Alvarado scoring in primary health care: managing acute surgical workload at the source Assessment of patients presenting to acute surgical services with possible appendicitis constitutes 20% of the surgical workload in Australasia 1 and, even with the use of preoperative computed tomography (CT) scanning, operative procedures to rule out or treat acute appendicitis constitute one-third of acute operations. 2 The Alvarado score utilizes a clinical scoring system (Table 1) to assess for the likelihood of appendicitis with a score of ≥4 indicative of appendicitis and a score of ≥7 in males and ≥9 in females giving diagnostic accuracy similar to CT scan. 3 We have used Alvarado scoring prospectively over a 6-month period at Te Puna Hauora, a large primary health care provider close to North Shore Hospital. All patients presenting to the practice were scored by a single practitioner (HH) with those having Alvarado scores of ≥6 referred for acute surgical assessment. Those with scores of <6 were rescored after 24 h and referred if they rescored at 6 or greater. Fifty-eight patients were seen of whom 13 scored ≥6. All 13 were referred and underwent surgical exploration with 10 having acute appendicitis. Of the remaining 45, nine patients scored ≥6 when assessed the following day. Four patients settled with observation alone while five patients were surgically explored (three acute appendicitis, two ruptured ovarian follicles). None of the remaining 36 patients were admitted to hospital or underwent further treatment. The Alvarado scoring system has traditionally been used by hospital emergency and surgical services. This small experience illustrates that it can be easily and safely applied in the primary care setting to assist general practitioners in assessing patients with suspected appendicitis and determining when surgical referral should be made. Potential partnerships between primary care services and acute surgical services offer an opportunity to manage the acute surgical workload at its source. References 1. Cox M, Cook L, Dobson J et al. Acute surgical unit: a new model of care. ANZ J. Surg. 2010; 80: 419-24. 2. Perry E, MacKintosh S, Connor S. Role of an acute assessment and review area for general surgical patients. ANZ J. Surg. 2010; 80: 425-9. 3. Tan WJ, Acharyya S, Goh YC et al. Prospective comparison of the Alvarado score and CT scan in the evaluation of suspected appendicitis: a proposed algorithm to guide CT use. J. Am. Coll. Surg. 2015; 220: 218-24.Fig.

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Background Use of rectal MRI evaluation of patients with rectal cancer for primary tumor staging and for identification for poor prognostic features is increasing. MR imaging permits precise delineation of tumor anatomy and assessment of mesorectal tumor penetration and radial margin risk. Objective To evaluate the ability of pre-treatment rectal MRI to classify tumor response to neoadjuvant chemoradiation. Design Retrospective, consecutive cohort study, central review. Setting Tertiary academic hospital. Patients 62 consecutive patients with locally advanced (stage cII-cIII)rectal cancer who underwent rectal cancer protocol high resolution MRI prior to surgery(12/09-3/11). Main Outcome Measures Probability of good (ypT0-2N0) vs. poor (≥ypT3N0) response as a function of mesorectal tumor depth, lymph node status, extramural vascular invasion, and grade assessed by uni- and multi-variate logistic regression. Results Tumor response was good in 25, 40.3% and poor in 37, 59.7%.Median interval from MRI to OP was 7.9weeks (IQR: 7.0–9.0). MRI tumor depth was <1 mm in 10 (16.9%), 1–5 mm in 30 (50.8%), and >5 mm in 21(33.9%). LN status was positive in 40 (61.5%) and vascular invasion was present in 16 (25.8%). Tumor response was associated with MRI tumor depth (P=0.001), MRI lymph nodes status (P=<0.001)and vascular invasion (P=0.009). Multivariate regression indicated >5mm MRI tumor depth (OR=0.08, 95% CI=0.01–0.93, p=0.04) and MRI LN positivity (OR=0.12, 95% CI=0.03–0.53, p=0.005) were less likely to achieve a good response to neoadjuvant chemoradiotherapy. Limitations Uncertain generalizability in centers with limited experience with MRI staging for rectal cancer. Conclusion MRI assessment of tumor depth and lymph node status in rectal cancer is associated to tumor response to neoadjuvant chemoradiotherapy. These factors should therefore be considered for stratification of patients for novel treatment strategies reliant on pathologic response to treatment or for the selection of poor-risk patients for intensified treatment regimens.

Importance-The overall incidence of colorectal cancer (CRC) has been decreasing since 1998, but there has been an apparent rise in the incidence of CRC in young adults.Objective-To evaluate age-related disparities in secular trends in CRC incidence in the United States.Design-A retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) CRC registry. Age at diagnosis was analyzed in 15-year intervals starting at the age of 20. SEER*Stat was used to obtain the annual cancer incidence rates, annual percent change (APC), and corresponding p-values for the secular trends. Main Outcome-Difference in CRC incidence by age. Setting-DataResults-Overall age-adjusted CRC incidence rate decreased by 0.92% between 1975 and 2010. There has been a steady decline in the incidence of CRC in patients age 50 years or older, but the opposite trend has been observed for young adults. For patients 20 to 34 years of age, the incidence rate of localized, regional and distant colon and rectal cancer has increased. Increasing incidence rate was also observed for rectal cancer patients aged 35 to 49. Based on current trends, in 2030 the incidence rate for colon and rectal cancer will increase by 90.0% and 124.2% for patients 20 to 34 years of age and by 27.7% and 46.0% for patients 35 to 49 years of age.Conclusion and Relevance-There has been a significant increase in the incidence of CRC diagnosed in young adults, with a decline in older patients. Further studies are needed to determine the cause for these trends and identify potential preventive and early detection strategies.

BACKGROUND:This study evaluates the independent association of Medicaid expansion on stage of presentation among patients of Black and White race with colorectal (CRC), breast, or non-small cell lung cancer (NSCLC). METHODS: A cohort study of patients with CRC, breast cancer, or NSCLC (2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017) in the National Cancer Database was performed. Difference-in-differences (DID) analysis was used to compare changes in tumor stage at diagnosis between Medicaid expansion (MES) and non-expansion states (non-MES) before and after expansion. Predictive margins were calculated by race, year, and insurance status to account for effect heterogeneity. Stage migration was determined by measuring the combined proportional increase in stage I and decrease in stage IV disease at diagnosis. RESULTS: Black patients gained less Medicaid coverage than White patients (6.0% vs 13.1%, p < 0.001) after expansion. Among Black and White patients, there was a shift towards increased early-stage diagnosis (DID 3.5% and 3.5%, respectively; p < 0.001) and decreased latestage diagnosis (DID White: −3.5%; Black −2.5%; p < 0.001) in MES compared to non-MES following expansion. Overall stage migration was greater for White compared to Black patients with CRC (10.3% vs. 5.1%) and NSCLC (8.1% vs. 6.7%) after expansion. Stage migration effects in patients with breast cancer were similar by race (White 4.8% vs. Black 4.5%). CONCLUSION: An increased proportion of Black and White patients residing in Medicaid expansion states presented with earlier stage cancer following Medicaid expansion. However, because the proportion of Black patients is higher in non-expansion states, national racial disparities in cancer stage at presentation appear worse following Medicaid expansion.