Systematic review and meta-analysis of the prognostic significance of Neutrophil-Lymphocyte Ratio (NLR) After R0 gastrectomy for cancer

Abstract Purpose A meta-analysis was performed to evaluate the prognostic value of neutrophil-lymphocyte ratio (NLR) in patients undergoing potentially curative gastrectomy for cancer (GC). Methods Thomson Reuters Web of Science, Ovid MEDLINE(R) and PUBMED databases were searched for relevant articles using search terms neutrophil-lymphocyte ratio (NLR), GC and survival. Articles reporting overall survival (OS), cancer-specific survival and disease-free survival (DFS), in patients undergoing R0 gastrectomy, were studied. Results Articles numbering 365 were identified during the preliminary search, and 10 containing 4164 patients were included in the final review. Most patients were &gt; 60 years of age, male (67%) and 2239 (53.8%) had pT3 disease. The number of NLR dichotomization thresholds reported numbered 7, with 2.00 and 3.00 (n = 2) the most common. NLR was associated with poor survival in eight studies with hazard ratios ranging from 1.54 (95% confidence interval (CI) 1.26–1.89) to 2.99 (1.99–4.49). Pooled odds ratio (OR) for OS was 2.31 (1.40–3.83, p = 0.001) and for DFS 2.72 (1.14–6.54, p = 0.020). Four studies presented T-stage data, OR 1.62 (1.33–1.96, p &lt; 0.001). Conclusion NLR is an important prognostic indicator associated with both OS and DFS after R0 resection of GC, but the critical level is equivocal. </jats:sec

Team strategic philosophy: requiem for the infinite game

Deliberate accountability has arrived in the medical arena, producing an age of reward for measured performance, and belief in publicizing metrics to ensure clarity, with winning defined as hitting targets, whereby staff are incentivised by arbitrary objectives. Finite game theory declares that players are known, rules are fixed, and the objective agreed, but infinite game theory asserts that players are both known and unknown, rules are changeable, and the objective is to perpetuate the game; these standards are clearly at odds and risk real world chaos in global universal medical education and clinical outcomes and functioning. Five principles are necessary to lead an infinite game: first, a fair basis, such that sacrifices for its advancement are promoted; second, a trusting blame-free team culture and environment; third, competitors viewed as worthy rivals, rather than adversaries, promoting healthy competition; fourth, existential flexibility when faced with credible evidence; and finally, transformational leadership; including infinite game theory into healthcare planning may be difficult, but the potential rewards are surely worth the existential fight

Neutrophil-lymphocyte ratio as a predictor of response to neoadjuvant chemotherapy and survival in oesophageal adenocarcinoma

Background: Inflammation has an important role in cancer survival, yet whether serum markers of inflammation predict response to potentially curative neoadjuvant chemotherapy (NAC) in oesophageal adenocarcinoma (OAC) is controversial. This study aimed to determine whether systemic inflammatory response (SIR) was associated with response to NAC and survival. Methods: Consecutive patients with OAC planned to undergo surgery with curative intent received blood neutrophil and lymphocyte measurements at diagnosis to calculate Neutrophil-lymphocyte ratio (NLR). Pathological variables including pTNM stage, differentiation, vascular invasion, and Mandard Tumour Regression Grade (TRG) were recorded. TRGs 1&2 were taken to represent good response and primary outcome was overall survival (OS). Results: During follow-up of 136 patients, 36 patients (26.5%) suffered recurrence and 69 patients (50.7%) died. Receiver-Operator-Characteristic (ROC) analysis of NLR before NAC predicted poor TRG (area-under-the-curve (AUC) 0.71 (95% confidence interval (CI) 0.58-0.83, p=0.002). On univariable analysis, pT-stage (p<0.001), pN-stage (p<0.001), poor differentiation (p=0.006), margin positivity (p=0.001), poor TRG (p=0.014), and NLR (dichotomised 2.25, p=0.017) were associated with poor OS. but only NLR (Hazard Ratio (HR) 2.28 95% CI (1.03-4.93), p=0.042) retained independent significance on multivariable analysis. Conclusions: Pre-treatment NLR was associated with OAC pathological response to NAC and OS

