Where the Other Half Dies: Analysis of Mortalities Occurring More Than 30 Days After Complex Cancer Surgery.

BACKGROUND: Nearly half of operative mortalities occur outside the traditionally studied 30-day period after surgery. To identify additional opportunities to improve surgical safety, the circumstances of deaths occurring 31-90 days after complex cancer surgery are analyzed. PATIENTS AND METHODS: Patients aged ≥ 65 years who died within 90 days of complex cancer surgery for nonmetastatic cancer were analyzed in the Surveillance, Epidemiology, and End Results (SEER)-Medicare and the Connecticut Tumor Registry (CTR) databases. RESULTS: Of the 36,114 patients undergoing complex cancer surgery from 2004 to 2013 in SEER-Medicare, 1367 (3.8%) died within 31-90 days ("late mortalities"). Seventy-eight percent of late mortalities were readmitted prior to death. The highest proportion of late mortalities occurred during a readmission (49%), and 11% were never discharged from their index admission. Cause of death (COD) was largely attributed to the malignancy itself (56%), which is unlikely to be the underlying cause. Of the noncancer COD, cardiac causes were most frequent (34%), followed by pulmonary causes (18%). Death was rarely attributed to thromboembolic disease (< 1%). The CTR provided location of death, which was most commonly in a hospital (65%) or nursing facility (20%); death at home was rare (6%). CONCLUSIONS: The vast majority of patients dying between 31 and 90 days of surgery were admitted to a hospital or nursing facility at the time of their death after initially being discharged, and few patients died at home. Greater clarity in death documentation is needed to identify specific opportunities to rescue patients from fatal complications arising in the later postoperative period.

Analysis of recurrence after the resection of pancreatic neuroendocrine tumors.

BACKGROUND AND OBJECTIVES: Outcomes after recurrence of resected pancreatic neuroendocrine tumors (PNETs) are not well described. We aim to assess the rate and sites of recurrence, and its effect on clinical outcomes. METHODS: Retrospective chart review of patients (n = 83) who underwent surgical resection of PNETs at 2 institutions. Patients were treated from September 2002 to July 2010. RESULTS: There were 13 (16%) recurrences. The most common site of recurrence was the liver (9 patients, 9.6%). The most common treatment of recurrences was chemotherapy (5 patients, 36%). The 1-, 3-, and 5-year disease-free survival was 90.9%, 82.7%, and 72.5%, respectively. Median recurrence-free survival was 127 months. The median follow-up for all PNET patients was 25.8 months (range, 1-140 months). The 3-year survival was 97%. The median follow-up of patients after the diagnosis of a recurrence was 13.8 months. The overall survival for those with and without recurrence was 96.3% and 100%, respectively (P = .36). The age ( P = .002) and lymph node ratio ( P < .001) were predictors of recurrence on multivariate analysis. CONCLUSIONS: Age and lymph node ratio are significant predictors of recurrence after the resection of PNETs with hepatic metastases being the most common. Survival of patients with recurrence is not significantly different from patients without recurrence.

Impact of distal pancreatectomy on outcomes of peritoneal surface disease treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Left upper quadrant involvement by peritoneal surface disease (PSD) may require distal pancreatectomy (DP) to obtain complete cytoreduction. Herein, we study the impact of DP on outcomes of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). METHODS: Analysis of a prospective database of 1,019 procedures was performed. Malignancy type, performance status, resection status, comorbidities, Clavien-graded morbidity, mortality, and overall survival were reviewed. RESULTS: DP was a component of 63 CRS/HIPEC procedures, of which 63.3 % had an appendiceal primary. While 30-day mortality between patients with and without DP was no different (2.6 vs. 3.2 %; p = 0.790), 30-day major morbidity was worse in patients receiving a DP (30.2 vs. 18.8 %; p = 0.031). Pancreatic leak rate was 20.6 %. Intensive care unit days and length of stay were longer in DP versus non-DP patients (4.6 vs. 3.5 days, p = 0.007; and 22 vs. 14 days, p < 0.001, respectively). Thirty-day readmission was similar for patients with and without DP (29.2 vs. 21.1 %; p = 0.205). Median survival for low-grade appendiceal cancer (LGA) patients requiring DP was 106.9 months versus 84.3 months when DP was not required (p = 0.864). All seven LGA patients undergoing complete cytoreduction inclusive of DP were alive at the conclusion of the study (median follow-up 11.8 years). CONCLUSIONS: CRS/HIPEC including DP is associated with a significant increase in postoperative morbidity but not mortality. Survival was similar for patients with LGA whether or not DP was performed. Thus, the need for a DP should not be considered a contraindication for CRS/HIPEC procedures in LGA patients when complete cytoreduction can be achieved.

