Bleeding risk from anticoagulant thromboprophylaxis in patients with multiple myeloma: a MarketScan analysis.

Background: Multiple myeloma (MM) is associated with high risk of venous thromboembolism (VTE). Anticoagulant prophylaxis is frequently recommended but underutilized partly due to the absence of studies assessing bleeding risk. Objectives: To determine the rate of severe (hospitalized) bleeding from thromboprophylaxis in patients treated for MM and identify clinical risk factors for bleeding in this population. Methods: Using the MarketScan database, we analyzed 6656 patients treated for MM between 2013 and 2021. Concomitant thromboprophylaxis was defined using prescription claims. Hospitalized bleeding was identified through the Cunningham algorithm. Bleeding rates were compared by thromboprophylaxis status, and Cox regression identified risk factors for bleeding. Results: Anticoagulant thromboprophylaxis was used in 6.6% (436) patients treated for MM. Patients on thromboprophylaxis had a higher rate of immunomodulatory-based therapy (63.8% vs 46.7%; P < .01) and lower rate of antiplatelet use (2.1% vs 4.7%; P < .01). Bleeding occurred in 1.4% of them during median follow-up of 1.3 years. Rate of severe bleeding was not different between those on prophylaxis (7.8 per 1000 person-years) and those not on prophylaxis (10.1 per 1000 person-years). No association was identified between thromboprophylaxis and bleeding. Factors associated with increased bleeding included age (hazard ratio [HR], 1.38 per 10 years increase in age), comorbidity index (HR, 1.18 per SD increase), history of bleeding (HR, 1.54), hypertension (HR, 1.87), and renal disease (HR, 1.56). Conclusion: Risk of serious bleeding from thromboprophylaxis in patients treated for MM was low, and concomitant anticoagulant therapy did not result in increased bleeding risk. Clinical risk factors for bleeding included age, comorbidity index, bleeding history, hypertension, and renal disease.

Development and validation of a risk model for hospital-acquired venous thrombosis: the Medical Inpatients Thrombosis and Hemostasis study.

BACKGROUND: Regulatory organizations recommend assessing hospital-acquired (HA) venous thromboembolism (VTE) risk for medical inpatients. OBJECTIVES: To develop and validate a risk assessment model (RAM) for HA-VTE in medical inpatients using objective and assessable risk factors knowable at admission. METHODS: The development cohort included people admitted to medical services at the University of Vermont Medical Center (Burlington, Vermont) between 2010 and 2019, and the validation cohorts included people admitted to Hennepin County Medical Center (Minneapolis, Minnesota), University of Michigan Medical Center (Ann Arbor, Michigan), and Harris Health Systems (Houston, Texas). Individuals with VTE at admission, aged <18 years, and admitted for <1 midnight were excluded. We used a Bayesian penalized regression technique to select candidate HA-VTE risk factors for final inclusion in the RAM. RESULTS: The development cohort included 60 633 admissions and 227 HA-VTE, and the validation cohorts included 111 269 admissions and 651 HA-VTE. Seven HA-VTE risk factors with t statistics ≥1.5 were included in the RAM: history of VTE, low hemoglobin level, elevated creatinine level, active cancer, hyponatremia, increased red cell distribution width, and malnutrition. The areas under the receiver operating characteristic curve and calibration slope were 0.72 and 1.10, respectively. The areas under the receiver operating characteristic curve and calibration slope were 0.70 and 0.93 at Hennepin County Medical Center, 0.70 and 0.87 at the University of Michigan Medical Center, and 0.71 and 1.00 at Harris Health Systems, respectively. The RAM performed well stratified by age, sex, and race. CONCLUSION: We developed and validated a RAM for HA-VTE in medical inpatients. By quantifying risk, clinicians can determine the potential benefits of measures to reduce HA-VTE.

Impact of preexisting autoimmune disease on myelodysplastic syndromes outcomes: a population analysis.

