Has the Increase of Women in Surgical Training Programs Led to a Concomitant Increase in Female Leadership Positions? A 10-Year Analysis.

INTRODUCTION: Women represent greater than 50% of medical students in America and are becoming increasingly well represented in surgical fields. However, parity at the trainee level has yet to be accomplished, and surgical leadership positions have remained disproportionately biased toward men. To date, there have been no comparisons on the progress within plastic surgery and other surgical specialties. This investigates the gender disparity in resident and leadership representation over the past 10 years within surgical specialties and how these disparities compare to plastic surgery. METHODS: Counts of female and male residents and surgical society leaders were collected from 2008 to 2018. Surgical fields included plastic, vascular, urologic, neurologic, orthopedic, cardiothoracic, and general surgery. Leadership positions were defined as board seats on executive committees of major surgical societies or board associations. Data were acquired from publicly available sources or provided directly from the organizations. Resident data were obtained from the Accreditation Council of Graduate Medical Education residents' reports. Individuals holding more than 1 leadership position within a year were counted only once. RESULTS: In our aggregated analysis, the proportion of women in surgical leadership lags behind women in surgical residency training across all specialties (13.2% vs 27.3%, P < 0.01). General surgery had the highest proportion of female residents and leaders (35% and 18.8%, P < 0.01), followed by plastic (32.2% and 17.3%, P < 0.01), vascular (28.2% and 11.3%, P < 0.01), urologic (24.3% and 5.1%), and cardiothoracic surgery (20.5% and 7.8%, P < 0.01). Women in surgical leadership, however, increased at a faster rate than women in surgical training (11% vs 7%, P < 0.05). Plastic surgery showed the greatest rate of increase in both residents and leaders (17% and 19%, P < 0.05) followed by cardiothoracic surgery (16% and 9%, P < 0.05) and general surgery (8% and 14%, P < 0.05). For neurologic and orthopedic surgery, neither the difference in proportions between residents and leaders nor the yearly growth of these groups were significant. CONCLUSIONS: Between 2008 and 2018, women in plastic surgery training and leadership positions have shown the most significant growth compared with other surgical subspecialties, demonstrating a strong concerted effort toward gender equality among surgical professions.

Risk Factors Associated With Postmastectomy Breast Cancer Lymphedema: A Multicenter Retrospective Analysis.

BACKGROUND: Lymphedema is an edematous condition that afflicts the postmastectomy breast cancer population, with diminished quality of life with substantial financial costs. The factors predictive of postmastectomy lymphedema development in breast cancer patients are unknown. The objective was to evaluate the trends over time in lymphedema development and the risk factors predictive of lymphedema-related events within 2 years of mastectomy. METHODS: Using the New York Statewide Planning and Research Cooperative System multicenter deidentified database from 2010 to 2016, a total of 65,543 breast cancer postmastectomy female patients (mean age, 59 ± 20 years) were identified across 177 facilities. The breast cancer patients were followed for any 2-year postmastectomy lymphedema-related events. A multivariable model identified predictors of 2-year lymphedema using eligible variables involving demographics, comorbidities, and complications. Elixhauser score was defined as a comorbidity index based on International Classification of Diseases codes used in hospital settings. RESULTS: Overall, 5.2% (n = 3409) of the breast cancer postmastectomy patients experienced a lymphedema-related event within 2 years of initial surgery. Over time, 2-year postmastectomy lymphedema rates have more than doubled from 4.62% in 2010 to 9.75% in 2016 (P < 0.001). Two-year postmastectomy lymphedema rates varied significantly by mastectomy procedure type: 5.69% of the mastectomy-only procedures, 5.96% of the mastectomies with lymph node biopsies, and 7.83% of the mastectomies with lymph node dissections (P < 0.0001). Full mastectomies had a greater 2-year lymphedema rate of 7.31% when compared with partial mastectomies with 2.79% (P < 0.0001). The top predictive risk factors for a lymphedema-related event included higher Elixhauser score, prolonged hospitalization for mastectomy, more recent mastectomy procedure, obesity, younger age, non-Asian race, Medicaid insurance, and hypertension (all P's < 0.01). CONCLUSIONS: Although more recent postmastectomy lymphedema rates may not be as high as historical estimates, the 2-year postmastectomy lymphedema rates have more than doubled from 2010 to 2016 requiring further elucidation as well as continued focus on treatment. Furthermore, risk factors were identified that predispose postmastectomy breast cancer patients to developing lymphedema. Given these findings, perioperative screening seems warranted to proactively identify, educate, and monitor postmastectomy patients at greatest risk of future lymphedema development.

