The technical skill of practicing bariatric surgeons varied widely, and greater skill was associated with fewer postoperative complications and lower rates of reoperation, readmission, and visits to the emergency department. Although these findings are preliminary, they suggest that peer rating of operative skill may be an effective strategy for assessing a surgeon's proficiency.

IntroductionAdaptive immunity plays a crucial role in tumor immunosurveillance. [1][2][3] It has been shown that tumor-infiltrating effector T cells are associated with improved prognoses in multiple human cancers, 4-6 whereas tumor-infiltrating regulatory T (Treg) cells are negatively associated with patient outcome. 6,7 Th17 cells are newly identified effector CD4 ϩ T cells. Th17 cells and interleukin-17 (IL-17) play an active role in inflammation and autoimmune diseases. [8][9][10][11][12][13][14][15] Th17 cells are found in both mouse and human tumors. 16,17 However, the biologic role of Th17 cells is poorly understood in the tumor microenvironment. In this report, we examined the phenotype, cytokine profile, generation, functional relevance, and immunologic and clinical predictive values of Th17 cells in 201 patients with ovarian cancers. We provide novel insight into the nature of Th17 cells in the tumor microenvironment in patients with cancer. This information may be useful for designing more effective cancer immunotherapies. Methods Human subjectsWe studied previously untreated patients with 201 ovarian carcinomas. Survival data were available for 85 patients (supplemental Table 1, available on the Blood website; see the Supplemental Materials link at the top of the online article). Patients gave written, informed consent in accordance with the Declaration of Helsinki. The study was approved by the University of Michigan Institutional Review Board. Cells and tissuesCells and tissues were obtained from ascites, blood, lymph nodes, and tumors as we described. 16,18,19 Immune cells, including monocytes, macrophages, myeloid dendritic cells, plasmacytoid dendritic cells, and T-cell subsets, were enriched using paramagnetic beads (StemCell Technologies) and sorted with FACSAria (Becton Dickinson) as we described. 16,18,19 Cell purity was more than 98% as confirmed by flow cytometry (LSR II; Becton Dickinson). FACSFor cytokine detection, the cells were stimulated with phorbol myristate acetate (50 ng/mL; Sigma-Aldrich), ionomycin (1 M; Sigma-Aldrich) for 4 hours before staining. Cells were first stained extracellularly with specific antibodies against human CD3, CD4, CD8, CD11b, CD11c, CD14, CD15, CD16, CD19, CD25, CD39, CD45, CD45RO, CD49a, CD49c, CD49d, CD49e, CD56, CD123, CD161, PD-1, CCR4, CCR6, CCR7, CXCR4, HLA-DR, and annexin V (BD Biosciences), CCR2, CXCR3, and CCR5 (R&D Systems), EpCam (StemCell Technologies), then were fixed and permeabilized with Perm/Fix solution (eBioscience), and finally were stained intracellularly with anti-IL-2, anti-IL-10, anti-IL-17, anti-tumor necrosis factor-␣, anti-interferon-␥ (IFN-␥), anti-Granzyme A, anti-Ki-67, and anti-FOXP3 (all from BD Biosciences, except anti-IL-17, eBioscience). Samples were acquired on a LSR II (BD Biosciences), and data were analyzed with DIVA software (BD Biosciences). Th17 induction and suppressionFresh peripheral blood and tumor-associated CD14 ϩ macrophages were sorted 19 and cocultured with T cells as indicated for 3 to 5 days in the An In...

