IMPORTANCE Melanoma is among the most common malignant neoplasms in the United States, with 91 270 cases estimated to be diagnosed in 2018. Since 2012, Mohs micrographic surgery (MMS) has gained popularity in the treatment of melanoma in situ. Although current guidelines for invasive melanoma without nodal metastases recommend surgery with wide margin excision (WME), use of MMS for this disease has increased as well, particularly in early stages. How the survival outcomes after each procedure compare with one another for early-stage invasive melanoma is unknown to date. OBJECTIVE To evaluate overall survival of patients with stage I melanoma defined by the American Joint Committee on Cancer Cancer Staging Manual, 8th edition (AJCC-8) after MMS vs traditional WME. DESIGN, SETTING, AND ANALYSIS This retrospective cohort study includes all patients with AJCC-8 stage I melanoma who underwent MMS or WME in the National Cancer Database with a diagnosis from January 1, 2004, through December 31, 2014. The National Cancer Database includes all reportable cases from Commission on Cancer-accredited facilities and represents approximately 50% of all newly diagnosed melanoma cases in the United States. Data were analyzed from November 13, 2018, through June 9, 2019. EXPOSURES MMS vs WME. MAIN OUTCOMES AND MEASURES Overall survival evaluated using multivariable Cox proportional hazards regression analysis. RESULTS A total of 70 319 eligible patients (52.3% male and 47.7% female; median [SD] age, 57.0 [16.2] years) were identified, including 67 085 treated with WME and 3234 treated with MMS. Multivariable Cox proportional hazards regression survival analysis controlling for clinical and tumor factors revealed that treatment with MMS was associated with a modest improvement in overall survival relative to WME (hazard ratio [HR], 0.86; 95% CI, 0.76-0.97). Propensity score-matched analysis of cohorts of patients treated with MMS vs WME also found modestly improved survival for those treated with MMS (HR, 0.82; 95% CI, 0.68-0.98). Academic facilities were more likely to use MMS than nonacademic facilities (odds ratio, 2.03; 95% CI, 1.88-2.18). CONCLUSIONS AND RELEVANCE These findings suggest that Mohs surgery may provide an alternative approach to traditional WME for appropriately selected cases of AJCC-8 stage I melanoma without compromising patient survival.

Adjuvant radiotherapy is associated with improved survival for patients with adverse features, regardless of stage. The addition of chemotherapy to the adjuvant treatment of patients with late-stage disease with adverse features is not associated with improved outcomes.

Objective Studies have suggested that the lymph node yield and lymph node density from selective or elective neck dissections are predictive of patient outcomes and may be used for patient counseling, treatment planning, or quality measurement. Our objective was to systematically review the literature and conduct a meta-analysis of studies that investigated the prognostic significance of lymph node yield and/or lymph node density after neck dissection for patients with head and neck cancer. Data Sources The Ovid/Medline, Ovid/Embase, and NLM PubMed databases were systematically searched on January 23, 2017, for articles published between January 1, 1946, and January 23, 2017. Review Methods We reviewed English-language original research that included survival analysis of patients undergoing neck dissection for a head and neck malignancy stratified by lymph node yield and/or lymph node density. Study data were extracted by 2 independent researchers (S.C. and M.O.). We utilized the DerSimonian and Laird random effects model to account for heterogeneity of studies. Results Our search yielded 350 nonduplicate articles, with 23 studies included in the final synthesis. Pooled results demonstrated that increased lymph node yield was associated with a significant improvement in survival (hazard ratio, 0.833; 95% CI, 0.790-0.879). Additionally, we found that increased lymph node density was associated with poorer survival (hazard ratio, 1.916; 95% CI, 1.637-2.241). Conclusions Increased nodal yield portends improved outcomes and may be a valuable quality indicator for neck dissections, while increased lymph node density is associated with diminished survival and may be used for postsurgical counseling and planning for adjuvant therapy.

United States census data project dramatic increases in the geriatric population ageing demographics by 2060 with concomitant health-care consequences. The purpose of this replication and continuation study was to collect new 2014 demographic data relative to ageing, swallow evaluation referral rates, and oral feeding status in geriatric-hospitalized patients for comparison with published data from 2000 to 2007. This was a planned data acquisition study of consecutive hospitalized patients referred for swallow assessments. Swallow evaluation referral rates for 2014 were described according to inpatient discharges, age range 60-105 years grouped by decade, gender, admitting diagnostic category, results of swallow evaluations, and oral feeding status. Determination of aspiration risk status was made with the Yale Swallow Protocol and diagnosis of dysphagia made with fiberoptic endoscopic evaluation of swallowing (FEES). There were 1348 referrals and 961 patients ≥60 years of age participated. Overall swallow evaluation referral rates increased an average of 63 % between the comparison years 2007 and 2014 with consistent increases corresponding to the decades, i.e., 60-69 (46 %), 70-79 (68 %), 80-89 (53 %), and 90+ (222 %). A total of 75 % of participants resumed oral alimentation and oral medications. Swallow evaluation referral rates increased by 63 % for 60-90+ year-old acute care geriatric-hospitalized participants despite only a 23 % increase in inpatient discharges for the years 2007 versus 2014. This corroborated previously reported increases for individual years from 2000 to 2007. For timely, safe, and successful initiation of oral alimentation, it is important to perform a reliable swallow screen for aspiration risk assessment with the Yale Swallow Protocol and, if failed, instrumental testing with FEES. More dysphagia specialists are needed through 2060 and beyond due to projections of continued population ageing resulting in ever increasing referral rates for swallow assessments.

