Cytologic grade independently predicts survival of patients with pancreatic adenocarcinoma

Our objectives were to devise a cytologic grading system and determine whether it would predict survival of patients with solid-type pancreatic adenocarcinoma. We evaluated 116 consecutive patients from July 2000 to November 2002; they were followed up until September 2003. We scored the following features on rapid Romanowsky-stained endoscopic ultrasound-guided fine-needle aspiration smears: cell group architecture, single cells, nuclear grade, mucus, bizarre cells, and necrosis. A cytologic grade (low vs high) was assigned. The Kaplan-Meier estimate of 6-month survival was 76% (SE, 7%) for patients with low-grade tumors vs 50% (SE, 6%) for patients with high-grade carcinoma. The median survival for patients with low-grade vs high-grade tumors was 1 year vs 6 months, respectively (chi2 = 4.45; P = .035). Cox proportional hazards regression showed tumor stage, cancer-specific treatment, and cytologic grade to be independent predictors of survival (P = .001). No other factors (age, mass location, placement of stent, presence of concomitant chronic pancreatitis, race, sex) predicted survival. We devised a grading system that independently predicted survival in patients with pancreatic adenocarcinoma.     

Low quality of dying and death in patients with septic shock as perceived by nurses and resident physicians

Septic shock is a disease with both high prevalence and mortality. Few studies have evaluated the quality of dying and death (QODD) in patients with septic shock. The authors compared the QODD of patients who died of septic shock versus other causes. They prospectively collected QODD surveys from nurses and residents caring for 196 patients who died in the medical intensive care unit (ICU) at an urban, university hospital. Patients were included in the analysis if either a nurse or resident returned a survey. Chart review established cause of death. The authors compared total QODD scores (on a scale of 0–100) and a single-item score (QODD-1; on a scale of 0–10) of patients who died of septic shock versus other causes. Survey response rates were 59% (n = 155) for residents and 49% (n = 129) for nurses. Nurses rated patients as having lower total QODD and QODD-1 scores for septic (Δ 7.5 points, p = 0.03, and 0.9 points, p = 0.05, respectively). Residents rated septic patients with lower QODD-1 scores than nonseptic patients (Δ 0.8 points, p = 0.03). This study shows that nurses rate patients with septic shock as having lower QODD than patients dying of other causes. These findings are important for clinicians who counsel families of patients dying of septic shock.     

EUS-guided FNA of the left adrenal gland in patients with thoracic or GI malignancies

BACKGROUND: The diagnostic yield and safety of trans-gastric EUS-guided FNA of the left adrenal gland are not well defined. METHODS: All patients with an enlarged left adrenal gland on abdominal imaging and known or suspected malignancy referred to two EUS centers over a 3-year period were included in this study. EUS-guided FNA was performed on an outpatient basis by one of 4 experienced endosonographers. RESULTS: Thirty-one consecutive patients (21 men, 10 women; mean age 64.8 years) were evaluated. Tissue adequate for interpretation was obtained in all patients; no attempt to obtain tissue was unsuccessful. The median number of needle passes was 4.5 (range 1-8). No immediate complications were encountered. EUS-guided FNA confirmed malignant left adrenal involvement in 42% (13/31) of the patients. Patients with malignant left adrenal masses were more likely to have known cancer at another site (OR 12.0: 95% CI[1.6, 87.9]). Patients with benign masses were more likely to have preservation of the normal sonographic appearance of the adrenal gland ("seagull" configuration) compared with those with malignant masses (OR 9.8: 95% CI[1.9, 51.0]). The accuracy of EUS imaging based on size (> or =3 cm) alone was 81%: 95% CI[63, 93]). Of the patients with malignant adrenal masses, 85% (11/13) died or their clinical condition deteriorated during follow-up, while 15% (2/13) were being treated and were stable clinically. CONCLUSIONS: EUS-guided FNA of the left adrenal gland is a minimally invasive, safe, and highly accurate method that confirms or excludes malignant adrenal involvement in patients with thoracic or GI malignancies.     

