The Impact of Sociodemographic Variables on Functional Recovery following Lower Extremity Amputation.

BACKGROUND: We hypothesize that sociodemographic variables, particularly disadvantaged financial environments, impact both rate of prosthetic utilization and the achievement of ambulation post major amputation. METHODS: All cases in the Vascular Quality Initiative amputation module were queried between April 2013 and January 2024. Inclusion was limited to patients who underwent below knee, through knee, and above knee amputation. Two primary outcomes were investigated: Nonambulatory status after amputation (minimum of 120 days follow-up); and, not having obtained a prosthetic limb (minimum of 90 days follow-up). The ambulation status and prosthetic status analyses had 6,984 and 6,793 patients meet inclusion, respectively. Multivariable binary logistic regression analysis was performed utilizing variables which achieved univariable significance (P < 0.05) for the outcomes. RESULTS: Mean follow-up for those meeting inclusion was 432 days. Among all patients meeting inclusion, 46.7% of patients did not acquire a prosthetic limb and 44.1% were nonambulatory. Sociodemographic factors with significant multivariable association for the outcome of no prosthetic limb acquisition in follow-up were as follows: advancing age (adjusted odds ratio [aOR] 1.011/year (1.006-1.016), P < 0.001); female sex (aOR 1.43 (1.28-1.61), P < 0.001); top 20% area deprivation index representing highest deprivation (aOR 1.24 (1.09-1.41) P = 0.001); race (P = 0.002) insurance status (P = 0.028) with protective status for commercial insurance (39% rate of no prosthetic) and non-US insurance (33%) versus Medicare (51%), Medicaid (48%), Veterans Affairs insurance (49%), Self-pay (42%), and Medicare Advantage (51%). There were numerous comorbidities which also had association with lack of prosthetic limb acquisition. Sociodemographic variables which achieved multivariable significance (P < 0.05) for the outcome of nonambulatory status after major amputation were as follows: female sex (aOR 1.37 (1.23-1.54), P < 0.001); Medicare insurance (P = 0.016); advancing age (aOR 1.009/year (1.004-1.014), P < 0.001); congestive heart failure (aOR 1.15 (1.02-1.31), P = 0.028); and, not living at home in follow-up (aOR (3.53 (2.99-4.17) P < 0.001). Physical therapy at any point after surgery (aOR 0.742 (0.662-0.832), P < 0.001) and commercial insurance (aOR 0.839 (0.737-0.956), P = 0.008) were protective. There were numerous comorbidities which also had association with nonambulatory status in follow-up. CONCLUSIONS: Living within the most financially disadvantaged areas and race both have a significant independent association with lack of prosthetic limb acquisition following major amputation. Black, Native American, and Pacific Islander demographic patients experience lack of acquisition at a higher rate than White and Asian patients independent of comorbidities and socioeconomic covariables. Female patients obtain a prosthetic limb and ambulate less frequently than males after major amputation, largely due to a higher rate of above knee amputation. Comorbidities and not socioeconomic variables are the leading drivers of nonambulation.

Delay in prior authorization of biologic therapy: Another possible cause of healthcare disparity in IBD patients.

BACKGROUND: Biologics, a mainstay in inflammatory bowel disease (IBD) treatment, typically require prior authorization from insurance companies. Multiple studies show that African Americans are less likely to be prescribed biologics. The prior authorization process may perpetuate disparities in healthcare. This study evaluated the approval time for biologics in IBD. METHODS: A chart review of IBD patients seen in a university gastroenterology clinic over 5 years was performed. Patient gender, race, IBD subtype, biologic use, and insurance type were recorded. Insurance type was classified as private or public (Medicaid or Medicare). Biologic agents evaluated included infliximab, adalimumab, vedolizumab and ustekinumab. Length of time to approval (TTA) and length of time to first infusion or administration (TFI) were recorded. Analysis was performed using t-testing, Fisher's exact testing, and ANOVA with significance set at p<0.05. The study was IRB approved. RESULTS: 458 charts were analyzed. 66 patients were being treated with a biologic. 42 had private insurance, 16 Medicaid and 8 Medicare. 37 patients had ulcerative colitis, 27 Crohn's disease, and 2 indeterminate colitis. There were 38 men and 28 women. 32 patients were white, 26 African American, 1 Asian, 5 other, and 2 declined identification. Average TTA was 30.5 days (range 1-145) and average TFI was 45.3 days (range 2-166). African Americans were more often on public insurance compared to whites (p=0.0001). Crohn's disease compared to ulcerative colitis patients were more often on public insurance (p=0.017). Significantly more private compared to public insurance patients were on infliximab (p=0.001). Medicaid and Medicare patients had significantly longer mean TTAs than private insurance patients (49.1 and 52.7 vs 19.4 days, p=0.007). African Americans had significantly longer mean TTA compared to whites (45.9 vs 24.8 days, p=0.044). Crohn's disease compared to ulcerative colitis patients had significantly longer mean TTA (39.7 vs 21.8 days, p=0.050). DISCUSSION: This study shows that prior authorization for biologic therapy was longer for African Americans. Patients on public insurance also tend to have a longer TTA, and more African Americans were on public insurance compared to White patients in this study which may explain the difference in biologic access for African Americans.

