Patient Anxiety Related to Patient-Perceived Delays in Surgical Treatment of Skin Cancer.

BACKGROUND: Patients undergoing dermatologic surgery report higher anxiety levels than those undergoing nonsurgical treatments. However, little is known about the association between patient-perceived delays in skin cancer surgery and patient-reported anxiety. OBJECTIVE: To examine the relationship between patient-perceived delays in surgery and patient-reported anxiety. METHODS MATERIALS: Patients undergoing wide local excision or Mohs micrographic surgery were recruited to complete a survey to assess perception of surgical delay and anxiety related to skin cancer surgery using the validated Psychosocial Screen for Cancer-Revised. Demographic and surgical characteristics were collected through chart review. Chi-square and Student t -tests were used to compare demographic and surgical information between patients who did and did not perceive a surgical delay. Differences in anxiety and depression scores for patients who did and did not report a delay were assessed using univariate and multivariate regressions. RESULTS: Twenty-seven percent ( N = 33) of patients perceived a surgical delay. Perception of surgical delay was associated with increased time between biopsy and surgery ( p = .0001) and increased self-reported anxiety scores after controlling for various demographic and surgical factors ( p = .038). CONCLUSION: Patient-perceived delays in dermatologic surgery are associated with increased time to surgery and patient-reported anxiety.

Time to treatment and complexity of Mohs micrographic surgery.

The impact of time to treatment (TTT) on the surgical management of keratinocyte carcinoma, specifically the complexity of Mohs micrographic surgery (MMS), is incompletely understood. We performed a retrospective chart review of patients undergoing MMS for keratinocyte carcinoma between July 1, 2019 and February 28, 2021 to examine associations between TTT and surgical characteristics. The median TTT for the 1571 patients treated with MMS during the study period was 42 days (interquartile range 28-61 days). In adjusted analyses, increasing TTT was not associated with increasing utilization of flap or graft repairs. Although a 42-day increase in TTT was associated with a 17.6 mm2 increase in the post-operative surgical defect size after MMS, TTT was not associated with linear repair length or flap/graft repair area. In conclusion, TTT was not independently associated with the type of repair or repair length after MMS, suggesting that the complexity of Mohs reconstruction is not influenced by TTT within the time range studied in this cohort.

Factors leading to loss to follow-up after strabismus surgery in children.

PURPOSE: To assess risk factors for loss to follow-up (LTFU) and identify obstacles to follow-up care in these patients. METHODS: The medical records of all children (<18 years old) who underwent strabismus surgery over a 6-year period at a single institution were reviewed retrospectively. Patients were considered LTFU if they failed to attend a follow-up appointment between 3 weeks and 6 months postoperatively. Variables collected for all patients included age, sex, race/ethnicity, and insurance type. A telephone survey of parents/guardians of all patients LTFU was conducted to determine potential barriers to follow-up care. Demographic information was compared between those not LTFU and those LTFU as well as those LTFU and those LTFU who completed the survey. Reasons for LTFU were quantified and classified by category. RESULTS: Patients LTFU were significantly more likely to be black than white or Asian and have state or government-based insurance rather than private or employer-based insurance. The most common reasons cited for not following-up included perceived positive outcome (47%), work conflicts (37%), transportation issues (30%), travel time (30%), and having forgotten (27%). CONCLUSIONS: Patients were LTFU because parents or guardians perceived follow-up as unnecessary, were faced with scheduling or transportation impediments, or simply forgot to appear. Possible remedies include increasing education through teach-back, offering telemedicine appointments, and sending multiple appointment reminders.

Real-World Experience With Antiplatelet Agents After Percutaneous Coronary Intervention in Patients With an Indication for an Oral Anticoagulant.

