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BACKGROUND AND OBJECTIVES: Pancreaticoduodenectomy (PD), the only surgical option for right-sided pancreatic ductal adenocarcinoma (PDAC), carries significant morbidity. Not all patients may be deriving a survival benefit from this operation. We sought to identify the rate of futile PD and its associated factors in a large national cohort. METHODS: We performed a retrospective analysis using the National Cancer Database (2004-2020), including all patients who underwent PD for non-metastatic PDAC. The primary outcome was operative futility, which was defined as death within 12 months of diagnosis despite PD. Multivariable regression was used to identify factors associated with futility. We performed a subgroup analysis on patients who received neoadjuvant systemic therapy. RESULTS: Data from 66 326 patients were analyzed, and 16 772 (25.3%) underwent PD that met criteria for futility. Macroscopically positive margins (odds ratio [OR]: 2.87; 95% confidence interval [CI]: 2.36-3.48), poor tumor differentiation (OR: 2.44; 95% CI: 2.25-2.65), and N2 nodal stage (OR: 2.09; 95% CI: 1.98-2.20) were associated with the greatest odds of futility. Meanwhile, receipt of any systemic therapy (OR: 0.33; 95% CI: 0.31-0.34), receipt of any radiation (OR: 0.60; 95% CI: 0.57-0.63), and receipt of neoadjuvant systemic therapy (OR: 0.62; 95% CI: 0.57-0.66) were associated with the lowest odds of futility. In the neoadjuvant subgroup, a longer diagnosis-to-surgery interval was associated with lower odds of futility. CONCLUSION: PD was futile in about one quarter of patients. Futility was associated with higher age and worse tumor biology. Receipt of neoadjuvant therapy resulted in fewer futile operations.
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BACKGROUND: Despite a glaring need and proven efficacy, prospective surgical registries are lacking in low- and middle-income countries. The objective of this study was to design and implement a comprehensive prospective perioperative registry in a low-income country. METHODS: This study was conducted at Hawassa University Comprehensive Specialized Hospital in Hawassa, Ethiopia. Design of the registry occurred from June 2021 to May 2022 and pilot implementation from May 2022 to May 2023. All patients undergoing elective or emergent general surgery were included. Following one year, operability and fidelity of the registry were analyzed by assessing capture rate, incidence of missing data, and accuracy. RESULTS: A total of 67 variables were included in the registry including demographics, preoperative, operative, post-operative, and 30-day data. Of 440 eligible patients, 226 (51.4%) were successfully captured. Overall incidence of missing data and accuracy was 5.4% and 90.2% respectively. Post pilot modifications enhanced capture rate to 70.5% and further optimized data collection processes. CONCLUSION: The establishment of a low-cost electronic prospective perioperative registry in a low-income country represents a significant step forward in enhancing surgical care in under-resourced settings. The initial success of this registry highlights the feasibility of such endeavors when strong partnerships and local context are at the center of implementation. Continuous efforts to refine this registry are ongoing, which will ultimately lead to enhanced surgical quality, research output, and expansion to other sites.