Laparoscopic versus open surgery: a systematic review evaluating Cochrane systematic reviews.

BACKGROUND: Laparoscopic surgical procedures (LSP) have grown in popularity due to their purported benefits of improved effectiveness and efficiency. This study summarizes the Cochrane systematic reviews' (CSRs') evidence comparing the use of LSP versus open procedures used for surgical patient management and comparing the CSRs' quality and consistency of LSP evidence reported across time and different surgical specialties. METHODS: The Cochrane Database was searched to identify CSRs comparing LSP versus open procedures; 36 CSRs and 15 CSR protocols were found as of February 16, 2016. Each CSR's clinical outcomes and major conclusions were evaluated; CSR's quality and completeness were assessed using PRISMA and AMSTAR criteria. Overall, CSRs' reporting variations across specialties and trends over time were summarized. RESULTS: A weighted analysis across all 36 CSRs found improved outcomes with LSP (odds ratio 0.90; 95% confidence interval 0.88, 0.92). Substantial CSR variation was found in the patient inclusion/exclusion criteria and clinical endpoints used. Individually, most CSR analyses showed no significant difference (65.4%) between LSP versus open procedures; 25.8% showed a LSP benefit versus 8.9% an open benefit. As a major conclusion, a positive LSP impact was documented by 8/36 (22.2%) CSRs; but only half of these CSRs decisively concluded that there was a LSP advantage. Undeclared conflicts of interest were identified in 9/36 CSRs (25.0%), raising the potential for a reporting bias. Both CSR variabilities (i.e., missing population, intervention, comparison, outcome, study design statements) and PRISMA-related deficiencies were documented. CONCLUSIONS: Overall, CSR evidence supports a LSP advantage; however, clinical decisions must be driven by CSR procedure-specific evidence. Variations and inconsistencies in CSR design and reporting identified future opportunities to improve CSR quality by increasing the methodological transparency, standardizing CSR reporting, and documenting comprehensively any non-financial conflicts of interest (i.e., ongoing research and historical publications) for all CSR team members.

Usefulness of two clinical chorioamnionitis definitions in predicting neonatal infectious outcomes: a systematic review.

OBJECTIVE: To assess the usefulness of two definitions of acute clinical chorioamnionitis (ACCA) in predicting risk of neonatal infectious outcomes (NIO) and mortality, the first definition requiring maternal fever alone (Fever), and the second requiring ≥ 1 Gibbs criterion besides fever (Fever + 1). STUDY DESIGN: PubMed, Web of Science, and the Cochrane Database of Systematic Reviews were searched from January 1, 1979 to April 9, 2013. Twelve studies were reviewed (of 316 articles identified): three studies with term patients, four with preterm premature rupture of membranes (PPROM) patients, and five mixed studies with mixed gestational ages and/or membrane status (intact and/or ruptured). RESULTS: Both definitions demonstrated an increased NIO risk for ACCA versus non-ACCA patients, with an odds ratio increase for the Fever + 1 definition that was about twofold larger than the Fever definition. CONCLUSION: As the Fever definition demonstrated increased NIO risk for ACCA versus non-ACCA patients, the Fever alone ACCA definition should be used to trigger future clinical treatment in many clinical situations.

Report from a quality assurance program on patients undergoing the MILD procedure.