Gender, BMI, Patient Comorbidities, and Hospital Characteristics Influence 30-Day Readmission Following Vertical Sleeve Gastrectomy.

PURPOSE: Obesity impacts 300 million people worldwide and the number continues to increase. Laparoscopic sleeve gastrectomy (LSG) is one of several bariatric procedures offered to help these individuals achieve a healthier life. Here, we report 30-day readmission rates and risk factors for readmission after gastrectomy. MATERIALS AND METHODS: We used the US Healthcare Utilization Project's Nationwide Readmission Database (NRD) from 2016 to 2019 for patients who underwent laparoscopic gastrectomy and evaluated 30-day readmission rates, comparing readmitted patients to non-readmitted patients. Confounder adjusted and unadjusted analysis were proceeded to the potential factors. RESULTS: The study population consisted of 235,563 patients, with a 3.0% readmission rate. Factors associated with a higher readmission rate included older age, male gender, higher BMI, Medicare as the primary payer, longer length of stay, higher total charge, higher Charlson Comorbidity Index, higher Elixhauser-Comorbidity Index, lower household income, non-elective admission type, and non-routine disposition. Additionally, larger hospital bed size, and private, invest-own hospital ownership were associated with higher readmission rates. After adjusting for confounders, several comorbidities and complications were found to be significantly associated with readmission, including ileus, abnormal weight loss, postprocedural complications of digestive system, acute posthemorrhagic anemia, and history of pulmonary embolism (all p < 0.001). CONCLUSIONS: Patient characteristics including age, BMI, and payment source, as well as hospital characteristics, can impact the 30-day readmission after LSG. Such factors should be considered by CMS when deciding on penalties related to readmission.

The effect of preoperative endoscopic tattooing on lymph node retrieval in colorectal cancer: a systematic review and meta-analysis.

PURPOSE: The effect of preoperative endoscopic tattooing (ET) on accurate colorectal cancer localization and resection has been well established. However, its effect on lymph node (LN) retrieval remains unclear. The purpose of this study was to systematically compare LN retrieval between patients with colorectal cancer who underwent preoperative ET and those who did not. METHODS: A systematic search for relevant studies was conducted using the following databases: PubMed, Embase, and Web of Science. Studies that compared LN retrieval in patients with colorectal cancer with and without preoperative ET were included. Weighted pooled odds ratio (OR) and mean difference (MD) with the corresponding 95% confidence intervals (CIs) for all outcomes using the random-effects model were calculated. RESULTS: 10 studies, including 2231 patients with colorectal cancer were included. Six studies reported total LN yield and showed significantly higher LN yield in the tattooed group (MD:2.61; 95% CI:1.01-4.21, P=0.001). Seven studies reported the number of patients with adequate LN retrieval and showed a significantly higher number of patients with adequate LN retrieval in the tattooed group (OR:1.89, 95% CI:1.08-3.32, P=0.03). However, subgroup analysis revealed that both outcomes were only statistically significant in patients with rectal cancer, and not in patients with colon cancer. CONCLUSIONS: Our results suggest that preoperative ET is associated with increased LN retrieval in patients with rectal cancer, but not in colon cancer. Further large-scale randomized control trials are necessary to validate our findings.

Quiet & deadly: Painless aortic dissection.

Aortic dissection is a life-threatening condition that classically presents as a sudden, sharp pain with a ripping sensation. This disease is caused by a weakened area within the aortic arterial wall, which can be classified using the Stanford classifications into type A or type B dissections, depending on the location of the tear. It is described that 17.6% of patients died before arriving at the hospital, and 45.2% of patients died within 30 days of diagnosis (Melvinsdottir et al., 2016). However, 10% of patients present without pain, leading to delayed diagnosis. In this case, a 53-year-old male with prior history of hypertension, sleep apnea, and diabetes mellitus presented to the emergency department with complaints of chest pain earlier that day. However, he was asymptomatic on presentation. He had no cardiac history. He was admitted, and a subsequent workup was performed to rule out myocardial infarction. The following morning a slight bump in troponin consistent with a Non-ST Elevated Myocardial Infarction (NSTEMI) was noted. An echocardiogram was ordered and showed aortic regurgitation. This was followed by computed tomography angiography (CTA), which revealed acute type A ascending aortic dissection. He was transferred to our facility and underwent an emergent Bentall procedure. Ultimately, the patient tolerated the surgery well and is recovering. This case is essential because it emphasizes the painless presentation of type A aortic dissection. Mis- or undiagnosed, this condition often leads to death.