ABSTRACT: Patients undergoing percutaneous coronary intervention (PCI) with a clinical indication for oral anticoagulation (OAC) in addition to antiplatelet therapy (APT) necessitate rigorous evaluation of bleeding and ischemic risk to guide therapy. The optimal OAC/APT drug combination and duration of treatment is not known. This study aimed to evaluate the incidence of patients undergoing PCI with an OAC indication and the rationale for post-PCI combined OAC/APT selection in clinical practice. Consecutive patients undergoing PCI with an indication for combined OAC/APT were included in a 12-month retrospective case series. Patient demographics, clinical characteristics, prescribed OAC/APT regimens, and rationale for drug selection were reviewed. PCI was performed in 1650 patients during the study period, with an indication for OAC/APT in 133 (8.1%). A combination of aspirin, P2Y12 inhibitor, and OAC was the most frequently prescribed regime on discharge (n = 103, 81%). Dual antiplatelet therapy (DAPT) in combination with OAC was continued for a mean duration of 6.4 ± 4.4 weeks (range 3-52 weeks) before one antiplatelet was discontinued. There was no significant difference between the mean CHA2DS2-VASc or HAS-BLED score of patients with atrial fibrillation discharged on OAC/DAPT compared with alternate combinations (DAPT alone or OAC/single APT), 3.6 ± 1.3 versus 3.8 ± 1, P = 0.37 and 2.04 ± 0.7 versus 2.05 ± 1.0, P = 0.98, respectively. This case series identifies high variability in OAC/APT treatment duration and limited application of risk scoring systems and high-risk PCI characteristics in the selection of OAC/APT regimens. A more systematic patient assessment is needed to help standardize OAC/APT prescribing for this important patient cohort.

Does the incidence of sore throat postoperatively increase with the use of a traditional intubation blade or the GlideScope?

STUDY OBJECTIVE: The GlideScope video-guided laryngoscope is an alternative standard of care for rescue laryngoscopies when direct laryngoscopy is unsuccessful. During postoperative checks by an anesthesiologist, it was noticed that patients who reported sore throat often required GlideScope laryngoscopy. Consequently, it is difficult to determine whether postoperative sore throats are caused by irritation inflicted by multiple laryngoscopic attempts or the actual utilization of the GlideScope itself. The goal of this study was to determine whether the use of the GlideScope leads to a greater or lesser incidence of sore throat when compared with traditional laryngoscope blades used for intubation. DESIGN: Eligible patients scheduled for elective inpatient surgeries requiring endotracheal tube intubation were enrolled into this single-blinded prospective cohort study. χ(2) Test, Fisher exact test, and t tests were used to compare differences across the primary end point and other demographic categories. SETTING: Operating rooms and postanesthesia recovery unit, Albany Medical Center, Albany, NY. PATIENTS: There were a total of 151 patients with American Society of Anesthesiologists grades 1 to 3 included in the study. INTERVENTIONS: Eighty-one patients were randomized to a control group that received traditional laryngoscopy via Macintosh/Miller blades and 70 patients received video-guided intubation via the GlideScope. MEASUREMENTS: The incidence of postoperative sore throat was recorded via a yes/no questionnaire within 24 hours after extubation. Secondary parameters such as provider type, sex, and perceived difficulty were also recorded. MAIN RESULTS: There was no significant difference in the proportion of patients reporting sore throat by type of blade used (Mac/Miller 36.3% vs GlideScope 32.4%, P = .619). For secondary outcomes, women were significantly more likely to report sore throat as compared with men (men 24.3% vs women 43.2%, P = .015), and the provider type was significantly associated with the occurrence of postoperative sore throat (attendings 26.8% vs certified registered nurse anesthetists 52.3% vs third-year clinical anesthesia residents 30%, P = .012). CONCLUSIONS: Use of the GlideScope videolaryngoscopy was not significantly associated with increased occurrence of postoperative sore throat when compared with traditional intubation techniques. Our results may enable more trainees to acquire intubation skills with the GlideScope during an initial intubation attempt in patients with American Society of Anesthesiologist grades 1 to 3, with optimization of patient satisfaction in respect to postoperative sore throats. In addition, a provider's choice of intubation technique based on either Macintosh/Miller blades or the GlideScope does not significantly impact a patient's risk of postoperative sore throat.

New-onset atrial fibrillation post-surgery for esophageal and junctional cancer: incidence, management, and impact on short- and long-term outcomes.

