Ipsilateral Lower Limb Weakness After Sarcoma Treatment: A Case Report

Case Diagnosis: Our patient experienced worsening left foot neuropathy following chemotherapy and radiation treatment for sarcoma. Case Description: A 24-year-old man underwent local resection of a 12cm x 8cm x 14.5cm rhabdomyosarcoma in the left vastus lateralis. Then, he was treated with vincristine for 40 weeks and radiation to the left lateral thigh with a maximum dose of 50.4 Gy. The sciatic nerve was outside the target area and received a lower dose. While undergoing chemotherapy, the patient experienced bilateral dysesthesias in his fingertips and feet. He had no history of neuropathy prior to treatment. After chemotherapy was completed, these symptoms subsided in all extremities except the left foot, which developed atraumatic plantar flexion and dorsiflexion weakness, great toe extensor and flexor weakness, decreased sensation in the distal left toe to the metatarsal. Electromyography and needle conduction studies demonstrated left worse than right polyneuropathy mainly affecting the tibial and peroneal motor nerves. There was no clear evidence of a single nerve compressive lesion and repeat scans of the thigh showed no new lesion. Given the presence of milder nerve abnormalities on the right in addition to left sided weakness, the cause is likely multifactorial and temporally related to cancer treatments. Discussions: Persistent or worsening features may appear in patients who received vincristine despite termination of treatment. The pattern is typically sensorimotor; however, this patient demonstrates mainly motor abnormalities. The left worse than right pattern could suggest radiation-induced neuropathy, but no myokymic potentials were seen. Myokymic potentials are common in radiation neuropathy, although their absence does not rule it out. Treatment included physical therapy, gabapentin, and an ankle foot orthosis. Conclusions: Fourteen months after completing radiation and seven months after completing chemotherapy (seven months after symptom onset), the patient’s symptoms are markedly improved. This case demonstrates that neuropathy after treatment in sarcoma patients may be multifactorial

Contemporary Analysis of Malignancies in Women of Child-Bearing Age: An NSQIP Analysis

Background: Recent evidence suggests that cancer incidence among pregnant women is increasing. The pattern of malignancies in pregnant women and how these compare to their nonpregnant counterparts has not been explored. Here we describe the differences in the proportion of resected malignancies in this population. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify women aged 18-49 who underwent an operation for malignancy from 2007-2012. Age-adjusted distribution of specific surgical interventions for malignancy based on ICD-9 codes were compared among pregnant and non-pregnant women using logistic regression analysis. Results: 42,732 subjects with malignancies surgically treated during child-bearing age were identified. 0.33% (n=143) were pregnant. The most common tumors requiring resection were breast (51%), thyroid (17%), and colorectal (9%). The distribution for most cancers was similar between groups. The age-adjusted proportion was significantly increased in breast, major salivary gland and oropharyngeal malignancies (p\u3c0.05). The proportion of resected colorectal cancers was significantly lower in pregnant women (p\u3c0.05; Table 1). Conclusion: This study serves as the first comprehensive and contemporary overview of malignancies resected in women of childbearing age. This study demonstrates that the proportion of resections among pregnant women was significantly greater in breast, major salivary gland and oropharyngeal cancers and lower for colorectal cancers. While these data might represent true differences in cancer incidence, further work is necessary to demonstrate if these are true differences in incidence versus differences in detection and treatment of the pregnant patient

Improving patient notification of solid abdominal viscera incidental findings with a standardized protocol

BACKGROUND: The increasing use of computed tomography (CT) scans in the evaluation of trauma patients has led to increased detection of incidental radiologic findings. Incidental findings (IFs) of the abdominal viscera are among the most commonly discovered lesions and can carry a risk of malignancy. Despite this, patient notification regarding these findings is often inadequate. METHODS: We identified patients who underwent abdominopelvic CTs as part of their trauma evaluation during a recent 1-year period (9/2011-8/2012). Patients with IFs of the kidneys, liver, adrenal glands, pancreas and/or ovaries had their charts reviewed for documentation of the lesion in their discharge paperwork or follow-up. A quality improvement project was initiated where patients with abdominal IFs were verbally informed of the finding, it was noted on their discharge summary and/or were referred to specialists for evaluation. Nine months after the implementation of the IF protocol, a second chart review was performed to determine if the rate of patient notification improved. RESULTS: Of 1,117 trauma patients undergoing abdominopelvic CT scans during the 21 month study period, 239 patients (21.4%) had 292 incidental abdominal findings. Renal lesions were the most common (146 patients, 13% of all patients) followed by hepatic (95/8.4%) and adrenal (38/3.4%) lesions. Pancreatic (10/0.9%) and ovarian lesions (3/0.3%) were uncommon. Post-IF protocol implementation patient notification regarding IFs improved by over 80% (32.4% vs. 17.7% pre-protocol, p = 0.02). CONCLUSION: IFs of the solid abdominal organs are common in trauma patients undergoing abdominopelvic CT scan. Patient notification regarding these lesions is often inadequate. A systematic approach to the documentation and evaluation of incidental radiologic findings can significantly improve the rate of patient notification