Peritoneal surface disease with synchronous hepatic involvement treated with Cytoreductive Surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

BACKGROUND: Patients with peritoneal surface disease (PSD) often present with synchronous hepatic involvement (HI). The impact of addressing the hepatic component during CRS/HIPEC on operative and survival outcomes is not clearly defined. METHODS: A prospective database of 1,067 procedures was reviewed based on primary tumor, performance status, resection status, type of liver involvement (superficial or parenchymal) and hepatic resection, morbidity, mortality, and overall survival. RESULTS: There were 108 (10 %) CRS/HIPEC procedures performed with synchronous liver debulking in 99 patients with PSD from 27 (33 %) appendiceal and 32 (39 %) colorectal primary lesions. Ninety percent of patients underwent subsegmental hepatic resection, whereas 22 % had disease with hepatic parenchymal involvement. Median intensive care unit (ICU) and hospital stay were 3.5 and 13.6 days, respectively. Clavien grade III/IV morbidity was similar for patients with or without resected HI (18.9 vs. 22.5 %; p = 0.39). The 30-day mortality rate was 6.5 and 2.8 % (p = 0.07) for patients with and without resected HI, respectively. The median survival for all patients with low-grade appendiceal cancer was 42.1 months with resected HI and 95.5 months without HI (p = 0.03). Median survival for colorectal cancer patients after complete cytoreduction was 21.2 months with HI versus 33.6 months without HI (p = 0.03). CONCLUSIONS: Synchronous resection of limited HI does not increase the morbidity or mortality of CRS/HIPEC procedures. The survival benefit, although still meaningful, was less for patients with HI. Resectable low volume HI in patients with PSD from colon and appendiceal primary lesions should not be considered a contraindication for CRS/HIPEC procedures.

Appendiceal goblet cell carcinomatosis treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is a treatment commonly applied to peritoneal surface disease from low-grade mucinous tumors of the appendix. Some centers have extended this therapy to carcinomatosis from more aggressive malignancies. Therefore, we reviewed our experience with CRS/HIPEC for patients with goblet cell carcinomatosis. METHODS: Patients with carcinomatosis from appendiceal primaries with goblet cell features were identified in a prospectively maintained database of 1198 CRS/HIPEC procedures performed between 1991 and 2014. Patient demographics, disease characteristics, morbidity, mortality, and survival were reviewed. RESULTS: A total of 31 patients with carcinomatosis originating from appendiceal goblet cell tumors underwent CRS/HIPEC during the study period. Patients were generally young (mean age, 53 y) and otherwise healthy (84% without comorbidities) with good performance status (94% Eastern Cooperative Oncology Group 0 or 1). The mean number of visceral resections was 3.5, and complete cytoreduction of macroscopic disease was accomplished in 36%. Major 90-d morbidity and mortality rates were 38.7% and 9.7%, respectively. Median overall survival (OS) for all patients was 18.4 mo. Patients with negative nodes had better survival than those with positive nodes (median OS, 29.2 versus 10.2 mo), respectively (P = 0.002). Although complete cytoreduction was associated with longer median OS after CRS/HIPEC (R0/R1 28.6 versus R2 17.2 mo, P = 0.47), the observed difference did not reach statistical significance. CONCLUSIONS: CRS/HIPEC may improve survival in patients with node negative goblet cell carcinomatosis when a complete cytoreduction is achieved. Patients with disease not amenable to complete cytoreduction should not be offered CRS/HIPEC.

