Background
There is growing evidence supporting the need for a short time delay before starting radiotherapy (RT) treatment post-surgery for most optimal responses. The timing of RT initiation and effects on outcomes have been evaluated in a variety of malignancies, but the relationship remains to be well established for brain metastasis.
Methods
Retrospective study of 176 patients (aged 18 to 89 years) with brain metastases at a single institution (03/2009 to 08/2018) who received RT following surgical resection. Time interval (≤ 22 days and > 22 days) from surgical resection to initiation of RT and any potential impact on patient outcomes were assessed.
Results
Patients who underwent RT > 22 days after surgical resection had a decreased risk for all-cause mortality of 47.2% (95% CI 8.60, 69.5%). Additionally, waiting > 40 days for RT after surgical resection more than doubled the risk of tumor progression; adjusted hazard ratio 2.02 (95% CI 1.12, 3.64).
Conclusions
Findings indicate that a short interval delay (> 22 days) following surgical resection is required before RT initiation for optimal treatment effects in brain metastasis. Our timing of RT post-surgical resection data add definition to current heterogeneity in RT timing, which is especially important for standardized clinical trial design and patient outcomes.
BACKGROUND
There is wide variation in opioid prescribing after appendectomy in children and adolescents, with recent increases noted in opioid-related pediatric deaths from prescription and illicit opioids. The goal of this project was to minimize opioid prescribing at the time of discharge for children undergoing appendectomy by using Quality Improvement (QI) methodology.
STUDY DESIGN
Children (18 years of age or less) who underwent appendectomy were evaluated from January to December 2019 using NSQIP-Pediatric at 10 children’s hospitals within the Western Pediatric Surgery Research Consortium. Before project initiation, 5 hospitals did not routinely prescribe opioids after appendectomy (protocol). At the remaining 5 hospitals, prescribing was not standardized and varied by surgeon (no-protocol). A prospective multi-institutional QI project was used to minimize outpatient opioid prescriptions for children after appendectomy. The proportion of children at each hospital receiving an opioid prescription at discharge was compared for 6 months before and after the intervention using chi-square analysis.
RESULTS
Overall, 1,524 children who underwent appendectomy were evaluated from January to December 2019. After the QI intervention, overall opioid prescribing decreased from 18.2% to 4.0% (p < 0.001), with significant decreases in protocol hospitals (2.7% vs 0.8%, p = 0.038) and no-protocol hospitals (37.9% vs 8.8%, p < 0.001). The proportion of 30-day emergency room visits did not change after the QI intervention (8.9% vs 9.9%, p = 0.54) and mean postintervention pain management satisfaction scores were high.
CONCLUSION
Opioid prescribing can be minimized in children after appendectomy without increasing emergency room visits or decreasing patient satisfaction. Furthermore, NSQIP-Pediatric can be used as a platform for multi-institutional collaboration for successful implementation of QI projects.
Background
Gallbladder cancer (GBC) is often incidentally diagnosed after cholecystectomy. Intra‐operative biliary tract violations (BTV) have been recently associated with development of peritoneal disease (PD). The degree of BTV may be associated with PD risk, but has not been previously investigated.
Methods
We reviewed patients with initially non‐metastatic GBC treated at our institution from 2003 to 2018. Patients were grouped based on degree of BTV during their treatment: major (e.g., cholecystotomy with bile spillage, n = 27, 29%), minor (e.g., intra‐operative cholangiogram, n = 18, 19%), and no violations (n = 48, 55%). Overall survival (OS) and peritoneal disease‐free survival (PDFS) were evaluated with Kaplan‐Meier and Cox proportional hazards modeling.
Results
Ninety‐three patients were identified; the median age was 64 years (range 31–87 years). Seventy‐six (82%) were incidentally diagnosed. The median follow‐up was 23 months; 20 (22%) patients developed PD. The 3‐year PDFS for patients with major, minor, and no BTV was 52%, 83%, and 98%, respectively (major vs. none: p < 0.001; minor vs. none: p < 0.01). BTV was not associated with 5‐year OS (HR 1.53, p = 0.16).
Conclusion
Increasing degree of BTV is associated with higher risk of peritoneal carcinomatosis in patients with GBC and should be considered during preoperative risk stratification. Reporting biliary tract violations during cholecystectomy is encouraged.
Lymphatic and mixed malformations are rare and variable in presentation. They arise due to errors in vascular and lymphatic formation during early embryonic development. This leads to persistent infiltration of lymph fluid into soft tissues and causes a locally invasive mass with pathologic sequelae. Departing from historically descriptive terminology, such as ''cystic hygroma,'' lymphatic malformations are now categorized as macrocystic, microcystic, or mixed lesions, based on size. Advances in imaging modalities, such as ultrasonography and magnetic resonance imaging, have made accurate characterization of these lesions possible and ultimately allow for early diagnosis and implementation of appropriate treatment based on the morphology of the lymphatic malformation. Management of lymphatic malformations can be quite challenging, and a multidisciplinary approach is most effective for optimum aesthetic and functional outcomes. New discoveries in the molecular biology of lymphatic malformations have provided treatment targets and established a role for pharmacotherapy. Sclerotherapy, laser, and radiofrequency ablation have all proven to be effective as minimally invasive treatment options for lymphatic malformations. Surgical intervention has a role in the treatment of focal lesions recalcitrant to these less invasive techniques. Operative planning is dictated by clinical goals, size, anatomic location, characteristics, and extent of infiltration.
Primary delayed onset craniosynostosis is defined as premature suture fusion that developed despite clear radiographic evidence of normal postnatal calvarial configuration and patent sutures earlier in life. It is rare in the literature and typically presents as secondary synostosis. In this brief clinical study, primary delayed onset craniosynostosis is described in its unique presentation at 4 years of age with a complex genetic history including ERF-related craniosynostosis syndrome and familial cerebral cavernous malformation syndrome. Although the delayed onset clinical course of ERF-related craniosynostosis syndrome has not been well described in the literature, our review suggests that it is distinctive to ERF-related craniosynostosis and should be considered when cases present without a history of trauma, when there is a positive family history, and particularly when cases present late onset; after 1 year of age.
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