Persistent Food Insecurity and Material Hardships: A Latent Class Analysis of Experiences among Venezuelan Refugees and Migrants in Urban Colombia.

The causes and conditions of displacement often increase the vulnerability of migrant and refugee populations to food insecurity, alongside other material hardships. We aimed to examine the multidimensional aspects and patterns of food insecurity and other material hardships in a cross-sectional sample of 6221 Venezuelan refugees and migrants in urban Colombia using a latent class analysis. Using multinomial and logistic regression models, we investigated the demographic and migratory experiences associated with identified classes and how class membership is associated with multiple health outcomes among Venezuelan refugees and migrants, respectively. Approximately two thirds of the sample was comprised cisgender women, and the participants had a median age of 32 years (IQR: 26-41). Four heterogeneous classes of food insecurity and material hardships emerged: Class 1-low food insecurity and material hardship; Class 2-high food insecurity and material hardship; Class 3-high income hardship with insufficient food intake; and Class 4-income hardship with food affordability challenges. Class 2 reflected the most severe food insecurity and material hardships and had the highest class membership; Venezuelans with an irregular migration status were almost 1.5 times more likely to belong to this class. Food insecurity and material hardship class membership was independently associated with self-rated health, mental health symptoms, and recent violence victimization and marginally associated with infectious disease outcomes (laboratory-confirmed HIV and/or syphilis infection). Social safety nets, social protection, and other interventions that reduce and prevent material hardships and food insecurity among refugees and migrants, alongside the host community, may improve public health, support development, and reduce healthcare costs. In the long term, regularization and social policies for migrants aimed at enhancing refugees' and migrants' social and economic inclusion may contribute to improving food security in this population.

The impact of policy and policy communication on COVID-19 vaccination inequalities among Venezuelan refugees and migrants in Colombia: a comparative cross-sectional interrupted time-series analysis.

INTRODUCTION: Equitable access to vaccines for migrants and refugees is necessary to ensure their right to health and to achieve public health goals of reducing vaccine-preventable illness. Public health policies require regulatory frameworks and communication to effect uptake of effective vaccines among the target population. In Colombia, the National COVID-19 Vaccination Plan implicitly included Venezuelan refugees and migrants; however, initial communication of the policy indicated that vaccine availability was restricted to people with regular migration status. We estimated the impact of a public announcement, which clarified access for refugees and migrants, on vaccination coverage among Venezuelans living in Colombia. METHODS: Between 30 July 2021 and 5 February 2022, 6221 adult Venezuelans participated in a cross-sectional, population-based health survey. We used a comparative cross-sectional time-series analysis to estimate the effect of the October 2021 announcement on the average biweekly change in COVID-19 vaccine coverage of Venezuelans with regular and irregular migration status. RESULTS: 71% of Venezuelans had an irregular status. The baseline (preannouncement) vaccine coverage was lower among people with an irregular status but increased at similar rates as those with a regular status. After the announcement, there was a level change of 14.49% (95% CI: 1.57 to 27.42, p=0.03) in vaccination rates among individuals with irregular migration status with a 4.61% increase in vaccination rate per biweekly period (95% CI: 1.71 to 7.51, p=0.004). By February 2022, there was a 26.2% relative increase in vaccinations among individuals with irregular migration status compared with what was expected without the announcement. CONCLUSION: While there was no policy change, communication clarifying the policy drastically reduced vaccination inequalities across migration status. Lessons can be translated from the COVID-19 pandemic into more effective global, regional and local public health emergency preparedness and response to displacement.

Syphilis prevalence and correlates of infection among Venezuelan refugees and migrants in Colombia: findings of a cross-sectional biobehavioral survey.

Background: Population-based estimates of syphilis prevalence are critical to informing public health response. We aimed to measure syphilis prevalence among Venezuelan refugees and migrants in Colombia to inform public health programming. Methods: Between July 2021 and February 2022, we surveyed 6221 adult Venezuelan refugees and migrants in four cities in Colombia using respondent-driven sampling (RDS). Participants completed a survey and dual-rapid HIV/treponemal syphilis screening. Confirmatory laboratory-based rapid plasma reagin testing was conducted on whole blood samples. Active syphilis infection was defined as RPR titer ≥ 1:8 and no self-reported syphilis treatment. We used multivariable regression models to identify associations with active syphilis infection among subgroups by gender and history of pregnancy (cisgender men n = 2123, cisgender women n = 4044, transgender/nonbinary people n = 47, pregnant women n = 150). Findings: Population (RDS-weighted) prevalence of laboratory-confirmed syphilis was 5.1% (95% CI: 4.6-5.6). Syphilis prevalence was 5.8% (weighted) among men; lifetime sexually transmitted infections (STI) diagnosis, same-sex relationships, HIV infection, and partner number were independently associated with syphilis infection. Syphilis prevalence was 4.6% (weighted) in women; correlates of infection included: lifetime STI diagnosis, food insecurity, current engagement in sex work, current pregnancy, any unsafe night in Colombia, irregular migration status, and no healthcare utilization in Colombia. 14.9% (unweighted) of transgender participants had syphilis infection; correlates of infection included partner number and HIV infection. The prevalence of syphilis was 9.0% (weighted) among pregnant women, which was associated with lifetime STI diagnosis. Interpretation: Syphilis among Venezuelans in Colombia is high. Correlates of infection are distinct among demographic groups, spanning sexual and social vulnerabilities, suggesting tailored public health strategies. Funding: US President's Emergency Plan for AIDS Relief through the U.S. Centers for Disease Control and Prevention.