Preexisting autoimmune disease affects between 10% and 30% of patients with myelodysplastic syndromes (MDS). Studies comparing outcomes in patients with MDS with and without autoimmune disease show discordant results. Using the Surveillance, Epidemiology, and End Results Medicare database, we conducted a population analysis to define the impact of autoimmunity on MDS outcomes. Cases were ascertained between 2007 and 2017 and claim algorithms used to identify autoimmune disease, demographic characteristics, comorbidity scores, MDS histology, transfusion burden, treatment with hypomethylating agents, and hematopoietic stem cell transplantation. Cox regression models estimated the impact on survival, and competing-risk regression models defined the effect on leukemic transformation. We analyzed 15 277 patients with MDS, including 2442 (16%) with preexisting autoimmune disease. The epidemiologic profile was distinctive in cases with preexisting autoimmunity, who were younger, were predominantly female, and had higher transfusion burden without difference in MDS histologic distribution. Autoimmune disease was associated with 11% decreased risk of death (hazard ratio [HR], 0.89; 95% confidence interval [CI], 0.85-0.94; P < .001). The effect on risk of leukemic transformation differed based on MDS histology. In low-risk MDS histologies, autoimmunity was associated with a 1.9-fold increased risk of leukemia (HR, 1.87; 95% CI, 1.17-2.99; P = .008), whereas no significant effect was seen in other groups. These results suggest that autoimmune disease affects survival in MDS and is associated with decreased mortality. The survival effect was evident in low-risk histologies despite higher risk of progression to leukemia. This could represent inflammation-driven hematopoiesis, simultaneously favoring less aggressive phenotypes and clonal expansion, which warrants further investigation.

Trends of Lymph Node Outcomes in Partial Cystectomy for Muscle-Invasive Urothelial Carcinoma of the Bladder.

INTRODUCTION: Local tumor invasion depth has been associated with lymph node metastasis in urothelial carcinoma, and, for muscle-invasive bladder cancer (MIBC), pelvic lymph node dissection (PLND) is a critical step in curative surgery. Gold standard treatment includes radical cystectomy (RC), but partial cystectomy (PC) is an important bladder-preserving modality reserved for patients with certain favorable prognostic indicators. There is poor evidence concerning the utility of PLND in PC and we seek to further define its role by comparing survival outcomes when PLND was cursory or omitted. METHODS: A retrospective analysis of 13,652 cT2N0M0 patients who underwent PC or RC between 2004 and 2016 was performed using the National Cancer Database. Patients undergoing PC were stratified by the presence of PLND as well as by node yield >15. The primary outcome was overall survival, analyzed using the Kaplan-Meier Method and multivariable Cox-proportional hazards regression. Multivariable models were adjusted for confounding clinicopathologic variables. RESULTS: From 2004 to 2016, PLND in PC increased from 44% to 57% with RC remaining over 90%. Compared to RC, PC was approximately twice as likely to be performed at community centers and approached laparoscopically/robotically (P < .001). When stratifying PC PLND yield into 1 to 15 and > 15 compared to PC without PLND, the adjusted hazard ratios for overall mortality were 0.78 and 0.54, respectively (P < .05). CONCLUSIONS: PC patients had a significantly lower rate of PLND compared to RC and improved survival when performed versus PC alone. Furthermore, increased node yield was associated with a larger reduction of adjusted mortality hazard. For MIBC patients that are appropriately selected for PC, high-yield PLND should be prioritized given the significantly improved survival outcomes.

Impact of Minimally Invasive Approach to Radical Cystectomy in Bladder Cancer Patients with Malnutrition.

