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Accessible Summary: What is already known about this topic?: Individuals with severe mental illness (SMI) have elevated risks for physical health problems and low screening rates.No previous studies have compared the physical health promotion needs of people with SMI using the same screening tool across different international settings. What this paper adds to existing knowledge?: It appears feasible to use the HIP to profile and compare physical health‐related risks in people with SMI across different international settings.The HIP tool identified significant differences in areas of risk across the four countries. What are the implications for practice?: The HIP could be used to identify unique clusters of health promotion needs in different countries.Use of HIP health checks may support implementation of individualized interventions. Introduction: To date, no studies have contrasted physical health profiles of people with severe mental illness (SMI) in different countries. Aim: To evaluate feasibility of using the Health Improvement Profile (HIP) to compare and contrast physical health and health behaviours of people with SMI from four countries. Method: An observational feasibility study using secondary analysis of pooled health state and lifestyle data. Physical health checks using modified versions of HIP were administered in four countries. Results: Findings suggest feasibility of HIP screening to profile and compare physical health and health behaviours of people with SMI across international settings. High overall numbers of risk items (red flags) were identified in all but the Thailand sample. Despite some commonalities, there were important differences in health profiles across countries. Discussion: This is the first study to demonstrate feasibility of the HIP to compare health risks in individuals with SMI across countries. Future multi‐national HIP studies should recruit a fully powered stratified random sample of people with SMI that is representative of each setting. Implications for practice: It appears feasible to utilize the HIP to identify specific areas of health risk in different countries, which may help to better focus nursing interventions and use of resources. [ABSTRACT FROM AUTHOR]

Background: This exploratory survey study examined the relationship between older adults' five socio-demographic determinants (urban/rural residence, gender, age, marital status, and education) and their self-reported perception of importance, desire to perform, and ability to perform nine self-care behaviors related to promoting health and getting preventive health care. Methods: We reported a secondary analysis of a dataset from an exploratory survey project; we analyzed 2015–2016 retrospective data collected from a cross-sectional survey study, including 123 adults aged 65 years and older living in southern United States. Data were collected from the Patient Action Inventory for Self-Care and a demographic questionnaire and analyzed using binary and multiple logistic regression analyses. Results: Advancing age, marital separation, and holding less than a high school education were significantly associated with at least one of the unfavorable perceptions of the importance, the desire to perform, and the ability to perform three self-care behaviors. These three behaviors were: (1) creating habits that will improve health and prevent disease, (2) discussing the use of health screening tests with healthcare providers, and (3) joining in local health screening or wellness events. Gender and urban/rural residence were not significant. Conclusions: Comprehensive health care should include an individual's socio-demographic context and self-care perception of importance, desire, and ability. [ABSTRACT FROM AUTHOR]

The aim of this study is to describe religious and spiritual beliefs of physicians and examine their influence on the decision to pursue medicine and daily medical practice. An anonymous survey was e-mailed to physicians at a large, multidisciplinary tertiary referral center with satellite clinics. Data were collected from January 2014 through February 2014. There were 2097 respondents (69.1 % men), and number of practicing years ranged from ≤1 to ≥30. Primary care physicians or medical specialists represented 74.1 %, 23.6 % were in surgical specialties, and 2.3 % were psychiatrists. The majority of physicians believe in God (65.2 %), and 51.2 % reported themselves as religious, 24.8 % spiritual, 12.4 % agnostic, and 11.6 % atheist. This self-designation was largely independent of specialty except for psychiatrists, who were more likely report agnosticism ( P = 0.003). In total, 29.0 % reported that religious or spiritual beliefs influenced their decision to become a physician. Frequent prayer was reported by 44.7 % of physicians, but only 20.7 % reported having prayed with patients. Most physicians consider themselves religious or spiritual, but the rates of agnosticism and atheism are higher than the general population. Psychiatrists are the least religious group. Despite the influence of religion on physicians' lives and medical practice, the majority have not incorporated prayer into patient encounters. [ABSTRACT FROM AUTHOR]

The article provides information on American prose and the influence of the September 11, 2001 terrorist attacks and aftermath on U.S. literature. It states that any social formation is a complex overlay of different methods of production which serve as a basis of different social groups. It relates that Americans find themselves caught between conflicting interests and voices that establish the national debate, situated at a meeting place between the culture of the nation and the culture of the global marketplace. Furthermore, it mentions that through the work of American writers and novelists, they can represent the reality of their culture as multiple, complex and internally antagonistic.