Does the Indication for Breast Surgery Impact Surgical Outcomes? A Contemporary Analysis of the ACS-NSQIP Database

Background. There is limited data about whether perioperative outcomes differ based on the indication for breast surgery. Herein we aim to assess if breast surgery for prophylaxis, compared to that for malignancy, impacts surgical outcomes. Methods. All women who underwent simple or subcutaneous mastectomy were identified from the 2007-2012 ACS-NSQIP database. Patients were identified by their ICD-9 codes and categorized into two groups. Group 1 consisted of patients diagnosed with breast cancer or carcinoma in situ; group 2 consisted of patients diagnosed with a genetic predisposition to malignant neoplasm of the breast (i.e., BRCA mutation). Demographic and preoperative variables were compared between groups and outcome variables. Outcome variables were analyzed using age- and operative time-adjusted logistic regression models. Results. 30,803 patients were identified. Group 1 consisted of 30,644 (99.5%) patients diagnosed with malignancy; group 2 consisted of 159 (0.5%) who underwent prophylactic surgery. In univariate analyses, those undergoing prophylactic surgery were significantly younger (p \u3c 0.01). There were no other preoperative differences between groups. When adjusted, the prophylactic group demonstrated a greater risk of DVT (p = 0.03). There were no differences in mortality, superficial/deep/organ space infections, UTI, wound dehiscence, or MI. Conclusion. In this analysis of a national cohort of breast surgery patients, those undergoing prophylactic surgery due to a genetic predisposition had a greater risk of perioperative DVT, compared to those who underwent surgery for a diagnosis of malignancy. This data may allow for improved perioperative management of patients to prevent DVT development and their devastating consequences

Somatic molecular analysis augments cytologic evaluation of pancreatic cyst fluids as a diagnostic tool

Objective: Better tools are needed for early diagnosis and classification of pancreatic cystic lesions (PCL) to trigger intervention before neoplastic precursor lesions progress to adenocarcinoma. We evaluated the capacity of molecular analysis to improve the accuracy of cytologic diagnosis for PCL with an emphasis on non-diagnostic/negative specimens. Design: In a span of 7 years, at a tertiary care hospital, 318 PCL endoscopic ultrasound-guided fine needle aspirations (EUS-FNA) were evaluated by cytologic examination and molecular analysis. Mucinous PCL were identified based on a clinical algorithm and 46 surgical resections were used to verify this approach. The mutation allele frequency (MAF) of commonly altered genes (BRAF, CDKN2A, CTNNB1, GNAS, RAS, PIK3CA, PTEN, SMAD4, TP53 and VHL) was evaluated for their ability to identify and grade mucinous PCL. Results: Cytology showed a diagnostic sensitivity of 43.5% for mucinous PCL due in part to the impact of non-diagnostic (28.8%) and negative (50.5%) specimens. Incorporating an algorithmic approach or molecular analysis markedly increased the accuracy of cytologic evaluation. Detection of mucinous PCL by molecular analysis was 93.3% based on the detection of KRAS and/or GNAS gene mutations (p = 0.0001). Additional genes provided a marginal improvement in sensitivity but were associated with cyst type (e.g. VHL) and grade (e.g. SMAD4). In the surgical cohort, molecular analysis and the proposed algorithm showed comparable sensitivity (88.9% vs. 100%). Conclusions: Incorporating somatic molecular analysis in the cytologic evaluation of EUS-FNA increases diagnostic accuracy for detection, classification and grading of PCL. This approach has the potential to improve patient management

Metastatic Renal Cell Carcinoma in a Hepatic Hemangioma: A Case Report and Review of the Literature