OBJECTIVE: To study new-onset postoperative atrial fibrillation in patients with esophageal and junctional cancer. DESIGN: Retrospective cohort study from a prospective data base. BACKGROUND: Atrial fibrillation (AF) is common after thoracic and esophageal surgical procedures. The full spectrum of risk factors, associations, and implications are unclear. METHODS: All patients undergoing multimodal therapy or surgery with curative intent from 2006 to mid-2013 were studied. New-onset AF was recorded prospectively. Risk factors, management and resolution, association with other complications, and impact on in-hospital mortality and longer-term oncologic outcomes were analyzed in retrospective cohort analysis. RESULTS: A total of 473 patients (mean age: 63 years; 73% male) underwent resection, 51% 2-stage, 18% 3-stage, 12% transhiatal, and 19% extended total gastrectomy. Ninety-six (20%) patients developed new-onset AF, in 18%, 27%, 29%, and 14% of 2-, 3-, transhiatal, and extended total gastrectomy cohorts, respectively (P=0.05). Age, diabetes, neoadjuvant therapy, and cardiac history predisposed (P<0.05) to AF, and AF was significantly (P<0.0001) associated with pneumonia, pleural effusions requiring drainage, and maximum postoperative C-reactive protein (CRP) (P<0.05) but not with anastomotic leak/conduit necrosis or mortality. Amiodarone was the primary treatment in 63% of cases, 1% underwent cardioversion, and 92% were in sinus rhythm on discharge. At a median follow-up of 40 months (7-109 months), the median survival was 40 months versus 53 months in the AF and non-AF cohorts, respectively (P=0.353) CONCLUSIONS: New-onset AF is common, linked to age, diabetes, cardiac disease, and neoadjuvant therapy. It is strongly associated with complications, principally respiratory sepsis, and systemic inflammation. For most, it resolves, with no impact on oncologic outcomes.

Can preoperative axillary US help exclude N2 and N3 metastatic breast cancer?

PURPOSE: To determine the false-negative rate of axillary ultrasonography (US) with respect to stage N2 and N3 metastatic disease in patients with newly diagnosed breast cancer. MATERIALS AND METHODS: The study was approved by the institutional review board and complied with the HIPAA; the requirement for informed consent was waived. A retrospective search of radiology records identified 435 consecutive patients with breast cancer aged 25-88 years who underwent preoperative axillary US from January 1, 2006, to December 31, 2007. Two hundred five patients (203 women and two men) had 208 negative US scans with correlative surgical and/or pathologic lymph node data. Criteria used to detect abnormal lymph nodes included subjective assessment of diffuse cortical thickening, focal cortical mass/thickening, and replacement or effacement of the fatty hilum. Tumor type, grade, size, and hormone receptor status were documented. Statistical analysis was performed with the Fisher exact test. RESULTS: Of the 208 axillae with negative findings at US, 14 (6.7%) had a final node stage of N2 or N3. Twelve of the 208 axillae (5.8%) had stage N2 disease and two (1.0%) had stage N3 disease. Of the 14 axillae with stage N2 or N3 disease, eight (57.1%) had lobular histologic characteristics and six (42.9%) had ductal histologic characteristics. The false-negative rate for N2 and N3 disease was 4.1% (six of 146 axillae) for invasive ductal cancer and 17% (eight of 47 axillae) for invasive lobular cancer (P < .01). None of the 14 axillae with stage N2 or N3 disease were "triple negative" (ie, estrogen receptor negative, progesterone receptor negative, and human epidermal growth factor receptor type 2 negative). CONCLUSION: Preoperative axillary US excluded 96% of N2 and N3 invasive ductal metastases. The false-negative rate for N2 and N3 invasive lobular cancer was significantly higher than that for invasive ductal cancer, which suggests that axillary US cannot be used to exclude N2 and N3 metastases in these patients.

Ensuring excision of intraductal lesions: marker placement at time of ductography.

RATIONALE AND OBJECTIVES: To propose grid coordinate marker placement for patients with suspicious ductogram findings occult on routine workup. To compare the success of marker placement and wire localization (WL) with ductogram-guided WL. MATERIALS AND METHODS: A retrospective search of radiology records identified all patients referred for ductography between January 2001 and May 2008. Results for 16 patients referred for ductogram-guided WL and 5 patients with grid coordinate marker placement at the time of ductography and subsequent WL were reviewed. Surgical pathology results and clinical follow-up were reviewed for concordance. RESULTS: Nine of 16 patients (56.3%) underwent successful ductogram-guided WL. Eight of nine patients had papillomas, one of which also had atypical ductal hyperplasia (ADH). One of nine patients had ectatic ducts with inspisated debris. Seven patients who failed ductogram-guided WL eventually underwent open surgical biopsy. Four of seven patients had papillomas, one of which also had lobular carcinoma in situ. Remaining patients had ADH (1/7) and fibrocystic changes with chronic inflammation (3/7). All five (100%) patients with grid coordinate marker placement underwent successful WL and marker excision. Pathology results included three papillomas, papillary intraductal hyperplasia, and fibrocystic change. CONCLUSION: Grid coordinate marker placement at the time of abnormal ductogram provided an accurate method of localizing ductal abnormalities that are occult on routine workup, thus facilitating future WL. Marker placement obviated the need for repeat ductogram on the day of surgery and ensured surgical removal of the ductogram abnormality.