OBJECTIVES: To characterize trends in pain and functional outcomes and identify risk factors in patients with lumbar spinal stenosis (LSS) and neurogenic claudication undergoing the "Minimally Invasive Lumbar Decompression" (MILD) procedure. DESIGN: Retrospective observational cohort study. SETTING: Academic multidisciplinary pain center at Stony Brook Medicine. SUBJECTS: Patients undergoing the MILD procedure from October 2010 to November 2012. METHODS: De-identified perioperative, pain and function related data for 50 patients undergoing MILD were extracted from the Center for Pain Management's quality assessment database. Data included numerical rating scale (NRS), symptom severity and physical function (Zurich Claudication Questionnaire), functional status (Oswestry Disability Index [ODI]), pain interference scores (National Institutes of Health Patient-Reported Outcomes Measurement Information System [PROMIS]), and patients' self-reported low back and lower extremity pain distribution. RESULTS: No MILD patient incurred procedure-related complications. Average NRS scores decreased postoperatively and 64.3% of patients reported less pain at 3 months. Clinically meaningful functional ODI improvements of at least 20% from baseline were present in 25% of the patients at 6 months. Preliminary analysis of changes in PROMIS scores at 3 months revealed that pre-MILD "severe" lumbar canal stenosis may be associated with high risk of "no improvement." No such impact was observed for NRS or ODI outcomes. CONCLUSION: Overall, pain is reduced and functional status improved in LSS patients following the MILD procedure at 3 and 6 months. Given the small sample size, it is not yet possible to identify patient subgroups at risk for "no improvement." Continued follow-up of longer-term outcomes appears warranted to develop evidence-based patient selection criteria.

Off-Pump Coronary Artery Bypass Grafting: Department of Veteran Affairs' Use and Outcomes.

Background Coronary artery bypass can be performed off pump (OPCAB) without cardiopulmonary bypass. However, trends over time for OPCAB versus on-pump (ONCAB) use and long-term outcome has not been reported, nor has their long-term outcome been compared. Methods and Results We queried the national Veterans Affairs database (2005-2019) to identify isolated coronary artery bypass procedures. Procedures were classified as OPCAB on ONCAB using the as-treated basis. Trend analyses were performed to evaluate longitudinal changes in the preference for OPCAB. The median follow-up period was 6.6 (3.5-10) years. An inverse probability weighted Cox model was used to compare all-cause mortality between OPCAB and ONCAB. From 47 685 patients, 6759 (age 64±8 years) received OPCAB (14%). OPCAB usage declined from 16% (2005-2009) to 8% (2015-2019). Patients with triple vessel disease who received OPCAB received a lower mean number of grafts (2.8±0.8 versus 3.2±0.8; P<0.01). The ONCAB 5-, 10-, and 15-year survival rates were 82.9% (82.5-83.3), 60.4% (59.8-61.1), and 37.2% (36.1-38.4); correspondingly, OPCAB rates were 80.7% (79.7-81.7), 57.4% (56-58.7), and 34.1% (31.7-36.6) (P<0.01). OPCAB was associated with increased risk-adjusted all-cause mortality (hazard ratio, 1.15 [1.13-1.18]; P<0.01) and myocardial infarction (incident rate ratio, 1.16 [1.05-1.28]; P<0.01). Conclusions Over 15 years, OPCAB use declined considerably in Veterans Affairs medical centers. In Veterans Affairs hospitals, late all-cause mortality and myocardial infarction rates were higher in the OPCAB cohort.

Cardiac surgical simulation program during general surgery residency increases resident physician exposure to cardiac surgery and technical expertise.

Objective: The changing surgical education landscape in surgical training pathways greatly diminished cardiac surgical knowledge, interest, and skills among general surgery trainees. To address this issue, our department developed a cardiac surgery simulation program. Methods: All simulation sessions lasted at least 2 hours and occurred during resident physician protected education time. Participants were postgraduate year 2 through 5 general surgery residents assisted by staff and led by cardiac surgery faculty. Five of the 6 sessions were porcine heart wet labs simulating coronary anastomoses, surgical aortic valve replacement, mitral valve repair and replacement, and left ventricular assist device implantation. The transcatheter aortic valve replacement session was designed as a video simulation and a manikin for wire manipulation and implantation. At the end of each lab, all participants were surveyed about their experiences. Results: An average of 10 resident physicians participated in each session (range, 8-13), for a total of 120 simulation hours. One hundred percent of residents surveyed agreed that the labs improved knowledge and understanding of the disease process, improved understanding of cardiac surgical principles, and helped acquire skills for surgical residency and treatment. Factors that residents cited for increased attendance rate included protected education time, hands-on experience, and a high faculty-to-resident ratio. Conclusions: This program successfully demonstrates that cardiac surgery training and simulation can be integrated into general surgery residency programs, despite the lack of cardiac surgery requirements. Additional metrics for future study includes technical grades on resident physicians' performance to further assess the value of this program.

Academic medicine's glass ceiling: Author's gender in top three medical research journals impacts probability of future publication success.

