A multinational monkeypox outbreak is currently underway in a growing number of non-endemic countries. Given the potential for future outbreaks, we evaluate the likely pathways for international exportation of monkeypox via commercial air travel from endemic regions.
Surgical resection following neoadjuvant therapy remains the cornerstone of curative management of esophageal cancer. In spite of this, there remains uncertainty regarding the optimal radicality of lymphadenectomy, and whether increasing lymph node yields confer a true survival benefit. This study aims to assess the impact of lymph node (LN) yield and LN ratio on survival following surgery for esophageal cancer, in addition to identifying factors that may influence LN yield and radicality of resection. All patients undergoing esophagectomy with curative intent from January 1, 2010 to December 31, 2020 were reviewed. Clinical and pathological variables were assessed, with univariable, multivariable, regression and survival analyses performed as appropriate. Cutpoint analysis was used to determine the optimal lymph node ratio. 397 patients underwent esophagectomy, with 288 having a minimally invasive operation (MIE). Stage (stage 3 HR: 1.64 (1.02–2.62), p = 0.04, stage 4 HR: 2.50 (1.43–5.01), p = 0.001), margin status (HR: 2.62 (1.57–4.36), p < 0.001), LN yield <15 (HR: 2.62 (1.57–4.36), p < 0.001) and elevated LN ratio (HR: 8.42 (2.85–24.90, p < 0.001) predicted survival. Patients undergoing MIE had higher LN yields compared with open (30.7 vs 25.3, p < 0.001). Patients undergoing neoadjuvant chemoradiation had lower LN yields compared with those without neoadjuvant therapy and those with neoadjuvant chemotherapy (26.4 vs 30.6 vs 36.8 respectively, p < 0.001). LN ratio < 0.05 was associated with a survival benefit. Lymphadenectomy is a cornerstone of resection of esophageal cancer. Low LN yield and high LN ratio are associated with reduced overall survival. Maintaining a LN yield >15 should remain a key quality metric. A LN ratio of <0.05 is associated with a significant survival benefit.
Background: A multi-country outbreak caused by monkeypox virus (MPXV) has been unfolding across endemic and non-endemic countries since May 2022. Throughout April and May 2022, Nigeria reported 31 MPXV cases, of which 11 were confirmed via testing. In May 2022 three internationally exported cases of MPXV, presumed to have originated in Nigeria, were reported, suggesting that a larger than reported outbreak might be occurring in the country. Methods: We used previously established methods to estimate the true size of the MPXV outbreak in Nigeria. We estimated the incidence rate of exported MPXV cases among all outbound international air travellers from Nigeria during the time period of April and May 2022, using forecasted air traveller volumes. We then applied this incidence rate to the entire population of Nigeria during April and May 2022 assuming that the rate of infection was the same in Nigeria for both travellers and the resident population. Information on the subset of population that were considered to be travellers was obtained from the United Nations World Tourism Organization (UNWTO). Results: We estimated that there were approximately 4000 (N = 4013; 95% CI: 828–11 728) active cases of MPXV in Nigeria in April and May 2022. This is approximately 360-fold greater than the confirmed number and approximately 130-fold greater than the reported number of cases in Nigeria. Conclusion: Our findings suggest that a larger outbreak than is appreciated may be ongoing in Nigeria. The observed international spread of MPXV offers important insights into the scale of the epidemic at its origin, where clinical detection and disease surveillance may be limited. These findings highlight the need to expand and support clinical, laboratory, and public health capacity to enable earlier detection of epidemics of international significance.
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