Significance of diabetes on morbidity and mortality following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

BACKGROUND AND OBJECTIVES: Patients with diabetes suffering from peritoneal surface disease represent a challenge to treat due to the effects of both processes on multiple organ systems. We sought to define the impact of diabetes on outcomes following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC). METHODS: A retrospective analysis of a prospective database of 1065 CRS/HIPEC procedures was conducted. Patient demographics, comorbidities, and tumor characteristics were reviewed. RESULTS: CRS/HIPEC was performed in 91 diabetic and 844 non-diabetic patients with peritoneal surface disease from 1991 to 2013. Diabetics and non-diabetics spent 6.8 and 3.1 (P = 0.009) days in the ICU, respectively. Diabetics were more likely to suffer major complications (P < 0.001) including infectious (P < 0.001) and thrombotic (P = 0.05) complications, arrhythmias (P = 0.007), renal insufficiency (P = 0.002) and respiratory failure (P = 0.002) than non-diabetics. Mortality was significantly worse for diabetic patients at 30-days (8.8% vs. 2.7%, P = 0.007) and at 90-days (13.2% vs. 5.2%, P = 0.008). Even after adjusting for other significant predictors of morbidity, diabetes predicted more major complications and increased mortality following CRS/HIPEC. CONCLUSIONS: Diabetes predicts major complications and specific complication patterns associated with increased ICU stay and worse mortality in patients undergoing CRS/HIPEC. Diabetic patients deemed to be appropriate candidates for CRS/HIPEC should be treated with caution.

Significance of diaphragmatic resections and thoracic chemoperfusion on outcomes of peritoneal surface disease treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

BACKGROUND: Diaphragmatic resection (DR) during CRS/HIPEC exposes the thoracic cavity to direct contamination from the peritoneal cavity. The effect of thoracic chemoperfusion in combination with HIPEC in these patients is unknown. METHODS: A prospective database of 1,077 procedures was analyzed. Type of malignancy, thoracic perfusion, resection status, comorbidities, morbidity, mortality, and overall survival were reviewed. RESULTS: DR was a component of 102 CRS/HIPEC procedures performed for 57 (55.9 %) appendiceal and 22 (21.6 %) colon primary lesions. DR was associated with higher volume of disease as evidenced by more organ resections (3.7 vs. 2.8, p < 0.001) and increased rates of incomplete cytoreduction (67 vs. 52 %, p = 0.004). Patients with and without DR had similar 30-day major morbidity (23.5 vs. 16.8 %, p = 0.1) and worse 90-day mortality (12.8 % vs. 6.12 %, p = 0.03), respectively. Multivariate analysis showed DR (p = 0.01) and diabetes (p = 0.005) to be associated with worse mortality. Nineteen (20 %) DR patients underwent synchronous abdominal and thoracic chemoperfusion. Intrathoracic recurrence following DR with thoracic perfusion was 17 % (3/18) vs. 2.3 % (2/85) without perfusion (p = 0.04). Median survival following complete cytoreduction was similar for patients with low-grade appendiceal (LGA) (not reached with DR and 175 months without DR, p = 0.17) and colorectal cancer (23 months with and 31 months without DR, p = 0.76). CONCLUSIONS: Diaphragmatic resection during CRS/HIPEC is an independent predictor of surgical mortality. Intrapleural perfusion was associated with more thoracic recurrence; however, complete cytoreduction with or without DR can achieve similar survival for patients with LGA and colorectal primary lesions. DR should be performed only if careful inspection deems all peritoneal disease resectable.

Efficacy of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in the management of malignant ascites.