INTRODUCTION: In December 2017, Lancet called for gender inequality investigations. Holding other factors constant, trends over time for significant author (i.e., first, second, last or any of these authors) publications were examined for the three highest-impact medical research journals (i.e., New England Journal of Medicine [NEJM], Journal of the American Medical Association [JAMA], and Lancet). MATERIALS AND METHODS: Using randomly sampled 2002-2019 MEDLINE original publications (n = 1,080; 20/year/journal), significant author-based and publication-based characteristics were extracted. Gender assignment used internet-based biographies, pronouns, first names, and photographs. Adjusting for author-specific characteristics and multiple publications per author, generalized estimating equations tested for first, second, and last significant author gender disparities. RESULTS: Compared to 37.23% of 2002 - 2019 U.S. medical school full-time faculty that were women, women's first author publication rates (26.82% overall, 15.83% NEJM, 29.38% Lancet, and 35.39% JAMA; all p < 0.0001) were lower. No improvements over time occurred in women first authorship rates. Women first authors had lower Web of Science citation counts and co-authors/collaborating author counts, less frequently held M.D. or multiple doctoral-level degrees, less commonly published clinical trials or cardiovascular-related projects, but more commonly were North American-based and studied North American-based patients (all p < 0.05). Women second and last authors were similarly underrepresented. Compared to men, women first authors had lower multiple publication rates in these top journals (p < 0.001). Same gender first/last authors resulted in higher multiple publication rates within these top three journals (p < 0.001). DISCUSSION: Since 2002, this authorship "gender disparity chasm" has been tolerated across all these top medical research journals. Despite Lancet's 2017 call to arms, furthermore, the author-based gender disparities have not changed for these top medical research journals - even in recent times. Co-author gender alignment may reduce future gender inequities, but this promising strategy requires further investigation.

Association of Posttraumatic Stress Disorder and Incident Ischemic Heart Disease in Women Veterans.

Importance: Posttraumatic stress disorder (PTSD) is associated with greater risk of ischemic heart disease (IHD) in predominantly male populations or limited community samples. Women veterans represent a growing, yet understudied, population with high levels of trauma exposure and unique cardiovascular risks, but research on PTSD and IHD in this group is lacking. Objective: To determine whether PTSD is associated with incident IHD in women veterans. Design, Setting, and Participants: In this retrospective, longitudinal cohort study of the national Veterans Health Administration (VHA) electronic medical records, the a priori hypothesis that PTSD would be associated with greater risk of IHD onset was tested. Women veterans 18 years or older with and without PTSD who were patients in the VHA from January 1, 2000, to December 31, 2017, were assessed for study eligibility. Exclusion criteria consisted of no VHA clinical encounters after the index visit, IHD diagnosis at or before the index visit, and IHD diagnosis within 90 days of the index visit. Propensity score matching on age at index visit, number of prior visits, and presence of traditional and female-specific cardiovascular risk factors and mental and physical health conditions was conducted to identify women veterans ever diagnosed with PTSD, who were matched in a 1:2 ratio to those never diagnosed with PTSD. Data were analyzed from October 1, 2018, to October 30, 2020. Exposures: PTSD, defined by International Classification of Diseases, Ninth Revision (ICD-9), or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), diagnosis codes from inpatient or outpatient encounters. Main Outcomes and Measures: Incident IHD, defined as new-onset coronary artery disease, angina, or myocardial infarction, based on ICD-9 and ICD-10 diagnosis codes from inpatient or outpatient encounters, and/or coronary interventions based on Current Procedural Terminology codes. Results: A total of 398 769 women veterans, 132 923 with PTSD and 265 846 never diagnosed with PTSD, were included in the analysis. Baseline mean (SD) age was 40.1 (12.2) years. During median follow-up of 4.9 (interquartile range, 2.1-9.2) years, 4381 women with PTSD (3.3%) and 5559 control individuals (2.1%) developed incident IHD. In a Cox proportional hazards model, PTSD was significantly associated with greater risk of developing IHD (hazard ratio [HR], 1.44; 95% CI, 1.38-1.50). Secondary stratified analyses indicated that younger age identified women veterans with PTSD who were at greater risk of incident IHD. Effect sizes were largest for those younger than 40 years at baseline (HR, 1.72; 95% CI, 1.55-1.93) and decreased monotonically with increasing age (HR for ≥60 years, 1.24; 95% CI, 1.12-1.38). Conclusions and Relevance: This cohort study found that PTSD was associated with increased risk of IHD in women veterans and may have implications for IHD risk assessment in vulnerable individuals.

