Variation in Receipt of Cancer Screening and Immunizations by 10-year Life Expectancy among U.S. Adults aged 65 or Older in 2019.

IMPORTANCE: The likelihood of benefit from a preventive intervention in an older adult depends on its time-to-benefit and the adult's life expectancy. For example, the time-to-benefit from cancer screening is >10 years, so adults with <10-year life expectancy are unlikely to benefit. OBJECTIVE: To examine receipt of screening for breast, prostate, or colorectal cancer and receipt of immunizations by 10-year life expectancy. DESIGN: Analysis of 2019 National Health Interview Survey. PARTICIPANTS: 8,329 non-institutionalized adults >65 years seen by a healthcare professional in the past year, representing 46.9 million US adults. MAIN MEASURES: Proportions of breast, prostate, and colorectal cancer screenings, and immunizations, were stratified by 10-year life expectancy, estimated using a validated mortality index. We used logistic regression to examine receipt of cancer screening and immunizations by life expectancy and sociodemographic factors. KEY RESULTS: Overall, 54.7% of participants were female, 41.4% were >75 years, and 76.4% were non-Hispanic White. Overall, 71.5% reported being current with colorectal cancer screening, including 61.4% of those with <10-year life expectancy. Among women, 67.0% reported a screening mammogram in the past 2 years, including 42.8% with <10-year life expectancy. Among men, 56.8% reported prostate specific antigen screening in the past two years, including 48.3% with <10-year life expectancy. Reported receipt of immunizations varied from 72.0% for influenza, 68.8% for pneumococcus, 57.7% for tetanus, and 42.6% for shingles vaccination. Lower life expectancy was associated with decreased likelihood of cancer screening and shingles vaccination but with increased likelihood of pneumococcal vaccination. CONCLUSIONS: Despite the long time-to-benefit from cancer screening, in 2019 many US adults age >65 with <10-year life expectancy reported undergoing cancer screening while many did not receive immunizations with a shorter time-to-benefit. Interventions to improve individualization of preventive care based on older adults' life expectancy may improve care of older adults.

Frailty Identification and Care Pathway: An Interdisciplinary Approach to Care for Older Trauma Patients.

BACKGROUND: Frailty is a well-established marker of poor outcomes in geriatric trauma patients. There are few interventions to improve outcomes in this growing population. Our goal was to determine if an interdisciplinary care pathway for frail trauma patients improved in-hospital mortality, complications, and 30-day readmissions. STUDY DESIGN: This was a retrospective cohort study of frail patients ≥65 years old, admitted to the trauma service at an academic, urban level I trauma center between 2015 and 2017. Patients transferred to other services and those who died within the first 24 hours were excluded. An interdisciplinary protocol for frail trauma patients, including early ambulation, bowel/pain regimens, nonpharmacologic delirium prevention, nutrition/physical therapy consults, and geriatrics assessments, was implemented in 2016. Our main outcomes were delirium, complications, in-hospital mortality, and 30-day readmission, which were compared with these outcomes in patients treated the year before the pathway was implemented. Multivariate logistic regression was used to determine the association of being on the pathway with outcomes. RESULTS: There were 125 and 144 frail patients in the pre- and post-intervention cohorts, respectively. There were no significant demographic differences between the 2 groups. Among both groups, the mean age was 83.51 years (SD 7.11 years), 60.59% were female, and median Injury Severity Score was 10 (interquartile range 9 to 14). In univariate analysis, there were no significant differences in complications (28.0% vs 28.5%, respectively, p = 0.93); however, there was a significant decrease in delirium (21.6% to 12.5%, respectively, p = 0.04) and 30-day readmission (9.6% to 2.7%, respectively, p = 0.01). After adjusting for patient characteristics, patients on the pathway had lower delirium (odds ratio [OR] 0.44, 95% CI 0.22 to 0.88, p = 0.02) and 30-day readmission rates (OR 0.25, 95% CI 0.07 to 0.84, p = 0.02), than pre-pathway patients. CONCLUSIONS: An interdisciplinary care protocol for frail geriatric trauma patients significantly decreases their delirium and 30-day readmission risk. Implementing pathways standardizing care for these vulnerable patients could improve their outcomes after trauma.

Conservative thickness layers in Mohs micrographic surgery.

BACKGROUND: Mohs micrographic surgery (MMS) is used to treat cutaneous malignancies in locations to maximize tissue sparing. The authors' aim is to demonstrate the utility of conservative thickness layers (CTL) in MMS and review patient and tumor characteristics and the potential anatomic locations where this technique may be most useful. METHODS: We performed a retrospective chart review of patients with tumors treated with CTL in MMS of 339 tumors, recording patient demographics, tumor characteristics, MMS stages for clearance, repairs, complications, and follow-up. RESULTS: A total of 339 tumors were treated with CTL. The most common site was the leg (28.6%), with 77.4% of these being female. The next most common sites were nose (24.5%), scalp (13.9%), and back (11.5%). Most tumors were cleared with one layer (269), but some required two layers (42), three layers (11), and four layers (1). A total of 264 tumors were left to granulate, while 75 of the nasal tumors had immediate dermabrasion. CONCLUSION: In the properly selected patient and anatomic location, CTL taken as the first stage in MMS can be an effective and time-saving technique, leaving wounds in optimal condition for granulation with a low complication rate. Tissue sparing may allow for more reconstructive options.