Focuses on the Brooklyn Program, an innovative substance abuse program initiated by the U. S. Probation Department for the Eastern District of New York. Conceptual foundations of the program; Method of the program; Statistical measures and personal response from the respondents of the program.

Discusses U.S. and Canada farm programs for grains and oilseeds. U.S. farm policy; Details of Canadian agricultural programs; Comparison between Canadian and U.S. farm programs; Economic cost and benefits of U.S. and Canadian programs.

This paper describes an experimental, strengths-based program for the treatment of substance abusing offenders under criminal justice supervision in the United States Probation Department. The program is based upon new physiological evidence that links addictions to the experience of hope, and consistent research that identifies self-efficacy, futurity and self-esteem as crucial elements in recovery. Rooted in concepts taken from Jungian and Maslowian ideas of the Self, the program uses techniques gleaned from Neuro-linguistic Programming (NLP) and Ericksonian hypnosis to provide a continuing sense of Self and the possibility of positive, self-actualizing futures. This article explores the theoretical background of the program, specific tools employed, program results and suggestions for further research. [ABSTRACT FROM AUTHOR]

Examines the role of stent deployment for central and peripheral venous stenosis in the hemodialysis access in the U.S. Identification of balloon angioplasty as a treatment alternative for surgical repair; Disadvantages of balloon angioplasty; Consideration of stent deployment as an alternative option to balloon angioplasty.

Examines the role of atherectomy in the failing dialysis access in the U.S. Effectiveness of balloon angioplasty for the non-surgical treatment option of hemodialysis-access related stenoses; Factors influencing the increase interest of alternative percutaneous techniques for the treatment of stenoses in dialysis patients; Usage background of atherectomy.

The article presents the ideal teacher on teaching journalism in the U.S. It explores the issue on who shall teach and what educational beliefs should be applied in journalism. The teacher should understand the media organization and flow of the news, which is helpful in class discussion. The ideal applicant in teaching journalism should have published in scholarly journals, show skill in handling small seminars and demonstrate a facility for counseling students and advising thesis work.

Security regimes constitute an important test of the 'liberal' school of thought in contemporary international relations. In the Asia-Pacific, interest is growing over how they may contribute to that region's future order and stability. It is argued here, however, that Asia-Pacific security regimes cannot succeed unless 'realist' power-balancing strategies are first applied, affording time for patterns of structural leadership to shape enduring security norms and institutions. The ASEAN Regional Forum (ARF) is arguably the region's first potential post-cold war security regime. Its fate, or that of its successor security regimes in the Asia-Pacific, depends upon satisfying four critical conditions for regime building and upon winning the acceptance of China and the United States, the region's two key 'structural leaders'. While the ARF does not at present seem close to satisfying these criteria, it may help to provide the breathing space necessary for a successful transition from a competitive cold war environment to a more cooperative climate in the Asia-Pacific. [ABSTRACT FROM AUTHOR]

Focuses on two United States District Court actions that addressed the question of the preclusive effect of a state court determination. Facts of the cases; Defendants' motions for summary judgment to dismiss claims asserted against them under various provisions of the 1934 Securities Exchange Act of 1934; Defendants' claim that prior state court determinations barred the federal claims.

Focuses on the United States' support for the Miskitus in Nicaragua. Armistice reached by Miskitus and the Sandinista National Liberation Front; Sandinistas' agreement to have a presidential election in Nicaragua in 1990.

