Introduction: The TNM classification for lung cancer, originally designed for NSCLC, is applied to staging of bronchopulmonary carcinoid tumors. The validity of the eighth edition of the staging system for carcinoid tumors has not been assessed. In this study, we evaluated its prognostic accuracy by using data from a large national population-based cancer registry.Methods: Patients with typical and atypical bronchopulmonary carcinoids diagnosed between 2000 and 2013 were identified from the National Cancer Institute's Surveillance, Epidemiology and End Results registry. We used competing risks analysis to compare 10-year diseasespecific survival (DSS) across stages.Results: Overall, 4645 patients with bronchopulmonary carcinoid tumors were identified. Worsening DSS with increasing TNM status and stage was demonstrated across both typical and atypical carcinoids, with overlaps between adjacent subcategories. The combined stages (I versus II, II versus III, and III versus IV) showed greater separation in DSS despite persistent overlaps between groups. For typical carcinoids, we found decreased DSS for stages II, III, and IV, with hazard ratios of 3.8 (95% confidence interval [CI]: 2.6-5.6), 4.3 (95% CI: 3.0-6.1), and 9.0 (95% CI: 6.1-13.1), respectively, compared with stage I. Conclusion:The combined stage categories of the eighth edition of the TNM staging system provide useful information on outcomes for typical and atypical carcinoids. However, persistent overlaps in combined stage and subcategories of the staging system limit the usefulness of the TNM staging system, particularly in intermediate stages. These limitations suggest the need for future further study and refinement.

BackgroundTime-driven activity-based costing (TDABC) is a methodology that calculates the costs of healthcare resources consumed as a patient moves along a care process. Limited data exist on the application of TDABC from the perspective of an anesthesia provider. We describe the use of TDABC, a bottom-up costing strategy and financial outcomes for three different medical-surgical procedures.MethodsIn each case, a multi-disciplinary team created process maps describing the care delivery cycle for a patient encounter using the TDABC methodology. Each step in a process map delineated an activity required for delivery of patient care. The resources (personnel, equipment and supplies) associated with each step were identified. A per minute cost for each resource expended was generated, known as the capacity cost rate, and multiplied by its time requirement. The total cost for an episode of care was obtained by adding the cost of each individual resource consumed as the patient moved along a clinical pathway.ResultsWe built process maps for colonoscopy in the gastroenterology suite, calculated costs of an aortic valve replacement by comparing surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) techniques, and determined the cost of carpal tunnel release in an operating room versus an ambulatory procedure room.ConclusionsTDABC is central to the value-based healthcare platform. Application of TDABC provides a framework to identify process improvements for health care delivery. The first case demonstrates cost-savings and improved wait times by shifting some of the colonoscopies scheduled with an anesthesiologist from the main hospital to the ambulatory facility. In the second case, we show that the deployment of an aortic valve via the transcatheter route front loads the costs compared to traditional, surgical replacement. The last case demonstrates significant cost savings to the healthcare system associated with re-organization of staff required to execute a carpal tunnel release.

For decades, cytotoxic therapy was considered ineffective for the treatment of metastatic castration-resistant prostate cancer (mCRPC). Earlier therapies such as estramustine and mitoxantrone received regulatory approval based upon improvement in palliative endpoints. In 2004, docetaxel became the first treatment to demonstrate a significant survival benefit in patients with mCRPC based on two randomized phase III studies, TAX327 and SWOG 99-16. Cabazitaxel, a third-generation taxane, was chosen for clinical development based on its decreased affinity for the drug efflux pump, p-glycoprotein, which is a frequent cause of drug resistance in docetaxel-resistant preclinical models. In 2010, cabazitaxel was approved by the US Food and Drug Administration as the first therapy to show a survival benefit for the treatment of patients with docetaxel-refractory mCRPC. This review summarizes the existing literature on the use of cabazitaxel, focusing on its efficacy and safety in combination with prednisone in the treatment of mCRPC, as well as its role in an era of new therapeutic options.