Access to healthcare among transgender women living with and without HIV in the United States: associations with gender minority stress and resilience factors.

BACKGROUND: Transgender women (TW) experience significant inequities in healthcare access and health disparities compared to cisgender populations. Access to non-transition related healthcare is understudied among TW. We aimed to assess the association between access to care and gender minority stress and resilience factors among TW living with and without HIV in eastern and southern United States. METHODS: This study was a cross-sectional analysis of baseline data drawn from a cohort of 1613 adult TW from the LITE Study. The cohort permitted participation through two modes: a site-based, technology-enhanced mode and an exclusively online (remote) mode. Exploratory and confirmatory factor analyses determined measurement models for gender minority stress, resilience, and healthcare access. Structural equation modeling was used to assess the relationships between these constructs. Models were evaluated within the overall sample and separately by mode and HIV status. RESULTS: Higher levels of gender minority stress, as measured by anticipated discrimination and non-affirmation were associated with decreased access to healthcare. Among TW living with HIV, higher levels of anticipated discrimination, non-affirmation, and social support were associated with decreased healthcare access. Among TW living without HIV in the site-based mode, resilience was positively associated with positive healthcare experiences and inversely associated with barriers to healthcare access. Among TW living without HIV in the online mode, anticipated discrimination was associated with barriers to healthcare access; resilience was positively associated with positive healthcare experiences and inversely associated with barriers to healthcare access. CONCLUSIONS: Gender minority stress was associated with increased barriers to healthcare access among TW in the US, regardless of HIV status. Resilience factors did not mediate this effect. Interventions aiming to increase healthcare access among TW can be aided by efforts to mitigate drivers of gender minority stress and improve patient experiences in healthcare facilities.

HIV infection and engagement in the care continuum among migrants and refugees from Venezuela in Colombia: a cross-sectional, biobehavioural survey.

BACKGROUND: Venezuela has experienced substantial human displacement since 2015. To inform HIV programmes and treatment distribution, we aimed to estimate HIV prevalence and associated indicators among migrants and refugees from Venezuela residing in Colombia, the largest receiving country. METHODS: We conducted a biobehavioural, cross-sectional survey using respondent-driven sampling among Venezuelan people aged 18 years or older who had arrived in Colombia since 2015 and resided in four cities (ie, Bogotá, Soacha, Soledad, and Barranquilla). Participants completed sociobehavioural questionnaires and rapid HIV and syphilis screening with laboratory-based confirmatory testing, CD4 cell counts, and viral load quantification. Policies related to migration status affect access to insurance and HIV services in Colombia, as in many receiving countries, so we provided legal assistance and navigation support to participants with HIV for sustained access to treatment. Population-based estimates were weighted for the complex sampling design. Penalised multivariable logistic regression analysis was used to identify correlates of viral suppression (HIV-1 RNA <1000 copies per mL). FINDINGS: Between July 30, 2021, and Feb 5, 2022, 6506 participants were recruited through respondent-driven sampling, of whom 6221 were enrolled. 4046 (65·1%) of 6217 were cisgender women, 2124 (34·2%) of 6217 were cisgender men, and 47 (0·8%) of 6217 were transgender or non-binary people. 71 (1·1%) of all 6221 participants had laboratory-confirmed HIV infection, resulting in a weighted population HIV prevalence of 0·9% (95% CI 0·6-1·4). Among participants living with HIV, 34 (47·9%) of 71 had been previously diagnosed with HIV and 25 (35·7%) of 70 had viral suppression. Individuals with irregular migration status compared with individuals with regular migration status (adjusted odds ratio 0·3, 95% CI 0·1-0·9) and with a most recent HIV test in Colombia compared with a most recent test in Venezuela (0·2, 0·1-0·8) were less likely to have suppressed viral loads. INTERPRETATION: HIV prevalence among migrants and refugees from Venezuela in Colombia suggests the HIV epidemic is close to being generalised, which could be addressed by the inclusion of migrants and refugees from Venezuela in local HIV services, improved access to and navigation support for HIV testing and care, and coordination with humanitarian programmes. There is an association between migration status and viral suppression, conferring both clinical and epidemiological implications. Therefore, legal support and access to insurance might lead to early detection of HIV and timely treatment for people with irregular migration status. FUNDING: US President's Emergency Plan for AIDS Relief through the US Centers for Disease Control and Prevention. TRANSLATION: For the Spanish translation of the abstract see Supplementary Materials section.