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Melhoria de Qualidade , Sistema de Registros , Etiópia , Humanos , Estudos Prospectivos , Feminino , Masculino , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/normas , Adulto , Pessoa de Meia-Idade , Países em Desenvolvimento , Projetos Piloto , Assistência Perioperatória/normasRESUMO
INTRODUCTION: Colon cancer (CC) is one of the most common cancers among South Asian Americans (SAAs). The objective of this study was to measure differences in risk-adjusted survival among SAAs with CC compared to non-Hispanic Whites (NHWs) using a representative national dataset from the United States. METHODS: A retrospective analysis of patients with CC in the National Cancer Database (2004-2020) was performed. Differences in presentation, management, median overall survival (OS), three-year survival, and five-year survival between SAAs and NHWs were compared. Kaplan-Meier analysis and multivariable Cox regression were used to assess differences in survival outcomes, adjusting for demographics, presentation, and treatments received. RESULTS: Data from 2873 SAA and 639,488 NHW patients with CC were analyzed. SAAs were younger at diagnosis (62.2 versus 69.5 y, P < 0.001), higher stage (stage III [29.0% versus 26.2%, P = 0.001] or Stage IV [21.4% versus 20.0%, P = 0.001]), and experienced delays to first treatment (SAA 5.9% versus 4.9%, P = 0.003). SAAs with CC had higher OS (median not achieved versus 68.1 mo for NHWs), three-year survival (76.3% versus 63.4%), and five-year survival (69.1% versus 52.9%). On multivariable Cox regression, SAAs with CC had a lower risk of death across all stages (hazard ratio: 0.64, P < 0.001). CONCLUSIONS: In this national study, SAA patients with CC presented earlier in life with more advanced disease, and a higher proportion experienced treatment delay compared to NHW patients. Despite these differences, SAAs had better adjusted OS than NHW, warranting further exploration of tumor biology and socioeconomic determinants of cancer outcomes in SAAs.
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Asiático , Neoplasias do Colo , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Asiático/estatística & dados numéricos , Neoplasias do Colo/etnologia , Neoplasias do Colo/mortalidade , Estudos Transversais , Bases de Dados Factuais , Estimativa de Kaplan-Meier , Estadiamento de Neoplasias , Estudos Retrospectivos , Estados Unidos/epidemiologia , Brancos/estatística & dados numéricos , Análise de SobrevidaRESUMO
SUMMARY: Whereas 100% of Congressional legislators vote on healthcare policy, only a minority have a background in healthcare. A review of the participation of healthcare professionals (HCPs) in Congress, highlighting participation by surgeons, is critical to the future policy-making endeavors in healthcare. This article seeks to better understand the characteristics of HCPs that engage in advocacy and describe the trends in their representation in Congress, with commentary on participation by surgeons and its impact on current health advocacy efforts.A search of Congress.gov and the Biographical Directory of the United States Congress was performed to identify professional healthcare history for each Congressperson, followed by review of official campaign websites for health advocacy work. Statistical analysis was performed using IBM® SPSS® Statistics Software for changes in representation of healthcare professionals, physicians, and surgeons in Congress over time.While there has been increasing representation of HCPs in Congress in the last 25 years, surgeons have the lowest increase in Congressional membership. For healthcare reform to optimally address high costs, variable insurance coverage and reimbursement rates, and equal access to care, more physicians must make healthcare advocacy efforts an integral part of their careers. Incorporation of education in areas of healthcare advocacy and/or reform into undergraduate and graduate medical education curricula may help address deficiencies in knowledge of current healthcare-related events to further encourage involvement in healthcare legislation.
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BACKGROUND: Long years of school/training have shown to be associated with infertility and pregnancy complications. Rates of infertility and pregnancy complications were compared among women in demanding professional careers to better understand career differences impacting family planning. METHODS: Inclusion criteria : English-speaking, childbearing professional women in surgery, medicine, law, and engineering. Exclusion criteria: men and women not in professional careers mentioned and non-childbearing women. Male-dominated fields identified to select non-medical female professionals. Top medical, law, and engineering schools' female faculty were surveyed from October 2022 to December 2022. Descriptive analysis and chi-squared tests were performed. RESULTS: 2302 surveys were distributed and 268 responses were obtained (11.6%): 121 non-surgeon physicians, 120 lawyers/other doctorate degree holders, and 27 other/unknown. Data analysis included prior study's surgeon data. The median age (IQR = 25%, 75%) of the surgeons was 40y (36,45), non-surgeon physicians 43y (37,50), and law/other doctorates 38y (35,46). Delayed childbearing was observed in 65.0% surgeons, 66.1% non-surgeon physicians, and 57.5% law/other doctorates (P < .001). Pregnancy loss <10wks was observed in 35.3% surgeons, 33.9% non-surgeon physicians, and 30.8% law/other doctorates (P < .001). Infertility testing was performed in 43.0% non-surgeon physicians and 34.2% law/other doctorates (P < .001). Assisted reproductive technology was utilized by 24.9% surgeons, 43.0% non-surgeon physicians, and 21.7% law/other doctorates (P < .001). DISCUSSION: Surgeons/physicians suffer more childbearing complications than other professional women.
