Influence of surgeon specialty and volume on the utilization of minimally invasive surgery and outcomes for colorectal cancer: a retrospective review.

BACKGROUND: Utilization of minimally invasive surgery (MIS) has multiple determinants, one being the specialization of the surgeon. The purpose of this study was to assess the differences in the utilization of MIS, associated length of stay (LOS), and complications for colorectal cancer between colorectal (CRS) and general surgeons (GS). Previous studies have documented the influence of surgical volume and surgeon specialty on clinical outcomes and patient survival following colorectal cancer surgery. It is unclear whether there are differences in the utilization of MIS for colorectal cancer based on surgeon's specialization and how this influences clinical outcomes. METHODS: Using the 2013-2015 Florida Inpatient Discharge Dataset and the National Plan & Provider Enumeration System, colorectal cancer patients experiencing a colorectal surgery were identified as well as the operating physician's specialty. Mixed-effects regression models were used to identify associations between the use of MIS, complications during the hospital stay, and patient LOS with patient, physician, and hospital characteristics. RESULTS: There is no difference in the use of MIS, complication, nor LOS between GS and CRS for colorectal cancer surgery. However, physician volume was associated with increased use of MIS (OR 1.26, 95% CI 1.09, 1.46) and MIS was associated with decreases in certain complications as well as reductions in LOS overall (ß = - 0.16, p < 0.001) and for each specialty (GS: ß = - 0.18, p < 0.001; CRS ß = - 0.12, p < 0.001) CONCLUSIONS: Despite the higher amount of proctectomies performed by CRS, no difference in MIS utilization, complication rate, or LOS was found for colorectal cancer patients based on surgeon specialty. While there are some differences in clinical outcomes attributable to specialized training, results from this study indicate that differences in surgical approach (MIS vs. Open), as well as the patient populations encountered by these two specialties, are key factors in the outcomes observed.

The Multifactorial Contribution of Publications in Plastic Surgery Journals in Microsurgery Education.

BACKGROUND: Microsurgery is one of the most complex operative skills. Recent restrictions on residents' working hours challenge residency program directors to ensure skill acquisition with scant time dedicated to microsurgery practice. We aimed to summarize the contribution of plastic surgery journals in microsurgical education. METHODS: A comprehensive literature search was performed. RESULTS: We observed an increasing number of publications on microsurgery education over the years. This could be due to the adoption of new technologies developed in the last 2 decades, the concerns about quality of resident training in the context of reduced work hours, the well-described benefit of medical simulations in other specialties, and the pressure on trainees to be proficient before operating on patients. The variety of aspects addressed in plastic surgery publications is broad: simulators, courses, skills assessment, national surveys, and technology trends. CONCLUSION: There is an upward trend in the number of publications and plastic surgery journals, demonstrating a remarkable contribution to microsurgery training.

Disparities in Access to Autologous Breast Reconstruction.

Background and objectives: This study aimed to determine if age, race, region, insurance, and comorbidities affect the type of breast reconstruction that patients receive. Materials and methods: This analysis used the Florida Inpatient Discharge Dataset from 1 January 2013 to 30 September 2017, which contains deidentified patient-level administrative data from all acute care hospitals in the state of Florida. We included female patients, diagnosed with breast cancer, who underwent mastectomy and a subsequent breast reconstruction. We performed an χ2 test and logistic regression in this analysis. Results: On the multivariable analysis, we found that age, race, patient region, insurance payer, and Elixhauser score were all variables that significantly affected the type of reconstruction that patients received. Our results show that African American (odds ratio (OR): 0.68, 95%CI: 0.58-0.78, p < 0.001) and Hispanic or Latino (OR: 0.82, 95%CI: 0.72-0.93, p = 0.003) patients have significantly lower odds of receiving implant reconstruction when compared to white patients. Patients with Medicare (OR: 1.57, 95%CI: 1.33-1.86, p < 0.001) had significantly higher odds and patients with Medicaid (OR: 0.61, 95%CI: 0.51-0.74, p < 0.001) had significantly lower odds of getting autologous reconstruction when compared to patients with commercial insurance. Conclusions: Our study demonstrated that, in the state of Florida over the past years, variables, such as race, region, insurance, and comorbidities, play an important role in choosing the reconstruction modality. More efforts are needed to eradicate disparities and give all patients, despite their race, insurance payer, or region, equal access to health care.