Malnutrition is associated with higher rates of complications following radical cystectomy (RC) for the treatment of muscle-invasive bladder cancer. The newer robotic approach to RC has yet to be analyzed against the open approach in malnourished patients with respect to perioperative complications. A retrospective cohort analysis of RC patients with a postoperative diagnosis of bladder cancer and non-disseminated disease was performed. Malnourishment was defined as either low serum albumin (<3.5 g/dL), >10% 6-month preoperative weight loss, or BMI <18.5 kg/m2). Multivariable and generalized logistic regression were used for categorical and continuous outcomes respectively. Malnourishment was associated with greater systemic sepsis, bleeding transfusions, 30-day mortality, postoperative C. difficile infection, and days from operation to discharge (DOD) (all P < 0.05). In malnourished patients, robotic approach was associated with lower adjusted odds of bleeding transfusions (aOR = 0.51, P < 0.05) and fewer adjusted days from operation to discharge (ß[SE]= -5.2[1.1], P < 0.05) compared to open. Typical benefits seen with minimally-invasive robotic surgery translate to malnourished patients, although they were still prone to longer hospital stay than their adequately nourished counterparts. Robotic approach to RC may help mitigate the increased need for transfusions and longer DOD seen in malnourishment and may be preferable for patients with preoperative nutritional deficits.

Outcome and Timing of Ostomy Reversal Surgery for Diverticular Disease in Veterans Administration Hospitals.

BACKGROUND: Veterans undergoing elective surgery for diverticular disease have an ostomy creation rate of 18%. The purpose of this study was to analyze the outcomes and timing of ostomy reversal surgery, perioperative complications, and differences between colostomy and ileostomy reversal outcomes. METHODS: A retrospective review of the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database was performed. Patients undergoing elective colectomy for diverticular disease between 2004 and 2018 were identified. Demographics, comorbidities, ostomy type, time to reversal, and postoperative complications were analyzed. RESULTS: 4,198 patients underwent elective colectomy for diverticular disease, with 751 patients (17.9%) receiving an ostomy. Of patients who received an ostomy, 407 had ostomy reversal surgery within the Veterans Health Administration system (54.2%), with 243 colostomies, 149 ileostomies, and 15 unspecified. Median time to ostomy reversal was 5.0 months (interquartile range 3.2, 7.8). Complication rate after reversal was 23.1%; surgical site infection was most common (9.1%). Patients with American Society of Anesthesiologists classification >3 (adjusted odds ratio (aOR) = .40[.22-.72]), increasing age (aOR = .98[.97-.99]), laparoscopic index procedure (aOR = .42[.27-.63]), and hypertension (aOR = .63[.46-.87]) were less likely to have their ostomy reversed. There were no differences in postoperative complication rates after ostomy vs ileostomy reversals. Reversals after 4.6 months were associated with 3.4-times higher odds of complications. CONCLUSION: Ostomy creation and reversal rates are similar between the veteran and non-veteran populations in the United States. Delays in reversal surgery were associated with worse postoperative outcomes, which underscore the importance of close follow-up for patients with an ostomy after elective colectomy for diverticular disease.

Geographic disparities in cardiovascular mortality among patients with myelodysplastic syndromes: A population-based analysis.

INTRODUCTION: Clonal hematopoiesis, a precursor to myelodysplastic syndromes (MDS), constitutes a novel cardiovascular disease (CVD) risk factor, causing growing interest in cardiovascular outcomes in MDS. Rurality is associated with increased CVD but studies on cardiovascular geographic disparities in MDS are lacking. METHODS: Using the U.S. Surveillance, Epidemiology, and End Results (SEER) registry, we identified 52,750 MDS patients between 2001 and 2016. Rurality was defined using Rural-Urban Continuum Codes. Cox regression estimated the association of rurality and cardiovascular death. RESULTS: MDS incidence was equal in urban and rural populations (6.7 per 100,000). Crude probability of cardiovascular death was higher among rural MDS patients. Adjusting for age, sex, race/ethnicity, marital status, insurance, and MDS risk (defined from histology), rural patients had 12% increased risk of CVD death compared to urban patients (HR=1.12, 95%CI 1.03-1.21). HR for CVD death was 1.22 (95%CI 1.01-1.5) in patients from the most rural areas (less than 2500 urban population). Among MDS patients younger than 65 years, rurality was associated with 25% increased risk of CVD death (HR=1.25, 95%CI 1.01-1.59). DISCUSSION: This population-based analysis suggests that rural residence is linked to higher burden of cardiovascular death in patients with MDS. The disparity is not explained by demographic factors or MDS risk. Interventions targeting CVD may improve outcomes in rural MDS patients.

