Micronutrient deficiencies in older patients with inflammatory bowel disease are not associated with worse adverse clinical outcome rates.

Background: Micronutrient deficiencies (MNDs) and age have been previously separately associated with adverse clinical outcomes in patients with inflammatory bowel disease (IBD). However, previous clinical outcomes in older patients with MNDs have been poorly described. We examined the age-related rates of adverse clinical outcomes in patients with 1 or more MNDs. Methods: We conducted a single-institution retrospective cohort study of 204 patients with IBD. Patients were divided into age-related cohorts: 1) younger adults aged 18-59; and 2) older adults aged ≥60 years. Patients were further delineated based upon the presence of zinc, vitamin D, vitamin B12, folate, and iron deficiency. We examined the age-related associations between MNDs and adverse clinical outcomes. Primary outcomes included subsequent corticosteroid use, combined intestinal complication (intra-abdominal abscess, intestinal stricture, internal fistula, perianal disease), IBD-related surgery, IBD-related hospitalization, and a composite clinical outcome. Statistical analyses included the Wilcoxon rank-sum test, chi-squared analysis, Fisher's exact test, and logistic regression. Results: Vitamin D (61.5%), iron (46.4%), and zinc (40.5%) deficiencies were common in older IBD patients, but were not significantly more prevalent. Older patients with 1 or more MNDs did not experience increased rates of adverse clinical outcomes. However, vitamin D, iron, and having multiple MNDs were associated with adverse clinical outcomes in the younger cohort. Conclusions: Vitamin D, iron and zinc deficiencies are common in IBD patients. In younger patients, vitamin D, iron, and multiple MNDs were associated with adverse clinical outcomes, but the same trend was not seen with MNDs in older patients.

Tamsulosin and Time to Spontaneous Void After Hysterectomy: A Randomized Controlled Trial.

OBJECTIVE: To evaluate whether a single preoperative dose of tamsulosin reduces the time to postoperative void and time to discharge in patients who are undergoing minimally invasive hysterectomy. METHODS: This single-center, block-randomized, placebo-controlled, double-blind superiority trial evaluated the effect of 0.4 mg tamsulosin compared with placebo on the time to void after hysterectomy. Patients who underwent outpatient minimally invasive hysterectomy were randomized to a single dose of tamsulosin or placebo 1 hour before surgery. All participants underwent a standardized backfill void trial to eliminate discrepancies in bladder volume that would otherwise affect the time to void. For our primary aim, we planned to enroll 150 participants to show a 30-minute reduction in the time to postoperative void (80% power, α<0.05). The secondary aim was to compare the time to discharge from the postanesthesia care unit. RESULTS: From June 2021 through January 2023, 344 patients were screened, and 150 were included in the final data analysis: 77 in the tamsulosin group and 73 in the placebo group. The time to spontaneous void was not different between the tamsulosin and placebo groups (106 minutes vs 100 minutes, P=.5). In addition, there was no statistical difference in time to discharge from the postanesthesia care unit (144 minutes vs 156 minutes, P=.4). Demographics and surgical details were not different between each group. CONCLUSION: A single dose of tamsulosin preoperatively does not lead to a decrease in postoperative time to void or time to discharge in patients undergoing minimally invasive hysterectomy for benign conditions. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT04859660.

A survey of the members of the American Society of Pediatric Neurosurgeons and factors associated with well-being.

OBJECTIVE: The goal of this study was to survey the members of the American Society of Pediatric Neurosurgeons (ASPN) to assess the prevalence and associated risks of burnout among pediatric neurosurgeons. The authors aimed to identify the factors that most significantly contributed to this risk to provide a baseline group of characteristics to improve physician well-being. METHODS: Institutional Review Board approval from the University of Arizona was obtained, and the 7-question and 9-question Mayo Physician Well-Being Index (WBI) was distributed to members of the ASPN (n = 275). This index screens for many different aspects of distress for physicians, including burnout risk, stress, depression, fatigue, suicidal ideation, and low career satisfaction. RESULTS: An analysis of 111 pediatric neurosurgeons (111/275 [40% response rate]) was completed. Respondent ages were distributed, with those aged 56-60 years representing the highest proportion (20%). University practice represented a majority (72%). One-third (32%) of respondents reported practicing greater than 25 years, and most physicians in the survey were married (76%). One-third of surgeons spend 61-70 hours working per week (33%), and a plurality are on call between 6 and 10 days per month (42%). Most surgeons reported treating fewer than 200 cases per year (37% reported 100-150 cases; 23%, 151-200). Most pediatric neurosurgeons (63%) stated their annual salary was sufficient. Analysis of each WBI question was performed to identify which factors specifically contributed to the risk of burnout. An overwhelming majority of respondents reported that they make significant efforts to do at least one thing each week that brings them joy (97%), and they either agree or strongly agree that they perform meaningful work (98% of all participants, 97% of females, and 98% of men, p = 0.010). Nearly half of all respondents (49%) reported feelings of burnout and a majority of them were female (67% of women and 42% of men, p = 0.021). Time, environment, case volumes, and quality-of-life concerns are all factors that significantly contribute to the overall risk of burnout and well-being. CONCLUSIONS: This survey study of the ASPN membership revealed a 49% rate of burnout with females at higher risk (67%). Factors associated with burnout were salary, more than 10 days on call per month, electronic medical record stressors, and work-life incongruity. The aforementioned notwithstanding, respondents believe pediatric neurosurgery is a meaningful career. This study provides evidence supporting a moral imperative toward recognition of burnout symptoms and a pivot point toward implementing change.