Abstract: Background: Surgery is the cornerstone of potentially curative therapy for upper gastrointestinal cancer. We analyzed the patterns of treatment regarding the use of surgery for early-stage upper gastrointestinal cancer in the United States. Methods: The Surveillance, Epidemiology, and End Research database was used to identify patients with cancer of the esophagus, stomach, pancreas, liver, gallbladder, biliary tract, or duodenum (2004–2007). Only patients with potentially resectable stage I and II disease were selected. The primary outcome measure was the use of curative intent surgery. The secondary outcomes were the predictors of surgery. Results: We identified 29,249 patients with a median age of 69 years. Only 54% of the patients underwent cancer-directed surgical resection, ranging from 28% for liver cancer to 89% for gallbladder cancer. The remaining patients underwent either local excision (8%) or no surgery (38%). Among the no surgery group, most patients (79%) were documented as “not being recommended for resection.” The independent variables on multivariate analysis predictive of a nonoperative approach included black race, age older than 75 years, tumor size greater than 5 cm, and high poverty level (P < 0.001). Patients who did not undergo surgery had worse median and overall survival at 3 years than patients undergoing surgery (11 months versus 36 months and 14% versus 43%, respectively; P < 0.001). Conclusions: Almost one half of patients with early-stage upper gastrointestinal cancer did not receive potentially curative surgery, with an adverse effect on overall survival. A combination of demographic, tumor, and socioeconomic factors were predictive of a lack of surgical resection. [Copyright &y& Elsevier]

Objective: To estimate the seroprevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies in health care personnel., Methods: The Mayo Clinic Serology Screening Program was created to provide a voluntary, two-stage testing program for SARS-CoV-2 antibodies to health care personnel. The first stage used a dried blood spot screening test initiated on June 15, 2020. Those participants identified as reactive were advised to have confirmatory testing via a venipuncture. Venipuncture results through August 8, 2020, were considered. Consent and authorization for testing was required to participate in the screening program. This report, which was conducted under an institutional review board-approved protocol, only includes employees who have further authorized their records for use in research., Results: A total of 81,113 health care personnel were eligible for the program, and of these 29,606 participated in the screening program. A total of 4284 (14.5%) of the dried blood spot test results were "reactive" and warranted confirmatory testing. Confirmatory testing was completed on 4094 (95.6%) of the screen reactive with an overall seroprevalence rate of 0.60% (95% CI, 0.52% to 0.69%). Significant variation in seroprevalence was observed by region of the country and age group., Conclusion: The seroprevalence for SARS-CoV-2 antibodies through August 8, 2020, was found to be lower than previously reported in other health care organizations. There was an observation that seroprevalence may be associated with community disease burden., (Copyright © 2021 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Objectives : The escalating cost of low back pain (LBP) care has not improved outcomes. Our purpose: to compare costs between LBP care guided by a quality-assured mechanical assessment (MC) and usual community care (CC). Study Design : Administrative claims data analysis. Methods : Employees and dependents of a large self-insured manufacturer seeking care for LBP in 2013 chose between the company's primary care clinic (where MC was delivered) and community care.The claims of 5,036 were analyzed for one year following subjects' initial evaluation excluding only those with diagnostic codes for fractures, dislocations, or infections. MC included an advanced form of Mechanical Diagnosis & Therapy (MDT). CC varied based on each subjects' selection of providers. Primary outcome measure: one-year cost of each subject's care. Secondary: number of MRIs, spinal injections, and lumbar surgeries undertaken. The payer's proprietary risk-adjustment algorithm was utilized. Results : After risk adjustment, the average cost per MC subject was 51.48% lower than the CC average cost (p < .0279). The utilization of MRIs, injections, and surgeries was lower with MC by 49.75%, 39.44%, 78.38% with relative risks of 1.99, 1.64, and 4.73, respectively. Conclusions : This 51.5% cost-savings reflects the substantial reduction in downstream care-seeking with MC, including lower utilization of MRIs, injections, surgeries, and downstream care after six months from the initial visit. It is well documented that the MDT clinical examination typically elicit patterns of pain response that in turn identify how most can rapidly recover with self-care with no need for other intervention.Level of Evidence: 1b.

