Risk Factors for Suboptimal Colon Cancer Diagnosis and Management at a Safety-Net Hospital System.

INTRODUCTION: Colon cancer (CC) is the second leading cause of cancer-related deaths in the United States. Quality measures have been introduced by the American Gastroenterological Association and Commission on Cancer for optimal management of CC. In this study, we sought to identify factors that may hinder the timely diagnosis and treatment of CC at a safety-net hospital system. METHODS: Retrospective chart review was performed for patients aged ≥18 y diagnosed with CC from 2018 to 2021. Primary outcomes were time from positive fecal immunochemical test to colonoscopy, time from diagnosis to surgery, and time from diagnosis to adjuvant chemotherapy. Secondary end points were demographic characteristics associated with suboptimal outcomes in any of the above measures. RESULTS: One hundred ninety patients were diagnosed with nonmetastatic CC. The majority were Hispanic and non-English-speaking. 74.1% of patients with a positive fecal immunochemical test received a colonoscopy within 180 d. 59.6% of nonemergent cases received surgery within 60 d of diagnosis. 77% of those eligible received adjuvant chemotherapy within 120 d of diagnosis. No clinically significant demographic factor was associated with delay in colonoscopy, surgery, or adjuvant chemotherapy. Most frequent cause of delay in surgery (38.0%) was optimization of comorbidities. Most frequent cause of delay in adjuvant chemotherapy (71.4%) was delay in surgery itself. CONCLUSIONS: No clinically significant demographic factor was associated with experiencing delays in diagnostic colonoscopy, surgery, or adjuvant chemotherapy.

To Resect or Not to Resect: A Nationwide Comparison of Management of Sigmoid Volvulus.

INTRODUCTION: Despite the high recurrence rate of sigmoid volvulus, there is reluctance to perform a prophylactic colectomy in frail patients due to the operation's perceived risks. We used a nationally representative database to compare risk of recurrence in patients undergoing a prophylactic colectomy versus endoscopic detorsion alone. METHODS: We performed a retrospective cohort study using the National Readmission Database (2016-2019) including patients aged ≥18 y who had an emergent admission for sigmoid volvulus and underwent endoscopic detorsion on the day of admission. We performed a 1:1 propensity matching adjusting for patient demographics, frailty score comprising of 109 components, and hospital characteristics. Our primary outcome was readmission due to colonic volvulus and secondary outcomes included mortality, complications, length of stay (LOS), and costs during index admission and readmission. We performed a subgroup analysis in patients with Hospital Frailty Score >5. RESULTS: We included 2113 patients of which 1046 patients (49.5%) underwent a colectomy during the initial admission. In the matched population of 830 pairs, readmission due to colonic volvulus was significantly lower in patients undergoing endoscopy followed by colectomy than endoscopy alone. Patients undergoing a colectomy had higher gastric and renal complications, longer LOS, and higher costs but no difference in mortality. In the subgroup analysis of frail patients, readmission was significantly lower in patients with prophylactic colectomy with no significant difference in mortality in 439 matched patients. CONCLUSIONS: Prophylactic colectomy was associated with lower readmission, a higher rate of complications, increased LOS, and higher costs compared to sigmoid decompression alone.

Impact of neoadjuvant immunotherapy on postoperative complications after surgery for rectal cancer.

INTRODUCTION: Despite the increasing use of immunotherapy in treating various cancer types, there is still limited understanding of its impact on surgical complications. We used a national database to examine the difference in surgical outcomes for rectal cancer patients who received standard neoadjuvant chemoradiation plus neoadjuvant immunotherapy and patients who received neoadjuvant chemoradiation only. METHODS: This retrospective cohort study used the National Cancer Database (NCDB). We selected patients aged 18-90 with T1-3, N1-2, and M0 rectal cancer who underwent curative-intent surgery between 2010 and 2020. We performed a 1:1 propensity match to control for patient age, sex, Charlson-Deyo comorbidity index, surgical approach, and tumor site. Our primary outcome was difference in surgical outcomes (hospital length of stay, unplanned 30-day readmission, 30-day mortality) between the two groups. Secondary outcomes included days from diagnosis to surgery and pathologic outcomes. RESULTS: Our study included 26 229 patients, of which 126 received immunotherapy in addition to chemoradiation and 26 103 received only chemoradiation. In our matched population of 125 pairs of patients, patients who received immunotherapy and chemoradiation underwent surgery later compared to patients who only received chemoradiation (median 245 vs. 144 days, p < 0.001). There were no significant differences in median length of stay (5 vs. 5 days, p = 0.202), unplanned 30-day readmission (7 vs. 9, p = 0.617), and 30-day mortality (0 vs. 1, p = 1.000) between the two groups. CONCLUSION: Neoadjuvant immunotherapy for rectal cancer is not associated with adverse surgical outcomes. This work can help clinicians optimize treatment protocols and move closer toward strategies tailored to specific patient profiles.