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Infertilidade , Medicina , Complicações na Gravidez , Cirurgiões , Gravidez , Humanos , Feminino , Masculino , Instituições AcadêmicasRESUMO
BACKGROUND: While lower socioeconomic status has been shown to correlate with worse outcomes in cancer care, data correlating neighborhood-level metrics with outcomes are scarce. We aim to explore the association between neighborhood disadvantage and both short- and long-term postoperative outcomes in patients undergoing pancreatectomy for pancreatic ductal adenocarcinoma (PDAC). PATIENTS AND METHODS: We retrospectively analyzed 243 patients who underwent resection for PDAC at a single institution between 1 January 2010 and 15 September 2021. To measure neighborhood disadvantage, the cohort was divided into tertiles by Area Deprivation Index (ADI). Short-term outcomes of interest were minor complications, major complications, unplanned readmission within 30 days, prolonged hospitalization, and delayed gastric emptying (DGE). The long-term outcome of interest was overall survival. Logistic regression was used to test short-term outcomes; Cox proportional hazards models and Kaplan-Meier method were used for long-term outcomes. RESULTS: The median ADI of the cohort was 49 (IQR 32-64.5). On adjusted analysis, the high-ADI group demonstrated greater odds of suffering a major complication (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.26-6.40; p = 0.01) and of an unplanned readmission (OR, 3.09; 95% CI, 1.16-9.28; p = 0.03) compared with the low-ADI group. There were no significant differences between groups in the odds of minor complications, prolonged hospitalization, or DGE (all p > 0.05). High ADI did not confer an increased hazard of death (p = 0.63). CONCLUSIONS: We found that worse neighborhood disadvantage is associated with a higher risk of major complication and unplanned readmission after pancreatectomy for PDAC.
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Carcinoma Ductal Pancreático , Neoplasias Pancreáticas , Humanos , Pancreatectomia/efeitos adversos , Pancreatectomia/métodos , Estudos Retrospectivos , Neoplasias Pancreáticas/patologia , Carcinoma Ductal Pancreático/patologia , Características da VizinhançaRESUMO
Aneurysms are characterized by focal dilation of the blood vessel wall due to weakening. The involvement of two layers of the vessel wall is classified as a pseudoaneurysm while the involvement of all three layers is called a true aneurysm. Involvement of neoplastic lesions is rare, but the few reported cases have been associated with pulmonary artery pseudoaneurysms as opposed to true pulmonary artery aneurysms (PAAs). Our case of a true left PAA of a patient with metastatic sarcoma of the lung shows an association that has previously not been reported to the best of our knowledge.
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Background: Current understanding of medical debt among various income ranges and insurance carriers is limited. We analyzed median household incomes, insurance carriers, and medical debt of plastic surgery patients at a major metropolitan children's hospital. Methods: A retrospective chart review for zip codes, insurance carriers, and account balances was conducted for 2018-2021. All patients were seen by members of the Division of Pediatric Plastic Surgery at Ann and Robert H. Lurie Children's Hospital of Chicago. Blue Cross was reported separately among other commercial insurance carriers by the hospital's business analytics department. Median household income by zip code was obtained. IBM SPSS Statistics was used to perform chi-squared tests to study the distribution of unpaid account balances by income ranges and insurance carriers. Results: Of the 6877 patients, 630 had unpaid account balances. Significant differences in unpaid account balances existed among twelve insurance classes (P < 0.001). There were significant differences among unpaid account balances when further examined by median household income ranges for Blue Cross (P < 0.001) and other commercial insurance carriers (P < 0.001). Conclusions: Although patients with insurance policies requiring higher out-of-pocket costs (ie, Blue Cross and other commercial insurance carriers) are generally characterized by higher household incomes, these patients were found to have higher unpaid account balances than patients with public insurance policies. This suggests that income alone is not predictive of unpaid medical debt and provides greater appreciation of lower income families who may make a more consistent effort in repaying their medical debt.