Readability of online patient education material for foregut surgery.

INTRODUCTION: Health literacy is the ability of individuals to use basic health information and services to make well-informed decisions. Low health literacy among surgical patients has been associated with nonadherence to preoperative and/or discharge instructions as well as poor comprehension of surgery. It likely poses as a barrier to patients considering foregut surgery which requires an understanding of different treatment options and specific diet instructions. The objective of this study was to assess and compare the readability of online patient education materials (PEM) for foregut surgery. METHODS: Using Google, the terms "anti-reflux surgery, "GERD surgery," and "foregut surgery" were searched and a total of 30 webpages from universities and national organizations were selected. The readability of the text was assessed with seven instruments: Flesch Reading Ease formula (FRE), Gunning Fog (GF), Flesch-Kincaid Grade Level (FKGL), Coleman Liau Index (CL), Simple Measure of Gobbledygook (SMOG), Automated Readability Index (ARI), and Linsear Write Formula (LWF). Mean readability scores were calculated with standard deviations. We performed a qualitative analysis gathering characteristics such as, type of information (preoperative or postoperative), organization, use of multimedia, inclusion of a version in another language. RESULTS: The overall average readability of the top PEM for foregut surgery was 12th grade. There was only one resource at the recommended sixth grade reading level. Nearly half of PEM included some form of multimedia. CONCLUSIONS: The American Medical Association and National Institute of Health have recommended that PEMs to be written at the 5th-6th grade level. The majority of online PEM for foregut surgery is above the recommended reading level. This may be a barrier for patients seeking foregut surgery. Surgeons should be aware of the potential gaps in understanding of their patients to help them make informed decisions and improve overall health outcomes.

Emotional awareness is correlated with ambulatory heart rate variability: A replication and extension.

OBJECTIVE: A positive association has previously been observed in healthy volunteers between emotional awareness (EA), the ability to identify and describe emotional experiences in oneself and others, and resting heart rate variability (HRV), which is dominated by vagus nerve activity. The current study aimed to investigate the EA-HRV association across multiple assessments in a "real-world" ambulatory context in patients with long QT syndrome (LQTS) who are at genetic risk for sudden cardiac death. METHOD: Participants (157 LQTS patients; MeanAge = 35.1, SDAge = 10.4; 115 women) completed the levels of emotional awareness scale (LEAS) on one occasion, which served as our measure of EA. In an ecological momentary assessment study involving 10 assessments per day over three days, multiple 5-minute ECG assessments (Mean = 24.6, SD = 5.1) were obtained in each patient using a Holter monitor, from which high-frequency HRV (HF-HRV) was computed on each occasion. RESULTS: There was a significant positive association between LEAS scores and HF-HRV controlling for biobehavioral covariates. We also detected a similar inverse relation between EA and mean heart rate. CONCLUSION: These findings suggest that, in patients with a well-defined genetic risk for ventricular arrhythmia and sudden death, the ability to experience emotions in a complex and differentiated way covaries with greater parasympathetic influences on the heart. These findings are consistent with the overlapping neural substrates of EA and HRV and their common contribution to adaptive emotional responding, consistent with the Neurovisceral Integration Model.

The impact of COVID-19 pandemic on patient selection and access to care, approach type, and postoperative outcomes in bariatric surgery.

