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Surgical resection and liver transplant remain the only curative therapies for most patients with hepatocellular carcinoma (HCC). Systemic therapy options have typically been ineffective, but recent advances, such as the combination of immune checkpoint inhibitors and targeted therapies, have shown great promise. Neoadjuvant systemic therapy in resectable or locally advanced HCC is under active investigation with encouraging results in small, early-phase trials. Many of these completed and ongoing trials include combinations of systemic therapy (e.g. immune checkpoint inhibitors, tyrosine kinase inhibitors), transarterial therapies, and radiation. Despite early successes, larger trials with evaluation of long-term oncologic outcomes are needed to determine the role of neoadjuvant systemic therapy in patients with HCC who may be eligible for curative intent surgery or transplant.

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BACKGROUND: Surgical resection of colorectal liver metastasis (CRLM) provides the best opportunity for prolonged survival. Eligibility for metastasectomy has expanded with technical advancements including parenchymal-sparing hepatectomy (PSH). Meanwhile, enthusiasm for minimally invasive surgery (MIS) has increased, though this approach may be preferentially utilized for technically straightforward cases. The purpose of this study is to characterize modern trends in open versus MIS approaches to partial hepatectomy and anatomic hepatectomy for CRLM within a nationwide cohort. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) was used to investigate trends in MIS versus open hepatectomy for CRLM from 2015 to 2019. We examined baseline clinicopathologic and disease-related characteristics and compared trends in treatments over the study period. RESULTS: A total of 7457 patients undergoing hepatectomy for CRLM were identified (1367 MIS, 6090 open). Patients had similar clinicopathologic features between the two groups. Patients undergoing MIS resection less frequently received neoadjuvant therapy (51.1% vs 64.0%, p < 0.001) or concurrent intraoperative ablation (15.0% vs 21.3%, p < 0.001). Patients with tumors < 2 cm (34.9% vs 26.8%, p < 0.001) or only one to two tumors (82.8% vs 65.0%, p < 0.001) more commonly underwent MIS. MIS and open partial hepatectomies both significantly increased over the study period, but open partial hepatectomy increased at a greater rate than MIS (p < 0.001). Rates of anatomic resections have remained the same, with a greater proportion performed using an open approach (34.9% vs 16.4%, p < 0.001). Rates of operations consisting of > 1 concurrent partial hepatectomy are stable, but significantly more likely to be performed open (p < 0.001). CONCLUSIONS: Hepatectomy for CRLM has increased from a rise in partial hepatectomy, potentially translating to increased use of PSH. Current trends suggest MIS approaches appear to be increasing, but selectively implemented for patients with less technically demanding disease characteristics. Educational efforts should be directed towards increased dissemination of parenchymal-sparing MIS techniques for more complex resections.

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OBJECTIVE: To describe the feasibility, efficacy, and learner perception of the flipped classroom model for teaching conferences within surgical training programs. DESIGN: For the flipped classroom conferences, video lectures were prepared by a faculty member, and sent to all attendees at least 2 days prior to lecture. The conference time was then spent going over cases and questions, rather than traditional lecture. We conducted a qualitative survey to assess learner's perceptions and pre-lecture quizzes to assess trainee preparedness. SETTING: The comparison of pre-conference quizzes between flipped classroom and traditional models was carried out at Brooke Army Medical Center (BAMC) in San Antonio, TX, a tertiary care facility with a general surgery residency program. The survey was conducted at BAMC and within the Complex General Surgical Oncology fellowship program at University of Texas MD Anderson Cancer Center, where a flipped classroom model was similarly employed. PARTICIPANTS: Surgical residents BAMC participated in pre-lecture quizzes. BAMC residents and MD Anderson fellows were invited to complete the online survey. RESULTS: Lecture videos did not increase mean preparation time (1.53 vs. 1.46 hours without vs. with video, p = 0.858), but did increase mean quiz scores from 67% to 80% (p = 0.031) with 32/35 learners utilizing videos. Videos increased the proportion of learners who self-reported preparing at all from 42% to 95% (p = 0.28), and preparing for at least one hour for conference from 23% to 49% (p = 0.014). Of survey respondents, 90% said videos were very helpful, 90% would use them weekly if available, and 90% prefer this format to traditional lecture. CONCLUSIONS: Utilization of a flipped classroom method was well received and preferred by surgical trainees, and it increased performance on pre-conference quizzes without increasing preparation time. Although creation of video lectures is work-intensive for lecturers, these results suggest it is more effective for learner preparation. These results could be generalizable to surgical residents nationwide as technology utilization increases in surgical education.