Acceptability and Feasibility of Text Message Interface to Assess Parents' Real-time PICU Experiences.

INTRODUCTION: Parents of children in the pediatric intensive care unit (PICU) experience substantial stress; a parent's perception of their child's illness severity, more than objective measures, predicts psychological outcomes. No tools exist to assess parents' real-time experiences. This pilot study evaluated the feasibility and acceptability of a text-based tool to measure parental experience. METHODS: Inclusion criteria included PICU stay >48 h, physician approval, smartphone access, and English-speaking caregiver. Eligible parents received a text-based baseline survey and surveys every other day while hospitalized regarding their mood/experiences and optional open-ended questions regarding stressors. They received post-discharge follow-up surveys at 1 week and 1, 3, and 6 months. Follow-up surveys assessed mood and symptoms of depression, anxiety, and post-traumatic stress. Interviews and surveys about the interface were conducted 1 week and 3 months following discharge. Feasibility was assessed by descriptive statistics (eg, response rates), and acceptability was assessed by descriptive statistics (survey results) and thematic analyses of interviews. RESULTS: Of 20 enrolled participants, the first 5 were excluded due to technical issues. Of the 15 included, results demonstrated feasibility and acceptability. Most participants (86%) completed all surveys during the PICU stay and continued to complete surveys at a high rate: 79%-94% 3 months post-discharge. All participants agreed that the system was easy to use and were satisfied with the system at discharge, and 91% remained satisfied 3 months post-discharge. Additionally, 76% reported comfort, and 69% reported benefit. From the interviews, participants lauded the system's convenience and applicability of content. Some proposed changes to improve ergonomics. Many suggested this interface could help teams better support families. CONCLUSIONS: A text-based interface for measuring experience in the PICU is feasible and acceptable to parents. Further research can explore how this could identify parents most at risk of adverse psychological sequelae and lead to earlier supportive interventions.

Association of time to resection with survival in patients with colon cancer.

PURPOSE: Colon cancer (CC) remains a leading cause of cancer-related mortality worldwide, for which colectomy represents the standard of care. Yet, the impact of delayed resection on survival outcomes remains controversial. We assessed the association between time to surgery and 10-year survival in a national cohort of CC patients. METHODS: This retrospective cohort study identified all adults who underwent colectomy for Stage I-III CC in the 2004-2020 National Cancer Database. Those who required neoadjuvant therapy or emergent resection < 7 days from diagnosis were excluded. Patients were classified into Early (< 25 days) and Delayed (≥ 25 days) cohorts after an adjusted analysis of the relationship between time to surgery and 10-year survival. Survival at 1-, 5-, and 10-years was assessed via Kaplan-Meier analyses and Cox proportional hazard modeling, adjusting for age, sex, race, income quartile, insurance coverage, Charlson-Deyo comorbidity index, disease stage, location of tumor, receipt of adjuvant chemotherapy, as well as hospital type, location, and case volume. RESULTS: Of 165,991 patients, 84,665 (51%) were classified as Early and 81,326 (49%) Delayed. Following risk adjustment, Delayed resection was associated with similar 1-year [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.97-1.04, P = 0.72], but inferior 5- (HR 1.24, CI 1.22-1.26; P < 0.001) and 10-year survival (HR 1.22, CI 1.20-1.23; P < 0.001). Black race [adjusted odds ratio (AOR) 1.36, CI 1.31-1.41; P < 0.001], Medicaid insurance coverage (AOR 1.34, CI 1.26-1.42; P < 0.001), and care at high-volume hospitals (AOR 1.12, 95%CI 1.08-1.17; P < 0.001) were linked with greater likelihood of Delayed resection. CONCLUSIONS: Patients with CC who underwent resection ≥ 25 days following diagnosis demonstrated similar 1-year, but inferior 5- and 10-year survival, compared to those who underwent surgery within 25 days. Socioeconomic factors, including race and Medicaid insurance, were linked with greater odds of delayed resection. Efforts to balance appropriate preoperative evaluation with expedited resection are needed to optimize patient outcomes.

Hippocampal volume and volume asymmetry prospectively predict PTSD symptom emergence among Iraq-deployed soldiers.