Factors associated with long-term survival in patients with stroke after coronary artery bypass grafting.

OBJECTIVE: Occurrence of a stroke within 30 days following coronary artery bypass grafting (CABG) is an uncommon, but often devastating, complication. This study aimed to identify factors associated with long-term survival (beyond 30 days) in patients with stroke after CABG. METHODS: De-identified patients' records from the Veterans Affairs Surgical Quality Improvement Program database were used to identify risk factors and perioperative complications associated with survival for up to 20 years in patients with post-CABG stroke. The multivariable Cox proportional hazards model was used for analyzing survival. RESULTS: The median survival time for patients with stroke (n = 1422) was 6.7 years. The mortality rate for these patients was highest in the first year post-CABG and was significantly elevated compared with non-stroke patients. Survival rates at 1, 5, and 10 years for stroke versus non-stroke patients were 79% vs. 96%, 58% vs. 83%, and 36% vs. 63%, respectively. High preoperative serum creatinine levels, postoperative occurrence of renal failure, prolonged ventilation, coma, and reoperation for bleeding were important predictors of 1-year mortality of patients with post-CABG stroke. CONCLUSIONS: Veterans with post-CABG stroke have a considerably higher risk for mortality during the first year compared with patients without stroke.

Clinical and Angiographic Predictors of Patient-Reported Angina 1 Year After Coronary Artery Bypass Graft Surgery.

BACKGROUND: Studies of the relationship between patient self-reported angina symptoms using the Seattle Angina Questionnaire (SAQ) and angiographic findings after coronary artery bypass grafting surgery (CABG) are lacking. Nested within a randomized controlled trial, this prospective observational cohort comparison study aimed to assess which clinical characteristics and angiographic findings are associated with self-reported angina 1 year after CABG. METHODS AND RESULTS: Patients from the ROOBY trial (Randomized On/Off Bypass) with protocol-specified 1-year post-CABG coronary angiography and SAQ assessments were included (n=1258). Patients reporting no angina (62.3%) within 4 weeks before the 1-year post-CABG study visit on the SAQ angina frequency domain were compared with patients reporting angina (37.7%). Multivariable modeling identified clinical variables and angiographic findings associated with angina. Sequential univariate and multivariable modeling found the following demographic and clinical factors were associated with angina after CABG: younger age, worse preoperative SAQ angina frequency score, smoking, diabetes mellitus, and pre-CABG depression. The only 1-year angiographic finding significantly associated with angina was incomplete revascularization of the left anterior descending (LAD) territory. Graft occlusions, incomplete revascularization of non-LAD territories, and ≥70% lesions in nonrevascularized native coronary arteries were not correlated with the presence or absence of angina. Further, only 30.6% of subjects reporting angina at 1 year had a residual major coronary artery stenosis of ≥70%. CONCLUSIONS: Self-reported angina 1 year after CABG is associated with younger age, worse baseline SAQ angina frequency score, smoking, diabetes mellitus, and depression. The only angiographic finding associated with angina was a poorly revascularized LAD territory. These results may help guide physicians when counseling patients on expected improvements in angina symptoms and in making decisions regarding the need for coronary angiography after CABG. Whether intensive treatment of these comorbidities improves post-CABG angina symptoms requires further study. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00032630.

Off-Pump Versus On-Pump Impact: Diabetic Patient 5-Year Coronary Artery Bypass Clinical Outcomes.