Factors Associated With Minimally Invasive Surgery for Colorectal Cancer in Emergency Settings.

BACKGROUND: Minimally invasive surgery (MIS) is associated with improved colorectal cancer (CRC) outcomes, but it is used less frequently in emergency settings. We aimed to assess patient-level factors associated with emergency presentation for CRC and the use of MIS in emergency versus elective settings. METHODS: This retrospective study examined the clinical data of patients who underwent emergency and elective resections for CRC from 2013 to 2015 using the Florida Inpatient Discharge Dataset. Multivariable analyses were performed to assess differences in gender, age, race, urbanization, region, insurance, and clinical characteristics associated with mode of presentation and surgical approach. In-hospital mortality and length of stay by mode of presentation were recorded. RESULTS: Of 16,277 patients identified, 10,224 (61%) had elective surgery and 6503 (39%) had emergency surgery. Emergency presentations were more likely to be black (14.2% versus 9.5%), Hispanic (18.9% versus 15.4%), Medicaid-insured (9.7% versus 4.2%), and have metastatic cancer (34.4% versus 20.2%) or multiple comorbidities (12.6% versus 4.0%). MIS was the surgical approach in 31.8% of emergency cases versus 48.1% of elective cases. Factors associated with lower odds of MIS for emergencies include Medicaid (odds ratio (OR) 0.79, 95% confidence interval (CI) 0.63-0.99), metastases (OR 0.56, CI 0.5-0.63), and multiple comorbidities (OR 0.53, CI 0.4-0.7). Emergency cases experienced higher in-hospital mortality (3.7% versus 1.0%) and a longer median length of stay (10 d versus 5 d). CONCLUSIONS: Emergency CRC presentations are associated with racial minorities, Medicaid insurance, metastatic disease, and multiple comorbidities. Odds of MIS in emergency settings are lowest for patients with Medicaid insurance and highest clinical disease burden.

Pharmacotherapy for Patients with Atrial Fibrillation and Cerebral Microbleeds.

BACKGROUND: Patients with cerebral microbleeds have increased risk of intracranial hemorrhage and ischemic stroke. No trial specifically informs antithrombotic therapy for patients with cerebral microbleeds and atrial fibrillation. We investigated the safety of anticoagulation versus no anticoagulation with regard to cerebrovascular outcomes and mortality. METHODS: All consecutive atrial fibrillation patients from 2015 to 2018 with MRI evidence of ≥1 cerebral microbleed at time of imaging were reviewed. Patients were treated with warfarin, direct oral anticoagulants, or neither. Primary outcome was all-cause mortality informed by National Death Registry and the composite of ischemic and hemorrhagic stroke. All statistical tests were 2-sided and significant at P < .05. RESULTS: The median interval from patient identification until the end of electronic health record surveillance was 9.93 months (interquartile range, 2.83-19.17 months). We identified 308 atrial fibrillation patients with cerebral microbleeds; 128(41.6%) were on warfarin, 88(28.6%) on direct oral anticoagulants, and 92(29.9%) on neither. Over the surveillance interval, 87 deaths, 51 ischemic strokes, and 14 hemorrhagic strokes occurred. The estimated likelihoods of the composite stroke outcome and ischemic stroke only did not differ significantly among the 3 groups. However, patients taking direct oral anticoagulants had a significantly smaller likelihood of all-cause mortality than patients who were not anticoagulated (adjusted hazard ratio: .44[.23, .83], P=.012). CONCLUSIONS: In patients with coprevalent atrial fibrillation and cerebral microbleeds, we did not detect differences in subsequent ischemic stroke, hemorrhagic stroke, or both, comparing warfarin, direct oral anticoagulants, or neither. Patients treated with direct oral anticoagulants had better survival than nonanticoagulated patients.