BACKGROUND: The COVID-19 pandemic had affected the health systems across the world since early 2020 with a concern about access to medical care during the first wave of COVID-19 pandemic. OBJECTIVES: The objective of this study was to examine how the COVID-19 pandemic influenced patient selection, approach type, and postoperative outcomes in elective bariatric surgery. SETTING: United States. METHODS: Data from the MBSAQIP database for the years 2016-2020 were queried. Wilcoxon rank-sum test and Fisher's exact test were employed for continuous and categorical variables, respectively. Postoperative outcomes within 30 days were assessed separately and based on the Clavien-Dindo (CD) classification of III-V. χ2 test and logistic regression were used to compare outcomes between procedure and approach types, as well as surgical operation periods. RESULTS: A total of 741,620 patients underwent robotic and laparoscopic sleeve gastrectomy and Roux-en-Y gastric-bypass. The cases performed in 2020 exhibited lower comorbidities and postoperative complications compared to prepandemic years, regardless of the approach type. Notably, the proportion of White patients decreased during the pandemic, while there was an increase in the number of African American and Hispanic patients who had bariatric surgery. CONCLUSIONS: Patients who underwent bariatric surgery during the COVID-19 pandemic appeared to be healthier with fewer comorbidities and experienced fewer adverse postoperative outcomes compared to those who had surgery prior to the pandemic. This study highlights the limited access to bariatric surgery for high-risk patients during the pandemic.

Disparities in hepatocellular carcinoma incidence among Hispanic and non-Hispanic adults in Arizona: Trends between 2009-2017.

BACKGROUND: Hepatocellular carcinoma (HCC) is a highly lethal cancer with few treatment options available to patients. Most HCC cases in Arizona, a state with a high proportion of Hispanic adults, have not been included in recent reports of HCC incidence. This study describes trends in HCC incidence and stage at diagnosis among Arizona residents between 2009-2017 and reports on racial and ethnic disparities for these outcomes. METHODS: The Arizona Cancer Registry was used to identify Arizonans aged 19 or older diagnosed with liver cell carcinoma diagnosed between 2009-2017. A total of 5043 cases were examined. Adjusted annual and 3-year HCC incidence rates (per 100,000) were examined for non-Hispanic White (NHW) and Hispanic adults. RESULTS: The total age-adjusted HCC incidence rate increased significantly between 2009-2012 and then declined significantly between 2012-2017. Across nearly all years, age-adjusted HCC incidence in Hispanic adults was twice that of NHW adults. Hispanic adults were more likely to be diagnosed at a later stage across all time periods. The disparity in 3-year age-adjusted HCC incidence rate between NHW and Hispanic adults decreased between 2009-2017. CONCLUSION: Whe total age-adjusted HCC incidence rate increased significantly between 2009-2012 and then declined significantly between 2012-2017. Across nearly all years, age-adjusted HCC incidence in Hispanic adults was twice that of NHW adults. Hispanic adults were more likely to be diagnosed at a later stage across all time periods. The disparity in 3-year age-adjusted HCC incidence rate between NHW and Hispanic adults decreased between 2009-2017.

Follow-up compliance in patients undergoing abdominal aortic aneurysm repair at Veterans Affairs hospitals.

OBJECTIVE: The Society for Vascular Surgery guidelines recommend annual imaging surveillance following endovascular aneurysm repair (EVAR) and every 5 years following open surgical repairs (OSR) of abdominal aortic aneurysms (AAAs). Adherence to these guidelines is low outside of clinical trials, and compliance at Veterans Affairs (VA) hospitals is not yet well-established. We examined imaging follow-up compliance and mortality rates after AAA repair at VA hospitals. METHODS: We queried the VA Surgical Quality Improvement Program database for elective infrarenal AAA repairs, EVAR and OSR, then merged in follow-up imaging and mortality information. Mortality rate over time was derived using Kaplan-Meier estimation. Generalized estimating equation with a logit link and a sandwich standard error estimate was performed to compare the probability of having annual follow-up imaging over time between procedure types and to identify variables associated with follow-up imaging for EVAR patients. RESULTS: Our analysis included 11,668 patients who underwent EVAR and 4507 patients who underwent OSR at VA hospitals between the years 2000 and 2019. The 30-day mortality rate for EVAR and OSR was 0.37% and 0.82%, respectively. OSR was associated with lower long-term mortality after adjusting age, sex, American Society of Anesthesiologists classification and preoperative renal failure with an adjusted hazard ratio of 0.88 (95% confidence interval, 0.84-0.92; P < .01). Of surviving patients, the follow-up imaging rate was 69.1% by 1 year post-EVAR. The follow-up rate after 5 years was 45.6% post-EVAR compared with 63.6% post-OSR of surviving patients. A history of smoking or drinking, baseline hypertension, and known cardiac disease were independently associated with poor follow-up after EVAR. CONCLUSIONS: Patients undergoing elective open AAA repair in the VA hospital system had lower long-term mortality compared with patients who underwent endovascular repair. Compliance with post-EVAR imaging is low. Patient factors associated with poor post-EVAR imaging surveillance were smoking within the last year, excess alcohol consumption, and cardiac risk factors including hypertension, prior myocardial infarction, and congestive heart failure.