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INTRODUCTION: With an incidence of 2-16%, radial nerve palsy is one of the common forms of nerve injuries globally. Radial nerve palsy causes debilitating effects including loss of elbow extension, wrist drop and loss of finger extension. Reparative surgical pathways range from primary repair and neurolysis, to nerve grafting, nerve transfers, and tendon transfers. Due to ease of performance and acceptability and reproducibility of outcomes, tendon transfers are considered the gold standard of radial nerve palsy repair. However, independent finger function cannot be achieved and as such may not give truly desirable results. In lower-middle income countries, the question of nerve transfer versus tendon transfer for patients who are keen to get back to work is key. While tendon transfer recovery is faster, the functional loss is often considered devastating for fine hand function due to loss of grip secondary to lack of wrist and finger extension. In this study, we present our experience of performing median nerve transfers for radial nerve palsy in Pakistan. METHODS: We performed a retrospective case-series of patients undergoing median to radial nerve transfer for radial nerve palsy over a period of 6 y, from 2012 to 2019. Patients with radial nerve palsy were diagnosed via electromyography and nerve conduction studies. The procedure involved coapting the branches of the flexor carpi radialis and flexor digitorum superficialis (long and ring finger) nerves to the posterior interosseous nerve and extensor carpi radialis brevis, respectively. Patients were assessed using the Medical Research Council scale for muscle strength of wrist, finger and thumb extension separately at 1 y time. Our results were then compared to results from similar nerve transfer studies. RESULTS: We operated on 10 right-hand dominant patients, eight males and two females with a median age of 33 y (6-63 y). four sustained injury to the right hand and six to the left. Causes of the injuries included road traffic accident (n = 3), firearm injury (n = 4), shrapnel (n = 1), iatrogenic injury (injection in deltoid region (n = 1) and fall (n = 1). Types of fracture included mid humerus fracture, fracture of the surgical neck of the humerus, and supracondylar fracture of the humerus. Median time to surgery since injury was 4 mo (1-8 mo). Independent wrist extension was M4+ in all patients and independent finger extension was M4+ in seven and M4-in two patients. However, a patient who presented late at 8 mo had poorer finger outcomes with extension at M2-. All patients had independent movement of fingers. CONCLUSIONS: Nerve transfer is a reliable method of post traumatic nerve repair and reinnervation, particularly in lower-middle income countries, even in cases where the nerve damage is severe and extensive and up to 6 mo may have elapsed between injury and presentation. Timely median to radial nerve transfer is a highly recommended option for radial nerve palsy, with regular follow-ups and physical therapy added to ensure positive outcomes.
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Armas de Fogo , Transferência de Nervo , Neuropatia Radial , Ferimentos por Arma de Fogo , Masculino , Feminino , Humanos , Transferência de Nervo/métodos , Neuropatia Radial/etiologia , Neuropatia Radial/cirurgia , Estudos Retrospectivos , Países em Desenvolvimento , Reprodutibilidade dos Testes , Ferimentos por Arma de Fogo/cirurgiaRESUMO
Growth of skin in response to stretch is the basis for tissue expansion (TE), a procedure to gain new skin area for reconstruction of large defects. Unfortunately, complications and suboptimal outcomes persist because TE is planned and executed based on physician's experience and trial and error instead of predictive quantitative tools. Recently, we calibrated computational models of TE to a porcine animal model of tissue expansion, showing that skin growth is proportional to stretch with a characteristic time constant. Here, we use our calibrated model to predict skin growth in cases of pediatric reconstruction. Available from the clinical setting are the expander shapes and inflation protocols. We create low fidelity semi-analytical models and finite element models for each of the clinical cases. To account for uncertainty in the response expected from translating the models from the animal experiments to the pediatric population, we create multifidelity Gaussian process surrogates to propagate uncertainty in the mechanical properties and the biological response. Predictions with uncertainty for the clinical setting are essential to bridge our knowledge from the large animal experiments to guide and improve the treatment of pediatric patients. Future calibration of the model with patient-specific data-such as estimation of mechanical properties and area growth in the operating room-will change the standard for planning and execution of TE protocols.