Surgical Care for Women with Endometrial Cancer in Florida.

Objective: The goal of this research was to analyze if disparities in route of hysterectomy for endometrial cancer exist in Florida. Materials and Methods: In this retrospective cohort study, Florida inpatient and ambulatory surgery databases (2014-2016) were examined to find cases of patients with endometrial cancer who underwent hysterectomy in the state. Logistic regression models were used to compare patient- and hospital-level factors associated with having minimally invasive surgery (MIS) versus open surgery, and complications in patients having open hysterectomy versus MIS. Results: Overall, 6513 patients met the inclusion criteria. MIS was performed in 81.4% of cases. The odds of using a minimally invasive approach to hysterectomy (vaginal, robotic, or laparoscopic) were significantly lower for black women (odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.34-0.50) as well as for other non-white patients (OR: 0.64; 95% CI: 0.49-0.84). Patients with Medicaid (OR: 0.42; 95% CI: 0.30-0.59) or Medicare managed care (OR: 0.73; 95% CI: 0.59-0.91), or who received care at a teaching hospital (OR: 0.82; 95% CI: 0.68-0.98) or government hospital (OR: 0.50; 95% CI: 0.38-0.65) were also less likely to receive MIS. Patients receiving care at a high-volume (OR: 1.69; 95% CI: 1.30-2.20) or medium-volume (OR: 3.11; 95% CI: 2.37-4.08) hospital, or patients who were located in the Central (OR: 1.71; 95% CI: 1.17-2.48) or Peninsula (OR: 1.73; 95% CI: 1.17-2.56) regions, compared to the Florida Panhandle, had greater odds of receiving MIS. Conclusions: Although Florida has a high adoption of MIS for treating endometrial cancer, disparities persist. Efforts of state-level entities should focus on improving access to minimally invasive hysterectomy for racial minorities with endometrial cancer.

Simulation: An Effective Method of Teaching Cosmetic Botulinum Toxin Injection Technique.

BACKGROUND: Learning to inject botulinum toxin for cosmetic purposes is difficult for beginners, given the nature of the procedure and patient population. Simulation training is an effective modality for medical professionals to acquire skills in an environment that provides low stress and ample opportunity for questions and correction of mistakes. OBJECTIVES: Compare posttraining comfort, knowledge, and practical botulinum toxin injection scores among trainees who underwent simulation vs video training only. METHODS: A total of 20 nurse practitioners, physician assistants, and resident physicians underwent cosmetic botulinum toxin injection training either through lecture and video, or lecture and hands-on simulation training. Comfort, knowledge, and practical test scores were recorded and compared between the groups. RESULTS: There was no evidence of a statistically significant difference in comfort or knowledge scores between simulation and video groups. The median (range) practical score was significantly higher in the simulation group compared to the video group (59.0 [31-60] vs 44.5 [27-57]; P < 0.01). CONCLUSIONS: Despite feeling similarly comfortable and having similar written knowledge test scores, the trainees who underwent simulation training had significantly higher hands-on practical test scores compared to trainees who underwent video training only for cosmetic botulinum toxin injections.

Evaluation of Novel Targets, Including CC-Chemokine Receptor 4, in Adult T-Cell Acute Lymphoblastic Leukemia/Lymphoma: A Mayo Clinic Clinical and Pathologic Study.