BACKGROUND: For diabetic patients who require coronary artery bypass graft (CABG) operation, controversy persists whether an off-pump or an on-pump approach may be advantageous. This US-based, multicenter, randomized, controlled trial, Department of Veterans Affairs Randomization On versus Off Bypass Follow-up Study, compared diabetic patients' 5-year clinical outcomes for off-pump versus on-pump procedures. METHODS: From 2002 to 2008, 835 medically treated (ie, oral hypoglycemic agent or insulin) diabetic patients underwent either off-pump (n = 402) or on-pump (n = 433) CABG. Five-year primary end points included all-cause death and major adverse cardiovascular events (MACE; composite included all-cause death, myocardial infarction, or repeat revascularization). Secondary 5-year end points included cardiac death and MACE-related components. With baseline risk factors balanced, outcomes were evaluated by using a p value less than or equal to 0.01; nonsignificant trends were reported for p values greater than 0.01 and less than or equal to 0.15. RESULTS: Five-year all-cause death rates were 20.2% off pump versus 14.1% on pump (p = 0.0198). No differences were seen in MACE (32.6% off-pump approach versus 28.6% on-pump approach, p = 0.216), repeat revascularization (12.4% off-pump approach versus 11.8% on-pump approach, p = 0.770), and nonfatal myocardial infarction (12.7% off-pump approach versus 10.4% on-pump approach, p = 0.299). Cardiac death trended worse with off-pump CABG (9.0%) than with on-pump CABG (6.25%, p = 0.137). Sensitivity analyses that removed conversions confirmed these findings. CONCLUSIONS: With a 6.1% absolute difference, a strong trend toward improved 5-year survival was observed with on-pump CABG for medically treated diabetic patients. No off-pump advantage was found for any 5-year end points. A future clinical trial now appears warranted to rigorously compare off-pump versus on-pump longer term outcomes for diabetic patients.

Costs Five Years After Off-Pump or On-Pump Coronary Artery Bypass Surgery.

BACKGROUND: Coronary artery bypass grafting (CABG) is a common surgical treatment for ischemic heart disease. Little is known about the long-term costs of conducting the surgery on-pump or off-pump. METHODS: As part of the Randomized On/Off Bypass follow-up study, we followed 2,203 participants randomized to on-pump (n = 1,099) and off-pump (n = 1,104) CABG for 5 years using Department of Veterans Affairs and Medicare administrative data. We examined annual costs through 5 years, standardized to 2016 dollars, using multivariate regression models, controlling for site and baseline patient factors. RESULTS: In the first year, including the CABG surgery, annual average costs were $66,599 (SE, $1,946) for the on-pump group and $70,552 (SE, $1,954) for the off-pump group. In years 2 to 5, average costs ranged from $15,000 to $20,000 per year. There was no significant difference between on-pump and off-pump across the 5 years. We explored differences among high-risk subgroups (diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, cerebrovascular disease, renal dysfunction, ejection fraction < 35%, over age 70 years), and found no treatment assignment by time interactions, except for a nonsignificant trend in patients with diabetes. CONCLUSIONS: At 5 years, the average costs of off-pump and on-pump CABG patients did not statistically differ. Costs do not favor one approach and the decision should be based on clinical risks, especially in subgroups. Future research is warranted to examine post-CABG costs and outcomes for diabetic patients over time.

A review of "suicidal intent" within the existing suicide literature.

The results of a systematic literature review that investigated suicide intent are presented. Of the 44 relevant articles identified, 17 investigated the relationships between various suicide risk factors and suicide intent and 25 publications investigated the relationships between suicide intent and various suicide outcomes. Despite recent advancements in the definition and nomological validity of suicide intent, a high degree of variability in the empirical measurement and analysis of suicide intent was found. Such variability limits future research related to measuring suicidal risk and outcomes, reporting suicide intent, or the meaningful comparison of diagnostic approaches or treatments across multiple studies.

Improving quality of care in cardiac surgery: evaluating risk factors, processes of care, structures of care, and outcomes.

The 1985 release of hospital report cards by the Health Care Financing Administration awakened the public's awareness of variations in outcomes following patient treatment. In 1972, the Department of Veterans Affairs initiated an oversight process for all VA-based cardiac surgery programs. In response to Public Law 99-166, the Continuous Improvement in Cardiac Surgery Program (CICSP) national database was developed in 1987. This CICSP effort reported variations in outcomes across VA cardiac programs. In 1997, the CICSP expanded (CICSP-X) to identify the interrelationships of risk factors with processes and structures of care, as well as clinical outcomes. Based on VA findings to date, these quality improvement endeavors appear to have positively affected short-term and longer-term cardiac surgical outcomes. To advance a new patient-focused paradigm for continuous improvement in cardiac surgical care quality for all US citizens, an integrated data-driven reporting approach with broad-based participation should be implemented to optimally improve patient care.