The impact of gender, race, and ethnicity on bariatric surgery outcomes.

BACKGROUND: The rates of postoperative complications can vary among specific patient populations. OBJECTIVES: The aim of this study is to examine how gender, race, and ethnicity can affect short-term postoperative complications in bariatric surgery patients. SETTING: United States. METHODS: Patients who underwent bariatric surgery between the years 2016 and 2021 were included and stratified based on gender, race/ethnicity, and procedure type. The 30-day outcomes were assessed using Clavien-Dindo (CD) classification of III-V. Wilcoxon rank-sum test was performed to compare continuous variables among groups and Chi-squared test for categorical variables. Logistic regression was performed to examine the effects of gender, race/ethnicity on CD classification ≥ III complications by the procedure type. RESULTS: A total of 975,642 bariatric surgery patients were included. Descriptive univariate analysis showed that CD ≥ III complications were higher among non-Hispanic blacks (NHB) and lowest in Hispanic patients, regardless of their gender, except in the duodenal switch DS group, where non-Hispanic whites (NHW) had the lowest complication rate. There was no difference between male and female patients with regards to postoperative complications, except in the sleeve gastrectomy (SG) group, where NHW males had more complications than NHW females. Sleeve gastrectomy showed the lowest complication rates followed by gastric bypass and DS in all groups. In multivariate logistic regression model, for both females and males NHBs had higher odds of postoperative complications compared to NHWs in sleeve gastrectomy (Female aOR:1.31, 95% CI: [1.23-1.40]; Male aOR:1.24, 95% CI: [1.08-1.43], P < .001) and gastric bypass (Female aOR:1.24, 95% CI: [1.16-1.33]; Male aOR:1.25, 95% CI: [1.06-1.48], P < .01). CONCLUSIONS: Non-Hispanic Black patients are at a higher rate of developing CD ≥ III complications compared to non-Hispanic Whites after bariatric surgery. The male gender was not a significant risk factor for serious postoperative complications. Among the different types of bariatric procedures, sleeve gastrectomy has the lowest rates of severe complications, followed by gastric bypass and duodenal switch. These results highlight the significance of considering gender, race, ethnicity, and procedure type during preoperative evaluation, surgical planning, and postoperative care.

Neighborhood social vulnerability and disparities in time to kidney cancer surgical treatment and survival in Arizona.

BACKGROUND: Hispanics and American Indians (AI) have high kidney cancer incidence and mortality rates in Arizona. This study assessed: (1) whether racial and ethnic minority patients and patients from neighborhoods with high social vulnerability index (SVI) experience a longer time to surgery after clinical diagnosis, and (2) whether time to surgery, race and ethnicity, and SVI are associated with upstaging to pT3/pT4, disease-free survival (DFS), and overall survival (OS). METHODS: Arizona Cancer Registry (2009-2018) kidney and renal pelvis cases (n = 4592) were analyzed using logistic regression models to assess longer time to surgery and upstaging. Cox-regression hazard models were used to test DFS and OS. RESULTS: Hispanic and AI patients with T1 tumors had a longer time to surgery than non-Hispanic White patients (median time of 56, 55, and 45 days, respectively). Living in neighborhoods with high (≥75) overall SVI increased odds of a longer time to surgery for cT1a (OR 1.54, 95% CI: 1.02-2.31) and cT2 (OR 2.32, 95% CI: 1.13-4.73). Race and ethnicity were not associated with time to surgery. Among cT1a patients, a longer time to surgery increased odds of upstaging to pT3/pT4 (OR 1.95, 95% CI: 0.99-3.84). A longer time to surgery was associated with PFS (HR 1.52, 95% CI: 1.17-1.99) and OS (HR 1.63, 95% CI: 1.26-2.11). Among patients with cT2 tumor, living in high SVI neighborhoods was associated with worse OS (HR 1.66, 95% CI: 1.07-2.57). CONCLUSIONS: High social vulnerability was associated with increased time to surgery and poor survival after surgery.