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Dispositivos para Expansão de Tecidos , Expansão de Tecido , Animais , Humanos , Pele , Suínos , Expansão de Tecido/métodosRESUMO
Introduction There is currently no consensus as to the comparative complication profiles of mini-plate (MP) and reconstruction bar (RB) osseous fixation in fibula flap mandibular reconstruction. The aim of this study is to compare complication rates associated with the use of MP versus RB fixation for vascularized fibula free flap (FFF) reconstruction of oncologic mandibular defects in an effort to better guide hardware utilization and pre-operative virtual surgical planning methods. Methods A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, EMBASE, and Cochrane Library databases were queried to identify studies related to FFF-based mandibular reconstruction with either MP or RB fixation. Primary endpoints of interest were plate complications, wound infection, mal- or non-union, and total flap loss. Complication rates were calculated as weighted proportions and compared via Fisher's exact testing. Results Sixteen studies met inclusion criteria, which examined 1,513 patients. Only three studies directly compared MP fixation with RB fixation. MP fixation was used in 828 (54.7%) cases and RB fixation in 685 (45.3%) cases. MP fixation demonstrated greater rates of plate-related complications (32.5% versus 18.8%, p < 0.01, respectively), fistula formation (15.8% versus 4.7%, p = 0.04), total flap loss (9.4% versus 4.7%, p = 0.02), partial flap loss (20.6% versus 6.1%, p < 0.01), and re-operation for vascular compromise (13.3% versus 4.0%, p < 0.01). Rates of infection, mal-union/non-union, and wound dehiscence were similar across both groups. Conclusion Our results suggest that MP use may be associated with higher rates of plate-related complications. Though limited by outcome reporting heterogeneity, this review can serve as a template for future investigations evaluating the safety profiles of MP and RB fixation in head and neck surgery.
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Retalhos de Tecido Biológico , Reconstrução Mandibular , Procedimentos de Cirurgia Plástica , Placas Ósseas , Transplante Ósseo/métodos , Fíbula , Retalhos de Tecido Biológico/irrigação sanguínea , Humanos , Mandíbula , Reconstrução Mandibular/métodos , Complicações Pós-Operatórias/epidemiologia , Procedimentos de Cirurgia Plástica/efeitos adversos , Estudos RetrospectivosRESUMO
INTRODUCTION: The need for precision in craniomaxillofacial surgery has necessitated the evolution of new technology to improve patient outcomes and subsequently augment the road to recovery. Surgical planning has variables that may influence outcomes, including the image quality, image acquisition and image processing. Our review focuses on the advancement of three dimensional (3D) printing to create patient-specific constructs and therefore aims to study the current trends in the implementation of 3-D printing in craniofacial surgeries, including preferred 3-D printing techniques and materials, computer-aided design and manufacturing techniques, and outcomes as measured by recent studies. METHODS: The authors conducted a systematic review following PRISMA guidelines to query PubMed, Embase, Cochrane library and ProQuest electronic databases. Mesh combinations and synonyms of "3Dprinting", "3Dprinted", "Craniofacial" were used. The authors included all original human studies that focused on the surgical implementation of 3D-printed implants for craniofacial defects. RESULTS: After screening 1253 studies, the authors included 49 articles consisting of a total of 745 subjects for qualitative analysis. Titanium (n = 13) and polycaprolactone (n = 6) were the most common 3D printed materials studied while Color Jet Printing (n = 12) and Stereolithography (n = 11) were the most common techniques. All studies that compared implants acquired by 3D printing with those acquired by conventional approaches showed a significantly better prognosis, and reductions in operative time, length of stay, and immediate complications. CONCLUSIONS: The use of patient-specific alternative materials, planning software and 3-D printing techniques shows satisfactory results in craniofacial reconstruction. Future studies should include standard levels of objective measurements to make better comparisons.