Elevated expression of keratin 17 in oropharyngeal squamous cell carcinoma is associated with decreased survival.

BACKGROUND: Overexpression of keratin 17 (K17) is highly associated with poor prognosis in squamous cell carcinoma (SCC) of the cervix. This study was performed to (1) determine whether K17 may be a prognostic biomarker in head and neck squamous cell carcinoma (HNSCC) and (2) to establish if K17 expression is associated with human papillomavirus (HPV) status. METHODS: Immunohistochemical staining was performed for K17 of oral, oropharyngeal, and laryngeal SCCs, and normal oropharyngeal mucosa. The HPV status was determined using polymerase chain reaction (PCR). RESULTS: Elevated K17 expression was significantly associated with an overall decreased patient survival (P = .02) and, more specifically, in patients with oropharyngeal SCC (P = .01). When controlling for HPV status and tumor location K17 was still a significant predictor of survival (P = .01). CONCLUSION: Therefore, K17 is a novel prognostic biomarker of poor survival for patients with HNSCCs, controlling for anatomic site and HPV status.

Single- Versus Multicenter Surgeons' Risk-Adjusted Coronary Artery Bypass Graft Procedural Outcomes.

BACKGROUND: Since 2010, 460+ hospital mergers have occurred in the United States, rerouting historical coronary artery bypass graft (CABG) referral patterns. The goals of this study were: (1) to compare risk-adjusted CABG outcomes between single-center versus multicenter surgeons; and (2) for multicenter surgeons, to evaluate the risk-adjusted outcomes between their home (primary) versus satellite (secondary) hospitals. METHODS: Using The Society of Thoracic Surgeons Adult Cardiac Surgery Database, nonemergent, first-time CABG procedures (n = 543,403) performed in the US between 2011 and 2014 were extracted across 1,120 centers and for 2,676 surgeons. Surgeons were classified as multicenter if they performed operations at two separate hospitals for ≥ 2 consecutive quarters; their home hospital was identified as their highest volume center. Observed-to-expected outcome ratios were reported using approved multivariable risk models for 30-day operative mortality and major morbidity. RESULTS: Of 2,676 cardiac surgeons, 668 (25.0%) operated at multiple centers. The observed-to-expected mortality ratios were 1.06 (95% confidence interval [CI], 1.01 to 1.12) and 0.97 (95% CI, 0.94 to 1.00) for multi- and single-center surgeons (p < 0.001). For multicenter surgeons, the observed-to-expected mortality ratios were 1.17 (95% CI, 1.09 to 1.27) versus 1.01 (95% CI, 0.96 to 1.07), p < 0.001, for their satellite versus home facilities, respectively. CONCLUSIONS: Single-center surgeons performing CABG had lower risk-adjusted outcome rates compared with multicenter surgeons, who performed better at their home versus satellite hospitals. To improve future quality of care, surgeons, health care networks, and health policy makers should now more closely scrutinize their single versus multicenter performance.

Comparison of Outcomes and Costs Associated With Aspirin ± Clopidogrel After Coronary Artery Bypass Grafting.

Optimal antiplatelet therapy after coronary artery bypass graft (CABG) surgery remains controversial. This study evaluated the role of dual antiplatelet therapy using aspirin and clopidogrel (DAPT) versus antiplatelet therapy using aspirin only (ASA) on post-CABG clinical outcomes and costs. In the Department of Veterans Affairs Randomized On/Off Bypass (ROOBY) trial, clopidogrel use after CABG was prospectively collected beginning in year 2 of this study to include 1,525 of the 2,203 original ROOBY patients who received aspirin after CABG. Discretionarily, surgeons after CABG administered either DAPT or ASA treatments. The ROOBY trial's primary 30-day composite (mortality or perioperative morbidity), 1-year composite (all-cause death, repeat revascularization, or nonfatal myocardial infarction), and costs were compared for these 2 strategies. Of the 1,525 subjects, 511 received DAPT and 1,014 received ASA. DAPT subjects, compared with ASA subjects, had lower rates of preoperative left ventricular ejection fraction of ≥45% (78.8% vs 85.7%, p <0.001), on-pump CABG (36.6% vs 57.1%, p = 0.001), and endoscopic vein harvesting (30.0% vs 42.8%, p <0.001). ASA patients were more likely to have earlier aspirin administration and receive 325 versus 81 mg dosages. The 30-day composite outcome rate was significantly lower for DAPT patients compared with ASA patients (3.3% vs 7.1%, p = 0.003), but the 1-year composite outcome was equal between the 2 groups (12.0% vs12.0%, p = 1.0). At 1 year, there were no cost differences between the 2 groups. Propensity analyses did not significantly alter the results. In conclusion, DAPT appeared safe and was associated with fewer 30-day adverse outcomes than aspirin only and with no 1-year outcome or cost differences.