Dynamic multiple thresholding breast boundary detection algorithm for mammograms.

PURPOSE: Automated detection of breast boundary is one of the fundamental steps for computer-aided analysis of mammograms. In this study, the authors developed a new dynamic multiple thresholding based breast boundary (MTBB) detection method for digitized mammograms. METHODS: A large data set of 716 screen-film mammograms (442 CC view and 274 MLO view) obtained from consecutive cases of an Institutional Review Board approved project were used. An experienced breast radiologist manually traced the breast boundary on each digitized image using a graphical interface to provide a reference standard. The initial breast boundary (MTBB-Initial) was obtained by dynamically adapting the threshold to the gray level range in local regions of the breast periphery. The initial breast boundary was then refined by using gradient information from horizontal and vertical Sobel filtering to obtain the final breast boundary (MTBB-Final). The accuracy of the breast boundary detection algorithm was evaluated by comparison with the reference standard using three performance metrics: The Hausdorff distance (HDist), the average minimum Euclidean distance (AMinDist), and the area overlap measure (AOM). RESULTS: In comparison with the authors' previously developed gradient-based breast boundary (GBB) algorithm, it was found that 68%, 85%, and 94% of images had HDist errors less than 6 pixels (4.8 mm) for GBB, MTBB-Initial, and MTBB-Final, respectively. 89%, 90%, and 96% of images had AMinDist errors less than 1.5 pixels (1.2 mm) for GBB, MTBB-Initial, and MTBB-Final, respectively. 96%, 98%, and 99% of images had AOM values larger than 0.9 for GBB, MTBB-Initial, and MTBB-Final, respectively. The improvement by the MTBB-Final method was statistically significant for all the evaluation measures by the Wilcoxon signed rank test (p < 0.0001). CONCLUSIONS: The MTBB approach that combined dynamic multiple thresholding and gradient information provided better performance than the breast boundary detection algorithm that mainly used gradient information.

Homocysteine increases the risk associated with hyperlipidaemia.

BACKGROUND: The European Concerted Action Project 'Homocysteine and Vascular Disease' showed that an elevated homocysteine is associated with a substantially increased risk of cardiovascular disease, and particularly when combined with other factors such as smoking, hypertension and hypercholesterolaemia. The purpose of this study was to examine the potential interactions between homocysteine and individual lipid subfractions. In addition, it was hypothesized that HDL cholesterol may protect against hyperhomocysteinaemia because HDL cholesterol is associated with the enzyme paroxonase, which reduces oxidization of homocysteine to the harmful metabolite, homocysteine thiolactonase. METHODS: Data from a multicentre European case-control study (750 cases and 800 controls) were used for analysis. The risks of vascular disease associated with homocysteine, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, apoprotein A1 and apoprotein B were established. The effect of elevated homocysteine on the cardiovascular risk associated with each lipid subfraction was then examined. RESULTS: As expected, homocysteine, total cholesterol, LDL cholesterol, triglycerides and apolipoprotein B were associated with cardiovascular risk. HDL cholesterol was inversely related to risk. Homocysteine increased the risk associated with all lipid measures. In contrast, a low plasma cholesterol does not seem to confer protection against the risk associated with a raised plasma homocysteine. Hyperhomocysteinaemia is associated with an increased risk at all levels of HDL cholesterol, conversely, in those with elevated homocysteine HDL cholesterol levels result in reduced risk. CONCLUSION: In general, the increased cardiovascular risk associated with elevated homocysteine is evident across the spectrum cholesterol subfraction levels.

Variable appearances of fat necrosis on breast MRI.

OBJECTIVE: The purpose of this article is to illustrate the varying appearances of fat necrosis on MRI. CONCLUSION: Fat necrosis may mimic malignancy with varying appearances on MRI. Suspicious morphologic and kinetic features may be present, necessitating biopsy to exclude new or recurrent breast cancer.