Background: The majority of newly diagnosed breast cancers in the US are in women aged older than 65 years who can have additional comorbidities. Balancing the risks and benefits of treatment should take into account these competing risks of death., Study Design: The Surveillance, Epidemiology, and End Results Program-Medicare database was used to identify women with stage I breast cancer undergoing operations from 2004-2012. Using neural network analysis, comorbidities associated with mortality were grouped into clinically relevant categories. Cumulative incidence graphs and Fine and Gray competing risk regression analyses were used to study the association of age, race, comorbidity groupings, and tumor variables with 3 competing mortality outcomes: dead of disease (DOD), dead of other cancers (DOC), and non-cancer death (NCD)., Results: The overall cumulative incidence of mortality was 4.9% for DOD, 3.7% for DOC, and 21.3% for NCD for the 47,220 patients studied. For all patients, the 5- and 8-year probability of DOD was 3% and 4.7%, for DOC 1.9% and 3.5%, and for NCD 9.8% and 18.9%, respectively. The presence of any major comorbidity (eg cardiovascular or neurologic disorders) significantly increased the probability of NCD, and estrogen receptor status was the strongest predictor of DOD. Given patient age, comorbidity, and estrogen receptor status, an estimate of competing risks of death from DOD, DOC, and NCD can be calculated., Conclusions: To aid clinical decision making, we quantify competing risks of death in patients with stage I breast cancer by taking into account patient age, comorbidity, and estrogen receptor status., (Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Surgeons are the fifth largest prescribers of opioids in the US. Few studies exist to describe surgeon prescribing practices., Methods: A survey was conducted of surgical providers at all ACGME-accredited surgical residency programs. Statistical comparisons between groups were made., Results: A total of 114 providers from 21 states responded; 58% male, 57% residents. Only 8% reported being told they were over-prescribing opioids. Oxycodone ± acetaminophen was most commonly prescribed (49%). Median opioids prescribed exceeded guidelines for acute pain management for every procedure except laparoscopic appendectomy/cholecystectomy, lumpectomy and laparoscopic inguinal hernia repair. Attending surgeons more often gave no opioids after laparoscopic appendectomy/cholecystectomy (9% vs 0%; p=0.012), more likely reported patient attempts to return opioids to them (33% vs 16%; p=0.04), and less likely considered patients giving their opioids to someone else (39% vs. 74%; p<0.001). PGY 1-2 residents prescribe fewer opioids than advanced residents for simple mastectomy (p=0.04), exploratory laparotomy (p=0.05), and thoracotomy (p=0.03)., Conclusions: Surgeons vary significantly in their opioid prescriptions, even for the same operation. There are few differences by gender but some important differences by experience., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The NCCN Guidelines for Breast Cancer Screening and Diagnosis have been developed to facilitate clinical decision making. This manuscript discusses the diagnostic evaluation of individuals with suspected breast cancer due to either abnormal imaging and/or physical findings. For breast cancer screening recommendations, please see the full guidelines on NCCN.org., (Copyright © 2018 by the National Comprehensive Cancer Network.)

