Distinct presentation of melanoma in Black patients may inform strategies to improve outcomes.

INTRODUCTION: Melanoma guidelines stem largely from data on non-Hispanic White (NHW) patients. We aimed to identify features of melanoma within non-Hispanic Black (NHB) patients to inform strategies for earlier detection and treatment. METHODS: From 2004 to 2019 Surveillance, Epidemiology, and End Results (SEER) data, we identified nonmetastatic melanoma patients with known TN category and race. Kaplan-Meier cancer-specific survival (CSS) estimates and multivariable Cox proportional hazard modeling analyses were performed. RESULTS: Of 492 597 patients, 1499 (0.3%) were NHB, who were younger (21% vs. 17% age <50) and more commonly female (54% vs. 41%) than NHW, both p < 0.0005. For NHBs, lower extremity was the most common site (52% vs. 15% for NHWs, p < 0.0001), T category was higher (55% Tis-T1 vs. 82%; 27% T3-T4 vs. 8%, p < 0.0001) and stage at presentation was higher (19% Stage III, vs. 6%, p < 0.0001). Within the NHB cohort, males were older, and more often node-positive than females. Five-year Stage III CSS was 42% for NHB males versus 71% for females, adjusting for age and clinical nodal status (hazard ratio 2.48). CONCLUSIONS: NHB melanoma patients presented with distinct tumor characteristics. NHB males with Stage III disease had inferior CSS. Focus on this high-risk patient cohort to promote earlier detection and treatment may improve outcomes.

Is the Rise of Medicare Advantage Impacting the Fidelity of Traditional Medicare Claims Data? Implications for Reporting of Long-Term Total Hip Arthroplasty Survivorship.

BACKGROUND: Arthroplasty registries often use traditional Medicare (TM) claims data to report long-term total hip arthroplasty (THA) survivorship. The purpose of this study was to determine whether the large number of patients leaving TM for Medicare Advantage (MA) has compromised the fidelity of TM data. METHODS: We identified 10,962 THAs in 9,333 Medicare-eligible patients who underwent primary THA from 2000 to 2020 at a single institution. Insurance type was analyzed, and 83% of patients had TM at the time of THA. Survivorship free from any revision or reoperation was calculated for patients who have TM. The same survivorship end points were recalculated with censoring performed when a patient transitioned to an MA plan after their primary THA to model the impact of losing patients from the TM dataset. Differences in survivorship were compared. The mean follow-up was 7 years. RESULTS: From 2000 to 2020, there was a decrease in TM insurance (93 to 73%) and a corresponding increase in MA insurance (0 to 19%) among THA patients. Following THA, 23% of TM patients switched to MA. For patients who had TM at the time of surgery, 15-year survivorship free from any reoperation or revision was 90% and 93%, respectively. When censoring patients upon transition from TM to MA, survivorship free from any reoperation became significantly higher (92 versus 90% at 15 years; hazard ratio = 1.16, P = .033), and there was a trend toward higher survivorship free from any revision (95 versus 93% at 15 years; hazard ratio = 1.16, P = .074). CONCLUSIONS: Approximately 1 in 4 patients left TM for MA after primary THA, effectively making them lost to follow-up within TM datasets. The mass exodus of patients out of TM appears to have led to a slight overestimation of survivorship free from any reoperation and trended toward overestimating survivorship free from any revision. If MA continues to grow, efforts to obtain MA data will become even more important.

Incident Heart Failure With Mildly Reduced Ejection Fraction: Frequency, Characteristics, and Outcomes.

BACKGROUND: Heart failure (HF) with an ejection fraction (EF) of 41%-49% is recognized as HF with a mildly reduced EF (HFmrEF). However, existing knowledge of the HFmrEF phenotype is based on HF clinical trial and registry cohorts that may be limited by multiple forms of bias. METHODS AND RESULTS: In a community-based, retrospective cohort study, adult residents of Olmsted County, Minnesota, with validated (Framingham criteria) incident HF from 2007 to 2015 were categorized by echocardiographic EF at first HF diagnosis. Among 2035 adults with incident HF, 12.5% had HFmrEF, 29.9% had HF with reduced EF (HFrEF), and 57.6% had HF with preserved EF (HFpEF). Mean age and sex varied by EF group, with HFmrEF (75.6 years, 45.3% female), HFrEF (70.9 years, 36.5% female), and HFpEF (76.9 years, 59.7% female). Most comorbid conditions were more common in HFmrEF vs HFrEF, but similar in HFmrEF and HFpEF. After a mean follow-up of 4.6 ± 3.5 years, adjusting for age, sex, and comorbidities, the risks of hospitalization and cardiovascular mortality did not differ by EF category. Of patients who began as HFmrEF, 26.9% declined to an EF of 40% or less and 44.8% improved to an EF of 50% or greater. CONCLUSIONS: In this community cohort of incident HF, 12.5% have HFmrEF. Clinical characteristics in HFmrEF resemble HFpEF more than HFrEF. Adjusted hospitalization and mortality risks did not vary by EF group. Patients with incident HFmrEF usually transitioned to a different EF category on follow-up.