Complicated breast cysts on sonography: is aspiration necessary to exclude malignancy?

RATIONALE AND OBJECTIVES: To determine the incidence of breast cancer in women presenting for fine needle aspiration of sonographically diagnosed complicated breast cysts. MATERIALS AND METHODS: Institutional review board approval was obtained. A retrospective study was performed of 186 consecutive women who presented for fine needle aspiration of 243 sonographic complicated cysts detected by clinical examination or imaging between January 2002 and August 2003. Sonographic complicated cysts were defined as those meeting most but not all criteria for simple cysts similar to current Breast Imaging Reporting and Data System classification. We excluded solid masses, cysts with solid components, intracystic masses, and simple cysts. Prospective mammography, ultrasound, and procedure reports were reviewed. A case was considered positive if cytology, core needle biopsy, or surgical excision was positive for cancer. Final diagnosis was established by biopsy, cytology, clinical resolution, or stability over time. RESULTS: One of 243 (0.4%) lesions proved malignant (95% confidence interval 0-1.94%); 210/243 (86.4%) of cases yielded fluid on aspiration. Of 141 samples submitted to cytology, 138 (97.9%) were benign and 3 (2.1%) atypical. All cases of atypia were benign at surgical excision. Ninety five of 243 (39.1%) aspiration samples with typical cyst fluid were discarded. A total of 33/243 (13.6%) cases did not yield fluid, 1 of which was positive for cancer. Thirty cases underwent core needle or excisional biopsy for imaging discordance with benign results. CONCLUSIONS: Breast cancer presenting as a complicated cyst by ultrasound was rare (0.4%, 95% confidence interval 0-1.94%). These results provide support for classification of complicated cysts as probably benign.

Management of cardiovascular risk in the peri-menopausal woman: a consensus statement of European cardiologists and gynaecologists.

Cardiovascular risk is poorly managed in women, especially during the menopausal transition when susceptibility to cardiovascular events increases. Clear gender differences exist in the epidemiology, symptoms, diagnosis, progression, prognosis, and management of cardiovascular risk. Key risk factors that need to be controlled in the peri-menopausal woman are hypertension, dyslipidaemia, obesity, and other components of the metabolic syndrome, with the avoidance and careful control of diabetes. Hypertension is a particularly powerful risk factor and lowering of blood pressure is pivotal. Hormone replacement therapy is acknowledged as the gold standard for the alleviation of the distressing vasomotor symptoms of the menopause, but the findings of the Women's Health Initiative (WHI) study generated concern for the detrimental effect on cardiovascular events. Thus, hormone replacement therapy cannot be recommended for the prevention of cardiovascular disease. Whether the findings of WHI in older post-menopausal women can be applied to younger peri-menopausal women is unknown. It is increasingly recognized that hormone therapy is inappropriate for older post-menopausal women no longer displaying menopausal symptoms. Both gynaecologists and cardiovascular physicians have an important role to play in identifying peri-menopausal women at risk of cardiovascular morbidity and mortality and should work as a team to identify and manage risk factors such as hypertension.

The initial management of stable angina in Europe, from the Euro Heart Survey: a description of pharmacological management and revascularization strategies initiated within the first month of presentation to a cardiologist in the Euro Heart Survey of Stable Angina.

AIMS: In order to assess adherence to guidelines and international variability in management, the Euro Heart Survey of Newly Presenting Angina prospectively studied medical therapy, percutaneous coronary intervention (PCI), and surgery in patients with new-onset stable angina in Europe. METHODS AND RESULTS: Consecutive patients, 3779 in total, with a clinical diagnosis of stable angina by a cardiologist were enrolled. After initial assessment by a cardiologist, 78% were treated with aspirin, 48% with a statin, and 67% with a beta-blocker. ACE-inhibitors were prescribed by the cardiologist in 37% overall. Revascularization rates were low, with only 501 (13%) patients having PCI or coronary bypass surgery performed or planned. However, when restricted to patients with coronary disease documented within 4 weeks of assessment, over 50% had revascularization performed or planned. Among other factors, the national rate of angiography and availability of invasive facilities significantly predicted the likelihood of revascularization, OR 2.4 and 2.0, respectively. CONCLUSION: This survey shows a shortfall between guidelines and practice with regard to the use of evidence-based drug therapy and evidence that revascularization rates are strongly influenced by non-clinical, in addition to clinical, factors.