Carotid Revascularization is Associated with Improved Mood in Patients with Advanced Carotid Disease.

OBJECTIVE: To investigate the impact of carotid interventions on patients' mental condition in patients with carotid stenosis. SUMMARY BACKGROUND DATA: Ongoing research highlights the impact of carotid interventions on neurocognitive function in patients with advanced carotid atherosclerosis. However, data regarding the impact of carotid revascularization on mood is scarce. METHODS: A total of 157 patients undergoing carotid revascularization were prospectively recruited. The primary outcome was depression, evaluated pre-operatively, and at 1-,6- and 12-month post-intervention using the long form of the geriatric depression scale (GDS-30) questionnaire. Other tests were also used to assess cognition at the respective timepoints. Statistical analyses were performed to assess the postoperative outcomes compared to baseline. RESULTS: Baseline depression (GDS>9) was observed in 49(31%) subjects, whereas 108(69%) patients were not depressed (GDS≤9). The average pre-operative GDS score was 15.42 ± 4.40(14.2-16.7) and 4.28 ±2.9(3.7-4.8) in the depressed and non-depressed groups, respectively. We observed a significant improvement in GDS scores within the depressed group at 1-month (P=0.002), 6-months (P=0.027), and 1-year (P<0.001) post-intervention compared to preop, whereas the non-depressed group had similar post-op GDS scores at all time points compared to baseline. Significant improvement in measures of executive function was seen in non-depressed patients at all three timepoints whereas depressed patients showed an improvement at 1-year follow-up. CONCLUSIONS: Our study highlights improvement in mood among patients with advanced carotid disease who screened positive for depression at baseline. Further studies with larger sample sizes are warranted to investigate the association between depression, carotid disease, and carotid intervention.

Early versus delayed coronary angiography in patients with out-of-hospital cardiac arrest and no ST-segment elevation: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Recent randomized controlled trials did not show benefit of early/immediate coronary angiography (CAG) over a delayed/selective strategy in patients with out-of-hospital cardiac arrest (OHCA) and no ST-segment elevation. However, whether selected subgroups, specifically those with a high pretest probability of coronary artery disease may benefit from early CAG remains unclear. METHODS: We included all randomized controlled trials that compared a strategy of early/immediate versus delayed/selective CAG in OHCA patients and no ST elevation and had a follow-up of at least 30 days. The primary outcome of interest was all-cause death. Odds ratios (OR) were calculated and pooled across trials. Interaction testing was used to assess for heterogeneity of treatment effects. RESULTS: In total, 1512 patients (67 years, 26% female, 23% prior myocardial infarction) were included from 5 randomized controlled trials. Early/immediate versus delayed/selective CAG was not associated with a statistically significant difference in odds of death (OR 1.12, 95%-CI 0.91-1.38), with similar findings for the composite outcome of all-cause death or neurological deficit (OR 1.10, 95%-CI 0.89-1.36). There was no effect modification for death by age, presence of a shockable initial cardiac rhythm, history of coronary artery disease, presence of an ischemic event as the presumed cause of arrest, or time to return of spontaneous circulation (all P-interaction > 0.10). However, early/immediate CAG tended to be associated with higher odds of death in women (OR 1.52, 95%-CI 1.00-2.31, P = 0.050) than in men (OR 1.04, 95%-CI 0.82-1.33, P = 0.74; P-interaction 0.097). CONCLUSION: In OHCA patients without ST-segment elevation, a strategy of early/immediate versus delayed/selective CAG did not reduce all-cause mortality across major subgroups. However, women tended to have higher odds of death with early CAG.

First Assistant In Bariatric Surgery: A Comparison Between Laparoscopic And Robotic Approaches: A 4-Year Analysis of the MBSAQIP Database (2016-2019).

PURPOSE: The first assistant (FA) plays an important role in the operating room for bariatric surgery. The aim of this study was to examine the relationship between the type of FA and operative time (OT) and postoperative outcomes comparing robotic and laparoscopic approaches in bariatric surgery. METHODS AND MATERIALS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data for 2016-2019 was queried. Log-normal regression was performed to evaluate the association of FAs and OT variations within and between groups. We used logistic regression to examine the relationship between the type of FA and 30-day outcomes across all procedures and approaches. RESULTS: A total of 691,789 patients who underwent robotic (R), and laparoscopic (L) sleeve gastrectomy (SG), Roux-en-Y gastric-bypass (RYGB), and duodenal switch (DS) were included. The percentage variation of OT was higher in the laparoscopic group (L-SG: 8.18%, L-RYGB: 9.88%, and L-DS: 15.00%) compared to the robotic group (R-SG: 2.43%, R-RYGB: 5.76%, and R-DS: 0.80%). There was not a significant difference in 30-day outcomes between laparoscopic and robotic approaches for the same procedures. CONCLUSIONS: The FA was associated with a decreased variability in OT in the robotic cohort compared to the laparoscopic group with no significant difference in complication rates. These results suggest that the robotic approach may decrease the need for skilled FAs in bariatric procedures.