Cryopreserved arterial allografts vs rifampin-soaked Dacron for the treatment of infected aortic and iliac grafts.

OBJECTIVE: Aortic and iliac graft infections remain complex clinical problems with high mortality and morbidity. Cryopreserved arterial allografts (CAAs) and rifampin-soaked Dacron (RSD) are options for in situ reconstruction. This study aimed to compare the safety and effectiveness of CAA vs RSD in this setting. METHODS: Data from patients with aortic and iliac graft infections undergoing in situ reconstruction with either CAA or RSD from January 2002 through August 2022 were retrospectively analyzed. Our primary outcomes were freedom from graft-related reintervention and freedom from reinfection. Secondary outcomes included comparing trends in the use of CAA and RSD at our institution, overall survival, perioperative mortality, and major morbidity. RESULTS: A total of 149 patients (80 RSD, 69 CAA) with a mean age of 68.9 and 69.1 years, respectively, were included. Endovascular stent grafts were infected in 60 patients (41 CAA group and 19 RSD group; P ≤ .01). Graft-enteric fistulas were more common in the RSD group (48.8% RSD vs 29.0% CAA; P ≤ .01). Management included complete resection of the infected graft (85.5% CAA vs 57.5% RSD; P ≤ .01) and aortic reconstructions were covered in omentum in 57 (87.7%) and 63 (84.0%) patients in the CAA and RSD group, respectively (P = .55). Thirty-day/in-hospital mortality was similar between the groups (7.5% RSD vs 7.2% CAA; P = 1.00). One early graft-related death occurred on postoperative day 4 due to CAA rupture and hemorrhagic shock. Median follow-up was 20.5 and 21.5 months in the CAA and RSD groups, respectively. Overall post-discharge survival at 5 years was similar, at 59.2% in the RSD group and 59.0% in the CAA group (P = .80). Freedom from graft-related reintervention at 1 and 5 years was 81.3% and 66.2% (CAA) vs 95.6% and 92.5% (RSD; P = .02). Indications for reintervention in the CAA group included stenosis (n = 5), pseudoaneurysm (n = 2), reinfection (n = 2), occlusion (n = 2), rupture (n = 1), and graft-limb kinking (n = 1). In the RSD group, indications included reinfection (n = 3), occlusion (n = 1), endoleak (n = 1), omental coverage (n = 1), and rupture (n = 1). Freedom from reinfection at 1 and 5 years was 98.3% and 94.9% (CAA) vs 92.5% and 87.2% (RSD; P = .11). Two (2.9%) and three patients (3.8%) in the CAA and RSD group, respectively, required graft explantation due to reinfection. CONCLUSIONS: Aorto-iliac graft infections can be managed safely with either CAA or RSD in selected patients for in situ reconstruction. However, reintervention was more common with CAA use. Freedom from reinfection rates in the RSD group was lower, but this was not statistically significant. Conduit choice is associated with long-term surveillance needs and reinterventions.

Accuracy of DOTATATE PET imaging in the preoperative planning of small bowel neuroendocrine tumor resection.