Prior exposure to sub toxic insults can induce a powerful endogenous neuroprotective program known as ischemic preconditioning. Current models typically rely on a single stress episode to induce neuroprotection whereas the clinical reality is that patients may experience multiple transient ischemic attacks (TIAs) prior to suffering a stroke. We sought to develop a neuron enriched preconditioning model using multiple oxygen glucose deprivation (OGD) episodes to assess the endogenous protective mechanisms neurons implement at the metabolic and cellular level for stress adaptations. We found that neurons exposed to a five minute period of glucose deprivation recovered oxygen utilization and lactate production using novel microphysiometry techniques. Using the non-toxic and energetically favorable five minute exposure, we developed a preconditioning paradigm where neurons are exposed to this brief OGD for three consecutive days. These cells experienced 45% greater survival following an otherwise lethal event and exhibited a longer lasting window of protection in comparison to our previous in vitro preconditioning model using a single stress. As in other models, preconditioned cells exhibited mild caspase activation, an increase in oxidized proteins and a requirement for reactive oxygen species for neuroprotection. Heat shock protein 70 was upregulated during preconditioning, yet the majority of this protein was released extracellularly. We believe coupling this neuron enriched multiday model with microphysiometry will allow us to assess neuronal specific real-time metabolic adaptations necessary for preconditioning.

Objectives This study aimed to determine the prognostic utility of the extent of lymph node involvement in patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs) by analyzing population-based data. Methods Patients in the Surveillance, Epidemiology, and End Results (SEER) registry were identified with histologically confirmed, surgically resected GEP-NETs. We divided patients into three lymph node ratio (LNR) groups based on the ratio of positive lymph nodes to total lymph nodes examined: ≤0.2, >0.2–0.5, and >0.5. Disease-specific survival was compared according to LNR group. Results We identified 3,133 patients with surgically resected GEP-NETs. Primary sites included stomach (11% of the total), pancreas (30%), colon (32%), appendix (20%), and rectum (7%). Survival was worse in patients with LNRs of ≤0.2 (hazard ratio [HR], 1.5; 95% confidence interval [CI], 1.2–2.0), >0.2–0.5 (HR, 2.0; 95% CI, 1.6–2.5), and >0.5 (HR, 3.1; 95% CI, 2.5–3.9) compared to N0 patients. Ten-year disease-specific survival decreased as LNR increased from N0 (81%) to ≤0.2 (69%), >0.2–0.5 (55%), and >0.5 (50%). Results were consistent for patients with both low and high grade tumors from most primary sites. Conclusions Degree of lymph node involvement is a prognostic factor at the most common GEP-NET sites. Higher LNR is associated with decreased survival.

Objective Frailty is a prevalent risk factor for adverse outcomes among patients with chronic lung disease. However, identifying frail patients who may benefit from interventions is challenging using standard data sources. We therefore sought to identify phrases in clinical notes in the electronic health record (EHR) that describe actionable frailty syndromes. Materials and Methods We used an active learning strategy to select notes from the EHR and annotated each sentence for 4 actionable aspects of frailty: respiratory impairment, musculoskeletal problems, fall risk, and nutritional deficiencies. We compared the performance of regression, tree-based, and neural network models to predict the labels for each sentence. We evaluated performance with the scaled Brier score (SBS), where 1 is perfect and 0 is uninformative, and the positive predictive value (PPV). Results We manually annotated 155 952 sentences from 326 patients. Elastic net regression had the best performance across all 4 frailty aspects (SBS 0.52, 95% confidence interval [CI] 0.49–0.54) followed by random forests (SBS 0.49, 95% CI 0.47–0.51), and multi-task neural networks (SBS 0.39, 95% CI 0.37–0.42). For the elastic net model, the PPV for identifying the presence of respiratory impairment was 54.8% (95% CI 53.3%–56.6%) at a sensitivity of 80%. Discussion Classification models using EHR notes can effectively identify actionable aspects of frailty among patients living with chronic lung disease. Regression performed better than random forest and neural network models. Conclusions NLP-based models offer promising support to population health management programs that seek to identify and refer community-dwelling patients with frailty for evidence-based interventions.

In PCNL, RPP is significantly affected by an additional tract during rigid nephroscopy and suctioning but not when using a flexible nephroscope. Understanding the effects of multiple tracts and equipment type on RPP may improve the safety of PCNL.

Current material identification techniques rely on estimating reflectivity or emissivity which vary with viewing angle. As off-nadir remote sensing platforms become increasingly prevalent, techniques robust to changing viewing geometries are desired. A technique leveraging polarimetric hyperspectral imaging (P-HSI), to estimate complex index of refraction, N̂(ν̃), an inherent material property, is presented. The imaginary component of N̂(ν̃) is modeled using a small number of "knot" points and interpolation at in-between frequencies ν̃. The real component is derived via the Kramers-Kronig relationship. P-HSI measurements of blackbody radiation scattered off of a smooth quartz window show that N̂(ν̃) can be retrieved to within 0.08 RMS error between 875 cm^-1 ≤ ν̃ ≤ 1250 cm^-1. P-HSI emission measurements of a heated smooth Pyrex beaker also enable successful N̂(ν̃) estimates, which are also invariant to object temperature.