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Purpose: Risk factors of gallbladder cancer (GBC) are not well-defined resulting in greater than 60% of GBCs being diagnosed incidentally following cholecystectomy performed for presumed benign indications. As most localized GBCs require more extensive oncologic surgery beyond cholecystectomy, this study aims to examine factors associated with incidentally found GBC to improve preoperative and intraoperative diagnoses. Methods: The American College of Surgeons National Surgical Quality Improvement Program Database from 2007 to 2017 was used to identify cholecystectomies performed with and without a final diagnosis of GBC. Univariate and multivariable logistic regressions were used to compare demographic, intraoperative, and postoperative characteristics among those with and without a diagnosis of GBC. Results: The incidence of GBC was observed to be 0.11% (441/403,443). Preoperative factors associated with risk of GBC included age > 60 (OR 6.51, p <.001), female sex (OR 1.75, p <.001), history of weight loss (2.58, p <.001), and elevated preoperative alkaline phosphatase level (OR 1.67, p =.001). Open approach was associated with 7 times increased risk of GBC compared to laparoscopic approach (OR 7.33, p <.001). In addition to preoperative factors and surgical approach, longer mean operative times (127 min vs 70.7 min, p <.001) were significantly associated with increased risk of GBC compared to benign final pathology. Conclusion: This study demonstrates that those with incidentally discovered GBC at cholecystectomy are unique from those undergoing cholecystectomy for benign indications. By identifying predictors of GBC, surgeons can choose high risk individuals for pre-operative oncologic evaluation and consider better tools for identifying GBC such as intraoperative frozen pathology. [ABSTRACT FROM AUTHOR]

Background: Retromuscular drains are commonly placed during retromuscular hernia repair (RHR) to decrease postoperative wound complications and help mesh in-growth. Drains are traditionally removed when output is low but the relationship between drain output at the time of removal and postoperative complications has yet to be delineated. This study aimed to investigate outcomes of RHR patients with drain removal at either high or low output volume. Methods: An institutional review board-approved retrospective chart review evaluated adult patients undergoing open RHR with retromuscular drain placement between 2013 and 2022 at a single academic medical center. Patients were stratified into low output drainage (LOD, < 50 mL/day) or high output drainage (HOD, ≥ 50 mL/day) groups based on volume on the day of drain removal. Results: We identified 336 patients meeting inclusion criteria: 58% LOD (n = 195) and 42% HOD (n = 141). Demographics and risk factors pertaining to hernia complexity were similar between cohorts. Low-drain output at the time of removal was associated with a significantly longer drain duration (6.3 ± 4.5 vs. 4.4 ± 1.6 days, p < 0.001) and postoperative hospital stay (5.9 ± 3.6 vs. 4.8 ± 2.8 days, p < 0.001). With a 97% 30-day follow-up, incidence of surgical site occurrence (SSO) was not statistically different between groups (29.2% LOD, 26.2% HOD, p = 0.63). Surgical site infection and SSO requiring procedural intervention was also not statistically significant between cohort. At 1-year follow-up, hernia recurrence rates were the same between groups (4.2% LOD, 1.4% HOD, p = 0.25). Conclusion: Following open ventral hernia repair with retromuscular mesh placement, the rate of postoperative wound complications was not statistically different based on volume of drain output day of removal. These results suggest that removing drains earlier despite higher output is safe and has no effect on short- or long-term hernia outcomes. [ABSTRACT FROM AUTHOR]

Background: Minority-serving hospitals (MSHs) have been associated with lower guideline adherence and worse outcomes for various cancers. However, the relationship among MSH status, concordance with sentinel lymph node biopsy (SLNB) guidelines, and overall survival (OS) for patients with cutaneous melanoma is not well studied. Methods: The National Cancer Database was queried for patients diagnosed with T1a*, T2, and T3 melanoma between 2012 and 2017. MSHs were defined as the top decile of institutions ranked by the proportion of minorities treated for melanoma. Based on National Comprehensive Cancer Network guidelines, guideline-concordant care (GCC) was defined as not undergoing SLNB if thickness was < 0.76 mm without ulceration, mitosis ≥ 1/mm2, or lymphovascular invasion (T1a*), and performing SLNB for patients with intermediate thickness melanomas between 1.0 and 4.0 mm (T2/T3). Multivariable logistic regressions examined associations with GCC. The Kaplan–Meier method and log-rank tests were used to evaluate OS between MSH and non-MSH facilities. Results: Overall, 5.9% (N = 2182/36,934) of the overall cohort and 37.8% of minorities (n = 199/527) were managed at MSHs. GCC rates were 89.5% (n = 33,065/36,934) in the overall cohort and 85.4% (n = 450/527) in the minority subgroup. Patients in the overall cohort (odds ratio [OR] 0.85; p = 0.02) and the minority subgroup (OR 0.55; p = 0.02) were less likely to obtain GCC if they received their care at MSHs compared with non-MSHs. Minority patients receiving care at MSHs had a decreased survival compared with those treated at non-MSHs (p = 0.002). Conclusions: Adherence to SLNB guidelines for melanoma was lower at MSHs. Continued focus is needed on equity in melanoma care for minority patients in the United States. [ABSTRACT FROM AUTHOR]