Examining health care access disparities in Hispanic populations with peripheral artery disease and diabetes.

INTRODUCTION: This study investigated disparities in health care access for Hispanic adults with diabetes and peripheral artery disease (PAD) who are at risk of lower-extremity amputation and other cardiovascular morbidities and mortalities. METHODS: We utilized the health care access survey data from the All of Us research program to examine adults (⩾ 18 years) with either diabetes and/or PAD. The primary associations evaluated were: could not afford medical care and delayed getting medical care in the past 12 months. Multivariable logistic regression models were used to assess the association of Hispanic ethnicity and survey responses, adjusting for age, sex, income, health insurance, and employment status. RESULTS: Among 24,104 participants, the mean age was 54.9 years and 67% were women. Of these, 8.2% were Hispanic adults. In multivariable analysis, Hispanic adults were more likely to be unable to afford seeing a health care provider, and receiving emergency care, follow-up care, and prescription medications (p < 0.05) than non-Hispanic adults. Furthermore, Hispanic adults were more likely to report being unable to afford medical care due to cost (odds ratios [OR] 1.72, 95% CI 1.50-1.99), more likely to purchase prescription drugs from another country (OR 2.20, 95% CI 1.69-2.86), and more likely to delay getting medical care due to work (OR 1.46, 95% CI 1.22-1.74) and child care (OR 1.80, 95% CI 1.35-2.39) issues than non-Hispanic White adults. CONCLUSION: The Hispanic population with diabetes and PAD faces substantial barriers in health care access, including a higher likelihood of delaying medical care and being unable to afford it.

The combination of atomoxetine and oxybutynin for the treatment of obstructive sleep apnea in children with Down syndrome.

STUDY OBJECTIVES: Children with Down syndrome (DS) are at very high risk for obstructive sleep apnea (OSA). Current OSA treatments have limited effectiveness in this population. We evaluated the effectiveness of atomoxetine and oxybutynin (ato-oxy) to treat OSA in children with Down syndrome. METHODS: Children ages 6-7 years old with Down syndrome and OSA participated in a double-blind crossover clinical trial evaluating two dose regimens of ato-oxy. Participants received low-dose ato-oxy (0.5 mg/kg atomoxetine and 5 mg oxybutynin) and high-dose ato-oxy (1.2 mg/kg atomoxetine and 5 mg oxybutynin) for 1 month in random order. The primary study outcome was change in obstructive apnea-hypopnea index. Health-related quality of life as measured by the OSA-18 as well as changes in sleep architecture were secondary outcomes. RESULTS: Fifteen participants qualified for randomization and 11 participants had complete data at all points. Baseline obstructive apnea-hypopnea index was 7.4 ± 3.7 (mean ± standard deviation), obstructive apnea-hypopnea index with low-dose ato-oxy was 3.6 ± 3.3 (P = .001 vs baseline), and obstructive apnea-hypopnea index with high-dose ato-oxy was 3.9 ± 2.8 (P = .003 vs baseline). No significant sleep architecture differences were present with ato-oxy. No significant difference in OSA-18 score was present. OSA-18 total score was 51 ± 19 at baseline, 45 ± 17 (P = .09) at the end of 4 weeks of low-dose ato-oxy, and 45 ± 16 (P = .37) at the end of high-dose ato-oxy therapy. The most common adverse effects were irritability and fatigue, and these were generally mild. CONCLUSIONS: Ato-oxy is a promising treatment for OSA in children with Down syndrome. CLINICAL TRIAL REGISTRATION: Registry: Clinicaltrials.gov; Name: Medications for Obstructive Sleep Apnea In Children With Down Syndrome (MOSAIC); URL: https://clinicaltrials.gov/ct2/show/NCT04115878; Identifier: NCT04115878. CITATION: Combs D, Edgin J, Hsu C-H, et al. The combination of atomoxetine and oxybutynin for the treatment of obstructive sleep apnea in children with Down syndrome. J Clin Sleep Med. 2023;19(12):2065-2073.

