Disparities in Access, Quality, and Clinical Outcome for Latino Californians with Colon Cancer.

OBJECTIVE: To compare access, quality, and clinical outcomes between Latino and non-Latino White Californians with colon cancer. SUMMARY BACKGROUND DATA: Racial and ethnic disparities in cancer care remain understudied, particularly among patients who identify as Latino. Exploring potential mechanisms, including differential utilization of high-volume hospitals, is an essential first step to designing evidence-based policy solutions. METHODS: We identified all adults diagnosed with colon cancer between January 1, 2010 and December 31, 2020 from a statewide cancer registry linked to hospital administrative records. We compared survival, access (stage at diagnosis, receipt of surgical care, treatment at a high-volume hospital), and quality of care (receipt of adjuvant chemotherapy, adequacy of lymph node resection) between patients who identified as Latino and as non-Latino White. RESULTS: 75,543 patients met inclusion criteria, including 16,071 patients who identified as Latino (21.3%). Latino patients were significantly less likely to undergo definitive surgical resection (marginal difference [MD] -0.72 percentage points, 95% CI -1.19,-0.26), have an operation in a timely fashion (MD -3.24 percentage points, 95% CI -4.16,-2.32), or have an adequate lymphadenectomy (MD -2.85 percentage points, 95% CI -3.59,-2.12) even after adjustment for clinical and sociodemographic factors. Latino patients treated at high-volume hospitals were significantly less likely to die and more likely to meet access and quality metrics. CONCLUSIONS: Latino colon cancer patients experienced delays, segregation, and lower receipt of recommended care. Hospital-level colectomy volume appears to be strongly associated with access, quality, and survival--especially for patients who identify as Latino--suggesting that directing at-risk cancer patients to high-volume hospitals may improve health equity.

Despite Increasing Costs, Perfusion Machines Expand the Donor Pool of Livers and Could Save Lives.

INTRODUCTION: Liver transplantation is a highly successful treatment for liver failure and disease. However, demand continues to outstrip our ability to provide transplantation as a treatment. Many livers initially considered for transplantation are not used because of concerns about their viability or logistical issues. Recent clinical trials have shown discarded livers may be viable if they undergo machine perfusion, which allows a more objective assessment of liver quality. METHODS: Using the Scientific Registry of Transplant Recipients dataset, we examined discarded and unretrieved organs to determine their eligibility for perfusion. We then used a Markov decision-analytic model to perform a cost-effectiveness analysis of two competing transplant strategies: Static Cold Storage (SCS) alone versus Static Cold Storage and Normothermic Machine Perfusion (NMP) of discarded organs. RESULTS: The average predicted successful transplants after perfusion was 385, representing a 5.8% increase in the annual yield of liver transplants. Our cost-effectiveness analysis found that the SCS strategy generated 4.64 quality-adjusted life years (QALYs) and cost $479,226. The combined SCS + NMP strategy generated 4.72 QALYs and cost $481,885. The combined SCS + NMP strategy had an incremental cost-effectiveness ratio of $33,575 per additional QALY over the 10-year study horizon. CONCLUSIONS: Machine perfusion of livers currently not considered viable for transplant could increase the number of transplantable grafts by approximately 5% per year and is cost-effective compared to Static Cold Storage alone.

Rectal Prolapse: Age-Related Differences in Clinical Presentation and What Bothers Women Most.