Number of medications and PIM use increased annually for participants with and without dementia. Persistent challenge of increasing PIM use in this group of older adults is of major concern and warrants interventions to minimize such prescribing.

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IMPORTANCE Merkel cell carcinoma (MCC) carries the highest mortality rate among cutaneous cancers and is rapidly rising in incidence. Identification of prognostic indicators may help guide patient counseling and treatment planning. Lymph node ratio (LNR), the ratio of positive lymph nodes to the total number of examined lymph nodes, is an established prognostic indicator in other cancers. OBJECTIVES The primary objective was to evaluate the association between LNR and patient survival after surgery for node-positive MCC. The secondary objective was to evaluate whether the survival rates associated with adjuvant therapies vary by patient LNR status. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of patients with node-positive MCC treated with surgery and lymphadenectomy. We queried the National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) registry for patient records. Data originated from 2004 through 2017 for the NCDB and from 1973 through 2016 for the SEER registry. The SEER registry comprises a population-based US cohort while cases from the NCDB include all reportable cases from Commission on Cancer-accredited facilities and represents approximately 70% of all newly diagnosed cancers in the United States. All data analysis took place between August 1, 2018, and February 11, 2019. EXPOSURES The ratio of positive lymph nodes to the total number of examined lymph nodes, LNR, was stratified into quartiles. MAIN OUTCOMES AND MEASURES Overall survival (NCDB) and disease-specific survival (SEER). RESULTS We identified 736 eligible cases in the NCDB and 538 eligible cases in the SEER registry. Among these 1274 patients, the mean (SD) age was 71.1 (11.5) years, and 401 (31.5%) were women. After controlling for clinical and tumor factors including AJCC N staging, patient LNR of 0.07 to 0.31 (hazard ratio [HR], 1.37; 95% CI, 1.03-1.81) and greater than 0.31 (HR, 2.84; 95% CI, 2.10-3.86) was associated with significantly worse survival than an LNR less than 0.07. Univariate supplementary analysis performed in the SEER data set revealed a similar association of LNR with disease-specific survival. For patients with an LNR greater than 0.31, treatment with surgery and adjuvant chemoradiation therapy was associated with improved survival compared with surgery and adjuvant radiation therapy alone (HR, 0.61; 95% CI, 0.38-0.97), while this was not found for patients with an LNR of 0.31 or lower (HR, 0.93; 95% CI, 0.65-1.33). CONCLUSIONS AND RELEVANCE For lymph node-positive MCC, LNR offers a potentially prognostic metric alongside traditional TNM staging that may be useful for both patient counseling and treatment planning after surgery.

In epidemiologic studies, measurement error in dietary variables often attenuates association between dietary intake and disease occurrence. To adjust for the attenuation caused by error in dietary intake, regression calibration is commonly used. To apply regression calibration, unbiased reference measurements are required. Short-term reference measurements for foods that are not consumed daily contain excess zeroes that pose challenges in the calibration model. We adapted two-part regression calibration model, initially developed for multiple replicates of reference measurements per individual to a single-replicate setting. We showed how to handle excess zero reference measurements by two-step modeling approach, how to explore heteroscedasticity in the consumed amount with variance-mean graph, how to explore nonlinearity with the generalized additive modeling (GAM) and the empirical logit approaches, and how to select covariates in the calibration model. The performance of two-part calibration model was compared with the one-part counterpart. We used vegetable intake and mortality data from European Prospective Investigation on Cancer and Nutrition (EPIC) study. In the EPIC, reference measurements were taken with 24-hour recalls. For each of the three vegetable subgroups assessed separately, correcting for error with an appropriately specified two-part calibration model resulted in about three fold increase in the strength of association with all-cause mortality, as measured by the log hazard ratio. Further found is that the standard way of including covariates in the calibration model can lead to over fitting the two-part calibration model. Moreover, the extent of adjusting for error is influenced by the number and forms of covariates in the calibration model. For episodically consumed foods, we advise researchers to pay special attention to response distribution, nonlinearity, and covariate inclusion in specifying the calibration model.