Successful stenting in ductal disruption favorably impacts treatment outcomes in patients undergoing transmural drainage of peripancreatic fluid collections

Background and Aim: The role of pancreatic duct (PD) stenting in patients undergoing endoscopic transmural drainage of peripancreatic fluid collection (PFC) remains unclear. The objective of this study is to evaluate the effect of PD stenting on treatment success in patients undergoing endoscopic transmural drainage of PFC. Methods: This is a retrospective follow‐up study of all patients who underwent endoscopic and endoscopic ultrasonography‐guided transmural drainage of PFC during a 5‐year period. Double‐pigtail stents were deployed in all patients; in addition, nasocystic catheters were deployed in those with abscess/necrosis. An endoscopic retrograde cholangiopancreatogram was attempted whenever feasible in all patients, and pancreatic stents were placed when the duct disruption could be bridged. Success was defined as an improvement in symptoms and resolution of PFC upon follow‐up computed tomography at 8 weeks. Results: Of the 110 patients who underwent PFC drainage, 40 (36%) underwent simultaneous PD stenting. Treatment was successful in 95 of the 110 patients (86%). The PFC types were: pseudocyst (62%), necrosis (20%), and abscess (18%). The median duration of follow up was 9.9 months. Those who underwent PD stenting were significantly more likely to have treatment success than those who did not undergo PD stenting (97.5% vs 80%; risk ratio [RR]_crude = 1.48, P = 0.01). In the multivariable analysis, this association remained significant (RR_adjusted = 1.14, 95% confidence interval: 1.01–1.29, P = 0.036), even after adjusting for the etiology of pancreatitis, type and location of PFC, luminal compression at endoscopy, enteral nutrition, white blood cell count, and number of endoscopic interventions. Conclusions: Transpapillary PD stenting improves treatment outcomes in patients undergoing endoscopic transmural drainage of PFC.     

Mental health service utilization is associated with retention in care among persons living with HIV at a university-affiliated HIV clinic

Background

Concurrent with the UNAIDS 90-90-90 and NHAS plans, the District of Columbia (DC) launched its 90/90/90/50 plan (Plan) in 2015. The Plan proposes that by 2020, 90% of all DC residents will know their HIV status; 90% of residents living with HIV will be in sustained treatment; 90% of those in treatment will reach “Viral Suppression” and DC will achieve 50% reduction of new HIV cases. To achieve these goals targeted prevention strategies are imperative for areas where the relative risk (RR) of not being linked to care (NL), not retained in any care (NRC) and low viral suppression (NVSP) are highest in the District. These outcomes are denoted in this study as poor outcomes of HIV care continuum. This study applies the Bayesian model for RR for area specific random effects to identify the census tracts with poor HIV care continuum outcomes for DC.

Methods

This analysis was conducted using cases diagnosed from 2010 to 2015 and reported to the surveillance system from the District of Columbia Department of Health (DC DOH), HIV/AIDS, Hepatitis, STD and TB Administration. The jurisdictions of the District of Columbia is divided into 179 census tracts. It is challenging to plot sparse data in ‘small’ local administrative areas, characteristically which may have a single-count datum for each geographic area. Bayesian methods overcome this problem by assimilating prior information to the underlying RR, making the predicted RR estimates robust.

Results

The RR of NL is higher in 59 (33%) out of 179 census tracts in DC. The RR of NRC was high in 46 (26%) of the census tracts while 52 census tracts (29%) show a high risk of having NVSP among its residents. This study also identifies clear correlated heterogeneity or clustering is evident in the northern tracts of the district.

Conclusion

The study finds census tracts with higher RR of poor linkage to care outcomes in the District. These results will inform the Plan which aims to increase targeted testing leading to early initiation of antiretroviral therapy. The uniqueness of this study lies in its translational scope where surveillance data can be used to inform local public health programs and enhance the quality of health for the people with HIV.

     

Multistage and mixture parallel gatekeeping procedures in clinical trials

Gatekeeping procedures have been developed to solve multiplicity problems arising in clinical trials with hierarchical objectives where the null hypotheses that address these objectives are grouped into ordered families. A general method for constructing multistage parallel gatekeeping procedures was proposed by Dmitrienko et al. (2008). The objective of this paper is to study two related classes of parallel gatekeeping procedures. Restricting to two-family hypothesis testing problems, we first use the mixture method developed in Dmitrienko and Tamhane (2011) to define a class of parallel gatekeeping procedures derived using the closure principle that can be more powerful than multistage gatekeeping procedures. Second, we show that power of multistage gatekeeping procedures can also be improved by using α-exhaustive tests for the component procedures. Extensions of these results for multiple families are stated. Illustrative examples from clinical trials are given.