BACKGROUND: Evidence suggests a link between smaller hippocampal volume (HV) and post-traumatic stress disorder (PTSD). However, there has been little prospective research testing this question directly and it remains unclear whether smaller HV confers risk or is a consequence of traumatization and PTSD. METHODS: U.S. soldiers (N = 107) completed a battery of clinical assessments, including structural magnetic resonance imaging pre-deployment. Once deployed they completed monthly assessments of traumatic-stressors and symptoms. We hypothesized that smaller HV would potentiate the effects of traumatic stressors on PTSD symptoms in theater. Analyses evaluated whether total HV, lateral (right v. left) HV, or HV asymmetry (right - left) moderated the effects of stressor-exposure during deployment on PTSD symptoms. RESULTS: Findings revealed no interaction between total HV and average monthly traumatic-stressors on PTSD symptoms b = -0.028, p = 0.681 [95% confidence interval (CI) -0.167 to 0.100]. However, in the context of greater exposure to average monthly traumatic stressors, greater right HV was associated with fewer PTSD symptoms b = -0.467, p = 0.023 (95% CI -0.786 to -0.013), whereas greater left HV was unexpectedly associated with greater PTSD symptoms b = 0.435, p = 0.024 (95% CI 0.028-0.715). CONCLUSIONS: Our findings highlight the importance of considering the complex role of HV, in particular HV asymmetry, in predicting the emergence of PTSD symptoms in response to war-zone trauma.

Racial Disparities in Surgical Outcomes of Acute Diverticulitis: Have We Moved the Needle?

INTRODUCTION: There has been increasing national attention on reducing healthcare disparities. Prior studies cite worse surgical outcomes and less use of laparoscopy for Black patients with diverticulitis. Re-evaluation of these disparities is lacking despite national initiatives to improve health equity. This study aimed to evaluate the association of race with short-term outcomes and surgical approaches in patients with acute diverticulitis. METHODS: The National Surgical Quality Improvement Program database was queried for patients who underwent nonelective surgery for acute diverticulitis from 2015 to 2019. Severity of presentation, morbidity, mortality, surgical approach, and ostomy creation were compared by race. RESULTS: Of the 13,996 patients included in the study, 82.4% were White, 7.6% were Black, 1.1% Asian, 0.61% American Indian/Alaska Native, and 0.20% Native Hawaiian/Pacific Islander (NH/PI). Overall 30-day morbidity was 44.3% and 30-day mortality was 3.9%. In a multivariate logistic regression analysis, compared to Whites, Black race was independently associated with higher 30-day morbidity (Odds Ratio: 1.24, 95% confidence interval: 1.07-1.43, P = 0.003) and NH/PI race was independently associated with higher mortality (Odds Ratio: 5.35, 95% confidence interval: 1.32-21.6, P = 0.019). There was no difference in complicated disease (abscess or perforation), use of laparoscopy, or ostomy creation among races. CONCLUSIONS: Despite national efforts to achieve equity in healthcare, disparities persist in surgical outcomes for those with diverticulitis. Black and NH/PI race are independently associated with increased morbidity and mortality, respectively. Use of laparoscopy, however, is no longer different by race suggesting some gaps may be closing.

Distal stenting technique for coil embolization of early branch aneurysms of middle cerebral artery.

BACKGROUND AND PURPOSE: Stent-assisted coil embolization of early branch aneurysms of the middle cerebral artery (MCA) can sometimes be challenging due to the small diameter and acute angle of the branches. This study aimed to analyze the treatment results and report the feasibility and outcomes of the distal stenting technique for these aneurysms. MATERIALS AND METHODS: The distal stenting technique was used for 15 wide-neck MCA aneurysms (females, 10; males, 5; mean age, 65.1 years) originating from the early branch between December 2018 and October 2021. The average sizes of the dome, depth, and neck of the aneurysms were 4.17 mm (range: 2.99-6.21 mm), 2.86 mm (range: 1.82-3.72 mm), and 3.42 mm (range: 2.44-4.32 mm), respectively. RESULTS: The average diameter of the stents was 4.0 mm (3.0 mm, 3; 4.0 mm, 6; 4.5 mm, 6). Stents were successfully deployed in all 15 aneurysms (100%). The average length of the procedure was 69 min (range: 45-117 min). On postoperative angiography, nine (60.0%) aneurysms were completely occluded, four (26.7%) had neck remnants, and two (13.3%) had contrast flow in the sac. During the procedure, vasospasm and thrombus formation occurred in one case each, but no neurological sequelae were observed. On follow-up digital subtraction angiography of the 10 aneurysms after an average of 13.7 months (range: 12-18 months), the branches were well preserved, and neck remnants were noted in four aneurysms (40.0%). No thromboembolic events occurred during the clinical follow-up. CONCLUSION: The distal stenting technique using an open-cell stent can be a good option for coil embolization of early branch MCA aneurysms.