Qualitative assessment of the impacts of the COVID-19 pandemic on migration, access to healthcare, and social wellbeing among Venezuelan migrants and refugees in Colombia.

Background: Colombia hosts a large number of Venezuelan migrants and refugees who are uniquely vulnerable and have been markedly impacted by the COVID-19 pandemic. It is necessary to understand their experiences to inform future policy decisions both in Colombia and during disease outbreaks in other humanitarian contexts in the future. As part of a larger study focused on HIV among Venezuelans residing in Colombia, qualitative interviews were conducted to understand this population's experiences and access to healthcare. Methods: Interviews were conducted with Venezuelan migrants and refugees as well as stakeholders such as care providers, humanitarian workers, and government officials. Interviews were recorded, transcribed, and coded using thematic content analysis. Select quotes were translated and edited for length and/or clarity. Results: Venezuelan migrants and refugees reported high levels of housing instability, job instability, increased barriers to accessing healthcare, and complications in engaging in the HIV care continuum, among other impacts of the COVID-19 pandemic. Stakeholders reported complications in provision of care and obtaining medicines, difficulty maintaining contact with patients, increased discrimination and xenophobia targeting Venezuelan migrants and refugees, increased housing instability among Venezuelan migrants and refugees, and other impacts as a result of the COVID-19 pandemic. Conclusions: This study demonstrates the unique impacts of the COVID-19 pandemic among Venezuelans residing in Colombia by both compounding extant vulnerabilities and introducing new challenges, such as high rates of eviction. Colombia has enacted increasingly inclusive migration policies for Venezuelan refugees and migrants within the country; findings from this study underscore the necessity for such policies both in and outside of the Colombian context.

Costal Cartilage Lateral Crural Strut Graft for Correction of External Nasal Valve Dysfunction in Primary and Revision Rhinoplasty.

OBJECTIVE: To evaluate and compare the costal cartilage lateral crural strut graft's (LCSG) ability to support a weak lateral crus in patients with external nasal valve dysfunction (EVD) undergoing primary versus revision functional rhinoplasty. METHODS: This is a prospective cohort study of 26 patients (mean [SD]: 40.23 [6.75] years of age; 10 [38%] females) with clinically diagnosed EVD, who underwent primary versus revision functional rhinoplasty with the use of a costal cartilage LCSG (10 [38%] primary functional rhinoplasty patients and the 16 [62%] revision patients). Preoperative and 12-month postoperative subjective and objective functional measurements along with statistical analysis were performed. RESULTS: While all baseline demographic and preoperative functional measurement scores were similar between the 2 groups, the primary cohort's preoperative scores were higher overall. Follow-up was a mean of 14.58 months. The primary group demonstrated a greater difference in score improvement postoperatively in all categories. All patients had significantly improved visual analog scale (VAS), Nasal Obstruction Symptom Evaluation Scale, 22-Item Sinonasal Outcome Test, and nasal peak inspiratory flow (NPIF) scores. When comparing the overall score outcome and surgical efficacy of the LCSG, both groups had near equal final score outcomes with the exception of VASL and NPIF. CONCLUSION: The LCSG is a viable and versatile option in the management of EVD for both primary and revision rhinoplasty patients.

HIV Surveillance and Research for Migrant Populations: Protocol Integrating Respondent-Driven Sampling, Case Finding, and Medicolegal Services for Venezuelans Living in Colombia.

BACKGROUND: Epidemiologic research among migrant populations is limited by logistical, methodological, and ethical challenges, but it is necessary for informing public health and humanitarian programming. OBJECTIVE: We describe a methodology to estimate HIV prevalence among Venezuelan migrants in Colombia. METHODS: Respondent-driven sampling, a nonprobability sampling method, was selected for attributes of reaching highly networked populations without sampling frames and analytic methods that permit estimation of population parameters. Respondent-driven sampling was modified to permit electronic referral of peers via SMS text messaging and WhatsApp. Participants complete sociobehavioral surveys and rapid HIV and syphilis screening tests with confirmatory testing. HIV treatment is not available for migrants who have entered Colombia through irregular pathways; thus, medicolegal services integrated into posttest counseling provide staff lawyers and legal assistance to participants diagnosed with HIV or syphilis for sustained access to treatment through the national health system. Case finding is integrated into respondent-driven sampling to allow partner referral. This study is implemented by a local community-based organization providing HIV support services and related legal services for Venezuelans in Colombia. RESULTS: Data collection was launched in 4 cities in July and August 2021. As of November 2021, 3105 of the target 6100 participants were enrolled, with enrollment expected to end by February/March 2022. CONCLUSIONS: Tailored methods that combine community-led efforts with innovations in sampling and linkage to care can aid in advancing health research for migrant and displaced populations. Worldwide trends in displacement and migration underscore the value of improved methods for translation to humanitarian and public health programming. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/36026.