Keratin 17 is overexpressed and predicts poor survival in estrogen receptor-negative/human epidermal growth factor receptor-2-negative breast cancer.

Clinicopathological features of breast cancer have limited accuracy to predict survival. By immunohistochemistry (IHC), keratin 17 (K17) expression has been correlated with triple-negative status (estrogen receptor [ER]/progesterone receptor/human epidermal growth factor receptor-2 [HER2] negative) and decreased survival, but K17 messenger RNA (mRNA) expression has not been evaluated in breast cancer. K17 is a potential prognostic cancer biomarker, targeting p27, and driving cell cycle progression. This study compared K17 protein and mRNA expression to ER/progesterone receptor/HER2 receptor status and event-free survival. K17 IHC was performed on 164 invasive breast cancers and K17 mRNA was evaluated in 1097 breast cancers. The mRNA status of other keratins (16/14/9) was evaluated in 113 ER-/HER2- ductal carcinomas. IHC demonstrated intense cytoplasmic and membranous K17 localization in myoepithelial cells of benign ducts and lobules and tumor cells of ductal carcinoma in situ. In ductal carcinomas, K17 protein was detected in most triple-negative tumors (28/34, 82%), some non-triple-negative tumors (52/112, 46%), but never in lobular carcinomas (0/15). In ductal carcinomas, high K17 mRNA was associated with reduced 5-year event-free survival in advanced tumor stage (n = 149, hazard ratio [HR] = 3.68, P = .018), and large (n = 73, HR = 3.95, P = .047), triple-negative (n = 103, HR = 2.73, P = .073), and ER-/HER2- (n = 113, HR = 2.99, P = .049) tumors. There were significant correlations among keratins 17, 16, 14, and 9 mRNA levels suggesting these keratins (all encoded on chromosome 17) could be coordinately expressed in breast cancer. Thus, K17 is expressed in a subset of triple-negative breast cancers, and is a marker of poor prognosis in patients with advanced stage and ER-/HER2- breast cancer.

Trends in Robotic-Assisted Coronary Artery Bypass Grafts: A Study of The Society of Thoracic Surgeons Adult Cardiac Surgery Database, 2006 to 2012.

BACKGROUND: Robotic technology is one of the most recent technological changes in coronary artery bypass graft (CABG) operations. The current analysis was conducted to identify trends in the use and outcomes of robotic-assisted CABG (RA-CABG). METHODS: A retrospective analysis was performed using data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2006 and 2012. Patient and site-level characteristics were compared between traditional CABG and RA-CABG. Operative death, postoperative length of stay, and postoperative complications were compared between the two groups. RESULTS: The number of sites using RA-CABG remained relatively constant during the study period (from 148 in 2006 to 151 in 2012). The volume of RA-CABG as a percentage of the total CABG procedures increased slightly from 0.59% (872 RA-CABG of 127,717 total CABG) in 2006 to 0.97% (1,260 RA-CABG of 97,249 total CABG) in 2012. The RA-CABG patients were significantly younger (64 vs 65 years, p < 0.0001), had fewer comorbidities, and had lower rates of cardiopulmonary bypass use (22.4% vs 80.4%, p < 0.0001). RA-CABG patients had significantly lower unadjusted major complication rates (10.2% vs 13.5%, p < 0.0001), including postoperative renal failure (2.2% vs 2.9%, p < 0.0001), and shorter length of stay (4 vs 5 days, p < 0.0001). The difference in operative death was not significant (odds ratio, 1.10; 95% confidence interval, 0.92 to 1.30, p = 0.29). CONCLUSIONS: RA-CABG use remained relatively stagnant during the analysis period despite lower rates of major perioperative complications and no difference in operative deaths. Additional analysis is needed to fully understand the role that robotic technology will play in CABG operations in the future.