Association of Preoperative Glycosylated Hemoglobin Level with 30-Day Outcomes Following Laparoscopic Roux-en-Y Gastric Bypass: an Analysis of the ACS-MBSAQIP Database.

PURPOSE: Elevated glycosylated hemoglobin (HbA1c) levels have been associated with increased morbidity and mortality following several cardiac, colorectal, orthopedic, and vascular surgery operations. The purpose of this study was to determine if there is a HgA1c cut-point that can be used in patients undergoing laparoscopic Roux-en-Y gastric bypass to decrease the risk of 30-day wound events and additional 30-day morbidity and mortality. MATERIALS AND METHODS: All patients undergoing first-time, elective Roux-en-Y gastric bypass in 2017 and 2018 with a diagnosis of diabetes mellitus (DM) and a preoperative HbA1c level were identified within the American College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (ACS-MBSAQIP) database. The association of preoperative HbA1c levels with 30-day morbidity and mortality was investigated. RESULTS: A total of 13,806 patients met inclusion criteria. Two natural HbA1c inflection points for composite wound events, including superficial, deep, and organ space surgical site infections (SSI) and wound dehiscence, were found. A HbA1c level of ≤ 6.5% was associated with a decreased odds of experiencing the composite 30-day wound event outcome while a HbA1c level of > 8.6% was associated with an increased odds of experiencing the composite 30-day wound event outcome. The differences in the incidence of the 30-day composite wound event outcomes were driven primarily by superficial and organ space SSI, including anastomotic leaks. CONCLUSION: Patients with DM being evaluated for RYGB surgery with a HbA1c level > 8.6% are at an increased risk for 30-day wound events, including superficial and organ space SSI.

Risk factors for cerebrovascular accident after isolated coronary artery bypass grafting in Veterans.

BACKGROUND: Cerebrovascular accident (CVA) after coronary artery bypass grafting (CABG) is a devastating complication. Patient comorbidities and intraoperative elements contribute to the risk of CVA. The aim of this study is to identify risk factors for CVA in Veterans undergoing CABG. METHODS: Veterans undergoing isolated CABG from 2008 to 2019 were retrospectively identified using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Thirty-day postoperative outcomes were observed. Univariate analysis followed by multivariable logistic regression identified independent risk factors for postoperative CVA. Receiver operating characteristic diagnostics identified optimal inflection points between continuous risk factors and odds of CVA. RESULTS: Twenty-eight thousand seven hundred fifty-seven patients met inclusion criteria. Incidence of CVA was 1.1% (310 cases). In multivariate analysis, preoperative cerebrovascular disease had the strongest association with postoperative CVA (adjusted odds ratio = 2.29; p < .001). There was an inverse relationship between CVA incidence and ejection fraction (EF), with EF of 35%-39% conferring a 2.11 times higher risk compared to EF >55% (p < .001). CVA incidence was not different in on-pump versus off-pump cases; however, after 104 min or more on bypass patients had a 55% greater adjusted odds of CVA (p < .001). Other risk factors included poor kidney function, prior myocardial infarction, and intra-aortic balloon pump use. CONCLUSION: The risk of CVA after CABG is multifactorial and involves multiple organ systems, including cardiac disease, poor renal function, and cerebrovascular disease, which was the strongest contributing risk factor. Optimization of these comorbidities and time on bypass may help improve clinical outcomes and lower the risk of this devastating complication.

Robotic Foregut Surgery in the Veterans Health Administration: Increasing Prevalence, Decreasing Operative Time, and Improving Outcomes.