In 1960, Cohen introduced the kappa coefficient to measure chance-corrected nominal scale agreement between two raters. Since then, numerous extensions and generalizations of this interrater agreement measure have been proposed in the literature. This paper reviews and critiques various approaches to the study of interrater agreement, for which the relevant data comprise either nominal or ordinal categorical ratings from multiple raters. It presents a comprehensive compilation of the main statistical approaches to this problem, descriptions and characterizations of the underlying models, and discussions of related statistical methodologies for estimation and confidence-interval construction. The emphasis is on various practical scenarios and designs that underlie the development of these measures, and the interrelationships between them. RESUME C'est en 1960 que Cohen a propost I'emploi du coefficient kappa comme outil de mesure de I'accord entre deux tvaluateurs exprimant leur jugement au moyen d'une Cchelle nominale. De nombreuses gentralisations de cette mesure d'accord ont Ct C proposies depuis lors. Les auteurs jettent ici un regard critique sur nombre de ces travaux traitant du cas ou I'Cchelle de rtponse est soit nominale, soit ordinale. Les principales approches statistiques sont passCes en revue, les modkles sous-jacents sont dicrits et caractCrisCs, et les problkmes liCs i I'estimation ponctuelle ou par intervalle sont abordCs. L'accent est m i s sur diffkrents scknarios concrets et sur des schtmas exp6rimentaux qui sous-tendent I'emploi de ces mesures et les relations existant entre elles.

Identification of cancer stem cells is crucial for advancing cancer biology and therapy. Several markers including CD24, CD44, CD117, CD133, ABCG, ESA and ALDH are utilized to identify and investigate human epithelial cancer stem cells in the literature. We have now systemically analyzed and compared the expression of these markers in fresh ovarian epithelial carcinomas. Although the expression levels of these markers were unexpectedly variable and partially overlapping in fresh ovarian cancer cells from different donors, we reliably detected important levels of CD133 and ALDH in the majority of fresh ovarian cancer. Furthermore, most of these stem cell markers including CD133 and ALDH were gradually lost following in vitro passage of primary tumor cells. However, the expression of ALDH and CD133, but not CD24, CD44 and CD117, could be partially rescued by the in vitro serum free and sphere cultures, and the in vivo passage in the immune deficient xenografts. ALDH+ and CD133+ cells formed three dimensional spheres more efficiently than their negative counterparts. These sphere forming cells expressed high levels of stem cell core gene transcripts, and could be expanded and formed additional spheres in long-term culture. ALDH+, CD133+, and ALDH+CD133+ cells from fresh tumors developed larger tumors more rapidly than their negative counterparts. This property was preserved in the xenografted tumors. Altogether, the data suggest that ALDH+ and CD133+ cells are enriched with ovarian cancer initiating (stem) cells, and ALDH and CD133 may be widely utilized as reliable markers to investigate ovarian cancer stem cell biology.

Background During in-hospital cardiac arrests, it is uncertain how long resuscitation should continue prior to termination of efforts. We hypothesized that the duration of resuscitation varies across hospitals, and that patients at hospitals with longer attempts have higher survival rates. Methods Between 2000 and 2008, we identified 64,339 patients with cardiac arrests at 435 hospitals within a large national registry. For each hospital, we calculated the median duration of resuscitation before termination of efforts among its non-survivors as a measure of the hospital’s overall tendency for longer attempts. We then determined the association between a hospital’s tendency for longer attempts and risk-adjusted survival using multilevel regression models. Findings The overall proportion of patients achieving immediate survival with return of spontaneous circulation (ROSC) was 48·5% while 15·4% survived to discharge. For patients achieving ROSC, the median resuscitation time was 12 minutes (IQR: 6–21) while it was 20 minutes (IQR: 14–30) for those not achieving ROSC (i.e., non-survivors). Compared with patients at hospitals with the shortest attempts (median duration, 16 minutes), patients at hospitals with the longest attempts (median duration, 25 minutes) had a higher likelihood of ROSC (adjusted risk-ratio 1·12, [95% CI: 1·06–1·18]; p <0·001) and survival to discharge (adjusted risk-ratio 1·12, [95% CI: 1·02–1·23]; p=0·021). These findings were more prominent in cardiac arrests due to asystole and pulseless electrical activity (p for interaction<0.01 for both ROSC and survival to discharge). Interpretation The duration of resuscitation attempts varies across hospitals. Patients at hospitals with longer attempts have a higher likelihood of ROSC and survival to discharge, particularly when the arrest is due to asystole and pulseless electrical activity. Funding The American Heart Association, the Robert Wood Johnson Foundation Clinical Scholars Program, the National Institutes of Health.