CONTEXT.­: Unlike B-cell acute lymphoblastic leukemia/lymphoma (ALL/LBL), there have been few therapeutic advances in T-cell ALL (T-ALL)/LBL, an aggressive ALL/LBL subtype. OBJECTIVE.­: To perform a focused tissue array study to elucidate tumor markers of therapeutic potential in T-ALL/LBL. DESIGN.­: Using immunohistochemistry, we evaluated expression of leukemic antigens of interest, specifically CC-chemokine receptor 4 (CCR4), among others, on available remnant diagnostic material, including tumor tissue slides obtained from formalin-fixed, paraffin-embedded preserved tissues. RESULTS.­: Our analysis identified, for the first time, expression of CCR4 in T-ALL/LBL in 11 of 27 cases (40.7%) and confirmed common expression of BCL2, CD38, and CD47, as reported previously. We also identified the expression of CD123 in 4 of 26 cases (15.4%), whereas BCL6 and PDL1 were expressed in a small number of T-ALL/LBL cases. The potential novel target CCR4 was significantly more common in the Pre/Pro-T immunophenotypic subtype, 6 of 9 (66.7%, P = .01). No additional differences in clinical and epidemiologic variables were noted among positive or negative CCR4 cases. CONCLUSIONS.­: These findings support preclinical and clinical testing of therapies targeting CCR4, CD47, BCL2, CD38, and CD123 in T-ALL/LBL, and may help guide the development of targeted clinical trials in T-ALL/LBL, a rare disease in urgent need of novel therapies.

Trends in Cardiovascular Implantable Electronic Device Insertion Between 1988 and 2018 in Olmsted County.

OBJECTIVES: This study sought to describe trends in cardiovascular implantable electronic device (CIED) insertion over the past 3 decades in Olmsted County. BACKGROUND: Trends in CIED insertion in the United States have not been extensively studied. METHODS: The Rochester Epidemiology Project is a medical records linkage system comprising the records of all residents of Olmsted County from 1966 to the present. CIED insertion between 1988 and 2018 was determined using International Classification of Diseases-Ninth Revision, International Classification of Diseases-10th Revision, and Current Procedural Terminology codes. Age- and sex-adjusted incidence rates, adjusted to the 2010 US White population, were calculated. Trends in incidence over time, across age groups, and between sex are estimated using Poisson regression models. RESULTS: The age- and sex-adjusted incidence of device implants for the study period were as follows: overall CIED: 82.4 (95% CI: 79.2-85.6); permanent pacemaker (PPM): 62.9 (95% CI: 60.0-65.7); implantable cardioverter-defibrillator (ICD): 14.0 (95% CI: 12.6-15.3); and cardiac resynchronization therapy (CRT): 5.6 (95% CI: 4.7-6.4) per 100,000 per year. The overall incidence of CIED insertion increased between 1988 to 1993 and 2000 to 2005 and then decreased between 2000 to 2005 and 2012 to 218 (P < 0.0001). PPM and ICD insertion incidence followed these trends, whereas the incidence of CRT insertion increased between 2000 to 2005 and 2012 to 2018. CIED insertion incidence increased with age (P < 0.0001). CIED insertion incidence was greater in men (116.3 vs 57.3 per 100,000 per year in men vs women; P < 0.0001). The overall survival of CRT recipients improved (P = 0.0044). CONCLUSIONS: The incidence values for PPM and ICD implants are decreasing, while the incidence of CRT implants is increasing. CIEDs are increasingly inserted in the elderly, men, and patients with higher comorbidities.

Effect of health care disparities on procedure selection of autologous breast reconstruction in Florida.

INTRODUCTION: Disparities in access to reconstructive surgery after breast cancer have been reported. We aim to evaluate demographic and socioeconomic factors influencing type of autologous breast reconstruction in Florida. METHODS: We queried the Florida Inpatient Discharge Dataset to evaluate disparities in type of autologous breast reconstructive surgery between January 1, 2013, and September 30, 2017. Patients 18 years of age or older were included. Women younger than 65 years old on Medicare were excluded. Patients were categorized into three groups according to type of autologous reconstruction: latissimus dorsi pedicled flap (pedicled flap), free flap, or pedicled flap with implant (combined flap). Demographic and socioeconomic variables were evaluated. 𝜒2 and Mann-Whitney tests were used to estimate statistical significance. A multivariate logistic regression was performed to find independent associations. RESULTS: Our results showed higher odds of reconstruction with free flap in Hispanic patients (odds ratio (OR), 1.66; 95% CI, 1.32-2.09; P < 0.0001) and patients with comorbidities (OR, 1.45; 95% CI, 1.23-1.71; P < 0.0001). However, patients treated in Central and South Florida were less likely to undergo free flap than combined and pedicled flap reconstructions compared with those treated in North Florida (P < 0.05). Patients insured by Medicaid and Medicare were less likely to undergo free flap than combined or pedicled flap reconstruction compared to patients with private insurance (P < 0.05). CONCLUSIONS: Our study identified that race, region, insurance, and comorbidity are factors associated with type of autologous breast reconstruction in Florida.