BACKGROUND: Historically, robotic surgery incurs longer operative times, higher costs, and nonsuperior outcomes compared with laparoscopic surgery. However, in areas of limited visibility and decreased accessibility such as the gastroesophageal junction, robotic platforms may improve visualization and facilitate dissection. This study compares 30-day outcomes between robotic-assisted foregut surgery (RAF) and laparoscopic-assisted foregut surgery in the Veterans Health Administration. STUDY DESIGN: This is a retrospective review of the Veterans Affairs Quality Improvement Program database. Patients undergoing laparoscopic-assisted foregut surgery and RAF were identified using CPT codes 43280, 43281, 43282, and robotic modifier S2900. Multivariable logistic regression and multivariable generalized linear models were used to analyze the independent association between surgical approach and outcomes of interest. RESULTS: A total of 9,355 veterans underwent minimally invasive fundoplication from 2008 to 2019. RAF was used in 5,392 cases (57.6%): 1.63% of cases in 2008 to 83.41% of cases in 2019. After adjusting for confounding covariates, relative to laparoscopic-assisted foregut surgery, RAF was significantly associated with decreased adjusted odds of pulmonary complications (adjusted odds ratio [aOR] 0.44, p < 0.001), acute renal failure (aOR 0.14, p = 0.046), venous thromboembolism (aOR 0.44, p = 0.009) and increased odds of infectious complications (aOR 1.60, p = 0.017). RAF was associated with an adjusted mean ± SD of 29 ± 2-minute shorter operative time (332 minutes vs 361 minutes; p < 0.001). CONCLUSIONS: Veterans undergoing RAF ascertained shorter operative times and reduced complications vs laparoscopy. As surgeons use the robotic platform, clinical outcomes and operative times continue to improve, particularly in operations where extra articulation in confined spaces is required.

Comparison of One-day Combined versus Staged Anterior and Posterior Cervical Decompression, Fixation, and Fusion.

AIM: To compare the perioperative outcomes between single-day combined or separate-day staged surgeries for cervical spinal stenosis. MATERIAL AND METHODS: A retrospective cohort analysis was conducted on consecutive patients admitted at a single institution between July 2015 and April 2019, who underwent either single-day combined or separate-day staged surgeries during the same hospitalization period. Demographics, comorbidities, hospital length of stay, and perioperative complications were compared between the patient groups. RESULTS: Eighty patients (combined surgery: n=68, staged surgery: n=12) were included. Dysphagia was the most commonly reported postoperative complication in 44/80 patients (55%). There were no significant differences in the baseline demographics between the two groups. The staged surgery group had significantly longer total time in the operating room (7.2 vs. 8.5 hours, p=0.002), longer duration of general anesthesia (6.7 vs. 7.6 hours, p=0.006), and higher incidence of postoperative delirium (12.1% vs. 50% p=0.005) than the combined surgery group. The mean hospital length of stay was similar in the two groups (combined surgery: 7.5 days vs. staged surgery: 15.1 days, p=0.09). CONCLUSION: Staged anterior and posterior cervical decompressions, stabilizations, and fusions are associated with longer total time in the operating room, longer duration of general anesthesia, and higher incidence of postoperative delirium than combined surgeries.

Validation of the cumulative deficit theory in bariatric surgery: new bariatric frailty score is associated with non-home discharge, prolonged hospital stay and mortality in the era of fast-track bariatric surgery.

BACKGROUND: Frailty is a wasting disorder that can coexist with obesity, thus, the term "obese frailty syndrome". Frailty can be measured using the cumulative deficit model demonstrated in the Canadian Study of Health and Aging-Frailty Index (CSHA-FI). OBJECTIVES: To develop a Bariatric Frailty Score (BFS) to predict 30-day adverse postoperative outcomes. SETTING: University hospital. METHODS: Patients (aged 18-80 yr) who underwent sleeve gastrectomy (SG) and Roux-en-Y-gastric bypass (RYGB) were included using the 2015-2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Fourteen variables of the CSHA-FI were mapped onto 10 variables of MBSAQIP (each component equal 1 point). Correlations and multivariate logistical regression analysis were performed between BFS and 4 postoperative outcomes (non-home discharge, mortality, prolonged hospital stay, and ICU admissions). Finally, a propensity matching score (PSM) between low BFS (0-4) and high BFS (5-10) was performed. RESULTS: In 650,882 patients (72% SG, 28% RYGB), the increasing BFS was strongly correlated on linear regression. In the multivariate analysis, scores of 5, 6, and 7 strongly predicted the 4 postoperative outcomes of interest. After the PSM, high BFS (5-10) was associated with an increased rate of postoperative complications in SG and RYGB groups. CONCLUSION: Our BFS is a better predictor of non-home discharge, prolonged hospital stay, mortality, and unplanned ICU admission compared with age >60 years or American Society of Anesthesiologists (ASA) score of IV-V. Our study validated the cumulative deficit theory in bariatric surgery, implying that the cumulative effects of the existing co-morbidities are higher than if these co-morbidities were simply added.