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HER2-targeted therapy has not benefited patients with low levels of HER2 expression; however, combination therapy may be effective. Primary analysis of a phase IIb trial investigating the HER2-derived vaccine nelipepimut-S (NPS) did not benefit the intention-to-treat population, but subset analysis showed a benefit in triple-negative breast cancer (TNBC) patients. The subset analysis of this multicenter, randomized, single-blind, phase IIb trial identified significant improvement in 36-month disease-free survival (DFS) between NPS (n = 55) and placebo (n = 44) in TNBC (HR 0.25, p = 0.01) and those who express HLA-A24 (HR 0.41, p = 0.05). The TNBC cohort demonstrated improved 36-month DFS in those with HER2 1+ expression (HR 0.17, p = 0.01), HLA-A24 positivity (HR 0.08, p < 0.01), or in those who received neoadjuvant chemotherapy (HR 0.21, p < 0.01). NPS vaccination with trastuzumab was associated with improved 36-month DFS among patients with TNBC. The observed benefit to this high-risk subgroup warrants confirmation in a phase III trial.

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This 42-day study evaluated the effects of dietary supplementation with ß-1,3-glucan (Aleta™) on the vaccination response to Newcastle disease virus (NDV), avian infectious bronchitis virus (IBV), and infectious bursal disease (IBD) in a non-challenged environment. This trial included 600 chicks (all vaccinated with IBD at the hatchery) which were assigned to 1 of 3 treatments: vaccination (NDV, IBV), no vaccination, or vaccination combined with feed supplemented with Aleta (100 g/MT of feed). The vaccination with Aleta treatment group showed a trend for improved FCR that was not statistically significant. Control birds that were not vaccinated for IBV had significantly lower IBV titers on day 21 compared to birds that were vaccinated (both with and without Aleta). Surprisingly, there was significant separation among treatment groups for NDV titer levels, especially on day 21, where birds vaccinated and supplemented with Aleta had significantly higher titer levels compared to vaccination alone or no vaccination at all. Critically, only 14% of the birds receiving the vaccine plus Aleta had titer levels below the critical titer threshold for immunity compared to 28% of the birds receiving the vaccine alone and 40% of the unvaccinated birds. This suggests that Aleta supplementation may help to improve the vaccination response by birds, especially for NDV.

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Thirty patients with proximal third femur fractures were treated with pins-in-thigh plaster. Patients were divided into two groups: (1) acute (pins-in-plaster applied within one month after injury); and (2) late (pins-in-plaster applied later than one month ater injury). Patients in the acute group had application of pins-in-plaster inserted at an average of nine days after injury, and were treated in plaster for 9.4 weeks with union occurring at 10.7 weeks. Patients in the late group had application of pins-in-plaster an average of 13.3 weeks after injury, treatment in plaster for 7.7 weeks, and union at 21 weeks. Subtrochanteric fractures healed as rapidly as other areas of the femur when braced early. Twenty-five fractures demonstrated less than 2 cm of shortening and less than 10 degrees of varus. There were no nonunions. One patient developed a deep wound infection. Antibiotics were required in seven patients because of pin tract drainage, which ceased once the pins were removed. This method is indicated in active patients with comminuted or open fractures but neither in the elderly or senile patients, or in intertrochanteric-subtrochanteric fractures.

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During a meniscectomy, thirty competitive athletes who were less than thirty years old were found to have a non-functional or absent anterior cruciate ligament. Preoperative examination without anesthesia had revealed minimum to mild anterior instability without a positive pivot-shift or jerk test. They all had a meniscectomy without reconstruction of the ligament and all were followed for up to four years (average, 2.6 years). Twenty-five (83 per cent) returned to full athletic activity. All had relief of the symptoms of the meniscal lesion and improved significantly, but six progressed to moderate anterior instability with a positive pivot-shift and jerk test. Nevertheless, four of the six were able to resume unrestricted athletic activity.

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