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Implantes Dentários , Procedimentos de Cirurgia Plástica , Desenho Assistido por Computador , Humanos , Duração da Cirurgia , Impressão Tridimensional , Procedimentos de Cirurgia Plástica/métodosRESUMO
Abstract Introduction Atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS) is one of the six diagnostic categories of the Bethesda System for Reporting Thyroid Cytopathology. The prevalence of malignancy among Bethesda category III cytology is variable, ranging from 5% to 37% in the literature. Objective To determine the rate of malignancy in thyroid nodules reported as Bethesda category III. Methods A total of 495 patients underwent surgical intervention for thyroid nodules from January 2015 to December 2017. The present study included 81 cases reported as Bethesda category III, and their medical records were reviewed. Results Out of 495 fine-needle aspiration cytology samples, 81 (16.4%) samples were labeled as AUS/FLUS. Among these 81 patients, the mean age was 43.0 years (±13.9), with only 11 (14%) patients older than 55 years of age.Most of our patients were female (n=69; 85.2%), and the rest were male. The rate of malignancy based on the final histology was of 33.3% (n=27). The majority were 17 cases (21%) of papillary carcinoma, followed by follicular carcinoma (n=6) (7.4%). Conclusion The risk of malignancy can be higher than it is commonly believed, and guidelines should be based on the data from the institutions themselves for a better assessment of the outcomes.
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Introduction Atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS) is one of the six diagnostic categories of the Bethesda System for Reporting Thyroid Cytopathology. The prevalence of malignancy among Bethesda category III cytology is variable, ranging from 5% to 37% in the literature. Objective To determine the rate of malignancy in thyroid nodules reported as Bethesda category III. Methods A total of 495 patients underwent surgical intervention for thyroid nodules from January 2015 to December 2017. The present study included 81 cases reported as Bethesda category III, and their medical records were reviewed. Results Out of 495 fine-needle aspiration cytology samples, 81 (16.4%) samples were labeled as AUS/FLUS. Among these 81 patients, the mean age was 43.0 years (± 13.9), with only 11 (14%) patients older than 55 years of age. Most of our patients were female ( n = 69; 85.2%), and the rest were male. The rate of malignancy based on the final histology was of 33.3% ( n = 27). The majority were 17 cases (21%) of papillary carcinoma, followed by follicular carcinoma ( n = 6) (7.4%). Conclusion The risk of malignancy can be higher than it is commonly believed, and guidelines should be based on the data from the institutions themselves for a better assessment of the outcomes.
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BACKGROUND: Malaria and dengue cause major morbidity in developing nations and are more severe in pregnancy. Maternal, fetal, and neonatal outcomes in pregnant patients infected with dengue or malaria were studied. METHODS: The medical records of pregnant women admitted with either dengue or malaria infections from 2011-2015â¯to this hospital were reviewed. Clinical outcomes and laboratory tests were examined. RESULTS: Of 85 women, 56%, 21%, and 22% had contracted dengue, malaria, and multiple infections, respectively. Pregnant women who had contracted dengue fever alone were more likely to present to the hospital at an earlier gestational age (24 weeks, pâ¯= 0.03). Women with multiple infections, were more likely to deliver earlier (30 weeks, pâ¯< 0.01). Women with malaria were more likely to have low birth weight deliveries (mean birth weight 2394â¯g, pâ¯= 0.03). The incidence of in-hospital deaths among the cohort was 7%. CONCLUSION: It is imperative to develop guidelines to screen for and diagnose dengue and malaria in pregnancy.