BACKGROUND AND OBJECTIVES: We assessed the accuracy of preoperative gallium-68 DOTA-Tyr3-octreotate (DOTATATE) positron emission tomography (PET) imaging in estimating multifocality and nodal metastases of small bowel neuroendocrine tumors (sbNETs). METHODS: A multicenter analysis was performed on patients with sbNETs who underwent preoperative DOTATATE PET imaging and surgical resection, with manual palpation of the entire length of the small bowel, between January 2016 and August 2022. Preoperative imaging reports and blinded secondary imaging reviews were compared to the final postoperative pathology reports. Descriptive statistics were applied. RESULTS: One-hundred and four patients met inclusion criteria. Pathology showed 53 (51%) patients had multifocal sbNETs and 96 (92%) had nodal metastases. The original preoperative DOTATATE PET imaging identified multifocal sbNET in 28 (27%) patients and lymph node (LN) metastases in 80 (77%) patients. Based on original radiology reports, sensitivity for multifocal sbNET identification was 45%, specificity was 92%, positive predictive value (PPV) was 86%, and negative predictive value (NPV) was 62%. For the identification of LN metastases, sensitivity was 82%, specificity was 88%, PPV was 99%, and NPV was 29%. CONCLUSIONS: Although DOTATATE PET imaging is specific and relatively accurate, sensitivity and NPV are insufficient to guide surgical planning. Preoperative use should not replace open palpation to identify additional synchronous lesions or to omit regional lymphadenectomy.

Association of socio-demographic characteristics with alcohol use initiation among never users during the COVID-19 pandemic: a longitudinal study.

BACKGROUND: In this longitudinal cohort study, we examined the socio-demographic and psychological predictors of alcohol use initiation during the COVID-19 pandemic in a sample of never alcohol users aged ≥21 prior to COVID-19. METHODS: Our study population consisted of 56 930 patients aged ≥21, as of 30 March 2019 were collected from a pre-COVID period of 1 year before 31 March 2020, and during-COVID, a period between 1 April 2020 and 30 March 2021. Univariable and multivariable logistic regression models were utilized to examine the roles of socio-demographic variables (gender, age, education, Area Deprivation Index and rural residence) changes in anxiety and depression severity as predictors of alcohol use initiation. RESULTS: Age, gender, race, ethnicity, education and rural status were significant predictors in multivariable analysis. A subgroup analysis showed neither anxiety nor depression had a significant association with alcohol use initiation. CONCLUSION: Women, younger individuals, those living in a rural area and people who smoke cigarettes were more likely to initiate alcohol use during the pandemic. Our study has public health and clinical implications such as the need for targeted alcohol use screening and intervention for vulnerable individuals.

Longitudinal factors associated with increased alcohol consumption in adults during the COVID-19 pandemic.

Background: Alcohol is the most abused substance among adults in the United States. The COVID-19 pandemic impacted patterns of alcohol use, but data are conflicting, and previous studies are largely limited to cross-sectional analyses.Objective: This study aimed to longitudinally assess sociodemographic and psychological correlates of changes in three patterns of alcohol use (number of alcoholic drinks, drinking regularity, and binge drinking) during COVID-19.Methods: We studied changes in self-reported drinking behaviors in 222,195 Mayo Clinic patients over 21 years of age (58.1% female and 41.9% male) between April 1, 2019, and March 30, 2021. Logistic regression models were used to estimate associations between patient characteristics and change in alcohol consumption.Results: Sociodemographically younger age, White race, having a college degree, and living in a rural area were associated with increased alcohol use regularity (all p < .05). Younger age, male, White, high-school education or less, living in a more deprived neighborhood, smoking, and living in a rural area were associated with increases in number of alcohol drinks (all p ≤ .04) and binge drinking (all p ≤ .01). Increased anxiety scores were associated with increased number of drinks, while depression severity was associated with both increased drinking regularity and increased number of drinks (all p ≤ .02) independent of sociodemographic characteristics.Conclusion: Our study showed that both sociodemographic and psychological characteristics were associated with increased alcohol consumption patterns during the COVID-19 pandemic. Our study highlights specific target groups previously not described in the literature for alcohol interventions based on sociodemographic and psychological characteristics.

Consequences of Perioperative Serotonin Reuptake Inhibitor Treatment During Hepatic Surgery.