Association of Race, Socioeconomic Factors, and Treatment Characteristics With Overall Survival in Patients With Limited-Stage Small Cell Lung Cancer.

Importance: It has been established that disparities in race and socioeconomic status are associated with outcomes of non-small cell lung cancer. However, it remains unknown whether this extends to stage I, II, or III small cell lung cancer (SCLC), or limited-stage SCLC (L-SCLC). Objective: To investigate the associations of race, socioeconomic factors, and treatment characteristics with survival among patients with L-SCLC. Design, Setting, and Participants: Demographic information for patients with L-SCLC diagnosed between 2004 and 2014 was obtained from the National Cancer Database. The follow-up end point is death or last follow-up (date of last contact). Patients were divided into 5 mutually exclusive cohorts by race. Data analysis was performed in October 2019. Main Outcomes and Measures: Cox proportional hazards models were used to calculate univariable and multivariable models. Multivariable analyses were conducted to assess the associations of race and socioeconomic factors with risk-adjusted outcomes. Overall survival between groups was depicted by Kaplan-Meier curves. Results: Of 72 409 patients analyzed (median [range] age, 67.0 [23.0-90.0] years), 40 289 (55.6%) were women. The distribution of disease stage was 10 619 patients (14.7%) with stage I disease, 7689 patients (10.6%) with stage II disease, and 54 101 patients (74.7%) with stage III disease. The median (range) duration of follow-up was 8.2 (2.4-15.8) months. Compared with White patients, the hazard of death decreased to 0.92 (95% CI, 0.89-0.95; P < .001) for African American patients and 0.83 (95% CI, 0.77-0.91; P < .001) for Asian patients. The difference in median survival among different racial groups was significant only among those with stage III SCLC. Other factors associated with better survival were female sex, high income, high education, private insurance, diagnostic confirmation by positive cytological analysis, increase in number of sampled regional lymph nodes, and earlier stage at diagnosis. Conclusions and Relevance: This analysis highlights disparities in race and socioeconomic factors associated with outcomes of L-SCLC. Racial minorities, including African American and Asian patients, have better survival than White patients for L-SCLC after adjustment for sociodemographic factors.

Hospital robotic use for colorectal cancer care.

The use of robotic surgery for colorectal cancer continues to increase. However, not all organizations offer patients the option of robotic intervention. This study seeks to understand organizational characteristics associated with the utilization of robotic surgery for colorectal cancer. We conducted a retrospective study of hospitals identified in the United States, State of Florida Inpatient Discharge Dataset, and linked data for those hospitals with the American Hospital Association Survey, Area Health Resource File and the Health Community Health Assessment Resource Tool Set. The study population included all robotic surgeries for colorectal cancer patients in 159 hospitals from 2013 to 2015. Logistic regressions identifying organizational, community, and combined community and organizational variables were utilized to determine associations. Results indicate that neither hospital competition nor disease burden in the community was associated with increased odds of robotic surgery use. However, per capita income (OR 1.07 95% CI 1.02, 1.12), average total margin (OR 1.01, 95% CI 1.001, 1.02) and large-sized hospitals compared to small hospitals (OR: 5.26, 95% CI 1.13, 24.44) were associated with increased odds of robotic use. This study found that market conditions within the U.S. State of Florida are not primary drivers of hospital use of robotic surgery. The ability for the population to pay for such services, and the hospital resources available to absorb the expense of purchasing the required equipment, appear to be more influential.