Incidence, Mortality, and Treatment Patterns of Synchronous Lower Genital Tract Squamous Cell Carcinoma.

OBJECTIVE: The aim of the study was to define the incidence, prognosis, and treatment patterns associated with synchronous lower genital tract squamous cell carcinoma (LGTSCC) among women diagnosed with any LGTSCC. MATERIALS AND METHODS: Surveillance, Epidemiology, and End Results (SEER) database patients diagnosed with synchronous cervical, vaginal, vulvar, and/or anal SCC from 2000 to 2016 were included. Incidence and mortality were evaluated using Kaplan-Meier curves. Multivariable Cox proportional hazards regression was used to identify treatment patterns, risk factors, and mortality associated with LGTSCC. RESULTS: Among 15,424 women with LGTSCC, 138 had synchronous LGTSCC (0.89%). Vulvar and vaginal SCC was the most common combination (49.3%), and cervical with anal SCC was the least common (1.4%). Only one patient had 3 or more primary LGTSCC. Synchronous LGTSCC was independently associated with higher mortality compared with single-site LGTSCC (adjusted hazards ratio [aHR] = 1.67; p < .001). Synchronous LGTSCC was significantly associated with older age (63 vs. 58 years, p < .001) and lower stage (adjusted odds ratio [aOR] = 0.38; p < .001) and grade of disease (aOR = 0.32; p < .001). Patients with synchronous LGTSCC were more likely to receive radiation (aOR = 1.74; p = .005) and were more likely to receive adjuvant radiation after primary surgical resection compared with single-site LGTSCC (aOR = 1.88; p = .007). Receipt of any treatment including radiation (aHR = 0.85; p < .001), chemotherapy (aHR = 0.50; p < .001), and surgery (aHR = 0.70; p < .001) was independently associated with decreased mortality hazard. CONCLUSIONS: Synchronous LGTSCC is rare but is associated with increased mortality and higher rates of adjuvant radiation compared with single-site LGTSCC despite lower stage and grade at diagnosis. More research is needed to define optimal therapy for these patients.

Hospital Operative Volume and Esophagectomy Outcomes in the Veterans Affairs System.

INTRODUCTION: Previous studies reported that increased hospital case volume improves outcomes after esophagectomy. Yet, the standard for high and low-volume hospitals varies in the literature. This study attempts to define the relationship between hospital operative volume and 30-day post-operative outcomes of esophagectomy in the Veterans Affairs (VA) system. METHODS: This is a retrospective review of patients that underwent esophagectomy from 2008 to 2019 utilizing the Veterans Affairs Surgical Quality Improvement Program Database. Receiver operating characteristic (ROC) analysis quantified an inflection point of optimal association between 30-day morbidity and mortality by facility volume. This point was used to separate cohorts for comparison of outcomes using 1:1 propensity score matching (PSM) to account for confounding covariates. RESULTS: Two thousand two hundred and twelve esophagectomies were performed from 2008 to 2019 and ROC analysis identified an inflection point at 43 cases (4 cases/y) where bidirectional operative volume significantly affected outcomes. Subsequent PSM resulted in 1718 cases utilized for analysis (n = 859 per cohort). Facility volume ≥4 cases/y was significantly associated with decreased odds of 30-day mortality (odds ratio(OR) = 0.57; P = 0.03), shorter length of stay (median 13 versus 14 d; P = 0.04) and longer operative times (6.5 versus 6.0 h; P < 0.001). CONCLUSIONS: VA hospitals that averaged ≥4 esophagectomies/y had significantly lower rates of mortality and length of stay. This volume threshold may serve as a benchmark to determine the optimal setting for esophageal resection. However, our findings also may reflect the benefits of cumulative operating room and multidisciplinary team experience at VA centers in conjunction with dedicated surgeons. Future studies should focus on long-term outcomes after esophagectomy in relation to hospital operative volume.