Cognitive effects of carotid revascularization in octogenarians.

BACKGROUND: Cognitive impairment is the epitome of cerebrovascular diseases, causing a significant economic burden on our health care system. Growing evidence has indicated the benefits of carotid interventions in patients with severe carotid atherosclerosis. However, the neurocognitive outcome of carotid revascularization in octogenarians is not clearly understood. We aim to evaluate postintervention cognitive changes in seniors older than 80 years. METHODS: We prospectively recruited 170 patients undergoing carotid interventions. Neurocognitive testing was performed preoperatively and at 1, 6, and 12 months postoperatively. Episodic memory was assessed with Rey's Auditory Verbal Learning Test. Other executive functions and language measures were also evaluated at individual time points. Raw test scores were converted to z-scores or scaled scores adjusted for age and education. The sample was divided into 2 groups based on age: octogenarian (≥80 years) and nonoctogenarian (<80 years old). Postoperative cognitive scores were compared to baseline within each subcohort. RESULTS: A total of 23 subjects (13%) were octogenarians, and 147 (87%) were younger than 80 years. Younger patients demonstrated significant cognitive improvements up to 12 months postop compared to the baseline. However, octogenarians exhibited a lack of improvement in verbal memory, measures of executive function, and language at all 3 postintervention time points. CONCLUSION: Carotid interventions improve cognitive functions in younger patients with carotid occlusive atherosclerosis. However, no cognitive benefits were seen in male seniors older than 80 years. Further investigations are warranted to better understand the postinterventional cognitive changes in octogenarians.

Gemcitabine as first-line therapy for high-grade non-muscle invasive bladder cancer: results from a tertiary center in the contemporary BCG-shortage era.

Background: To evaluate the safety profile and efficacy of intravesical gemcitabine as first-line adjuvant therapy for non-muscle invasive bladder cancer (NMIBC) in the setting of ongoing Bacillus Calmette-Guérin (BCG) shortage. Methods: We performed an institutional, retrospective review of patients treated with intravesical gemcitabine induction and maintenance therapy from March 2019 to October 2021. Patients with intermediate or high-risk NMIBC who were BCG-naïve or experienced a high-grade (HG) recurrence after 12 months since the last dose of BCG were included in the analysis. The primary endpoint was complete response (CR) rate at the 3-month visit. Secondary endpoints were recurrence-free survival (RFS) and assessment of adverse events. Results: A total of 33 patients were included. All had HG disease and 28 (84.8%) were BCG-naive. The median follow-up was 21.4 months (range, 4.1-39.4). Tumor stages were cTa in 39.4%, cT1 in 54.5%, and cTis in 6.1% of patients. Most patients (90.9%) were in the AUA high-risk category. The 3-month CR was 84.8%. Among patients who achieved CR with adequate follow-up, 86.9% (20/23) remained disease-free at 6 months. The 6-month and 12-month RFS were 87.2% and 76.5%, respectively. The estimated median RFS was not reached. Approximately 78.8% of patients were able to complete full induction. Common adverse events (incidence ≥10%) included dysuria and fatigue/myalgia. Conclusions: Intravesical gemcitabine for intermediate and high-risk NMIBC in areas where BCG supply is limited was safe and feasible at short-term follow-up. Larger prospective studies are needed to better ascertain the oncologic efficacy of gemcitabine.

Robotic Bariatric Surgery in Older Adults, Is It Safer Than the Laparoscopic Approach? A 7-Year Analysis of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Database.

BACKGROUND: Utilization of the robotic platform in bariatric surgery has increased over the past several years. The population of older adults who benefit from bariatric surgery is also growing. This study evaluated the safety of robotic-assisted bariatric surgery in older adults using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Database. METHODS: Adults who underwent gastric bypass or sleeve gastrectomy and were ≥ 65 years old between the years 2015 and 2021 were included. The 30-day outcomes were assessed and stratified based on Clavien-Dindo (CD) classification of III-V. Univariable and multivariable logistic regressions were performed to identify predictors of CD ≥ III complications. RESULTS: A total of 62,973 bariatric surgery patients were included. Most of the patients (90%) underwent laparoscopic surgery, and the remainder (10%) underwent robotic surgery. Robotic sleeve gastrectomy (R-SG) was associated with lower odds of developing CD ≥ III complications compared to three other procedures (adjusted odds ratio (aOR), 0.741; confidence interval (CI), 0.584-0.941; p 0.014). CONCLUSIONS: Bariatric surgery using a robotic approach is considered safe for older patients. Robotic sleeve gastrectomy (R-SG) has the lowest morbidity and mortality rates compared to laparoscopic sleeve gastrectomy (L-SG), laparoscopic Roux-en-Y gastric bypass (L-RYGB), and robotic Roux-en-Y gastric bypass (R-RYGB). The findings of this study can help surgeons and their elderly patients to make informed decisions regarding the safety of different bariatric surgical approaches.