Ultrasonography training and utilization in surgical critical care fellowships: a program director's survey.

BACKGROUND: Intensivist-performed ultrasound (IPUS) is an adjunctive tool used to assist in resuscitation and management of critically ill patients. It allows clinicians real-time information through noninvasive methods. We aimed to evaluate the types of IPUS performed and the methods surgical critical care (SCC) fellows are trained along with challenges in training. METHODS: One hundred SCC fellowship directors were successfully sent an email inviting them to participate in a short Web-based survey. We inquired about program characteristics including hospital type, fellowship size, faculty size and training, dedicated surgical critical care beds, and ultrasound equipment availability. The survey contained questions regarding the program directors' perception on importance on cost effectiveness of IPUS, types of IPUS examinations performed, fellows experience with IPUS, challenges to training, and presence and methods of quality assurance (QA) programs. RESULTS: A total of 38 (38.0%) program directors completed the survey. Using a 100-point Likert scale, the majority of the respondents indicated that IPUS is important to patient care in the SICU and is cost-effective (mean score 85.5 and 84.6, respectively). Most (34, 89.5%) utilize IPUS and conduct a mean of 5.1 different examination types with FAST being the most prevalent examination (33, 86.8%). Thirty-three (86.8%) programs include IPUS in their SCC training with varying amounts of time spent training. Of these programs, 19 (57.6%) have a specific curriculum. The most frequently used modalities for training fellows were informal bedside teaching (28, 84.8%), hands-on lectures (20, 60.6%) and formal lectures (19, 57.6%). The top three challenges program directors cited for IPUS education was time (23, 69.7%), followed by concerns for ongoing QA (19, 57.6%) and lack of faculty trained in IPUS (18, 53.9%). Only 20 (60.6%) programs review images as a part of QA/quality improvement. CONCLUSIONS: Utilization and training of IPUS is common in SCC fellowships. There is varied education type and training time devoted to IPUS which could lead to gaps in knowledge and care. Development of a standard curriculum for SCC fellowships could assist surgical intensivists in achieving a base of knowledge in IPUS to create a more homogenously trained workforce and standards of care.

Effective Leadership and Management of an ACS Injury Prevention Program: Current Opinions and Perspectives From Where the Rubber Meets the Road.

The American College of Surgeons (ACS) mandates that each verified trauma center must have an injury prevention coordinator (IPC); however, Chapter 18 in the Resources for Optimal Care of the Injured Patient (2014) provides minimal information on how to effectively lead or manage an injury prevention (IP) program. This opinion article addresses 3 fundamental components of an effective IP program: (1) construction of an innovative vision of IP programming using current technology; (2) intentional investment and involvement; and (3) stakeholder leadership, engagement, and sustainability. This article also provides leadership and management methods from other professions both within and outside of the health care field that can be translated into sustainable IP program planning, implementation, and longevity.

Epithelial sheath neuroma: evidence supporting a hyperplastic etiology and epidermal origin.

An epithelial sheath neuroma (ESN) is a rare benign process of unknown pathogenesis, which is characterized histologically by multiple enlarged peripheral nerve fibers ensheathed by mature squamous epithelium. The histologic features can elicit concern for carcinomatous perineural invasion. The process is limited to the superficial dermis and is surrounded by a loose myxoid stroma, lymphocytic infiltrate and sometimes prominent infundibular cysts. The etiology of this peculiar entity has been debated and theories include a benign neoplasm, a hamartoma or an unusual reactive hyperplasia. There are only seven prior cases reported of ESN in the literature. Our case presented here is the first report to show connection of the ESN to the overlying epidermis and reactive epidermal hyperplasia. This suggests that ESN is indeed an unusual form of benign reactive hyperplasia. In addition, the clinical setting in this case was of pruritus and scratching in a background of papular urticaria, supporting the previous notion that ESN is probably a response to an external stimulus such as rubbing.

Malignant melanoma in transplant patients: a case report and review of the literature.

The clinical course and outcome of malignant melanoma (MM) are well-established for immunocompetent groups; however, they are not well-documented for immunosuppressed populations. Specifically, the influence of immunosuppression may result in poorer outcomes, especially in more advanced cases of melanoma. We report a 67-year-old woman who had previously undergone a kidney and pancreas transplant and presented with American Joint Committee on Cancer (AJCC) stage IIIA melanoma with subsequent rapid demise. As medicine advances with greater numbers of organ transplant recipients, a multi-institutional prospective study for this at-risk population would be greatly beneficial to help characterize the incidence, progression, and prognosis of melanoma in posttransplant immunosuppressed populations.