BACKGROUND: In peritoneal surface disease, accumulation of malignant ascites represents a difficult problem to treat, with adverse impact on quality of life. The role of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in controlling malignant ascites is not well defined. METHODS: A retrospective analysis of a prospectively maintained database of 1,000 procedures was performed. Type of malignancy, resolution of ascites, duration and agent of chemoperfusion, performance status, resection status, morbidity, mortality, and survival were reviewed. RESULTS: Ascites was found in 299 patients (310 procedures) either before or during exploration. A total of 142 (46 %) procedures were performed for appendiceal primary disease, 53 (17 %) colorectal, 20 (6 %) gastric, 45 (15 %) mesothelioma, and 26 (8 %) ovarian. A total of 288 (93 %) patients had resolution of ascites by 3 months' follow-up. In patients with ascites, complete cytoreduction was obtained in 15 versus 59 % when ascites was not present (p < 0.001). In the group of patients who had their ascites controlled, 243 of 288 (84 %) had resection with residual macroscopic disease (R2 status). Twenty-two patients (7 %) had persistent ascites at 3 months' follow-up, 19 (86 %) of whom had an R2 resection. Univariate analysis revealed that type of primary disease, resection status, duration or agent of chemoperfusion, and performance status did not predict failure. CONCLUSIONS: CRS-HIPEC is effective in controlling ascites in 93 % of patients with malignant ascites, even when a complete cytoreduction is not feasible. Ascites is predictive of incomplete cytoreduction and worse overall survival. Although complete cytoreduction remains the goal of this procedure, HIPEC can provide palliative value in selected patients with malignant ascites.

Significance of urinary tract involvement in patients treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

BACKGROUND: Urinary tract involvement in patients with peritoneal surface disease treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) often requires complex urologic resections and reconstruction to achieve optimal cytoreduction. The impact of these combined procedures on surgical outcomes is not well defined. METHODS: A prospective database of CRS/HIPEC procedures was analyzed retrospectively. Type of malignancy, performance status, resection status, hospital and intensive care unit stay, morbidity, mortality, and overall survival were reviewed. RESULTS: A total of 864 patients underwent 933 CRS/HIPEC procedures, while 64 % (550) had preoperative ureteral stent placement. A total of 7.3 % had an additional urologic procedure without an increase in 30-day (p = 0.4) or 90-day (p = 1.0) mortality. Urologic procedures correlated with increased length of operating time (p < 0.001), blood loss (p < 0.001), and length of hospitalization (p = 0.003), yet were not associated with increased overall 30-day major morbidity (grade III/IV, p = 0.14). In multivariate analysis, independent predictors of additional urologic procedures were prior surgical score (p < 0.001), number of resected organs (p = 0.001), and low anterior resection (p = 0.03). Long-term survival was not statistically different between patients with and without urologic resection for low-grade appendiceal primary lesions (p = 0.23), high-grade appendiceal primary lesions (p = 0.40), or colorectal primary lesions (p = 0.14). CONCLUSIONS: Urinary tract involvement in patients with peritoneal surface disease does not increase overall surgical morbidity. Patients with urologic procedures demonstrate survival patterns with meaningful prolongation of life. Urologic involvement should not be considered a contraindication for CRS/HIPEC in patients with resectable peritoneal surface disease.

Perioperative systemic chemotherapy for appendiceal mucinous carcinoma peritonei treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

BACKGROUND: The role of systemic chemotherapy (SC) in conjunction with cytoreductive surgery (CS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in appendiceal mucinous carcinoma peritonei (MCP) is unknown. METHODS: A retrospective review (1999-2011) of MCP patients who had undergone CS/HIPEC with or without perioperative SC. RESULTS: Twenty-two low-grade MCP patients treated with CS/HIPEC and SC were matched to patients who received CS/HIPEC alone. Median overall survival (OS) was 107 months for patients treated with perioperative SC compared to 72 without (P = 0.46). CS/HIPEC was performed on 109 patients with high-grade MCP: 70 were treated with perioperative SC, while 39 were not. Median OS (22.1 vs. 19.6 months, P = 0.74) and progression-free survival (PFS) (10.9 vs. 7.0 months, P = 0.47) were similar in patients treated with SC compared to CS/HIPEC alone. Progression while on pre-operative SC was seen in eight patients (17%), while four (8%) had a partial response. Treatment with post-operative SC was associated with longer PFS (13.6 months) compared to pre-operative SC (6.8 months, P < 0.01) and CS/HIPEC alone (7.0 months, P = 0.03). CONCLUSIONS: Post-operative SC appears to improve PFS in patients with high-grade appendiceal MCP treated with CS/HIPEC. In contrast, there is no evidence to support the routine use of perioperative SC in low-grade disease.