Consumer Perspectives on and Utilization of Medical Cannabis to Treat Dermatologic Conditions.

BACKGROUND: Access to medical cannabis products (MCPs) has rapidly increased though literature on consumer behaviors and attitudes with regards to dermatologic use is limited. OBJECTIVE: We sought to address the gap of knowledge regarding consumer utilization and perspectives surrounding MCPs for dermatologic indications. METHODS: A survey was emailed via SurveyMonkey’s platform to adult users of their rewards panel asking about usage patterns and beliefs regarding MCP use to treat dermatologic conditions. RESULTS: 504 of 700 survey invitations sent out were completed (72% response rate). 17.6% of respondents used an over-the-counter (OTC) cannabis product without dermatologist recommendation to treat a skin condition [most common indications: acne (28.4%) and psoriasis (26.1%)]. Of those who had seen a dermatologist, 15.3% used an OTC product [most common indications: psoriasis (32%) and rosacea (30%)] and 7.8% used an MCP which required a Department of Health-approved card per their dermatologist’s recommendations [most common indications: acne (68%) and psoriasis (28%)]. 11.8% of respondents were not comfortable seeing a dermatologist who recommended MCPs. LIMITATIONS: Limitations include small sample size as well as selection bias. CONCLUSION: Consumers are interested in and are using MCPs for dermatologic indications, most commonly for inflammatory skin disorders. Targeted education for dermatologists is recommended. J Drugs Dermatol. 2022;21(1):31-36. doi:10.36849/JDD.6540.

Disparities in utilization of robotic surgery for colon cancer: an evaluation of the U.S. National Cancer Database.

Despite the benefits of minimally invasive surgery for colorectal procedures, significant disparities in access to these techniques remain. While these gaps have been well-documented for laparoscopy, few studies have evaluated inequalities in access to robotic surgery. We analyze whether disparities exist in the use of robotic surgery in the management of colon cancer. The U.S. National Cancer Database was queried for patients with non-metastatic colon adenocarcinoma who underwent resection with the robotic platform (2010-2016). Demographic, clinicopathologic, and treatment facility-related variables were analyzed with respect to preferential utilization of robotic surgery with multivariable logistic regression. Patients with metastatic disease, missing or incomplete surgical information, and those who underwent local tumor excision were excluded. 74,984 patients were identified, 3001 (4%) of whom underwent robotic surgery. In multivariable analysis, patients who were older, Black, or were living in an urban area had decreased odds of receiving robotic surgery compared with open or laparoscopic surgery. Patients who were privately insured or living in areas with higher education had increased odds of receiving robotic surgery. Robotic surgery was also preferentially associated with lower clinical stage, more recent year of diagnosis, and hospitals with higher procedural volume. As advantages of the robotic platform are becoming better understood, use of this approach is increasing in popularity for treatment of non-metastatic colon cancer. Despite this, significant disparities exist with respect to patient demographics and socioeconomic factors, and access may only be limited to certain types of hospitals. Further studies are needed to define why these inequalities exist.

Impact of Variant Histology on Occult Nodal Metastasis after Neoadjuvant Chemotherapy for Muscle-Invasive Bladder Cancer: A Review of the National Cancer Database.