We report the case of 55-year-old female with biopsy-proven clear cell renal cell carcinoma with a suspicious lesion found in the liver who presented for right radical nephrectomy and partial hepatectomy. Histologic evaluation of the hepatic specimen demonstrated metastatic renal cell carcinoma within a hepatic hemangioma. Herein we provide a review of the literature for this uncommon scenario

Patterns of General Surgery Residency Social Media Use in the Age of COVID-19

OBJECTIVE: The role for social media use by General Surgery departments continues to expand and social media accounts have been increasingly implemented as a tool for residency program for promotion and engagement. The importance of these accounts appears to have increased given the unprecedented changes with COVID-19 and the dramatic and unpredictable change to the application cycle including the use of virtual interviews, suggesting a perceived need for increased online engagement with applicants. The purpose of this study was to determine the patterns of creation and usage of Twitter and Instagram accounts of Accreditation Council for Graduate Medical Education (ACGME)-accredited General Surgery residency programs and their associated surgical departments. METHODS: A cross-sectional study of the use of Twitter and Instagram by the 332 ACGME-accredited General Surgery residency programs and their associated departments was conducted in February 2021. Twitter and Instagram accounts were identified by accessing program/department websites as well as social media platform and internet searches. Year of creation, number of followers, and number of posts (July 1, 2018-December 31, 2020) were collected. Trends in usage were compared across years stratified by platform and by account owner (department vs. residency). RESULTS: Instagram accounts are more than five-times greater for residencies compared to departments (42% vs 8%, p \u3c 0.001). There was not a significant difference between the number of department and residency Twitter accounts (26% vs 23%, p=0.37). Significantly more residency Instagram and Twitter accounts were created or first posted in 2020 compared to department accounts (Instagram: 100 vs 7, p \u3c 0.001; Twitter: 31 vs 6, p=0.001). Over 18% of residency programs had both Twitter and Instagram accounts compared to only 6% of departments (p \u3c 0.001). However, department Twitter and Instagram accounts had significantly higher median total posts from 7/1/2018-12/31/2020 (Twitter: p=0.0001, Instagram p=0.004). While the number of Instagram followers and accounts being followed were similar between residencies and departments, department Twitter accounts had a larger median number of followers (1141 vs. 430, p=0.003) and account followings (308 vs. 192, p=0.001) compared to residency accounts. CONCLUSIONS: The number of residency social media accounts has significantly increased in 2020 compared to account creation of departments, with Instagram account creation exceeding that of Twitter and of departments. The opposite pattern in usage was seen related to number of posts, and with Twitter, followers, and number of followings, with departments outpacing residencies. This significant increase in account creation may have been influenced by the COVID-19 pandemic and the change to a virtual interview season, suggesting an unprecedented need for online engagement with applicants. As the increased social media presence will likely persist in future application cycles, further study about the impact of residency social media use on recruitment and applicant decision-making as well as effective strategies, is needed

Fractures in the collegiate athlete

Etude épidémiologique des types de fractures chez des étudiants, en fonction de leur âge, de leur poids, de leur taille, de leur sexe et du sport pratiqué

Identification of genetic risk for pancreatic adenocarcinoma

Recent consortium guidelines support research-based screening for those at high risk of pancreatic cancer (pancreatic ductal adenocarcinoma (PDAC)). Genetic testing plays an important role in the establishment of high-risk PDAC research clinics by delineating those individuals who would benefit from screening protocols. We retrospectively examined patients referred for PDAC-related genetic testing from January 2009 to June 2014. Patients were referred for a personal and/or family history of PDAC or a questioned diagnosis of hereditary pancreatitis (HP). Of the 75 referred patients, 36 underwent testing, of which 11 (31%) were mutation-positive. In total, 36% of patients with chronic pancreatitis carried a mutation, 11% of patients with a family history of PDAC carried a mutation, and 20% of patients with a personal history of PDAC carried a mutation. The most common barrier to testing was lack of insurance coverage. Genetic testing yields a suitable number of mutation-positive individuals who may benefit from increased screening. Subjects with possible HP yielded the highest positive rate. Individuals with idiopathic pancreatitis, onset of pancreatitis before the age of 30 years, and those with a family history of PDAC should be considered for testing. Sub-optimal insurance coverage remains a major deterrent to obtaining testing