A retrospective single-institution review of the impact of COVID-19 on severity of biliary disease.

BACKGROUND: The COVID-19 pandemic possessed far-reaching health implications beyond the public health impact that have yet to be fully elucidated. We hypothesized that the COVID-19 pandemic led to an increase in biliary disease complexity and incidence of emergency cholecystectomy. METHODS: We reviewed our institutional experience with cholecystectomy from February 2019-February 2021, n = 912. Pre COVID-19 pandemic patients were compared to patients after the onset of the pandemic. Baseline characteristics were compared between groups. A Cochran-Armitage test for trend assessed the temporal impact of COVID-19 on emergency presentation and gallbladder disease complexity. RESULTS: We identified 442 patients pre-pandemic and 470 patients during the pandemic. No significant differences were noted in demographics. COVID-19 significantly impacted emergency presentation (43.2% vs. 56.8%, p= <0.01), cholecystitis (53.2% vs 61.8%; p=<0.01), and gangrenous cholecystitis (2.8% vs 6.1%; p=<0.01). Both groups had similar clinical outcomes. CONCLUSIONS: The COVID-19 pandemic affected an increased incidence of emergency presentation and complexity of gallbladder disease but did not significantly impact clinical outcomes. These findings may have broader implications for other diseases possibly affected by COVID-19.

Random forest modeling using socioeconomic distress predicts hernia repair approach.

BACKGROUND: Surgical techniques for abdominal wall hernia repair have advanced, yet it is unclear if all patient populations experience these innovations equally. We hypothesized that in patients undergoing abdominal wall herniorrhaphy, there would be socioeconomic variation between robotic, laparoscopic, and open approaches. METHODS: We performed a retrospective review of patients undergoing abdominal wall herniorrhaphy at a tertiary care center from 2013 through 2019. Patients were stratified by approach: laparoscopic (LH), open (OH), or robotic (RH). Insurance type was categorized as private, Medicare, or Medicaid/uninsured. Using zip code data, we obtained a Distressed Communities Index (DCI), which is comprised of 7 unique socioeconomic variables. We employed random forest (RF) modeling to predict surgical approach and determined each factor's variable importance (VI) for our model. RESULTS: There were 559 patients; 39.7% (n = 222) LH, 33.3% (n = 186) OH, and 27% (n = 151) RH. The DCI (p < 0.01) and rates of poverty (p = 0.01), adults without diplomas (p < 0.01), and unemployment (p < 0.01) were highest in the OH group while job growth (p = 0.02) and median income ratio (p < .01) were highest in the RH group. The LH group had a greater proportion of privately insured patients than Medicaid/ uninsured patients (43.4% vs 15.9%, p < 0.01). The most important variables identified by our RF model were job growth (for RH), insurance type (for LH), and no high school diploma (for OH). CONCLUSION: Insurance type, job growth, and educational attainment may influence operative approach and can contribute to the existing disparities in hernia surgery. Surgeons should address these inequalities and commit to parity in the delivery of surgical care.

Decreasing Postoperative Opioid Prescribing through Education.

OBJECTIVES: To study how an educational intervention given to surgical residents affected postoperative opioid prescribing. To determine whether decreased opioid prescription amounts increased patients' rate of refills, emergency department visits, or readmissions. DESIGN: Prospective sequential cohort study. SETTING: Level 1 tertiary care center in Savannah, Georgia. PARTICIPANTS: Opioid-naive patients who underwent general surgery (appendectomy, cholecystectomy, colectomy, hernia repair, lumpectomy, and mastectomy) between November 2017 and February 2018. RESULTS: Over a 6 month period, morphine milligram equivalents (MME) prescribed after general surgery per patient was decreased by 21.8% on average, with the largest reductions seen after breast and gallbladder surgeries (38% and 25% respectively). Patients who underwent laparoscopic surgery were prescribed 18.3% fewer MME. There was no significant change in MME prescribed after open abdominal surgery. Smaller prescription amounts were not associated with an increased rate of opioid refills. There was no increase in pain-related calls to clinic offices, emergency department visits, or readmissions for pain. CONCLUSION: After a single education intervention given to surgical residents, MME prescribed after common general surgeries can be decreased significantly without increasing rates of refills or utilization of care.