BACKGROUND: Rectal prolapse has a diverse symptom profile that affects patients of all ages. OBJECTIVE: We sought to identify bothersome symptoms and clinical presentation that motivated patients who have rectal prolapse to seek care, characterize differences in symptom severity with age, and determine factors associated with bothersome symptoms. DESIGN: This study is a retrospective analysis of a prospectively maintained registry. SETTINGS: This study was conducted at a tertiary referral academic center. PATIENTS: Included were 129 consecutive women with full-thickness rectal prolapse. MAIN OUTCOME MEASURES: The main outcomes measured were primary bothersome symptoms, 5-item Cleveland Clinic/Wexner Fecal Incontinence questionnaire, and the 5-item Obstructed Defecation Syndrome questionnaire. Patients were categorized by age <65 vs age ≥65 years. RESULTS: Cleveland Clinic/Wexner Fecal Incontinence score >9 was more common in older patients (87% vs 60%, p = 0.002). Obstructed Defecation Syndrome score >8 was more common in younger patients (57% vs 28%, p < 0.001). Older patients were more likely than younger patients to report bothersome symptoms of pain (38% vs 19%, p = 0.021) and bleeding (12% vs 2%, p = 0.046). Mucus discharge was reported by most patients (older, 72% vs younger, 66%, p = 0.54) but was bothersome for only 18%, regardless of age. Older patients had more severe prolapse expression than younger patients (at rest, 33% vs 11%; during activity, 26% vs 19%; only with defecation, 40% vs 64%, p = 0.006). Older patients were more likely to seek care within 6 months of prolapse onset (29% vs 11%, p = 0.056). On multivariable regression, increasing age, narcotic use, and nonprotracting prolapse at rest were associated with reporting pain as a primary concern. LIMITATIONS: This was a single-center study with a small sample size. CONCLUSIONS: Rectal prolapse-related bothersome symptoms and health care utilization differ by age. Although rectal pain is often not commonly associated with prolapse, it bothers many women and motivates older women to undergo evaluation. Patient-reported functional questionnaires may not reflect patients' primary concerns regarding specific symptoms and could benefit from supplementation with questionnaires to elicit individualized symptom priorities. See Video Abstract at http://links.lww.com/DCR/B492. PROLAPSO DE RECTO: INFLUENCIA DE LA EDAD EN DIFERENCIAS VINCULADAS CON LA PRESENTACIÓN CLÍNICA Y LOS SÍNTOMAS MAS DESAGRADABLES: El prolapso de recto tiene una gran variedad de síntomas que afectan a pacientes con edades diferentes.Identificar los síntomas mas molestos y la presentación clínica que motivaron a los pacientes con un prolapso de recto a consultar por atención médica, caracterizar las diferencias de gravedad de los síntomas con relación a la edad y determinar los factores asociados con los síntomas mas molestos.Análisis retrospectivo de un registro prospectivo.Centro académico de referencia terciaria.Consecutivamente 129 mujeres que presentaban un prolapso rectal completo.Síntomas y molestias primarias, cuestionario de incontinencia fecal de la Cleveland Clinic / Wexner de 5 ítems, cuestionario de síndrome de defecación obstruida de 5 ítems. Los pacientes fueron categorizados en < 65 años versus ≥ 65 años.El puntaje de incontinencia fecal de la Cleveland Clinic / Wexner > 9 fue más común en pacientes mayores (87% vs 60%, p = 0.002). La puntuación del síndrome de defecación obstructiva > 8 fue más común en pacientes más jóvenes (57% vs 28%, p <0,001). Los pacientes mayores fueron más propensos que los pacientes jóvenes a informar síntomas y molestias de dolor (38% vs 19%, p = 0.021) y sangrado (12% vs 2%, p = 0.046). La mayoría de los pacientes informaron secresión de moco (mayores, 72% frente a más jóvenes, 66%, p = 0,54), pero sólo el 18% tuvo molestias, independientemente de la edad. Los pacientes mayores tenían una exteriorización de prolapso más grave que los pacientes jóvenes (en reposo, 33% frente a 11%; durante la actividad, 26% frente a 19%; solo con defecación, 40% frente a 64%, p = 0,006). Los pacientes mayores tenían más probabilidades de buscar atención médica dentro de los 6 meses posteriores al inicio del prolapso (29% frente a 11%, p = 0.056). Tras la regresión multivariable, el aumento de la edad, el uso de narcóticos y el prolapso no prolongado en reposo se asociaron con la notificación de dolor como queja principal.Centro único; tamaño de muestra pequeño.Los síntomas y molestias relacionadas con el prolapso rectal y la solicitud de atención médica difieren según la edad. Aunque el dolor rectal a menudo no se asocia comúnmente con el prolapso, incomoda a muchas pacientes y motiva a las mujeres mayores a someterse a un examen médico. Los cuestionarios funcionales con las respuestas de las pacientes pueden no reflejar las preocupaciones principales de éstos con respecto a los síntomas específicos y podrían requerir cuestionarios complementarios para así obtener prioridades individualizadas con relación a los síntomas identificados. Consulte Video Resumen en http://links.lww.com/DCR/B492. (Traducción-Dr. Xavier Delgadillo).

Association of Parathyroidectomy With 5-Year Clinically Significant Kidney Stone Events in Patients With Primary Hyperparathyroidism.