Impact on urinary oxalate levels with use of ezetimibe.

Background: Calcium oxalate stones are the most common cause of nephrolithiasis in the United States. Smaller studies of <15 patients investigating ezetimibe, a selective cholesterol absorption inhibitor, have suggested increased urine oxalate levels with use of the drug. We attempt to better define this relationship of ezetimibe on urinary oxalate using a larger patient sample analysing multiple urine collections on and off treatment. Materials and Methods: We retrospectively reviewed all consecutive patients from 01/2018 through 04/2019 evaluated for nephrolithiasis with use of ezetimibe documented in their medical record at Mayo Clinic Florida. Primary outcomes included increase in urinary oxalate with use of ezetimibe and reduction in urinary oxalate with discontinuation of medication. Results: Of 57 reviewed patients, 30 (53%) met inclusion criteria yielding 117 24-h urine measurements either on ezetimibe (72 measurements) or off ezetimibe (41 measurements). The mean urinary oxalate level off ezetimibe was 39.86 mg versus 40.45 mg with ezetimibe. After adjusting for age and sex, the estimated difference was 1.239 mg (95% CI, -4.856 to 7.335 mg; p = 0.93). A subset of six patients with urinary oxalate values both on and off ezetimibe showed a difference in 24-h urinary oxalate levels ranged from -16.40 to 14.95 mg (mean difference = 0.93 mg; median difference = 3.84 mg). Conclusion: Use of ezetimibe does not provide clear evidence of a difference in urinary oxalate levels.

Invasive Nocardiosis in Transplant and Nontransplant Patients: 20-Year Experience in a Tertiary Care Center.

OBJECTIVE: To present the clinical characteristics and outcome of transplant and nontransplant patients with invasive nocardiosis. PATIENTS AND METHODS: We conducted a retrospective chart review of 110 patients 18 years and older diagnosed with culture-proven invasive nocardiosis (defined as the presence of clinical signs and/or radiographic abnormalities) between August 1, 1998, and November 30, 2018. Information on demographic, clinical, radiographic, and microbiological characteristics as well as mortality was collected. RESULTS: One hundred ten individuals with invasive nocardiosis were identified, of whom 54 (49%) were transplant and 56 nontransplant (51%) patients. Most transplant patients were kidney and lung recipients. The overall mean age was 64.9 years, and transplant patients had a higher prevalence of diabetes and chronic kidney disease. A substantial proportion of nontransplant patients were receiving corticosteroids (39%), immunosuppressive medications (16%), and chemotherapy (9%) and had chronic obstructive pulmonary disease (20%), rheumatologic conditions (18%), and malignant neoplasia (18%). A higher proportion of transplant patients (28%) than nontransplant patients (4%) received trimethoprim-sulfamethoxazole prophylaxis. In both groups, the lung was the most common site of infection. Seventy percent of all Nocardia species isolated were present in almost equal proportion: N brasiliensis (16%), N farcinica (16%), N nova (15%), N cyriacigeorgia (13%), and N asteroides (11%). More than 90% of isolates were susceptible to trimethoprim-sulfamethoxazole, linezolid, and amikacin. There was no significant difference in mortality between the 2 groups at 1, 6, and 12 months after the initial diagnosis. CONCLUSION: The frequency of invasive Nocardia infection was similar in transplant and nontransplant patients and mortality at 1, 6, and 12 months was similar in both groups. Trimethoprim-sulfamethoxazole prophylaxis failed to prevent Nocardia infection.

Valchlor® in the Treatment of Lichen Planopilaris and Frontal Fibrosing Alopecia: A Single Arm, Open-label, Exploratory Study.