Exposure to influenza virus aerosols during routine patient care.

BACKGROUND: Defining dispersal of influenza virus via aerosol is essential for the development of prevention measures. METHODS: During the 2010-2011 influenza season, subjects with influenza-like illness were enrolled in an emergency department and throughout a tertiary care hospital, nasopharyngeal swab specimens were obtained, and symptom severity, treatment, and medical history were recorded. Quantitative impaction air samples were taken not ≤0.305 m (1 foot), 0.914 m (3 feet), and 1.829 m (6 feet) from the patient's head during routine care. Influenza virus was detected by rapid test and polymerase chain reaction. RESULTS: Sixty-one of 94 subjects (65%) tested positive for influenza virus. Twenty-six patients (43%) released influenza virus into room air, with 5 (19%) emitting up to 32 times more virus than others. Emitters surpassed the airborne 50% human infectious dose of influenza virus at all sample locations. Healthcare professionals (HCPs) were exposed to mainly small influenza virus particles (diameter, <4.7 µm), with concentrations decreasing with increasing distance from the patient's head (P < .05). Influenza virus release was associated with high viral loads in nasopharyngeal samples (shedding), coughing, and sneezing (P < .05). Patients who reported severe illness and major interference with daily life also emitted more influenza virus (P < .05). CONCLUSIONS: HCPs within 1.829 m of patients with influenza could be exposed to infectious doses of influenza virus, primarily in small-particle aerosols. This finding questions the current paradigm of localized droplet transmission during non-aerosol-generating procedures.

Hypertension Prevalence among Hispanics/Latinos of Dominican Background: A Transnational Comparison of HCHS/SOL and ENPREFAR-HAS-17.

Background: Hispanics/Latinos of Dominican background living in United States (US) have the highest hypertension prevalence compared with other Hispanic/Latino persons. Objective: To understand cardiovascular health among Dominicans, we evaluated hypertension prevalence and risk factors among Dominicans from the US and Dominican Republic (DR) using data from Hispanic Community Health Study/ Study of Latinos [HCHS/SOL] and the Prevalencia de Hipertension Arterial y Factores de Riesgo Cardiovasculares en la República Dominicana al 2017 (ENPREFAR-HAS 17) study. Methods: Hypertension was defined as blood pressure ≥140/90 mmHg, self-reported hypertension, or antihypertensive use. Exposures included sociodemographic/socioeconomic, clinical, and lifestyle/behavioral characteristics. Weighted generalized linear models were used to estimate associations between study characteristics and hypertension prevalence (PR = prevalence ratio), age-and-sex adjusted. HCHS/SOL (n = 1,473, US Dominicans; mean age 41 years, 60.4% female) was analyzed with survey procedures, while ENPREFAR-HAS 17 (n = 2,015 DR Dominicans; mean age 40 years, 50.3% female) was analyzed with statistical analyses for simple random sampling. Results: Hypertension prevalence was 30.5% and 26.9% for DR and US Dominicans, respectively. Hypertension control was low in both cohorts (36.0% DR, 35.0% US). Alcohol use among DR Dominicans was inversely associated with hypertension prevalence (PRDR = 0.8) with no association among US Dominicans. In both settings, diabetes (PRDR = 1.4; PRUS = 1.4) and obesity (PRDR = 1.8; PRUS = 2.0) were associated with greater hypertension prevalence in Hispanics/Latinos of Dominican background. Physical activity was lower among US Dominicans (PR = 0.80) but higher among DR Dominicans (PR = 1.16); all p < 0.05. Conclusions: Variations in social, lifestyle/behavioral, and clinical characteristics associated with hypertension among Dominicans in the US and DR were identified, suggesting that social context and cultural factors matter among immigrant populations.