Phospho-ERK and AKT status, but not KRAS mutation status, are associated with outcomes in rectal cancer treated with chemoradiotherapy.

BACKGROUND: KRAS mutations may predict poor response to radiotherapy. Downstream events from KRAS, such as activation of BRAF, AKT and ERK, may also confer prognostic information but have not been tested in rectal cancer (RC). Our objective was to explore the relationships of KRAS and BRAF mutation status with p-AKT and p-ERK and outcomes in RC. METHODS: Pre-radiotherapy RC tumor biopsies were evaluated. KRAS and BRAF mutations were assessed by pyrosequencing; p-AKT and p-ERK expression by immunohistochemistry. RESULTS: Of 70 patients, mean age was 58; 36% stage II, 56% stage III, and 9% stage IV. Responses to neoadjuvant chemoradiotherapy: 64% limited, 19% major, and 17% pathologic complete response. 64% were KRAS WT, 95% were BRAF WT. High p-ERK levels were associated with improved OS but not for p-AKT. High levels of p-AKT and p-ERK expression were associated with better responses. KRAS WT correlated with lower p-AKT expression but not p-ERK expression. No differences in OS, residual disease, or tumor downstaging were detected by KRAS status. CONCLUSIONS: KRAS mutation was not associated with lesser response to chemoradiotherapy or worse OS. High p-ERK expression was associated with better OS and response. Higher p-AKT expression was correlated with better response but not OS.

Racial differences in trust and regular source of patient care and the implications for prostate cancer screening use.

BACKGROUND: : Nonmedical factors may modify the biological risk of prostate cancer (PCa) and contribute to the differential use of early detection; curative care; and, ultimately, greater racial disparities in PCa mortality. In this study, the authors examined patients' usual source of care, continuity of care, and mistrust of physicians and their association with racial differences in PCa screening. METHODS: : Study nurses conducted in-home interviews of 1031 African-American men and Caucasian-American men aged > or =50 years in North Carolina and Louisiana within weeks of their PCa diagnosis. Medical records were abstracted, and the data were used to conduct bivariate and multivariate analyses. RESULTS: : Compared with African Americans, Caucasian Americans exhibited higher physician trust scores and a greater likelihood of reporting a physician office as their usual source of care, seeing the same physician at regular medical encounters, and historically using any PCa screening. Seeing the same physician for regular care was associated with greater trust and screening use. Men who reported their usual source of care as a physician office, hospital clinic, or Veterans Administration facility were more likely to report prior PCa screening than other men. In multivariate regression analysis, seeing the same provider remained associated with prior screening use, whereas both race and trust lost their association with prior screening. CONCLUSIONS: : The current results indicated that systems factors, including those that differ among different sources of care and those associated with the continuity of care, may provide tangible targets to address disparities in the use of PCa early detection, may attenuate racial differences in PCa screening use, and may contribute to reduced racial disparities in PCa mortality. Cancer 2009. Published 2009 by the American Cancer Society.

Gene-expression analysis and the basal-like breast cancer subtype.

Analysis of the patterns of gene expression in breast cancer suggests that it is not a single entity, but is comprised of several biologically distinct subtypes with characteristic molecular profiles. These molecular profiles confirm the clinical impression that estrogen receptor (ER)-negative differs from ER-positive, and expands our understanding by identifying breast cancer subtypes, including the basal-like and human epidermal growth factor receptor (HER)2/ER subtypes within the ER-negative subset, and the luminal A and B subtypes within ER-positive disease. The basal-like subtype is characterized by the low expression levels of the ER-related and the HER2-related group of genes, and therefore is often 'triple negative' on clinical assays for these proteins. This review discusses the molecular profiles of breast cancer with a focus on the clinical characteristics of, and treatment options for, the basal-like subtype.