Objective: The purpose of this study was to assess radiologists' choice of imaging modality for the evaluation of clinical symptoms of physiologic nipple discharge (e.g., bilateral discharge, multiple-duct orifices, and yellow, green, or white color) and pathologic nipple discharge (e.g., unilateral discharge, single-duct orifices, spontaneous and serous discharge, and clear or bloodstained color)., Materials and Methods: An online survey was sent to lead interpreting physicians at mammography facilities accredited by the American College of Radiology (ACR). Statistical analysis was performed using chi-square tests for frequency data and multinomial logistic regression., Results: A total of 849 responses to 8170 distributed surveys were received, for a response rate of 10.4%. For the workup of physiologic nipple discharge, 30% of respondents recommended screening mammography (SM); 24%, diagnostic mammography (DM) only; and 46%, both DM and targeted ultrasound (US) (DM plus US). For the workup of physiologic nipple discharge, practitioners in nonacademic settings and those who read breast images during less than 50% of their practice were significantly more likely to recommend DM (with or without US), compared with SM (the standard recommended by the ACR). Those reading breast images less than 50% of the time were also more likely to recommend MRI after conventional imaging revealed negative results. For the workup of pathologic nipple discharge, 91.0% of respondents recommended DM plus US; 8.5%, DM only; and fewer than 1.0%, SM. Nonacademic providers and those who read breast images less than 50% of the time were significantly less likely to recommend DM plus US (the standard recommended by the ACR), compared with DM only., Conclusion: The present study shows variability in imaging modality selection among U.S. radiologists handling the imaging workflow for benign and pathologic nipple discharge. Radiologists do not uniformly follow ACR practice guidelines, which potentially leads to unnecessary workups and extra health care costs.

Background: Regionalization of complex visceral surgery across the US has followed identification of a volume to outcomes association. However, a simultaneous trend toward improved surgical outcomes might have attenuated this relationship. We hypothesize that the difference in adjusted postoperative mortality between low- (LV), medium- (MV), and high-volume (HV) hospitals has decreased over time., Study Design: The National Inpatient Sample (NIS) was used to identify patients undergoing bladder, esophageal, pancreatic, liver, lung, and rectal surgery from 2003 to 2011. Hospitals were divided into LV (<33 rd centile), MV (34 th to 66 th ), and HV (>67 th centile) groups. Annual organ-specific adjusted in-hospital mortality (AIHM) for each volume strata was calculated and the difference in AIHM between volume strata was plotted over time., Results: The proportion of hospitals classified as HV was 6% for lung; 5% for rectal; 3% for esophageal, pancreatic, and bladder; and 2% for liver surgery patients. The AIHM after operation was higher in LV compared with HV hospitals in 2003 to 2005 for all visceral resections except liver surgery. The difference in AIHM between LV, MV, and HV hospitals showed a decreasing trend from 2003 to 2005 to 2009 to 2011 for pancreatic, esophageal, bladder, and lung surgery. For patients undergoing rectal resections, the difference in AIHM was low and stable, and increased for liver resections only., Conclusions: A reduction in the differences in AIHM among LV, MV, and HV hospitals for 5 of 6 organs studied suggests attenuation of the volume to outcomes relationship with time. This is likely due to system-wide improvements in surgical care., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Although major cancer surgery at a high-volume hospital is associated with lower postoperative mortality, the use of such hospitals may not be equally distributed., Objective: Our aim was to study socioeconomic and racial differences in cancer surgery at Commission on Cancer (CoC)-accredited high-volume hospitals., Methods: The National Cancer Database (NCDB) was used to identify patients undergoing surgery for colon, esophageal, liver, and pancreatic cancer from 2003 to 2012. Annual hospital volume for each cancer was categorized using quartiles of patient volume. Patient-level predictors of surgery at a high-volume hospital, trends in the use of a high-volume hospital, and adjusted likelihood of surgery at a high-volume hospital in 2012 versus 2003 were analyzed., Results: African American patients were less likely to undergo surgery at a high-volume hospital for esophageal (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.49-0.73) and pancreatic cancer (OR 0.83, 95% CI 0.74-0.92), while uninsured patients and those residing in low educational attainment zip codes were less likely to undergo surgery at a high-volume hospital for esophageal, liver, and pancreatic cancer. In 2012, African Americans, uninsured patients, and those from low educational attainment zip codes were no more likely to undergo surgery at a high-volume hospital than in 2003 for any cancer type. These differences were not seen in colon cancer patients, for whom significant regionalization was not seen., Conclusions: Differences in the use of CoC-accredited high-volume hospitals for major cancer surgery were seen nationwide and persisted over the duration of the study. Strategies to increase referrals and/or access to high-volume hospitals for African American and socioeconomically disadvantaged patients should be explored.