A Rapid Prototyping Method for Sub-MHz Single-Element Piezoelectric Transducers by Using 3D-Printed Components.

We present a rapid prototyping method for sub-megahertz single-element piezoelectric transducers by using 3D-printed components. In most of the early research phases of applying new sonication ideas, the prototyping quickness is prioritized over the final packaging quality, since the quickness of preliminary demonstration is crucial for promptly determining specific aims and feasible research approaches. We aim to develop a rapid prototyping method for functional ultrasonic transducers to overcome the current long lead time (>a few weeks). Here, we used 3D-printed external housing parts considering a single matching layer and either air backing or epoxy-composite backing (acoustic impedance > 5 MRayl). By molding a single matching layer on the top surface of a piezoceramic in a 3D-printed housing, an entire packaging time was significantly reduced (<26 h) compared to the conventional methods with grinding, stacking, and bonding. We demonstrated this prototyping method for 590-kHz single-element, rectangular-aperture transducers for moderate pressure amplitudes (mechanical index > 1) at focus with temporal pulse controllability (maximum amplitude by <5-cycle burst). We adopted an air-backing design (Type A) for efficient pressure outputs, and bandwidth improvement was tested by a tungsten-composite-backing (Type B) design. The acoustic characterization results showed that the type A prototype provided 3.3 kPa/Vpp far-field transmitting sensitivity with 25.3% fractional bandwidth whereas the type B transducer showed 2.1 kPa/Vpp transmitting sensitivity with 43.3% fractional bandwidth. As this method provided discernable quickness and cost efficiency, this detailed rapid prototyping guideline can be useful for early-phase sonication projects, such as multi-element therapeutic ultrasound array and micro/nanomedicine testing benchtop device prototyping.

Neuroprotective Effect and Antioxidant Potency of Fermented Cultured Wild Ginseng Root Extracts of Panax ginseng C.A. Meyer in Mice.

Wild ginseng has better pharmacological effects than cultivated ginseng. However, its industrialization is limited by the inability to grow wild ginseng on a large scale. Herein, we demonstrate how to optimize ginseng production through cultivation, and how to enhance the concentrations of specific ginsenosides through fermentation. In the study, we also evaluated the ability of fermented cultured wild ginseng root extract (HLJG0701-ß) to inhibit acetylcholinesterase (AChE), as well as its neuroprotective effects and antioxidant activity. In invitro tests, HLJG0701-ß inhibited AChE activity and exerted neuroprotective and antioxidant effects (showing increased catalyst activity but decreased reactive oxygen species concentration). In invivo tests, after HLJG0701-ß was orally administered at doses of 0, 125, 250, and 500 mg/kg in an animal model of memory impairment, behavioral evaluation (Morris water maze test and Y-maze task test) was performed. The levels of AChE, acetylcholine (ACh), blood catalase (CAT), and malondialdehyde (MDA) in brain tissues were measured. The results showed that HLJG0701-ß produced the best results at a dose of 250 mg/kg or more. The neuroprotective mechanism of HLJG0701-ß was determined to involve the inhibition of AChE activity and a decrease in oxidative stress. In summary, both invitro and invivo tests confirmed that HJG0701-ß administration can lead to memory improvement.

Delayed urinary bladder perforation in a hostile post-radiation pelvis.

The radiation-induced injury to normal tissue is a well-described phenomenon that incites tissue hypoxia, vascular damage, and parenchymal cell death. In addition to the morbidity caused by the radiation-induced injury itself, surgical management adds to the overall morbidity in these patients. We herein present a case demonstrating challenges of surgical management of urological complications in a radiated pelvis including delayed bladder perforation, recurrence of vesicovaginal fistula, and ureteral stricture. Nonoperative management strategies should be exhausted prior to surgical intervention.

Steps to Develop a Mobile App for Pain Assessment of Cancer Patients: A Usability Study.

Health-related mobile apps have the potential to allow patients and providers to proactively and responsibly manage pain together. However, there is a gap between the science of pain and current mobile apps. To develop a prototype science-based pain assessment mobile app (PainSmart) for Android smartphones, pain assessment tasks were extracted from a clinical guideline. These tasks were then converted to activity diagrams and became the logic of PainSmart. Five participants diagnosed with breast cancer evaluated usability of PainSmart with the System Usability Scale. Patient experience was recorded using Camtasia Studio Version 9 software. The five participants were able to explore the pain app after only 20 minutes of training. Using the System Usability Scale with comments, participant mean usability score was 77.5; above 68 is considered an above average system. A prototype of a pain assessment mobile app for cancer patients demonstrated high usability and will be refined based on participant feedback.