OBJECTIVE: Patients with primary hyperparathyroidism (PHPT) are at increased risk of kidney stones. Guidelines recommend parathyroidectomy in patients with PHPT with a history of stone disease. This study aimed to compare the 5-year incidence of clinically significant kidney stone events in patients with PHPT treated with parathyroidectomy versus nonoperative management. METHODS: We performed a longitudinal cohort study of patients with PHPT in a national commercial insurance claims database (2006-2019). Propensity score inverse probability weighting-adjusted multivariable regression models were calculated. RESULTS: We identified 7623 patients aged ≥35 years old with continuous enrollment >1 year before and >5 years after PHPT diagnosis. A total of 2933 patients (38.5%) were treated with parathyroidectomy. The cohort had a mean age of 66.5 years, 5953 (78.1%) were female, and 5520 (72.4%) were White. Over 5 years, the unadjusted incidence of ≥1 kidney stone event was higher in patients who were managed with parathyroidectomy compared with those who were managed nonoperatively overall (5.4% vs 4.1%, respectively) and among those with a history of kidney stones at PHPT diagnosis (17.9% vs 16.4%, respectively). On multivariable analysis, parathyroidectomy was associated with no statistically significant difference in the odds of a 5-year kidney stone event among patients with a history of kidney stones (odds ratio, 1.03; 95% CI, 0.71-1.50) or those without a history of kidney stones (odds ratio, 1.16; 95% CI, 0.84-1.60). CONCLUSION: Based on this claim analysis, there was no difference in the odds of 5-year kidney stone events in patients with PHPT who were treated with parathyroidectomy versus nonoperative management. Time horizon for benefit should be considered when making treatment decisions for PHPT based on the risk of kidney stone events.

Situating Artificial Intelligence in Surgery: A Focus on Disease Severity.

OBJECTIVES: Artificial intelligence (AI) has numerous applications in surgical quality assurance. We assessed AI accuracy in evaluating the critical view of safety (CVS) and intraoperative events during laparoscopic cholecystectomy. We hypothesized that AI accuracy and intraoperative events are associated with disease severity. METHODS: One thousand fifty-one laparoscopic cholecystectomy videos were annotated by AI for disease severity (Parkland Scale), CVS achievement (Strasberg Criteria), and intraoperative events. Surgeons performed focused video review on procedures with ≥1 intraoperative events (n = 335). AI versus surgeon annotation of CVS components and intraoperative events were compared. For all cases (n = 1051), intraoperative-event association with CVS achievement and severity was examined using ordinal logistic regression. RESULTS: Using AI annotation, surgeons reviewed 50 videos/hr. CVS was achieved in ≤10% of cases. Hepatocystic triangle and cystic plate visualization was achieved more often in low-severity cases (P < 0.03). AI-surgeon agreement for all CVS components exceeded 75%, with higher agreement in high-severity cases (P < 0.03). Surgeons agreed with 99% of AI-annotated intraoperative events. AI-annotated intraoperative events were associated with both disease severity and number of CVS components not achieved. Intraoperative events occurred more frequently in high-severity versus low-severity cases (0.98 vs 0.40 events/case, P < 0.001). CONCLUSIONS: AI annotation allows for efficient video review and is a promising quality assurance tool. Disease severity may limit its use and surgeon oversight is still required, especially in complex cases. Continued refinement may improve AI applicability and allow for automated assessment.

Are parental self-efficacy and family flexibility mediators of treatment for anorexia nervosa?

OBJECTIVE: Family-based treatment (FBT) for adolescent anorexia nervosa (AN) promotes faster weight restoration when compared to other treatments. However, the mechanisms through which this occurs are not clarified. This study explored the trajectories of parental self-efficacy and perceived family flexibility during FBT and systemic family therapy (SyFT). We also explored whether parental self-efficacy mediates the effects of treatment on weight gain early in treatment. METHOD: 158 adolescents (12-18 years old; 89% girls) and their parents were randomized to FBT or SyFT. Parental self-efficacy as well as adolescents' and parental perceptions of the family's flexibility were collected at baseline and at sessions 2, 4, 6, and 8. RESULTS: Over time, only parents in FBT reported significantly greater self-efficacy. The change in maternal self-efficacy over the first 8 weeks of treatment was a significant mediator of session 10 weight gain. There were no significant group differences in perceived flexibility by session 8. DISCUSSION: Both parents in FBT and mothers in SyFT understand early the need to change their family's rules and roles. However, the specific strategies of FBT appear to mediate early weight gain in AN.