BACKGROUND: Lichen Planopilaris (LPP) is a lymphocyte-mediated scarring alopecia that frequently is treatment resistance to both topical and systemic therapies. AIMS AND OBJECTIVES: The object of this pilot study was to assess the effectiveness of topical mechlorethamine 0.016% gel (Valchlor®) in decreasing disease activity in LPP and the related clinical variant frontal fibrosing alopecia (FAA). METHODS: Twelve patients with biopsy-proven LPP/FAA who failed prior topical or systemic therapy with active disease were included. Participants applied mechlorethamine 0.016% gel to involved areas daily for 24 weeks. Outcome measures included LPP Activity Index (LPPAI) score, Physician Global Assessment (PGA) score, Dermatology Quality of Life Index (DQLI) score, and phototrichograms assessing follicular counts before and after six months of therapy. RESULTS: LPP Activity Index (LPPAI) before and after treatment was significantly different (5.0 before treatment, 2.0 after treatment; p value=0.006). Mean follicular density and follicular units were unchanged during the treatment period. CONCLUSION: Treatment with mechlorethamine 0.016% gel for 24 weeks resulted in statistically significant improvement of LLP/FFA with no change in phototrichogram parameters. Treatment duration was limited by high rate of contact dermatitis. Further investigation to optimize dosing frequency and to assess the role of combination topical therapy is needed.

Impact of travel distance on quality outcomes in colorectal cancer.

OBJECTIVES: This study sought to examine the impact of distance traveled from place of residence to surgical facility for elective colorectal surgery on surgical outcomes, length of stay, and complication rate. STUDY DESIGN: Retrospective study. METHODS: Patients with colorectal cancer were identified from the Florida Inpatient Discharge Database. Distance traveled from primary residence to surgical facility was estimated using zip code. After adjusting for patient and hospital characteristics, multivariate regression models compared bypassed hospitals, the length of stay, and complication rates for patients traveling different distances to receive care. RESULTS: Patients residing in rural areas and in South (odds ratio [OR], 2.37; 95% CI, 1.55-3.63) and Central Florida (OR, 5.86; 95% CI, 3.86-8.89) were more likely to travel more than 50 miles for treatment. Teaching status of the hospital (OR, 9.99; 95% CI, 6.98-14.31), a hospital's availability of a colorectal surgeon (OR, 1.83; 95% CI, 1.45-2.31), and metastasized cancer (OR, 1.43; 95% CI, 1.17-1.82) influenced the patient's decision to travel farther for treatment. Length of stay was significantly higher for patients traveling farther (P < .0343). However, there was no significant difference in the rate of complications among the groups (those traveling 25-50 miles vs < 25 miles [P = .5766] and those traveling > 50 miles vs < 25 miles [P = .4516]). CONCLUSIONS: A greater number of patients travel more than 50 miles to the surgical facility at a later stage of disease. These patients do not significantly differ from those traveling less than 50 miles in their rates of complications; however, they stay longer at the surgical facility.

Disparities influencing rates of urgent/emergent surgery for diverticulitis in the state of Florida.

BACKGROUND: Patients with diverticulitis have a 20% risk of requiring urgent/emergent treatment. Since morbidity and mortality rates differ between elective and urgent/emergent care, understanding associated disparities is critical. We compared factors associated with treatment setting for diverticulitis and evaluated disparities regarding access to Minimally Invasive Surgery (MIS) and development of complications. METHODS: The Florida Inpatient Discharge Dataset was queried for patients diagnosed with diverticulitis. Three multivariate models were utilized: 1) elective vs urgent/emergent surgery, 2) MIS vs open and 3) presence of complications. RESULTS: The analysis included 12,654 patients. Factors associated with increased odds of urgent/emergent care included being uninsured or covered by Medicaid, African American, obese, or more comorbid. MIS was associated with reduced odds of complications. Patients treated by high-volume or colorectal surgeons had increased odds of receiving MIS. CONCLUSIONS: Patients were more likely to receive MIS if they were treated by a colorectal surgeon, or a high-volume surgeon (colorectal, or general surgeon). Additionally, patients that were older, had increased comorbidities, or did not have health insurance were less likely to receive MIS.

