Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND: The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting. METHODS: Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups. RESULTS: Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005). CONCLUSION: Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery

Global Retinoblastoma Presentation and Analysis by National Income Level

Importance: Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale. Objectives: To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis. Design, Setting, and Participants: A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017. Main Outcomes and Measures: Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis. Results: The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4) were female. Most patients (n = 3685 84.7%) were from low-and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 62.8%), followed by strabismus (n = 429 10.2%) and proptosis (n = 309 7.4%). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 95% CI, 12.94-24.80, and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 95% CI, 4.30-7.68). Conclusions and Relevance: This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs. © 2020 American Medical Association. All rights reserved

Presencia de <i>Stegomastodon</i> (Gomphotheriidae, Proboscidea) en el Pleistoceno Superior de la zona costera de Santa Clara del Mar (Argentina)

Gomphotheriidae fossil remains from shore level of Santa Clara del Mar (Mar del Plata, Argentina) are described. The comparative morphological and multivariate analysis of the m3 with other South American gomphotheres remains, mainly from Argentina, Bolivia and Brazil, allow their identification as <i>Stegomastodon platensis</i>. This species seems better adapted to live on the middle latitudes and warm climatic conditions. The possible movement routes from north to the most austral zones or areas are discussed. <i>Stegomastodon</i> from South America is a big-size form which is present along the East route and in several shore areas of Ecuador and Peru. In the present work some palaeoecological and palaeogeographical considerations are included. From a radiometric AMS datum, the remains of Santa Clara del Mar are dated in the late Pleistocene (17,880 ± 60 AP).<br><br>Se describen restos bien conservados de gonfoterios (Mammalia, Proboscidea) encontrados en los niveles pleistocenos que afloran en los acantilados costeros de Santa Clara del Mar (Mar del Plata, Argentina). Se analizan algunos de sus caracteres más importantes y se compara con otros gonfoterios provenientes de distintas localidades de Argentina, Brasil y Bolivia. El estudio comparativo, mediante análisis multivariante del m3, permitió su identificación como <i>Stegomastodon platensis</i>. Nosotros consideramos que todos los Gomphotheriidae del territorio actual de Argentina deberían incluirse en un único género y una única especie: <i>Stegomastodon platensis</i>. Esta especie parece estar mejor adaptada a vivir en latitudes medias, y en condiciones climáticas templadas. Se discuten sus posibles vías de desplazamiento desde el norte hacia zonas o áreas más australes. <i>Stegomastodon</i> de América del Sur es una forma de gran tamaño, que se encuentra a lo largo de la ruta del este y en algunas áreas costeras de Ecuador y Perú. En el presente artículo se incluyen algunas consideraciones paleoecológicas y paleogeográficas de esta especie de América del Sur. A partir de una datación radio-métrica por AMS de una muestra de esmalte dentario se sitúan estratigráficamente los restos de Santa Clara del Mar en el Pleistoceno superior (17.880 ± 60 AP)