Background: A significant proportion of hospital admissions in the US are secondary to emergency general surgery (EGS). The aim of this study is to quantify outcomes for EGS patients with cancer., Methods: The Nationwide Inpatient Sample (2007 to 2011) was queried for patients with a diagnosis of an EGS condition as determined by the American Association for the Surgery of Trauma. Of these, patients with a diagnosis of malignant cancers (ICD-9-CM diagnosis codes; 140-208.9, 238.4, 289.8) were identified. Patients with and without cancer were matched across baseline characteristics using propensity-scores. Outcome measures included all-cause mortality, complications, failure-to-rescue, length of stay, and cost. Multivariable logistic regression analyses further adjusted for hospital characteristics and volume., Results: Analysis of 3,625,906 EGS patients revealed an 8.9% prevalence of concurrent malignancies. The most common EGS conditions in cancer patients included gastro-intestinal bleeding (24.8%), intestinal obstruction (13.5%), and peritonitis (10.7%). EGS patients with cancer universally had higher odds of complications (odds ratio [OR] 95% confidence interval [CI]: 1.20 [1.19 to 1.21]), mortality (OR [95% CI]: 2.00 [1.96 to 2.04]), failure-to-rescue (OR [95% CI]: 1.52 [1.48 to 1.56]), and prolonged hospital stay (OR [95% CI]: 1.69 [1.67 to 1.70])., Conclusions: EGS patients with concurrent cancer have worse outcomes compared with patients without cancer after risk-adjustment., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The American College of Surgeons Oncology Group Z0011 trial results have the potential to bias the number of sentinel lymph nodes (SLNs) surgeons remove and axillary lymph node dissections (ALNDs) performed., Methods: A single-institution prospectively collected database was queried for T1 to T2 clinically node-negative breast cancer patients., Results: A total of 923 patients underwent breast conserving therapy with SLN biopsy. The mean number of SLNs retrieved before the trial's presentation (June 2010) was 2.7 compared with 2.6 after (P = .19). The mean number of SLNs retrieved before the trial's publication (February 2011) was 2.7 compared with 2.5 after (P = .10). Overall, the rate of completion ALND in patients with SLN macrometastases decreased from after presentation (84% to 63%; P < .01) and publication (83% to 62%; P < .01)., Conclusions: There was no difference in the number of SLNs harvested after either the Z0011 trial presentation or publication; however, surgeons should be aware of the potential for bias. The trial appears to influence practice management with fewer completion ALNDs performed after its release., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The diverse attitudes and motivations of surgeons and surgical trainees within different age groups present an important challenge for surgical leaders and educators. These challenges to surgical leadership are not unique, and other industries have likewise needed to grapple with how best to manage these various age groups. The authors will herein explore management and leadership for surgeons in a time of age diversity, define generational variations within "Baby-Boomer", "Generation X" and "Generation Y" populations, and identify work ethos concepts amongst these three groups. The surgical community must understand and embrace these concepts in order to continue to attract a stellar pool of applicants from medical school. By not accepting the changing attitudes and motivations of young trainees and medical students, we may disenfranchise a high percentage of potential future surgeons. Surgical training programs will fill, but will they contain the highest quality trainees?, (Copyright © 2013 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