Up to 14% of bladder urothelial carcinoma has variant histology (VH), which is associated with a higher incidence of occult regional lymph node metastasis. Neoadjuvant chemotherapy (NAC) is the gold-standard for resectable cT2-4 disease as it achieves pathologic complete response (pCR) in select patients at the time of radical cystectomy (RC). A landmark trial demonstrated chemosensitivity and pT0 status in the setting of VH. pT0N+ pathology in patients undergoing subsequent RC has prompted concerns about post-chemotherapy bladder preservation. We investigate how VH impacts pathologic primary site and nodal downstaging post-NAC. We queried the National Cancer Database for cT2-4N0M0 patients who underwent NAC and RC between 2004 and 2016. These patients were stratified into pure urothelial cell carcinoma (UCC) and VH. The rate of downstaging to ≤pT1 was analyzed, along with pN+ status. Overall survival was analyzed using the Kaplan-Meier method and multivariable Cox proportional hazards regression model. Multivariable models were adjusted for demographic and clinicopathologic variables. Of 5,335 patients, 92.1% were UCC and 7.9% VH. UCC was associated with better unadjusted survival and lower adjusted odds of being pN+ (aOR = 0.60, P < .001). Squamous cell, glandular, and sarcomatoid histologies were significantly associated with decreased adjusted odds of any pT downstage. Neuroendocrine histology (NE) trended towards increased adjusted odds of downstage to pT0N0. Patients with VH were more likely to harbor occult regional lymph node metastasis in the setting of intravesical pCR. NE had the highest pT0N0 rate, with potential implications on post-NAC bladder preservation. These findings reinforce the role of RC after NAC especially for VH.

Early Chemoprophylaxis Against Venous Thromboembolism in Patients With Traumatic Brain Injury.

INTRODUCTION: Timing to start of chemoprophylaxis for venous thromboembolism (VTE) in patients with traumatic brain injury (TBI) remains controversial. We hypothesize that early administration is not associated with increased intracranial hemorrhage. METHODS: A retrospective study of adult patients with TBI following blunt injury was performed. Patients with penetrating brain injury, any moderate/severe organ injury other than the brain, need for craniotomy/craniectomy, death within 24 hours of admission, or progression of bleed on 6 hour follow-up head computed tomography scan were excluded. Patients were divided into early (≤24 hours) and late (>24 hours) cohorts based on time to initiation of chemoprophylaxis. Progression of bleed was the primary outcome. RESULTS: 264 patients were enrolled, 40% of whom were in the early cohort. The average time to VTE prophylaxis initiation was 17 hours and 47 hours in the early and late groups, respectively (P < .0001). There was no difference in progression of bleed (5.6% vs. 7%, P = .67), craniectomy/-craniotomy rate (1.9% vs. 2.5%, P = .81), or VTE rate (0% vs. 2.5%, P = .1). CONCLUSION: Early chemoprophylaxis is not associated with progression of hemorrhage or need for neurosurgical intervention in patients with TBI and a stable head CT 7 hours following injury.

Presenting Symptomatology of Mediastinal Masses and Its Effect on Surgical Outcomes.

OBJECTIVE: Mediastinal masses are commonly encountered by the thoracic surgeon. Few studies have reported on the frequency and characteristics of symptoms at presentation. The primary objective of this study is to determine how often patients present with symptoms from a mediastinal mass. The secondary objective is to determine if the presence of symptoms has an effect on outcomes after surgery. METHODS: A retrospective review of an institutional database was performed. All patients who underwent surgical resection of a mediastinal mass from 2013 to 2019 were included in the analysis. Medical records were reviewed for the presence or absence of symptoms preoperatively, and these cohorts were compared. Multivariable analysis was performed, adjusting for clinical variables to assess for differences between these cohorts. RESULTS: 70 patients underwent surgery for a mediastinal mass. The average age was 49.2 years, and 46 patients (65.7%) presented with symptoms. There were no significant differences in demographics between the symptomatic and asymptomatic groups. The most common symptom was dyspnea in 18 patients (22%), followed by chest pain (15 patients, 19%) and dysphagia (8 patients, 10%). When comparing symptomatic and asymptomatic patients, symptomatic patients had a larger tumor size (5.8 cm vs 3.8 cm, P = .04) and a longer length of stay (2.0 days vs 1.2 days, P = .02). CONCLUSIONS: The majority of patients with mediastinal masses present with symptoms, with the most common symptom being dyspnea. Symptomatic patients are more likely to have a larger tumor and tend to have a longer length of hospital stay postoperatively compared to asymptomatic patients.