Obesity and peritoneal surface disease: outcomes after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for appendiceal and colon primary tumors.

BACKGROUND: It is estimated that 37% of the U.S. population is obese. It is unknown how obesity influences the operative and survival outcomes of cytoreductive surgery (CRS)/hyperthermic intraperitoneal chemotherapy (HIPEC) procedures. METHODS: A retrospective analysis of a prospective database of 1,000 procedures was performed. Type of malignancy, performance status, resection status, hospital and intensive care unit stay, comorbidities, morbidity, mortality, and survival were reviewed. RESULTS: A total of 246 patients with body mass index (BMI) of >30 kg/m(2) underwent 272 CRS/HIPEC procedures. Ninety-five (38.6%) were severely obese (BMI > 35 kg/m(2)). A total of 135 (49.6%) procedures were performed for appendiceal and 60 (22.1%) for colon cancer. Median follow-up was 52 months. Both major and minor morbidity were similar for obese and non-obese patients. The 30-day mortality rates for obese and non-obese patients were 1.5 and 2.5%, respectively. Median intensive care unit and hospital stay were 1 and 9 days, regardless of BMI. The 30-day readmission rate was similar between obese and non-obese patients (24.8 vs. 19.4%, p = 0.11). Median survival for low-grade appendiceal cancer (LGA) was 76 months for obese patients and 107 months for non-obese patients (p = 0.32). Survival was worse for severely obese patients (median survival 54 months) versus non-obese patients with LGA (p = 0.04). Survival was similar for obese and non-obese patients with peritoneal surface disease (PSD) from colon cancer or high-grade appendiceal cancer. CONCLUSIONS: Obesity does not influence postoperative morbidity or mortality of patients with PSD, regardless of primary tumor. Severe obesity is associated with decreased long-term survival only in patients with LGA primary disease; however, application of CRS/HIPEC still offers meaningful prolongation of life. Obesity should not be considered a contraindication for CRS/HIPEC procedures.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in peritoneal carcinomatosis from rectal cancer.

BACKGROUND: Cytoreductive surgery (CS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is the treatment most likely to achieve prolonged survival in peritoneal carcinomatosis (PC). Yet the efficacy of HIPEC in rectal patients is controversial because of the retroperitoneal location of the primary tumor. Therefore, we reviewed our experience in patients with PC from a rectal primary tumor. METHODS: A retrospective analysis of a prospective database of 950 HIPEC procedures was performed. Performance status, age, albumin level, prior surgical score, resection status, morbidity, mortality, and survival were reviewed. RESULTS: A total of 13 and 204 patients with PC from rectal and colon cancer, respectively, were identified. Median follow-up was 40.1 and 88.1 months, respectively. Eastern Cooperative Oncology Group (ECOG) score was zero or one for 92 % of patients with rectal cancer and 83 % for colon, while R1 resection was achieved in 54 and 51 %. The 30-day mortality was 5 % for colon cancer. There were no deaths in the rectal group. The morbidity for the colon and rectal groups was 57 and 46 %, respectively, with a 23 % 30-day readmission rate. In univariate analysis, age, ECOG, prior surgical score, albumin level, and node and resection status were not statistically significant in predicting survival for the rectal cancer patients. Median survival for the rectal and colon groups was 14.6 versus 17.3 months, while the 3-year survival was 28.2 versus 25.1 %. CONCLUSIONS: Our data demonstrate similar 3-year survival for patients with rectal and colon cancer PC treated with CS/HIPEC. This can be attributed to patient selection bias. Selected rectal cancer PC patients should not be excluded from an attempted cytoreduction and HIPEC.

The plastic surgery match: predicting success and improving the process.