Purpose: Although racial inequalities in referral and access to bariatric surgical care have been well reported, racial difference in the selection of surgical techniques is understudied. This study examined factors associated with the utilization of the two main bariatric surgical techniques: laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). Materials and Methods: The National Inpatient Sample database was queried for patients who underwent elective LSG or LRYGB for the treatment of severe obesity. Chi-square tests and multivariable logistic regression assessed associations of surgical approach with patient and facility characteristics. Sensitivity analyses examined the following body mass index (BMI) subgroups: < 40.0 kg/m2, 40.0–44.9 kg/m2, 45.0–49.9 kg/m2, and ≥ 50.0 kg/m2. Results: Within the final cohort (N = 86,053), 73.0% (N = 62,779) underwent LSG, and 27.0% (N = 23,274) underwent LRYGB. Patients with BMI 45.0–49.9 kg/m2 (OR = 0.85) and BMI ≥ 50.0 kg/m2 (OR = 0.80) were less likely to undergo LSG than patients with BMI 40.0–45.0 kg/m2 (all p < 0.001). However, Black (OR = 1.74) and White Hispanic patients (OR = 1.30) were more likely to undergo LSG than White non-Hispanic patients (all p < 0.005). In the BMI ≥ 50.0 kg/m2 group, Black patients were still more likely to undergo LSG compared to White non-Hispanic patients (OR = 1.69, p < 0.001), while Asians/Pacific Islanders were less likely to receive LSG than White non-Hispanic patients (OR = 0.41, p < 0.05). Conclusion: In this observational study, we identified racial differences in the selection of common bariatric surgical approaches across various BMI categories. Future investigations are warranted to study and to promote awareness of the racial/ethnic influence in attitudes on obesity, weight loss, financial support, and surgical risks during bariatric discussions with minorities. [ABSTRACT FROM AUTHOR]

Background: Male breast cancer (MBC) represents <1% of all breast cancer (BC) diagnoses. Recent publications in female stage IV BC have shown that surgical intervention has a survival benefit. This study aims to determine the impact of surgical intervention in men with stage IV BC and known estrogen (ER) and progesterone receptor (PR) status. Methods: The National Cancer Database was used to identify 539 stage IV MBC patients with known ER/PR status from 2004 to 2017. Chi-square tests examined subgroup differences between the treatment modalities received. Overall survival (OS) was assessed using the Kaplan–Meier method. Multivariate Cox proportional hazard models examined factors associated with survival. Results: The Kaplan–Meier estimation showed that ER-positive (ER+) and PR-positive (PR+) patients who received surgery, systemic therapy, and radiation (Trimodality) or systemic therapy and surgery (ST+Surg) had improved survival compared with systemic therapy alone (ST) [ER+, p < 0.003; PR+, p < 0.033]. For ER+ patients, the 5-year OS rates by treatment were: Trimodality, 40%; ST+Surg, 27%; and ST, 20%. For PR+ patients, the 5-year OS rates were: Trimodality, 39%; ST+Surg, 24%; and ST, 20%. The Cox proportional hazard model revealed a survival advantage in patients who received Trimodality compared with ST (hazard ratio 0.622; p < 0.002). The timing of systemic therapy in relation to surgery was not found to be significant. Conclusions: Trimodality therapy has a survival benefit in stage IV MBC patients with known ER+ status than in male patients who receive systemic therapy alone. [ABSTRACT FROM AUTHOR]

Software-based self-testing strategies have been mainly proposed to tackle microprocessor testing, but may also be applied to peripheral testing. However, testing system peripherals (e.g., DMA controllers, interrupt controllers, and internal counters) is a challenging task, since their observability and controllability are even more reduced when compared to microprocessors and to peripherals devoted to I/O communication (e.g., serial or parallel ports). In this paper an approach to develop functional tests for system peripherals is proposed. The presented methodology requires two correlated phases: module configuration and module operation. The first one prepares the peripheral to work in the different operation modes, whereas the second one is in charge of exciting the whole device and observing its behavior. We propose a methodology that guides the test engineer in building a compact set of test programs able to reach high structural fault coverage levels in a short time. Experimental results demonstrating the method effectiveness for two real-world case studies are finally reported. [ABSTRACT FROM AUTHOR]

Today's SoCs are composed of a wide variety of modules, such as microprocessor cores, memories, peripherals, and customized blocks directly related to the targeted application. To effectively perform simulation-based design verification of peripheral cores, it is necessary to stimulate the description in a broad range of behavior possibilities, checking the produced results. Different strategies for generating suitable stimuli have been proposed by the research community to functionally verify these modules and their interconnection when embedded in a SoC: however, their verification often remains a largely manual and unstructured operation. In this paper we describe a general approach to develop concise and effective sets of inputs by modeling the configuration modes of a peripheral with a graph, and creating paths able to cover all of its nodes: proper stimuli for the device are then directly derived from the paths. The resulting inputs sequences are aimed at design verification of system peripherals such as DMA controllers, and can be applied via simulation by means of dedicated testbenches or by setting up an environment including a processor, which executes a proper test priogram. In the latter case, the developed programs can be exploited in later stages for testing, by adding suitable observability features. Experimental results demonstrating the method effectiveness are reported. [ABSTRACT FROM AUTHOR]