Cyclosporine-Induced Kaposi Sarcoma in a Patient With Ulcerative Colitis.

Kaposi sarcoma (KS) is an angioproliferative neoplasm associated with human herpesvirus-8. Gastrointestinal KS has been well documented in immunosuppressed solid organ transplant patients, with only 26 iatrogenic cases published in patients with inflammatory bowel disease. We report a 24-year-old patient with ulcerative colitis, maintained on cyclosporine for 2 years, who presented with watery, nonbloody diarrhea and weight loss. Colonoscopy revealed human herpesvirus-8-positive hemorrhagic nodules throughout the colon and terminal ileum, with diffuse lymphadenopathy on computed tomography consistent with KS. As gastrointestinal KS may present with symptoms that mimic inflammatory bowel disease, it is critical to maintain suspicion in patients on prolonged immunosuppression to reduce complications.

Association of Patients' Perception of Quality of Healthcare Received and Colorectal Cancer Screening Uptake: An Analysis of 2 National Surveys in the USA.

OBJECTIVE: It is not known whether patients' ratings of the quality of healthcare services they receive truly correlate with the quality of care from their providers. Understanding this association can potentiate improvement in healthcare delivery. We evaluated the association between patients' ratings of the quality of healthcare services received and uptake of colorectal cancer (CRC) screening. SUBJECTS AND METHODS: We used 2 iterations of the Health Information National Trends Survey (HINTS) of adults in the USA. HINTS 2007 (4,007 respondents; weighted population = 75,397,128) evaluated whether respondents were up to date with CRC screening while HINTS 4 cycle 3 (1,562 respondents; weighted population = 76,628,000) evaluated whether participants had ever received CRC screening in the past. All included respondents from both surveys were at least 50 years of age, had no history of CRC, and had rated the quality of healthcare services that they had received at their healthcare provider's office in the previous 12 months. RESULTS: HINTS 2007 data showed that respondents who rated their healthcare as good or fair/poor were significantly less likely to be up to date with CRC screening compared to those who rated their healthcare as excellent. We found comparable results from analysis of HINTS 4 cycle 3 data with poorer uptake of CRC screening as the healthcare quality ratings of respondents reduced. CONCLUSION: Our study suggests that patients who reported receiving lower quality of healthcare services were less likely to have undergone and be compliant with CRC screening recommendations. It is important to pay close attention to patient feedback surveys in order to improve healthcare delivery.

Gene Therapy Leaves a Vicious Cycle.

The human genetic code encrypted in thousands of genes holds the secret for synthesis of proteins that drive all biological processes necessary for normal life and death. Though the genetic ciphering remains unchanged through generations, some genes get disrupted, deleted and or mutated, manifesting diseases, and or disorders. Current treatment options-chemotherapy, protein therapy, radiotherapy, and surgery available for no more than 500 diseases-neither cure nor prevent genetic errors but often cause many side effects. However, gene therapy, colloquially called "living drug," provides a one-time treatment option by rewriting or fixing errors in the natural genetic ciphering. Since gene therapy is predominantly a viral vector-based medicine, it has met with a fair bit of skepticism from both the science fraternity and patients. Now, thanks to advancements in gene editing and recombinant viral vector development, the interest of clinicians and pharmaceutical industries has been rekindled. With the advent of more than 12 different gene therapy drugs for curing cancer, blindness, immune, and neuronal disorders, this emerging experimental medicine has yet again come in the limelight. The present review article delves into the popular viral vectors used in gene therapy, advances, challenges, and perspectives.

Morbid obesity is an independent risk factor for postoperative renal dysfunction in young adults: a review of the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Little information exists on the acute effects of elective surgery on renal function. Our aim was to determine if obesity was an independent risk factor for postoperative renal complications (RCs). METHODS: A total of 119,142 patients aged 18 to 35 years with body mass index (BMI) ≥18 kg/m(2) obtained from American College of Surgeons National Surgical Quality Improvement Project (2005 to 2010) were classified into standard BMI categories. Association between BMI and preoperative estimated glomerular filtration rate (eGFR; calculated using modification of diet in renal disease formula) was analyzed. Postoperative changes in eGFR and RCs were measured. Multivariate regression analysis was performed adjusting for all variables. RESULTS: Postoperatively, there was a reduction in eGFR among the overweight (-3.4 mL/min/1.73 m(2), P < .001), obese class I (-3.9 mL/min/1.73 m(2), P = .001), and obese class II (-5.3 mL/min/1.73 m(2), P < .001). The odds of any postoperative RC was significantly higher in obese class III patients (odds ratio = 2.01 95% confidence interval 1.07 to 3.76, P = .029). CONCLUSIONS: Results seen in patients with BMI greater than 40 indicate that BMI can serve as an independent predictor of RCs.