Plastic surgery continues to be a very competitive program to match into out of medical school. To analyze the match process, all applicants to our plastic surgery residency program in 2012 were surveyed. Our results showed that with matching into plastic surgery as the primary outcome measure, those who matched applied to more plastic surgery programs, received and accepted more interview invitations, were younger, were less likely to be foreign medical graduates, reported higher costs, had higher Step 1 and Step 2 scores, were more likely to be an Alpha Omega Alpha member, and conducted more research. In addition to looking at variables that affected the success of the match, other questions regarding the match process were posed. Most interestingly, 10% of applicants still reported violations of the match communication guidelines. Furthermore, the mean cost of interviewing for the plastic surgery match was $6073.In summary, applicants with diversified strengths had the best chance of matching. On the basis of the results of this study, applicants should attend a large number of interviews to optimize their match success. With medical student debt a growing problem, programs need to find ways to control interview costs. Residency program compliance with match communication guidelines has improved, but compliance should be universal. With these data, applicants can be better prepared for the match to optimize their success and programs can work to improve the match process.

Pre-Heart Failure Longitudinal Change in a Hispanic/Latino Population-Based Study: Insights From the Echocardiographic Study of Latinos.

BACKGROUND: Pre-heart failure (pre-HF) is an entity known to progress to symptomatic heart failure (HF). OBJECTIVES: This study aimed to characterize pre-HF prevalence and incidence among Hispanics/Latinos. METHODS: The Echo-SOL (Echocardiographic Study of Latinos) assessed cardiac parameters on 1,643 Hispanics/Latinos at baseline and 4.3 years later. Prevalent pre-HF was defined as the presence of any abnormal cardiac parameter (left ventricular [LV] ejection fraction <50%; absolute global longitudinal strain <15%; grade 1 or more diastolic dysfunction; LV mass index >115 g/m2 for men, >95 g/m2 for women; or relative wall thickness >0.42). Incident pre-HF was defined among those without pre-HF at baseline. Sampling weights and survey statistics were used. RESULTS: Among this study population (mean age: 56.4 years; 56% female), HF risk factors, including prevalence of hypertension and diabetes, worsened during follow-up. Significant worsening of all cardiac parameters (except LV ejection fraction) was evidenced from baseline to follow-up (all P < 0.01). Overall, the prevalence of pre-HF was 66.7% at baseline and the incidence of pre-HF during follow-up was 66.3%. Prevalent and incident pre-HF were seen more with increasing baseline HF risk factor burden as well as with older age. In addition, increasing the number of HF risk factors increased the risk of prevalence of pre-HF and incidence of pre-HF (adjusted OR: 1.36 [95% CI: 1.16-1.58], and adjusted OR: 1.29 [95% CI: 1.00-1.68], respectively). Prevalent pre-HF was associated with incident clinical HF (HR: 10.9 [95% CI: 2.1-56.3]). CONCLUSIONS: Hispanics/Latinos exhibited significant worsening of pre-HF characteristics over time. Prevalence and incidence of pre-HF are high and are associated with increasing HF risk factor burden and with incidence of cardiac events.

Heterogeneity of Lipoprotein(a) Levels Among Hispanic or Latino Individuals Residing in the US.

