amperometry parameter. • The detection limit was 22 nM, and the sensitivity was 2.16 µAnM−1cm−2. Creatinine (Crn) is an important biomarker for kidney function, and early detection could help to avoid end-stage renal disease. In this study, a label-free and ultra-selective platform was developed for Crn detection by modifying the screen-printed carbon electrode (SPCE) with the copper nanoparticle integrated with poly (methyl methacrylate- co -divinylbenzene) molecularly imprinted polymer (Cu 2 O@MIP) by the electrodeposition method. The synthesized Cu 2 O@MIP was investigated by transmission electron microscopy (TEM), atomic force microscopy (AFM), fourier transform infrared spectroscopy (FT-IR), cyclic voltammetry, and electrochemical impedance spectroscopy (EIS). In addition, response surface methodology (RSM) is used to optimize the effects of potential and time intervals to increase its sensitivity. Under optimized conditions, Crn was determined in the presence of other interferences to be 2.16 AnM−1cm−2 and the limit of detection (LOD) was 22 nM. The sensor platform showed a response in the nanomolar range of 0–75 nM. The developed non-enzymatic electrochemical sensing responded well to Crn, and is highly specific without any significant compromise to non-specific macromolecules found in urine which presents a promising platform for the development of potable kidney disease detectors. [ABSTRACT FROM AUTHOR]

Objective: to gain a deeper understanding of Arabic fathers' involvement in maternity care during their wives' pregnancy, and to give a descriptive interpretative explanation of their lived experience. Design and method: a phenomenological study was undertaken to understand the perspectives of Arabic fathers regarding their involvement in maternity care. In-depth, semi-structured, audio taped interviews were conducted with 19 Arabic fathers. The analysis was done using Interpretative Phenomenological Analysis. Findings: the main theme of our findings can be expressed as 'the role of fathers during pregnancy,' which encompasses the degree and type of support that fathers offered to their wives. Four sub-themes emerged from the data: sharing of responsibility, compassion and attention, the father is the guardian of the wife, and prayer and supplication. Key conclusion and implications for practice: the study revealed the perspectives of Arabic fathers about the degree and type of support they offered to their wives during pregnancy. The present maternity health policies in Arabic countries need revision to allow for fathers' inclusion. The findings of this study may offer insight that helps stakeholders of maternal health programs to support the meaningful involvement of fathers in maternity care. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study is to develop a novel 3D magnetic resonance imaging (MRI)-based Statistical Shape Modeling (SSM) and apply it in knee MRIs in order to extract and compare relevant shapes of the tibia and femur in patients with and without acute Anterior cruciate ligament (ACL) injuries. Methods: Bilateral MR images were acquired and analyzed for 50 patients with acute ACL injuries and for 19 control subjects. A shape model was extracted for the tibia and femur using an SSM algorithm based on a set of matched landmarks that are computed in a fully automatic manner. Results: Shape differences were detected between the knees in the ACL-injury group and control group, suggesting a common shape feature that may predispose these knees to injury. Some of the detected shape features that discriminate between injured and control knees are related to intercondylar width and posterior tibia slope, features that have been suggested in previous studies as ACL morphological risk factors. However, shape modeling has the great potential to quantify these characteristics with a comprehensive description of the surfaces describing complex 3D deformation that cannot be represented with simple geometric indexes. Conclusions: 3D MRI-based bone shape quantification has the ability to identify specific anatomic risk factors for ACL injury. A better understanding of the role in bony shape on ligamentous injuries could help in the identification of subjects with an increased risk for an ACL tear and to develop targeted prevention strategies, including education and training. [ABSTRACT FROM AUTHOR]

