Does the false-negative rate for 1 or 2 negative sentinel nodes after neo-adjuvant chemotherapy translate into a high local recurrence rate?

Prospective trials demonstrate that sentinel node (SN) biopsy after neo-adjuvant chemotherapy (NACT) has a significant false-negative rate (FNR) when only 1 or 2 SNs are removed. It is unknown whether this increased FNR correlates with an elevated risk of recurrence. Tumor Registry data at an NCI-Designated Comprehensive Cancer Center were reviewed from 2004 to 2018 for patients having a negative SN biopsy after NACT. Among 190 patients with histologically negative nodes after NACT having 1 (n = 42), 2 (n = 46), and ≥3 (n = 102) SNs, axillary recurrences occurred in 7.14%, 0%, and 1.96% (p = 0.09), breast recurrences occurred in 2.38%, 6.52%, and 0.98% (p = 0.12), and distance recurrences occurred in 16.67%, 8.70%, and 7.84% (p = 0.27), respectively. Time to first recurrence did not differ by SN count (p = 0.41). After adjustment for age, race, clinical stage, and receptor status, there were no differences in the rates of axillary (p = 0.26), breast (p = 0.44), or distance recurrence (p = 0.24) by numbers of SNs harvested. Median follow-up was 46.8 months. Despite higher post-NACT FNRs reported in randomized trials for patients having <3 sentinel nodes, recurrence rates were not significantly different for 1 versus 2 versus ≥3 SNs. This suggests that patients having 1 or 2 post-NACT SNs identified may not necessitate axillary dissection.     

It’s the Culture!—How systemic and societal constructs impact well‐being

Pediatric anesthesiologists practice within a culture, a system, and a society. In this article, we provide an overview of the influence these have on the well‐being or the unwellness of pediatric anesthesiologists. The scope of these issues is broad and far‐reaching; thus, our goal has been to highlight those areas which would be likely to have the largest impact on well‐being if addressed fully by society, institutions, and leaders in our field. We discuss the burnout‐promoting aspects of medical education and training. We survey occupational factors, such as the high‐stake pediatric anesthesia environment, occupational health hazards, time pressure, and the reduction in physician autonomy. We then describe societal barriers, such as the marginalization of certain populations, the US system of malpractice litigation, the stigma surrounding psychiatric care, and some of the issues related to physician reimbursement in the United States. We conclude that in order to move forward, improving physician wellness must be a focus of society, of the medical system as a whole, and of individual departments and leaders in pediatric anesthesia.     

Sex differences in clinical characteristics and their influence on clinical outcomes in an observational cohort of patients with rheumatoid arthritis

ObjectiveRheumatoid arthritis (RA) is more prevalent in women, but sex differences remain incompletely understood. This study aimed to elucidate sex differences in clinical characteristics and their potential impact on clinical outcomes in a large Korean cohort of patients with RA.MethodsIn total, 5376 RA patients from the KORean Observational study Network for Arthritis (KORONA) database were examined at baseline and for 3 consecutive years using the disease activity score 28 (DAS28), health assessment questionnaire (HAQ), and patient-reported outcomes (PROs). Within a subgroup with active disease (DAS28 ≥ 3.2) at baseline, sex impacts on clinical outcome during follow-up were analyzed using generalized estimating equation (GEE) models. The factors related to achieving clinical remission were analyzed using Cox-proportional hazard regression.ResultsAt baseline, women (n = 4574) were younger and had more erosive disease and longer disease duration than men (n = 802) with higher scores in DAS28, HAQ, and PROs. The prevalence of interstitial lung disease, cardiovascular disease, and diabetes in men was higher than that of women. In a RA subgroup with active disease at baseline, GEE analyses demonstrated that women RA significantly influenced the rate of change of DAS28 over time. In that group, men are associated with achieving DAS28 sustained remission and point remission.ConclusionsWomen with RA in Korea report higher levels of disease activity and PROs compared to men, whereas most comorbidities were more prevalent in men. The longitudinal change in disease activity and the rate of achieving clinical remission were found to be worse in women with RA.     

Comparison of extreme lateral approach with posterior approach in the treatment of lumbar degenerative diseases: A meta-analysis of clinical and imaging findings

ObjectiveTo compare clinical and imaging findings between extreme lateral lumbar interbody fusion (XLIF) and posterior fusion (PF) via meta-analysis for the treatment of lumbar degenerative diseases.MethodsEnglish papers reporting clinical and imaging findings for the treatment of lumbar degenerative diseases with XLIF and PF published electronically in the PubMed, Embase, Cochrane Library, and Web of Science databases from January 2006 to August 2019 were retrieved. Two authors independently extracted data and evaluated the quality of the included literature. Meta-analysis of outcome measures was performed using Stata 14 and RevMan 5.3 software.ResultsThis meta-analysis included 744 patients from nine studies, two of which were prospective studies, while the others were retrospective studies. The quality of each study was determined to be high. The meta-analysis showed no significant differences in the operative time, length of hospital stay, clinical effectiveness, and improvement in postoperative global sagittal alignment between two approaches (P > 0.05). However, XLIF was significantly better than PF in reducing intraoperative blood loss and recovery of local sagittal alignment (P < 0.05). Moreover, the high incidence of postoperative complications were detected in XLIF group (P < 0.05).ConclusionsBoth surgical approaches have equally promising clinical effectiveness for the treatment of lumbar degenerative diseases. Although XLIF can reduce intraoperative blood loss and obtain better postoperative local sagittal alignment than PF, the high incidence of postoperative complications should prompt us to consider why XLIF procedure is still being offered to our patients and how we can reduce these complications. In addition, any conclusions should be taken with caution because of the mix of prospective and retrospective studies, and the high heterogeneity and bias.