BACKGROUND AND AIMS: Platelet-stored serotonin critically affects liver regeneration in mice and humans. Selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenalin reuptake inhibitors (SNRIs) reduce intraplatelet serotonin. As SSRIs/SNRIs are now one of the most commonly prescribed drugs in the United States and Europe and given serotonin's impact on liver regeneration, we evaluated whether perioperative use of SSRIs/SNRIs affects outcome after hepatic resection. APPROACH AND RESULTS: Consecutive patients undergoing hepatic resection (n = 754) were retrospectively included from prospectively maintained databases from two European institutions. Further, an independent cohort of 495 patients from the United States was assessed to validate our exploratory findings. Perioperative intake of SSRIs/SNRIs was recorded, and patients were followed up for postoperative liver dysfunction (LD), morbidity, and mortality. Perioperative intraplatelet serotonin levels were significantly decreased in patients receiving SSRI/SNRI treatment. Patients treated with SSRIs/SNRIs showed a higher incidence of morbidity, severe morbidity, LD, and LD requiring intervention. Associations were confirmed in the independent validation cohort. Combined cohorts documented a significant increase in deleterious postoperative outcome (morbidity odds ratio [OR], 1.56; 95% confidence interval [CI], 1.07-2.31; severe morbidity OR, 1.86; 95% CI, 1.22-2.79; LD OR, 1.96; 95% CI, 1.23-3.06; LD requiring intervention OR, 2.22; 95% CI, 1.03-4.36). Further, multivariable analysis confirmed the independent association of SSRIs/SNRIs with postoperative LD, which was closely associated with postoperative 90-day mortality and 1-year overall survival. CONCLUSIONS: We observed a significant association of perioperative SSRI/SNRI intake with adverse postoperative outcome after hepatic resection. This indicates that SSRIs/SNRIs should be avoided perioperatively in patients undergoing hepatic resections.

Tradition Versus Value: Is There Utility in Protocolized Postoperative Laboratory Testing After Elective Colorectal Surgery?

OBJECTIVE: Determine if routine ordering of postoperative day 1 (POD 1) serum laboratory tests after elective colorectal surgery are clinically warranted and valuable given the associated costs of these lab tests. SUMMARY OF BACKGROUND DATA: Routine postoperative serum laboratory tests are a part of many colorectal surgery order sets. Whether these protocolized lab tests represent cost-effective care is unknown. METHODS: Patients undergoing elective colorectal surgery between January 1, 2015 and December 31, 2017 at our institution were identified. The protocolized POD 1 lab tests obtained as part of the postoperative order set were reviewed to determine the rate of abnormal values and any intervention in response. Costs associated with protocolized laboratory testing were calculated using dollar amounts representing 2017 outpatient Medicare reimbursement. RESULTS: A total of 2252 patients were identified with 8205 total lab test values. Of these, only 4% were abnormal (3% of hemoglobin values, 6% of creatinine values, 3% of potassium of values, and 3% of glucose values), and only 1% were actively intervened upon. The total aggregate cost of the protocolized POD 1 laboratory tests in these years was $64,000 based on Medicare outpatient reimbursement dollars. CONCLUSIONS: Routine POD 1 lab tests after elective colorectal surgery are rarely abnormal, and they even less frequently require active intervention beyond rechecking. This results in increased resource utilization and cost of care without appreciable impact on clinical care, and is not cost-effective. Protocolized POD 1 laboratory testing should be replaced with clinically-based criteria to trigger serum laboratory investigations.

Liposomal bupivacaine during subcutaneous implantable cardioverter defibrillator implantation for pain management.

BACKGROUND: The subcutaneous implantable cardioverter-defibrillator (S-ICD) has a larger generator and its implantation involves more dissection and tunneling compared to traditional transvenous defibrillator system. Liposomal bupivacaine, an extended-release bupivacaine with 72 h of duration has been used for postoperative pain management in patients undergoing S-ICD implantation. Our aim was to compare postoperative pain and opioid prescription patterns among patients undergoing S-ICD implantation who received intraprocedural liposomal bupivacaine and those who did not. METHODS: We performed a retrospective analysis of all patients who underwent subcutaneous ICD implantation from January 1, 2013 to March 30, 2018 at the Mayo Clinic in Rochester, Minnesota. Patients were categorized into those who received liposomal bupivacaine and those who did not. Data on inpatient pain score, outpatient opioid prescription rates at discharge, and doses based on oral morphine equivalents (OME) were collected. RESULTS: A total of 104 patients underwent S-ICD implantation. Intraprocedural liposomal bupivacaine was used in 69% of patients. Patients who received intraprocedural liposomal bupivacaine had similar mean inpatient pain scores (2.9 vs. 2.9, p = .786). There was also no difference in the rate of inpatient opioid administration (79.2% vs. 87.5%, p = .4139), outpatient opioid prescription (23.6% vs. 12.5%, p = .29), or mean OME (41.7-mg vs. 16.6-mg, p = .188) when comparing patients those who received intraprocedural liposomal bupivacaine and those who did not. CONCLUSION: Intraprocedural liposomal bupivacaine administration was not associated with any significant impact on postoperative pain scores, inpatient opioid administration, and outpatient opioid prescription rates or OME amounts at discharge.