Background Considerable hospital-to-hospital variations in surgical outcomes have been reported across surgical procedures. However, it is unclear whether hospital quality rankings are consistent for noncancer and cancer operations. We investigated the differences in hospital performance for noncancer and cancer colorectal resections at 52 hospitals participating in the Michigan Surgical Quality Collaborative (MSQC). Study Design Patients undergoing colorectal resections between 2008 and 2012 were identified. Hierarchical risk-adjusted models were used to evaluate hospital level 30-day morbidity, major morbidity, extended length-of-stay (LOS > 75 th percentile), and mortality outcomes. Hospital performance, as ranked by observed-to-expected ratios, was compared by rank-order changes, interquartile ranges (IQR), and Spearman's correlations. Results Of the 19,990 colorectal resections, 7,292 (36.5%) were for cancer. We observed wide variations in all risk-adjusted 30-day outcomes between hospitals, but only weak correlations in cancer and noncancer performance within hospitals. Overall hospital performance in mortality after noncancer and cancer operations was not correlated (Spearman's rho: 0.02). Of the best performing hospitals in mortality after noncancer resections, 69% were reclassified to a worse quartile for cancer operations (median rank-change of 12.5 ranks [IQR 5 to 27]). Similarly, hospital performance in morbidity was only moderately correlated (rho: 0.59; p < 0.001). Of the hospitals with lowest morbidity rates for noncancer resections, 31% were reclassified. We noted a similar lack of relationship in major morbidity and extended LOS. Conclusions A hospital's performance ranking in risk-adjusted outcomes after noncancer colorectal resections does not correlate to its performance for cancer-related colorectal resections. Indication for operation should be considered when leveraging risk-adjusted hospital outcomes for quality improvement efforts. [ABSTRACT FROM AUTHOR]

The effect of warm rolling on the evolution of microstructure, microtexture and mechanical properties of a duplex stainless steel (DSS) was investigated. For this purpose, the DSS alloy was warm rolled at 625 °C up to 90% reduction of thickness. Development of ultrafine lamellar morphology with alternate arrangement of the two phases was revealed during warm rolling. The ferrite in DSS developed stronger RD-fiber (RD//<110>) than ND-fiber (ND//<111>) while austenite in DSS showed pure metal or copper type texture. The DSS in the as warm-rolled condition showed tremendous increase in ultimate tensile strength to∼1.4 GPa. The present results demonstrate that warm rolling can be used successfully for developing ultrahigh strength DSS. [ABSTRACT FROM AUTHOR]

Abstract: In this paper, a fractional order differential system for modeling human T-cell lymphotropic virus I (HTLV-I) infection of CD4+ T-cells is studied and its approximate solution is presented using a multi-step generalized differential transform method. The method is only a simple modification of the generalized differential transform method, in which it is treated as an algorithm in a sequence of small intervals (i.e. time step) for finding accurate approximate solutions to the corresponding systems. The solutions obtained are also presented graphically. [Copyright &y& Elsevier]

Abstract: In this study, a reliable approach for convergence of the homotopy analysis method when applied to nonlinear problems is discussed. First, we present an alternative framework of the method which can be used simply and effectively to handle nonlinear problems. Then, mainly, we address the sufficient condition for convergence of the method. The convergence analysis is reliable enough to estimate the maximum absolute truncated error of the homotopy series solution. The analysis is illustrated by investigating the convergence results for some nonlinear differential equations. The study highlights the power of the method. [ABSTRACT FROM AUTHOR]

Abstract: Variational iteration method has been widely used to handle linear and nonlinear models. The main property of the method is its flexibility and ability to solve nonlinear equations accurately and conveniently. In this paper, we present an alternative approach of the method then we study the convergence of the method for nonlinear differential equations. Our emphasis is to address the sufficient condition for convergence and the error estimate. Simple approaches of variational iteration method to nonlinear ordinary, partial and fractional differential equations are presented and the convergence results are briefly discussed. Some examples are investigated to verify convergence results and to illustrate the efficiency of the method. The basic ideas described in this paper are expected to be further employed to handle nonlinear models. [Copyright &y& Elsevier]