The National Comprehensive Cancer Network has formulated guidelines for the management of cutaneous malignant melanoma with regard to resection margins (RMs) and regional staging. The aim of this study was to assess compliance with these recommendations in the general population of the USA. The Surveillance, Epidemiology and End-Results database was examined to identify 60 194 patients with malignant melanoma from 2004 to 2008. Multivariate logistic regression analysis was used to identify factors predictive of RM less than 1 cm and noncompliance with sentinel lymph node biopsy (SLNB). The median age of the population was 60 years and the mean Breslow thickness was 1.20±0.16 mm. The majority of patients had a RM of less than 1 cm (58%) and only 53% of eligible patients had undergone SLNB. Regional nodal dissection was performed in 69% of patients with a positive SLNB and in 78% with palpable lymphadenopathy. On multivariate analysis age more than 80 years [odds ratio (OR) 1.3, 95% confidence interval (CI) 1.2-1.4], T1 stage (OR 1.5, 95% CI 1.4-1.6), and head and neck primary (OR 1.4, 95% CI 1.3-1.4) all predicted RM of less than 1 cm. Factors predictive of noncompliance with SLNB recommendations included age more than 60 years (OR 1.6, 95% CI 1.5-1.8), T1 stage (OR 2.0, 95% CI 1.8-2.2), head and neck primary (OR 2.0, 95% CI 1.9-2.2), and RM less than 1 cm (OR 2.1, 95% CI 2.0-2.2). RMs and appropriate SLNB are inadequate in the majority of patients currently being treated for malignant melanoma in the USA. A combination of patient and physician education and perhaps regionalization of melanoma care is needed to improve compliance.

Background: Lymph lymph node metastasis from melanoma ≤0.50 mm (ultrathin) is an infrequent event. However, because many newly diagnosed melanomas are ultrathin, a significant proportion of patients who present with lymph node disease have an ultrathin melanoma. The authors hypothesized that ultrathin melanomas that present with lymph node metastasis represent biologically aggressive lesions with a worse prognosis., Methods: The Surveillance, Epidemiology, and End Results registry data were queried to identify patients with cutaneous melanoma who presented with lymph node metastasis diagnosed between 1998 and 2008. Hazard ratios (HRs) from Cox proportional hazards regression models were used to compare disease-specific survival (DSS) between various tumor depths., Results: In total, 6134 patients with lymph node-positive melanoma were identified and stratified according to tumor depth, including 588 (10%) with a tumor depth ≤0.50 mm, 519 (8%) with a tumor depth from 0.51 to 1.00 mm, 1669 (27%) with a tumor depth from 1.01 to 2.00 mm, 1871 (31%) with a tumor depth from 2.01 to 4.00 mm, and 1487 (24%) with a tumor depth >4.00 mm; and the respective 5-year DSS rates were 63%, 76%, 75%, 60%, and 43%. Multivariable analysis confirmed a similar trend in HRs for DSS: The HR was 1.00 for a tumor depth ≤0.50 mm (reference category) and 0.64 (P < .001), 0.65 (P < .001), 0.95 (P = .57), and 1.42 (P < .001) for tumor depths of 0.51 to 1.00 mm, 1.01 to 2.00 mm, 2.01 to 4.00 mm, and >4.00 mm, respectively. This association of tumor depth with DSS persisted for N1 and N2 disease but not for N3 disease., Conclusions: Ultrathin melanoma (≤0.50 mm) was identified as a marker of poor prognosis in the setting of lymph node metastasis. These results may improve recommendations for adjuvant therapy, surveillance protocols, and risk stratification for clinical trials., (Copyright © 2013 American Cancer Society.)

Introduction: Although trends and variations in the use of breast conservation therapy (BCT) for ductal carcinoma have been studied, little is known about uncommon breast cancer histologies., Methods: The Surveillance, Epidemiology and End Results (SEER) database was used to identify 338,682 patients with T1 or T2 (≤5 cm) ductal, lobular, tubular, mucinous, medullary, or papillary carcinoma of the breast from 1998 to 2008. Multivariate logistic regression analysis was used to identify predictors of BCT., Results: The majority of patients underwent BCT (60%). The rate of BCT remained relatively constant from 1998 to 2008 overall but varied from 50% for lobular to 79% for tubular. The highest rate of mastectomy was seen in lobular (49%). Nodal positivity following surgical staging was lowest for tubular (6%) and mucinous (8%). Adjuvant radiation was given to 72% overall and was lowest for papillary (58%). Predictors of BCT included tubular (OR 1.8, 95% CI 1.7-1.9) and medullary (OR 2.0, 95% CI 1.8-2.2) subtypes (vs. ductal)., Conclusions: Patients with uncommon breast cancer histologies show wide variation in the application of BCT depending on the primary tumor. This suggests that an individualized approach in the use of BCT depending on histology should be used., (Copyright © 2011 Wiley Periodicals, Inc.)