Use of a simulation-based advanced resuscitation training curriculum: Impact on cardiopulmonary resuscitation quality and patient outcomes.

BACKGROUND: Despite a continued focus on improved cardiopulmonary resuscitation quality, survival remains low from in-hospital cardiac arrest. Advanced Resuscitation Training has been shown to improve survival to hospital discharge and survival with good neurological outcome following in-hospital cardiac arrest at its home institution. We sought to determine if Advanced Resuscitation Training implementation would improve patient outcomes and cardiopulmonary resuscitation quality at our institution. METHODS: This was a prospective, before-after study of adult in-hospital cardiac arrest victims who had cardiopulmonary resuscitation performed. During phase 1, standard institution cardiopulmonary resuscitation training was provided. During phase 2, providers received the same quantity of training, but with emphasis on Advanced Resuscitation Training principles. Primary outcomes were return of spontaneous circulation, survival to hospital discharge, and neurologically favorable survival. Secondary outcomes were cardiopulmonary resuscitation quality parameters. RESULTS: A total of 156 adult in-hospital cardiac arrests occurred during the study period. Rates of return of spontaneous circulation improved from 58.1 to 86.3% with an adjusted odds ratios of 5.31 (95% CI: 2.23-14.35, P < 0.001). Survival to discharge increased from 26.7 to 41.2%, adjusted odds ratios 2.17 (95% CI: 1.02-4.67, P < 0.05). Survival with a good neurological outcome increased from 24.8 to 35.3%, but was not statistically significant. Target chest compression rate increased from 30.4% of patients in P1 to 65.6% in P2, adjusted odds ratios 4.27 (95% CI: 1.72-11.12, P = 0.002), and target depth increased from 23.2% in P1 to 46.9% in P2, adjusted odds ratios 2.92 (95% CI: 1.16-7.54, P = 0.024). CONCLUSIONS: After Advanced Resuscitation Training implementation, there were significant improvements in cardiopulmonary resuscitation quality and rates of return of spontaneous circulation and survival to discharge.

Residual Tumor on Wide Excisional Margins After Treatment of Invasive Melanoma.

BACKGROUND/AIM: The surgical management of invasive melanoma has been debated for many years and recommended excisional margins have been established. We aimed to describe the factors and survival related to the presence of residual tumor in patients with invasive melanoma lymph nodes negative. PATIENTS AND METHODS: We performed a retrospective study by querying the National Cancer Database from 2004 to 2015. Associations were tested using a multivariate analysis. Overall survival was compared using the Kaplan-Meier method. RESULTS: A total of 26,440 patients met the inclusion criteria. For Breslow depth groups ≤1 mm and >2 mm, older age and location in the head and neck were factors associated to residual tumor in margins (p<0.05), whereas only location in the head and neck was associated to residual tumor for patients with Breslow depth between 1.01-2.00 mm (p<0.05). CONCLUSION: Knowledge of the factors associated with the residual tumor will help establish a patient-centered management and decrease the recurrence of disease.

Wide Excisional Surgery in Invasive Melanoma Treatment: Factors Driving Non-compliance With National Guidelines.

BACKGROUND/AIM: Margin size during wide excisional surgery for invasive melanoma treatment have been established by national guidelines. This study identified factors associated with wider than recommended excisional margins and its impact on survival. PATIENTS AND METHODS: The National Cancer Database was queried to identify patients with primary invasive melanoma. Statistical analysis was performed using univariate and multivariate analysis. Overall survival was compared using Kaplan-Meier method. RESULTS: A total of 26,440 patients were included in the analysis. Melanomas located on the trunk were more likely to be treated using wider than recommended excisional margins for certain Breslow depth groups (p<0.05), while the opposite was true for those being treated in an academic/research program (p<0.05). The practice of taking wider than recommended margins was not associated with improved survival. CONCLUSION: Tumor location and facility type influence non-compliance with the National Comprehensive Cancer Network guidelines. Lack of survival benefit in patients with wider excisional margins seems to support guideline recommendations.