Feasibility of 5-fluorouracil and imiquimod for the topical treatment of cervical intraepithelial neoplasias (CIN) 2/3.

OBJECTIVES: To determine the feasibility (as measured by tolerability and safety) and efficacy of topical 5-fluorouracil (5-FU) and imiquimod for the treatment of cervical intraepithelial neoplasia (CIN) 2/3. METHODS: This pilot prospective study was conducted in women aged 18-45 years with p16+ CIN 2/3. Participants underwent an 8-week alternating regimen of self-applied 5% 5-FU on weeks 1, 3, 5, and 7 and physician-applied imiquimod on weeks 2, 4, 6, and 8. Adverse events (AEs) were collected by symptom diary and clinical exam. Feasibility was measured by tolerability and safety (AEs) of the study intervention. Tolerability was assessed as the number of participants able to apply 50% or more of the treatment doses. The safety outcome was calculated as the number of participants who experienced "specified AEs" defined as possibly, probably, or definitely related grade 2 or worse AE or grade 1 genital AEs (blisters, ulcerations, or pustules) lasting more than 5 days. The efficacy of the intervention was determined by histology and high-risk human papillomavirus (hrHPV) testing was done after treatment. RESULTS: The median age of the 13 participants was 27 ± 2.9 years. Eleven (84.61%) participants applied 50% or more of the treatment. All participants reported grade 1 AEs; 6 (46.15%) reported grade 2 AEs; and 0 reported grade 3/4 AEs. Three (23.08%) participants had specified AEs. Histologic regression to normal or CIN 1 among those completing 50% or more of the treatment doses was observed in 10 (90.91%) participants, and 7 (63.63%) tested negative for hr-HPV at the end of the study. CONCLUSIONS: Topical treatment for CIN 2/3 with 5-FU/imiquimod is feasible, with preliminary evidence of efficacy. Topical therapies need further investigation as adjuncts or alternatives to surgical therapy for CIN 2/3.

Gastric Cancer Surgery in the US: a Contemporary Trend Analysis of Lymphadenectomy and the Impact of Minimally Invasive Approaches.

BACKGROUND: The National Comprehensive Cancer Network guidelines recommend harvesting 16 or more lymph nodes for the adequate staging of gastric adenocarcinoma. This study examines the rate of adequate lymphadenectomy over recent years, its predictors, and its impact on overall survival(OS). STUDY DESIGN: The National Cancer Database was utilized to identify patients who underwent surgical treatment for gastric adenocarcinoma between 2006-2019. Trend analysis was performed for lymphadenectomy rates during the study period. Logistic regression, Kaplan-Meier survival plots, and Cox proportional hazard regression were utilized. RESULTS: A total of 57,039 patients who underwent surgical treatment for gastric adenocarcinoma were identified. Only 50.5% of the patients underwent a lymphadenectomy of ≥ 16 nodes. Trend analysis showed that this rate significantly improved over the years, from 35.1% in 2006 to 63.3% in 2019 (p < .0001). The main independent predictors of adequate lymphadenectomy included high-volume facility with ≥ 31 gastrectomies/year (OR: 2.71; 95%CI:2.46-2.99), surgery between 2015-2019 (OR: 1.68; 95%CI: 1.60-1.75), and preoperative chemotherapy (OR:1.49; 95%CI:1.41-1.58). Patients with adequate lymphadenectomy had better OS than patients who did not: median survival: 59 versus 43 months (Log-Rank: p < .0001). Adequate lymphadenectomy was independently associated with improved OS (HR:0.79; 95%CI:0.77-0.81). Laparoscopic and robotic gastrectomies were independently associated with adequate lymphadenectomy compared to open, OR: 1.11, 95%CI:1.05-1.18 and OR: 1.24, 95%CI:1.13-1.35, respectively. CONCLUSION: Although the rate of adequate lymphadenectomy improved over the study period, a large number of patients still lacked adequate lymph node dissection, negatively impacting their OS despite multimodality therapy. Laparoscopic and robotic surgeries were associated with a significantly higher rate of lymphadenectomy ≥ 16 nodes.