A qualitative analysis of male eating disorder symptoms.

Insights into how males experience eating disorder symptoms early in the course of illness are important to improve detection efforts and may also provide valuable information for treatment. In this qualitative study, 10 adolescent males and 10 matched female patients completed standardized questionnaires and were interviewed. Results indicated that although there were many similarities between the genders, females were more likely to describe the involvement of family systems and males were more likely to describe involvement in sports as being catalysts for their disorders. Males in this study were more positive about being in treatment.

The interactions of mothers with eating disorders with their toddlers: identifying broader risk factors.

The connection between maternal eating disorders and feeding and eating problems among their children has been substantially demonstrated. This pilot study focused on the interactions between mothers with eating disorders and their toddlers in non-feeding situations. Twenty-eight dyads of mothers with prenatal eating disorders and their toddlers were compared to a case-matched control group with no eating disorder. Maternal current eating and co-occurring psychopathology, children's symptoms and mother-child interactions were measured. Mothers with eating disorders were less sensitive to their children, tried to control their children's behaviors more, and were less happy during mother-child interactions. The children in the maternal eating disorder group were rated as less responsive to their mothers and their mothers also reported more behavioral problems than those in the control group. Findings imply that maternal eating disorders may be linked with a wide range of adverse maternal and child behaviors beyond those associated with eating.

An exploratory examination of patient and parental self-efficacy as predictors of weight gain in adolescents with anorexia nervosa.

OBJECTIVE: To determine whether increases in adolescent or parental self-efficacy predicted subsequent weight gain in two different therapies for adolescent anorexia nervosa (AN). METHOD: Participants were 121 adolescents with AN (M = 14.4 years, SD = 1.6), from a two-site randomized clinical trial for family-based treatment (FBT) and individual adolescent focused therapy (AFT). Both adolescent and parental self-efficacy were assessed at baseline and sessions 2, 4, 6, and 8. Adolescent self-efficacy was assessed using a generic measure of self-efficacy, while parental self-efficacy was assessed using a measure specific to the recovery of an eating disorder. Weight was assessed at baseline, sessions 1 through 8, and end of treatment. Mixed-effects models were used to evaluate the relation between patient and parent self-efficacy and subsequent weight gain, controlling for weight at the previous time point. RESULTS: For families who received FBT, greater within-treatment increases in parental self-efficacy predicted greater subsequent adolescent weight gain compared to those who received FBT with lesser change in parental self-efficacy and those who received AFT. Interestingly, adolescent self-efficacy did not significantly predict subsequent weight gain. DISCUSSION: Greater increases in parental self-efficacy predicted significantly greater subsequent weight gain for adolescents who received FBT, but the same was not true for adolescents who received AFT. Neither overall level nor change in adolescent self-efficacy significantly predicted subsequent weight gain in either treatment group. These findings emphasize the importance of increasing parental self-efficacy in FBT in order to impact adolescent weight outcomes.

Development and evaluation of a treatment fidelity instrument for family-based treatment of adolescent anorexia nervosa.

OBJECTIVE: This study provides data on the psychometric properties of a newly developed measure of treatment fidelity in Family-Based Treatment (FBT) for adolescent anorexia nervosa (AN). The Family Therapy Fidelity and Adherence Check (FBT-FACT) was created to evaluate therapist adherence and competency on the core interventions in FBT. METHOD: Participants were 45 adolescents and their families sampled from three randomized clinical trials evaluating treatment for AN. Trained fidelity raters evaluated 19 therapists across 90 early session recordings using the FBT-FACT. They also rated an additional 15 session 1 recordings of an alternate form of family therapy-Systemic Family Therapy for the purpose of evaluating discriminant validity of the FBT-FACT. The process of development and the psychometric properties of the FBT-FACT are presented. RESULTS: Overall fidelity ratings for each session demonstrated moderate to strong inter-rater agreement. Internal consistency of the measure was strong for sessions 1 and 2 and poor for session 3. Principal components analysis suggests sessions 1 and 2 are distinct interventions. DISCUSSION: The FBT-FACT demonstrates good reliability and validity as a measure of treatment fidelity in the early phase of FBT.