Completion Dissection or Observation for Sentinel-Node Metastasis in Melanoma.

Sentinel-lymph-node biopsy is associated with increased melanoma-specific survival (i.e., survival until death from melanoma) among patients with node-positive intermediate-thickness melanomas (1.2 to 3.5 mm). The value of completion lymph-node dissection for patients with sentinel-node metastases is not clear. In an international trial, we randomly assigned patients with sentinel-node metastases detected by means of standard pathological assessment or a multimarker molecular assay to immediate completion lymph-node dissection (dissection group) or nodal observation with ultrasonography (observation group). The primary end point was melanoma-specific survival. Secondary end points included disease-free survival and the cumulative rate of nonsentinel-node metastasis. Immediate completion lymph-node dissection was not associated with increased melanoma-specific survival among 1934 patients with data that could be evaluated in an intention-to-treat analysis or among 1755 patients in the per-protocol analysis. In the per-protocol analysis, the mean (±SE) 3-year rate of melanoma-specific survival was similar in the dissection group and the observation group (86±1.3% and 86±1.2%, respectively; P=0.42 by the log-rank test) at a median follow-up of 43 months. The rate of disease-free survival was slightly higher in the dissection group than in the observation group (68±1.7% and 63±1.7%, respectively; P=0.05 by the log-rank test) at 3 years, based on an increased rate of disease control in the regional nodes at 3 years (92±1.0% vs. 77±1.5%; P<0.001 by the log-rank test); these results must be interpreted with caution. Nonsentinel-node metastases, identified in 11.5% of the patients in the dissection group, were a strong, independent prognostic factor for recurrence (hazard ratio, 1.78; P=0.005). Lymphedema was observed in 24.1% of the patients in the dissection group and in 6.3% of those in the observation group. Immediate completion lymph-node dissection increased the rate of regional disease control and provided prognostic information but did not increase melanoma-specific survival among patients with melanoma and sentinel-node metastases. (Funded by the National Cancer Institute and others; MSLT-II ClinicalTrials.gov number, NCT00297895 .)

Toward a 21st-century health care system: Recommendations for health care reform

The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform: 1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. 2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. 3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions. 4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange. 5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers. 6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans. 7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage. 8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges

Management of acute hypercortisolism

An occasional patient with Cushing's syndrome may require urgent management primarily because the chronic ravages of hypercortisolism have caused the patient to be in a precarious metabolic condition. The side effects of prolonged excess corticosteroids increase the risk of operations in such patients and must be considered in overall management. Among the many effects of hypercortisolism to be considered are hypertension, diabetes, ocular hypertension, myopathies, dermatologic changes including skin infection, pancreatitis, osteoporosis, pathological fractures, peptic ulcers, renal calculi, coagulopathies, hypokalemia, poor wound healing, and increased susceptibility to infection. The most effective way to avert these complications is by earlier diagnosis and definitive treatment of Cushing's syndrome. The present report includes a review of the etiology and diagnosis of Cushing's syndrome and the management of problems associated with hypercortisolism . Il est possible qu'un malade atteint de maladie de Cushing ait besoin d'être traité sans attente en raisons de troubles métaboliques sévères dus aux effets nocifs de l'hypercortisolisme chronique qui augmentent les risques opératoires et doivent être pris en considération avant tout traitement. Il en est ainsi de l'hypertension, du diabète, de l'hypertension intra-oculaire, des lésions dermiques comprenant l'infection cutanée, la pancréatite, l'ostéoporose, les fractures pathologiques, l'ulcère peptique, les calculs rénaux, les coagulopathies, l'hypokaliémie, la lenteur du processus de cicatrisation et l'augmentation de la suceptibilité à l'infection.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/41309/1/268_2005_Article_BF01655367.pd

Search for heavy resonances decaying to a top quark and a bottom quark in the lepton+jets final state in proton–proton collisions at 13 TeV

A search is presented for narrow heavy resonances decaying to a top quark and a bottom quark using data collected by the CMS experiment at √s = 13TeV in 2016. The data set analyzed corresponds to an integrated luminosity of 35.9 fb−1. Final states that include a single lepton (e, μ), multiple jets, and missing transverse momentum are analyzed. No evidence is found for the production of a W′ boson, and the production of right-handed W′ bosons is excluded at 95% confidence level for masses up to 3.6 TeV depending on the scenario considered. Exclusion limits for W′ bosons are also presented as a function of their coupling strength to left- and right-handed fermions. These limits on a W′ boson decaying via a top and a bottom quark are the most stringent published to date

Measurement of angular parameters from the decay B⁰ → K⁎0^{⁎0} μ⁺ μ⁻ in proton–proton collisions at √s 8 TeV

Angular distributions of the decay B⁰  → K$^{⁎0}$ μ⁺ μ⁻ are studied using a sample of proton–proton collisions at √s=8TeV collected with the CMS detector at the LHC, corresponding to an integrated luminosity of 20.5fb⁻¹ . An angular analysis is performed to determine the P₁ and P$^{\u27}$₅ parameters, where the P$^{\u27}$₅ parameter is of particular interest because of recent measurements that indicate a potential discrepancy with the standard model predictions. Based on a sample of 1397 signal events, the P₁ and P$^{\u27}$₅ parameters are determined as a function of the dimuon invariant mass squared. The measurements are in agreement with predictions based on the standard model

Nuclear modification factor of D0 mesons in PbPb collisions at sNN=5.02TeV

The transverse momentum (pT) spectrum of prompt D0 mesons and their antiparticles has been measured via the hadronic decay channels D0→K−π+ and D‾0→K+π− in pp and PbPb collisions at a centre-of-mass energy of 5.02 TeV per nucleon pair with the CMS detector at the LHC. The measurement is performed in the D0 meson pT range of 2–100GeV/c and in the rapidity range of |y|<1. The pp (PbPb) dataset used for this analysis corresponds to an integrated luminosity of 27.4 pb−1 (530 μb−1). The measured D0 meson pT spectrum in pp collisions is well described by perturbative QCD calculations. The nuclear modification factor, comparing D0 meson yields in PbPb and pp collisions, was extracted for both minimum-bias and the 10% most central PbPb interactions. For central events, the D0 meson yield in the PbPb collisions is suppressed by a factor of 5–6 compared to the pp reference in the pT range of 6–10GeV/c. For D0 mesons in the high-pT range of 60–100GeV/c, a significantly smaller suppression is observed. The results are also compared to theoretical calculations