Gitonga Munene

Early experience with cytoreduction and hyperthermic intraperitoneal chemotherapy at a newly developed center for peritoneal malignancy

Background Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has improved outcomes for patients with peritoneal carcinomatosis (PC). We present our experience from a newly developed peritoneal surface malignancy program. Methods An IRB approved retrospective review was performed for the first 50 patients treated with CRS/HIPEC with clinicopathologic data described. Results Patients treated with CRS/HIPEC were Caucasian (64%), female (66%) with a median age of 53 years (range, 11-73 years). Primary pathology included: appendix (40%, n=20), ovary (20%, n=10), colon (14%, n=7), desmoplastic small round cell tumor (14%, n=7) or other (12%, n=6). The median peritoneal cancer index (PCI) score was 15.5 (range, 1-39) and 92% underwent complete cytoreduction (CCR 0/1). Median hospital length of stay was 9.0 days (range, 6-35 days). Eight patients (16%) suffered major morbidity with 2 (4%) 30-day mortalities. Conclusions Short-term outcomes observed after CRS/HIPEC in a newly developed center for PC are consistent with published higher volume center experiences.

The role of academic achievements and psychometric measures in the ranking process

INTRODUCTION Ranking candidates for residency positions is challenging. We hypothesize that applicant academic achievements and performance during the interview are equally important in the ranking process. METHODS This is a retrospective study. Of 53 candidates interviewed during 2016-2017 cycle, 44 (83%) were ranked for 3 PGY1 positions. Each candidate was interviewed and scored in each of the following: USMLE Step 1 score, USMLE Step 2 score, research (RS), letters of recommendation (LOR), personal statement (PS), the way the candidate represented him/herself (RP), interest in the area (IN), answers to standardized questions (SQ), and degree of connection between the candidate and the interviewer (CN). RESULTS Correlation and multiple regression analyses indicated an inverse relationship between ranking the candidates and USMLE2 (r = -0.14, p = -0.364), LOR (r = -0.513, p < 0.001), PS (r = -0.414, p = 0.006), RP (r = -0.485, p = 0.001), CN (r = -0.605, p < 0.001), IN (r = -0.349, p = 0.022), and SQ (r = -0.480, p = 0.001), USMLE1 (r = -0.036, p = 0.838) and RS (r = -0.008, p = 0.96). After controlling for the other variables, only CN reached statistical significance (p = 0.033). CONCLUSION Candidate non-cognitive measures during the interview weigh higher than academic performance in the ranking process.

An unusual case of jaundice: Biliary tumor thrombus in fibrolamellar hepatocellular carcinoma

Highlights • Fibrolamellar hepatocellular carcinoma is a rare form of hepatocellullar cancer seen in younger patients without underlying liver disease.• Liver resection with lymph node dissection is the mainstay of treatment.• Bile duct tumor thrombus that has been reported in hepatocellular cancer has to date never been described in fibrolamellar hepatocellular cancer and must be a consideration in patients who present with obstructive jaundice.

A Bayesian network and heuristic approach for systematic characterization of radiotherapy receipt after breast-conservation surgery

BackgroundBreast-conservation surgery with radiotherapy is a treatment highly recommended by the guidelines from the National Comprehensive Cancer Network. However, several variables influence the final receipt of radiotherapy and it might not be administered to breast cancer patients. Our objective is to propose a systematic framework to identify the clinical and non-clinical variables that influence the receipt of unexpected radiotherapy treatment by means of Bayesian networks and a proposed heuristic approach.MethodsWe used cancer registry data of Detroit, San Francisco-Oakland, and Atlanta from years 2007–2012 downloaded from the Surveillance, Epidemiology, and End Results Program. The samples had patients diagnosed with in situ and early invasive cancer with 14 clinical and non-clinical variables. Bayesian networks were fitted to the data of each region and systematically analyzed through the proposed Zoom-in heuristic. A comparative analysis with logistic regressions is also presented.ResultsFor Detroit, patients under stage 0, grade undetermined, histology lobular carcinoma in situ, and age between 26−50 were found more likely to receive breast-conservation surgery without radiotherapy. For stages I, IIA, and IIB patients with age between 51−75, and grade II were found to be more likely to receive breast-conservation surgery with radiotherapy. For San Francisco-Oakland, patients under stage 0, grade undetermined, and age >75 are more likely to receive BCS. For stages I, IIA, and IIB patients with age >75 are more likely to receive breast-conservation surgery without radiotherapy. For Atlanta, patients under stage 0, grade undetermined, year 2011, and primary site C509 are more likely to receive breast-conservation surgery without radiotherapy. For stages I, IIA, and IIB patients in year 2011, and grade III are more likely to receive breast-conservation surgery without radiotherapy.ConclusionFor in situ breast cancer and early invasive breast cancer, the results are in accordance with the guidelines and very well demonstrates the usefulness of the Zoom-in heuristic in systematically characterizing a group receiving a treatment. We found a subset of the population from Detroit with ductal carcinoma in situ for which breast-conservation surgery without radiotherapy was received, but potential reasons for this treatment are still unknown.

Coagulation profile following liver resection: Does liver cirrhosis affect thromboelastography?

BACKGROUND Thromboelastography has called into question the coagulopathy seen following partial hepatectomy. However the coagulation profile in cirrhotic livers has not been studied. Our objective was to determine the coagulation profile following partial hepatectomy in normal and cirrhotic livers. METHODS Patients undergoing liver resection were prospectively enrolled in the study. The prothrombin time and international normalized ratio, as well as the thromboelastogram, were obtained preoperatively, post-operatively, and on post-operative days 1, 3, and 5. RESULTS 22 noncirrhotic and 11 cirrhotic patients undergoing liver resection were enrolled. Postoperatively the thromboelastogram demonstrated a hypercoagulable profile in 64%, 33%, 39% and 36% of patients on post-operative days 0, 1, 3 and 5 respectively. There was no difference between patients with cirrhosis and those without underlying liver disease. CONCLUSION Patients appear to have a similar coagulation profile after liver resection regardless of underlying cirrhosis with many having a hypercoagulable profile.