Egalitarianism in surgical training: let equity prevail

This study aimed to quantify core surgical trainee (CST) differential attainment (DA) related to three cohorts; white UK graduate (White UKG) versus black and minority ethnic UKG (BME UKG) versus international medical graduates (IMGs). The primary outcome measures were annual review of competence progression (ARCP) outcome, intercollegiate Membership of the Royal College of Surgeons (iMRCS) examination pass and national training number (NTN) selection. Intercollegiate Surgical Curriculum Programme (ISCP) portfolios of 264 consecutive CSTs (2010–2017, 168 white UKG, 66 BME UKG, 30 IMG) from a single UK regional post graduate medical region (Wales) were examined. Data collected prospectively over an 8-year time period was analysed retrospectively. ARCP outcomes were similar irrespective of ethnicity or nationality (ARCP outcome 1, white UKG 60.7% vs BME UKG 62.1% vs IMG 53.3%, p=0.395). iMRCS pass rates for white UKG vs BME UKG vs IMG were 71.4% vs 71.2% vs 50.0% (p=0.042), respectively. NTN success rates for white UKG vs BME UKG vs IMG were 36.9% vs 36.4% vs 6.7% (p=0.023), respectively. On multivariable analysis, operative experience (OR 1.002, 95% CI 1.001 to 1.004, p=0.004), bootcamp attendance (OR 2.615, 95% CI 1.403 to 4.871, p=0.002), and UKG (OR 7.081, 95% CI 1.556 to 32.230, p=0.011), were associated with NTN appointment. Although outcomes related to BME DA were equitable, important DA variation was apparent among IMGs, with iMRCS pass 21.4% lower and NTN success sixfold less likely than UKG. Targeted counter measures are required to let equity prevail in UK CST programmes

Trainee perspective of the causes of stress and burnout in surgical training: a qualitative study from Wales

Objectives Stress and burn-out among surgical trainees has been reported most prevalent in core surgical trainees (CST) and female trainees in particular. This study aimed to identify factors perceived by CSTs to be associated with stress and burnout in those at risk. Design An open-ended questionnaire was distributed to 79 CSTs and two researchers categorised responses independently, according to Michie’s model of workplace stress. Setting A UK regional postgraduate medical region (Wales). Participants Sixty-three responses were received; 42 males, 21 females. The response rate was 79.7%. Results Inter-rater reliability was good (k=0.792 (79.2%), p<0.001). The most common theme of Michie’s model related to CST stress and burnout was career development, with most statements associated with curriculum, examination and academic demands required to attain a CST certificate of completion of training, and higher surgical national training number appointment. This was closely followed by those intrinsic to the job with recurrent discussion around the difficulties balancing work perceived to be service provision (ward work and on-calls), outpatient clinic and operative experience. Conversely, the most common themes relevant to stress and burnout among female trainees were associated with relationships at work (primarily the male-dominated nature of surgery), extraorganisational factors (family–work life balance) and individual characteristics (personality and physiological differences). Conclusion CSTs’ perceptions regarding the causes of National Health Service related stress and burnout are numerous, and these findings provide a basis for the development of targeted stressor counter-measures to improve training and well-being

The Glasgow Microenvironment Score associates with prognosis and adjuvant chemotherapy response in colorectal cancer

Background The Glasgow Microenvironment Score (GMS) combines peritumoural inflammation and tumour stroma percentage to assess interactions between tumour and microenvironment. This was previously demonstrated to associate with colorectal cancer (CRC) prognosis, and now requires validation and assessment of interactions with adjuvant therapy. Methods Two cohorts were utilised; 862 TNM I–III CRC validation cohort, and 2912 TNM II–III CRC adjuvant chemotherapy cohort (TransSCOT). Primary endpoints were disease-free survival (DFS) and relapse-free survival (RFS). Exploratory endpoint was adjuvant chemotherapy interaction. Results GMS independently associated with DFS (p = 0.001) and RFS (p < 0.001). GMS significantly stratified RFS for both low risk (GMS 0 v GMS 2: HR 3.24 95% CI 1.85–5.68, p < 0.001) and high-risk disease (GMS 0 v GMS 2: HR 2.18 95% CI 1.39–3.41, p = 0.001). In TransSCOT, chemotherapy type (pinteraction = 0.013), but not duration (p = 0.64) was dependent on GMS. Furthermore, GMS 0 significantly associated with improved DFS in patients receiving FOLFOX compared with CAPOX (HR 2.23 95% CI 1.19–4.16, p = 0.012). Conclusions This study validates the GMS as a prognostic tool for patients with stage I–III colorectal cancer, independent of TNM, with the ability to stratify both low- and high-risk disease. Furthermore, GMS 0 could be employed to identify a subset of patients that benefit from FOLFOX over CAPOX