Importance: Lipoprotein(a) (Lp[a]) is a genetically determined risk-enhancing factor for atherosclerotic cardiovascular disease (ASCVD). The Lp(a) distribution among the diverse Hispanic or Latino community residing in the US has not been previously described, to the authors' knowledge. Objective: To determine the distribution of Lp(a) levels across a large cohort of diverse Hispanic or Latino adults living in the US and by key demographic groups. Design, Setting, and Participants: The Hispanic Community Health Study/Study of Latinos (HCHS/SOL) is a prospective, population-based, cohort study of diverse Hispanic or Latino adults living in the US. At screening, participants aged 18 to 74 years were recruited between 2008 and 2011 from 4 US metropolitan areas (Bronx, New York; Chicago, Illinois; Miami, Florida; San Diego, California). HCHS/SOL included 16 415 noninstitutionalized adults recruited through probability sampling of randomly selected households. The study population represents Hispanic or Latino participants from diverse self-identified geographic and cultural backgrounds: Central American, Cuban, Dominican, Mexican, Puerto Rican, and South American. This study evaluated a subset of HCHS/SOL participants who underwent Lp(a) measurement. Sampling weights and surveys methods were used to account for HCHS/SOL sampling design. Data for this study were analyzed from April 2021 to April 2023. Exposure: Lp(a) molar concentration was measured by a particle-enhanced turbidimetric assay with minimized sensitivity to apolipoprotein(a) size variation. Main Outcome and Measure: Lp(a) quintiles were compared using analysis of variance among key demographic groups, including self-identified Hispanic or Latino background. Median percentage genetic ancestry (Amerindian, European, West African) were compared across Lp(a) quintiles. Results: Lp(a) molar concentration was measured in 16 117 participants (mean [SD] age, 41 [14.8] years; 9680 female [52%]; 1704 Central American [7.7%], 2313 Cuban [21.1%], 1436 Dominican [10.3%], 6395 Mexican [39.1%], 2652 Puerto Rican [16.6%], 1051 South American [5.1%]). Median (IQR) Lp(a) level was 19.7 (7.4-59.7) nmol/L. Across Hispanic or Latino background groups, there was significant heterogeneity in median Lp(a) levels ranging from 12 to 41 nmol/L in those reporting a Mexican vs Dominican background. Median (IQR) West African genetic ancestry was lowest in the first quintile of Lp(a) level and highest in the fifth quintile (5.5% [3.4%-12.9%] and 12.1% [5.0%-32.5%]; respectively; P < .001), whereas the converse was seen for Amerindian ancestry (32.8% [9.9%-53.2%] and 10.7% [4.9%-30.7%], respectively; P < .001). Conclusions and Relevance: Results of this cohort study suggest that differences in Lp(a) level distribution across the diverse US Hispanic or Latino population may carry important implications for the use of Lp(a) level in ASCVD risk assessment for this group. Cardiovascular outcomes data are needed to better understand the clinical impact of differences in Lp(a) levels by Hispanic or Latino background.

Corrigendum to "Risk Factor Control Across the Spectrum of Cardiovascular Risk: Findings from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)" [American Journal of Preventive Cardiology, Volume 5, March 2021, 100147].

[This corrects the article DOI: 10.1016/j.ajpc.2021.100147.].

Echocardiographic Investigation of Low-Flow State in a Hispanic/Latino Population.

Objective: To assess the prevalence of low-flow state (LFS) with left ventricular (LV) stroke volume index of less than 35 mL/m2 and the demographics, clinical and echocardiographic characteristics associated with LV remodeling and function in a Hispanic/Latino population. Participants and Methods: The study included 1346 asymptomatic participants from the Hispanic Community Health Study/Study of Latinos with normal LV ejection fraction (≥55%) and no valvular heart disease. LV volume, mass and left atrial volume, LV ejection fraction, global longitudinal strain, and myocardial contraction fraction were measured by echocardiography. The participants were divided into LFS or normal flow state (NFS: stroke volume index ≥35 mL/m2). Demographics, clinical and echocardiographic characteristics, and measures of LV remodeling and function were compared between the LFS and NFS groups. Results: The prevalence of LFS was 41%. In comparison with NFS, the LFS had lower LV mass index (77.2±0.96 g/m2 vs 84.6±0.86 g/m2; P<.001), left atrial volume index (20.6±0.35 mL/m2 vs 23.5±0.37 mL/m2; P<.001), global longitudinal strain (-16.8±0.16% vs -17.7±0.17%; P<.001), and myocardial contraction fraction (43.3±0.63% vs 55.7±0.64%; P<.001). There was no significant difference in the relative wall thickness (LFS: 0.40±0.004 vs NFS: 0.40±0.005; P=.57). The LFS group had significantly higher hemoglobin A1c (6.18±0.07% vs 5.97±0.04%; P=.01) than the NFS group. Conclusion: A high prevalence of LFS associated with echocardiographic characteristics reflecting unfavorable LV remodeling and function was observed in a Hispanic/Latino population. Further studies of the prognostic significance of LFS in a large multiethnic population are warranted.