Treatment Inequity: Examining the Influence of Non-Hispanic Black Race and Ethnicity on Pancreatic Cancer Care and Survival in Wisconsin.

INTRODUCTION: We investigated race and ethnicity-based disparities in first course treatment and overall survival among Wisconsin pancreatic cancer patients. METHODS: We identified adults diagnosed with pancreatic adenocarcinoma in the Wisconsin Cancer Reporting System from 2004 through 2017. We assessed race and ethnicity-based disparities in first course of treatment via adjusted logistic regression and overall survival via 4 incremental Cox proportional hazards regression models. RESULTS: The study included 8,490 patients: 91.3% (n = 7,755) non-Hispanic White; 5.1% (n = 437) non-Hispanic Black, 1.8% (n = 151) Hispanic, 0.6% Native American (n = 53), and 0.6% Asian (n = 51) race and ethnicities. Non-Hispanic Black patients had lower odds of treatment than non-Hispanic White patients for full patient (OR, 0.52; 95% CI, 0.41-0.65) and Medicare cohorts (OR, 0.40; 95% CI, 0.29-0.55). Non-Hispanic Black patients had lower odds of receiving surgery than non-Hispanic White patients (full cohort OR, 0.67 [95% CI, 0.48-0.92]; Medicare cohort OR, 0.57 [95% CI, 0.34-0.93]). Non-Hispanic Black patients experienced worse survival than non-Hispanic White patients in the first 2 incremental Cox proportional hazard regression models (model II HR, 1.18; 95% CI, 1.06-1.31). After adding insurance and treatment course, non-Hispanic Black and non-Hispanic White patients experienced similar survival (HR, 0.98; 95% CI, 0.88-1.09). CONCLUSION: Non-Hispanic Black patients were almost 50% less likely to receive any treatment and 33% less likely to receive surgery than non-Hispanic White patients. After including treatment course, non-Hispanic Black and non-Hispanic White patient survival was similar. Increasing non-Hispanic Black patient treatment rates by addressing structural factors affecting treatment availability and employing culturally humble approaches to treatment discussions may mitigate these disparities.

Rethinking Routine Intensive Care After Cytoreductive Surgery With Heated Intraperitoneal Chemotherapy: The Fiscal Argument.

BACKGROUND: Patients undergoing cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) are frequently admitted to the intensive care unit (ICU) for mitigation of potential complications, although ICU length of stay (LOS) is a significant driver of cost. This study asked whether a fiscal argument could be made for the selective avoidance of ICU admission after CRS/HIPEC. METHODS: Prospective data for select low-risk patients (e.g., lower peritoneal cancer index [PCI]) admitted to the intermediate care unit (IMC) instead of the ICU after CRS/HIPEC were matched with a historic cohort routinely admitted to the ICU. Cohort comparisons and the impact of the intervention on cost were assessed. RESULTS: The study matched 81 CRS/HIPEC procedures to form a cohort of 49 pre- and 15 post-intervention procedures for patients with similar disease burdens (mean PCI, 8 ± 6.7 vs. 7 ± 5.1). The pre-intervention patients stayed a median of 1 day longer in the ICU (1 day [IQR, 1-1 day] vs. 0 days [IQR, 0-0 days]) and had a longer LOS (8 days [IQR, 7-11 days] vs. 6 days [IQR, 5.5-9 days]). Complications and complication severity did not differ statistically. The median total hospital cost was lower after intervention ($30,845 [IQR, $30,181-$37,725] vs. $41,477 [IQR, $33,303-$51,838]), driven by decreased indirect fixed cost ($8984 [IQR, $8643-$11,286] vs. $14,314 [IQR, $12,206-$18,266]). In a weighted multiple variable linear regression analysis, the intervention was associated with a savings of $2208.68 per patient. CONCLUSIONS: Selective admission to the IMC after CRS/HIPEC was associated with $2208.68 in savings per patient without added risk. In this era of cost-conscious practice of medicine, these data highlight an opportunity to decrease cost by more than 5% for patients undergoing CRS/HIPEC.

The sleepy surgeon: does night-time surgery for trauma affect mortality outcomes?

BACKGROUND: Sleepiness and fatigue affect surgical outcomes. We wished to determine the association between time of day and outcomes following surgery for trauma. METHODS: From the National Trauma Data Bank (2007 to 2010), we analyzed all adults who underwent an exploratory laparotomy between midnight and 6 am or between 7 am and 5 pm. We compared hospital mortality between these groups using multivariate logistic regression. Additionally, for each hour, a standardized mortality ratio was calculated. RESULTS: About 16,096 patients and 15,109 patients were operated on in the night time and day time, respectively. No difference was found in the risk-adjusted mortality rate between the 2 time periods (odds ratio .97, 95% confidence interval .893 to 1.058). However, hourly variations in mortality during the 24-hour period were noted. CONCLUSION: Trauma surgery during the odd hours of the night did not have an increased risk-adjusted mortality when compared with surgery during the day.

Laparoscopic surgery for trauma: the realm of therapeutic management.

BACKGROUND: The use of laparoscopy in trauma is, in general, limited for diagnostic purposes. We aim to evaluate the therapeutic role of laparoscopic surgery in trauma patients. METHODS: We analyzed the National Trauma Data Bank (2007 to 2010) for all patients undergoing diagnostic laparoscopy. Patients undergoing a therapeutic laparoscopic surgical procedure were identified and tabulated. Mortality and hospital length of stay for patients with isolated abdominal injuries were compared between the open and laparoscopic groups. RESULTS: Of a total of 2,539,818 trauma visits in the National Trauma Data Bank, 4,755 patients underwent a diagnostic laparoscopy at 467 trauma centers. Of these, 916 (19.3%) patients underwent a therapeutic laparoscopic intervention. Common laparoscopic operations included diaphragm repair, bowel repair or resection, and splenectomy. Patients undergoing laparoscopic surgery had a significantly shorter length of stay than the open group (5 vs 6 days; P < .001). CONCLUSION: Therapeutic laparoscopic surgery for trauma is feasible and may provide better outcomes.

Prevalence and predictors of depression among an elderly population of Pakistan.

OBJECTIVE: To assess the magnitude and risk factors of the problem of depression in an elderly population of Pakistan. METHOD: A cross-sectional study was conducted using a sample of 402 people aged 65 and above visiting the Community Health Center of the Aga Khan University, Karachi. Questionnaire based interviews were conducted for data collection and the 15-Item Geriatric Depression Scale was used to screen for depression. Univariate and multivariate logistic regression analyses were performed to identify factors associated with depression. RESULTS: Of the 402 participants; 69.7% (95% CI=+/-4.5%) were men, 76.4% (95% CI=+/-4.2%) were currently married, 36.8% (95% CI=+/-5%) had received 11 or more years of education and 24.4% (95% CI=+/-4.2%) were employed. The mean age was 70.57 years (SD=+/-5.414 years). The prevalence of depression was found to be 22.9% (95% CI=+/-4.1%) and multiple logistic regression analysis indicated that higher number of daily medications (p-value=0.03), total number of health problems (p-value=0.002), financial problems (p-value<0.001), urinary incontinence (p-value=0.08) and inadequately fulfilled spiritual needs (p-value = 0.067) were significantly associated with depressive symptoms. CONCLUSION: We have identified several risk factors for depression in the elderly which need to be taken into account by practicing family physicians and health care workers.