Northern Light Eastern Maine Medical Center (frequently shorted to Eastern Maine or simply EMMC) is a hospital located in Bangor, Maine that serves communities throughout central, eastern, and northern Maine. NLEMMC is the second largest hospital in the state with 411 inpatient beds, serves more than 40% of the population of the state, and is the sixth largest employer in the state.NLEMMC is a Level II trauma center and a home for one of three helicopters from Lifeflight of Maine. Northern Light Eastern Maine Medical Center is also a major training affiliate of the University of New England College of Osteopathic Medicine. According to Leapfrog Group, NLEMMC is one of 16 hospitals that were "A"-rated for safety in Maine; 80% of the state's hospitals received "A"-grades, surpassed only by Massachusetts with 83%.
Omphalocele with a concomitant patent vitelline duct is a rare presentation, with very few cases reported in the literature. Most reported cases present with visible bowel prolapse, meconium drainage or mucosal exposure at birth. Presentations without obvious intestinal herniation or mucosal exposure are extremely uncommon and pose diagnostic challenges. A male neonate was born to a G3P2 mother at 38 + 6/7 weeks via spontaneous vaginal delivery after a pregnancy notable for a 20-week prenatal ultrasound concerning for omphalocele. Upon delivery, the omphalocele membrane was intact. Shortly after birth, the neonate developed persistent bilious emesis. Abdominal ultrasound demonstrated normal rotation, and abdominal X-ray was reassuring without evidence of obstruction or volvulus. No other congenital anomalies were demonstrated after VACTERL workup, including echocardiogram, abdominal and spinal ultrasounds. Genetic testing for Beckwith-Wiedmann syndrome was found to be normal. Surgical exploration revealed a patent vitelline duct fistula connecting the small bowel to the omphalocele sac. The fistula and adjacent small bowel were resected, followed by primary end-to-end anastomosis and primary fascial closure. The postoperative course was uncomplicated, and the neonate was thriving without any evidence of infection or obstruction at 2-month and 6-month follow-up visits. There have been very few cases of omphalocele with a patent vitelline duct reported in the literature, and those that have been described present with either visible mucosal prolapse or intestinal extrusion at birth. This case demonstrates that a vitelline duct anomaly may remain clinically occult and present only with obstructive symptoms such as bilious emesis. In neonates with omphalocele who develop gastrointestinal obstruction despite unrevealing imaging studies, clinicians may entertain the possibility of a concurrent vitelline duct remnant as a part of their differential diagnosis. Recognition of this association may guide operative planning and improve diagnostic awareness of this uncommon embryologic anomaly.
Data to inform surgical management of the axilla after neoadjuvant endocrine therapy (NET) are limited. Here we report nodal status, surgical procedure, and outcomes among patients enrolled between 2016 and 2020 in the Palbociclib and Endocrine therapy for LObular breast cancer Preoperative Study (NCT02764541). Women with hormone receptor-positive, HER2-negative tumors > 1.5 cm, any cN, were randomized 2:1 to NET ± palbociclib for 24 weeks. Axillary surgery (sentinel lymph node biopsy [SLNB] ± axillary dissection [ALND]) and nodal evaluation (H E ± IHC) were not specified in the protocol. Pathologic node-positive (ypN+) rates, local-regional recurrence-free interval (LRRFI), and breast cancer-specific survival (BCSS), compared by univariate Cox proportional hazards, were prespecified exploratory endpoints. A total of 188 patients were analyzed (128 treated with NET + palbociclib, 60 NET), median age 56.5 years (interquartile range [IQR] 50–66). 82 (43.6
Background: The number of bariatric surgeries has risen in the past decades. Hyperammonemia related to ornithine transcarbamylase (OTC) deficiency is a potentially lethal disorder in patients with neurological symptoms. The apparent prevalence of OTC deficiency and potential predictors of mortality was examined in patients after bariatric surgery.Methods: This is a retrospective study of postoperative patients who developed hyperammonemia in a large, urban teaching hospital. Urinary orotic acid levels were ordered in individuals with elevated plasma ammonia.Results: Between January 2012 and August 2017, 1597 bariatric surgical procedures were performed. Seven women hospitalized with consistent symptoms had a mean peak plasma ammonia level of 155 umol/L (range: 57 to 273) and mean urinary orotic acid excretion of 3.3 mmol/mol creatinine (range: 1.6-7.9) after vertical sleeve gastrectomy, duodenal switch, or gastric bypass surgery, and there were four mortalities (57%). The apparent postoperative prevalence of OTC deficiency is 0.31%. Peak lactic acid (p = 0.011) level is a predictor of mortality.Conclusions: Hyperammonemia is associated with a high mortality rate predicted by high lactic acid levels. Postoperative prevalence of OTC deficiency is higher than the general population. Further investigations should examine potential mechanisms for its development.
IntroductionThe treatment of cancer is associated with high risk for toxicity and high cost. Strategies to enhance the value, quality, and safety of cancer care are often managed independently of one another. Oncology stewardship is a potential framework to unify these efforts and enhance outcomes. This landscape survey establishes baseline information on oncology stewardship in the United States.MethodsThe Hematology/Oncology Pharmacy Association (HOPA) distributed a 38-item survey composed of demographic, institutional, clinical decision-making, support staff, metrics, and technology sections to 675 HOPA members between 9 September 2022 and 9 October 2022.ResultsMost organizations (78%) have adopted general pharmacy stewardship practices; however, only 31% reported having established a formalized oncology stewardship team. More than 70% of respondents reported implementation of biosimilars, formulary management, and dose rounding as oncology stewardship initiatives in both inpatient and outpatient settings. Frequently cited barriers to oncology stewardship included lack of clinical pharmacist availability (74%), lack of oncology stewardship training (62%), lack of physician/provider buy-in (32%), and lack of cost-saving metrics (33%). Only 6.6% of survey respondents reported their organization had defined "value in oncology." Lack of a formalized stewardship program was most often cited (77%) as the rationale for not defining value.ConclusionsLess than one-third of respondents have established oncology stewardship programs; however, most are providing oncology stewardship practices. This manuscript serves as a call to action for stakeholders to work together to formalize oncology stewardship programs that optimize value, quality, and safety for patients with cancer.