Repair of Parastomal Hernia with Component Separation at Reversal of Loop Ileostomy. A technical note.

AIM: The aim of this technical note is to describe a surgical technique to repair parastomal hernias with component separation and mesh at reversal of loop ileostomy. BACKGROUND: Stage III rectal cancer patients who have completed neoadjuvant chemoradiation will undergo low anterior resection with loop ileostomy. Following completion of adjuvant chemotherapy, the ileostomy will be reversed after an average of five to six months. A minority of patients presenting with an obstructed rectal cancer may undergo laparoscopic loop ileostomy prior to commencing neoadjuvant chemoradiation, resulting in a longer ileostomy time. TECHNIQUE: Loop ileostomy reversal consists of five steps: mobilization of the stoma, side-to-side anastomosis, component separation, placement of biologic mesh, and purse-string skin closure. CONCLUSION: The surgical technique described here, consisting of component separation and mesh at loop ileostomy reversal, is effective for repairing parastomal hernia.

Double-barreled Wet Colostomy Versus Separate Urinary and Fecal Diversion in Patients Undergoing Total Pelvic Exenteration: A Cohort Meta-analysis.

BACKGROUND: The aim of this meta-analysis was to determine whether double-barreled wet colostomy (DBWC) provides similar urinary tract infection rates as separate urinary and fecal diversion (SUFD) in patients undergoing pelvic exenteration. METHODS: The MEDLINE, PubMed, Cochrane Library, and Scopus databases were systematically searched by two independent researchers. The primary endpoint was the urinary tract infection rate. The Mantel-Haenszel method with odds ratios with 95% confidence intervals (OR (95%CI)) was used as an effect measure for dichotomous variables. A random-effects model was used for the meta-analysis. Statistical heterogeneity among effect estimates was evaluated using I2 and Tau2. RESULTS: Three observational studies that included a total of 257 patients (159 DBWC; 98 SUFD) were included after 14 potentially eligible records were screened. Pooled urinary tract infection rates were 1.9% (3/159) in DBWC and 6.1% (6/98) in SUFD. This difference was not statistically significant [OR (95%CI) = 0.27 (0.06, 1.19); p=0.08] with low among-study heterogeneity (I2=0%). CONCLUSIONS: This meta-analysis did not find a significant difference in urinary tract infection rates between DBWC and SUFD in patients undergoing total pelvic exenteration. Further clinical studies will be required to further understand the pros and cons of these procedures.

Predictors of acute outcomes for intensive residential treatment of obsessive-compulsive disorder.

For those who suffer with chronic and disruptive obsessive-compulsive disorder (OCD), who have not been sufficiently helped by outpatient treatments or medications, intensive residential treatment (IRT) is often the next best treatment option. To date, research of the predictors of treatment outcome in IRT for OCD are mixed and sometimes contradictory. Additionally, although comorbidity is common for patients in this setting, the inclusion of comorbidity as a potential predictor of outcome has been mostly lacking in research to date. The current study aimed to address these issues by utilizing optimal indices of treatment outcomes, while incorporating comorbidity into our analyses, in order to identify the predictors of treatment outcomes in the IRT for OCD setting. To this end, we analysed outcome data from 379 patients receiving IRT for OCD at the Rogers Memorial OCD Center between August 2012, and December 2017. Results indicated that the most important predictor of treatment outcome was obsession severity at admission. Specifically, higher obsession severity at admission predicted poorer treatment outcomes at discharge. Clinical implications and suggestions for future research were discussed in the manuscript.

Noncontact Strain Monitoring of Osseointegrated Prostheses.

The objective of this study was to develop a noncontact, noninvasive, imaging system for monitoring the strain and deformation states of osseointegrated prostheses. The proposed sensing methodology comprised of two parts. First, a passive thin film was designed such that its electrical permittivity increases in tandem with applied tensile loading and decreases while unloading. It was found that patterning the thin films could enhance their dielectric property's sensitivity to strain. The film can be deposited onto prosthesis surfaces as an external coating prior to implant. Second, an electrical capacitance tomography (ECT) measurement technique and reconstruction algorithm were implemented to capture strain-induced changes in the dielectric property of nanocomposite-coated prosthesis phantoms when subjected to different loading scenarios. The preliminary results showed that ECT, when coupled with strain-sensitive nanocomposites, could quantify the strain-induced changes in the dielectric property of thin film-coated prosthesis phantoms. The results suggested that ECT coupled with embedded thin films could serve as a new noncontact strain sensing method for scenarios when tethered strain sensors cannot be used or instrumented, especially in the case of osseointegrated prostheses.