Introduction: The recently published 7th edition of the American Joint Committee on Cancer (AJCC) TNM staging criteria for gastric adenocarcinoma contains important revisions to T and N classifications, as well as overall stage grouping. Our goal was to validate the new staging system using a cancer registry., Methods: Retrospective review of gastric cancer patients from Surveillance, Epidemiology, and End Results (SEER) registry data (2004-2007). Patients were staged according to both 6th and 7th edition criteria, and 3-year disease-specific survival was compared., Results: Thirteen thousand five hundred forty-seven patients with gastric adenocarcinoma were identified with complete staging information. When using 7th edition criteria, there was an increase in the number of patients classified as stage III (23% vs. 13%), and a decrease in patients classified as stage IV (47% vs. 53%). Statistically significant differences in 3-year disease-specific survival were observed for all T and N categories and re-staging the same population according to the 7th edition criteria improved survival discrimination. Multivariate analysis revealed statistically significant differences in survival and linear progression of hazard ratios for each stage grouping., Conclusions: The 7th edition AJCC staging criteria for gastric adenocarcinoma demonstrate better survival discrimination and risk stratification than previous criteria.

Background: For patients with microinvasive breast cancer, the value of intraoperative analysis of sentinel lymph nodes (SLNs) and complete axillary lymph node dissection (CALND) is not well known., Methods: All patients staged T1mic from 2001 to 2005 were analyzed., Results: Among all 81 patients, 4 (5%) had SLN metastases detected with hematoxylin and eosin staining and 2 (2%) had metastases identified by immunohistochemistry staining only. Seventy-seven patients (95%) underwent SLN biopsy; 3 (4%) had hematoxylin and eosin SLN metastases and 2 (3%) had immunohistochemistry-detected metastases. One SLN metastasis was identified on frozen section analysis. No patient with a SLN metastasis had additional metastases on CALND. The patient charges for frozen section analyses were $39,578 for 77 patients. This prevented 1 reoperative CALND at a charge of $20,274., Conclusions: Frozen section analysis should be used only in select patients with microinvasive breast cancer and CALND is of limited value for these patients.

The incidence rate of treated end-stage renal disease in the united states is 180 per million and continues to rise at a rate of 7.8% per year. Arteriovenous hemodialysis access (AV access) creation and maintenance are two of the most difficult issues associated with the management of patients on hemodialysis. The 1-year complication rate of a primary prosthetic AV access for hemodialysis ranges from 33% to 99%. Various investigators report on patency and complications of AV access. However, it is rather difficult to compare outcomes because of the wide variety of access materials, configurations, locations, risk factors, and quality of inflow and outflow vessels. Although there have been reporting standards for dialysis access endovascular interventions and for central venous access placement, standards regarding surgical access placement and its revision are lacking. The "Dialysis Outcome Quality Initiative," published by the National Kidney Foundation, provides recommendations for optimal clinical practices aimed at improving dialysis outcome and patient survival. This reporting standards document is not meant to be a "practice guidelines" or "best practices" document. Rather, the purpose of this document is to provide standardized definitions related to AV access procedures and to recommend reporting standards for patency and complications, to be used by surgeons, nephrologists, and interventional radiologists, that will permit meaningful comparisons among AV access procedures. The terms, definitions, and categories featured in this article have been approved by the Committee on Reporting Standards of the Society for Vascular Surgery and the American Association for Vascular Surgery and should be observed in preparing manuscripts on AV accesses for submission to the Journal Of Vascular Surgery.