Variability of the Anterior Ethmoid Artery in Endoscopic Sinus Surgery.

INTRODUCTION: The anterior ethmoidal artery (AEA) demonstrates anatomic variability relative to its descent from the anterior skull base. Our study's objective was to assess for correlation of AEA descent and laterality, in addition to correlation of AEA descent and the presence of supraorbital ethmoid cells (SOEC) and concha bullosae (CB). METHOD: A retrospective study was performed at a tertiary rhinology center from January 2019 to January 2020. Noncontrast maxillofacial computed tomography scans were examined independently by 2 fellowship trained rhinologists. The vertical distance from both left and right AEAs to the ipsilateral skull base were compared and correlated with the presence of ipsilateral SOEC and CB. RESULTS: Computed tomography scans from 50 subjects were included. Mean age was 50.68 years (40% females). The distance of AEA to the skull base was greater on the left when compared to the right (62% vs 48%) (P < .05). The left AEA had an average descent of 2.84 mm versus 1.78 mm on the right (P < .05). An SOEC was present in 56% of cases. Thirty-eight percent of subjects had both SOEC and AEA descent on the right, while 52% of subjects had both on the left. This reached a statistical significance on both sides (P < .05). Concha bullosa was present in 35% of cases, with both AEA descent and CB present in 16% on the right, and 32% on the left. CONCLUSION: The AEA displays variability in vertical descent from the skull base, with greater variability on the left. These findings implore vigilance with evaluation of preoperative imaging and during sinus surgery, especially in the presence of SOEC and CB.

Association Between Bitter Taste Receptor Phenotype and Clinical Outcomes Among Patients With COVID-19.

Importance: Bitter taste receptors (T2Rs) have been implicated in sinonasal innate immunity, and genetic variation conferred by allelic variants in T2R genes is associated with variation in upper respiratory tract pathogen susceptibility, symptoms, and outcomes. Bitter taste receptor phenotype appears to be associated with the clinical course and symptom duration of SARS-CoV-2 infection. Objective: To evaluate the association between T2R phenotype and patient clinical course after infection with SARS-CoV-2. Design, Setting, and Participants: A prospective cohort study was performed from July 1 through September 30, 2020, at a tertiary outpatient clinical practice and inpatient hospital in the United States among 1935 participants (patients and health care workers) with occupational exposure to SARS-CoV-2. Exposure: Exposure to SARS-CoV-2. Main Outcomes and Measures: Participants underwent T2R38 phenotype taste testing to determine whether they were supertasters (those who experienced greater intensity of bitter tastes), tasters, or nontasters (those who experienced low intensity of bitter tastes or no bitter tastes) and underwent evaluation for lack of infection with SARS-CoV-2 via polymerase chain reaction (PCR) testing and IgM and IgG testing. A group of participants was randomly selected for genotype analysis to correlate phenotype. Participants were followed up until confirmation of infection with SARS-CoV-2 via PCR testing. Phenotype of T2R38 was retested after infection with SARS-CoV-2. The results were compared with clinical course. Results: A total of 1935 individuals (1101 women [56.9%]; mean [SD] age, 45.5 [13.9] years) participated in the study. Results of phenotype taste testing showed that 508 (26.3%) were supertasters, 917 (47.4%) were tasters, and 510 (26.4%) were nontasters. A total of 266 participants (13.7%) had positive PCR test results for SARS-CoV-2. Of these, 55 (20.7%) required hospitalization. Symptom duration among patients with positive results ranged from 0 to 48 days. Nontasters were significantly more likely than tasters and supertasters to test positive for SARS-CoV-2 (odds ratio, 10.1 [95% CI, 5.8-17.8]; P < .001), to be hospitalized once infected (odds ratio, 3.9 [1.5-10.2]; P = .006), and to be symptomatic for a longer duration (mean [SE] duration, 23.7 [0.5] days vs 13.5 [0.4] days vs 5.0 [0.6] days; P < .001). A total of 47 of 55 patients (85.5%) with COVID-19 who required inpatient admission were nontasters. Conversely, 15 of 266 patients (5.6%) with positive PCR test results were supertasters. Conclusions and Relevance: This cohort study suggests that T2R38 receptor allelic variants were associated with participants' innate immune response toward SARS-CoV-2. The T2R phenotype was associated with patients' clinical course after SARS-CoV-2 infection. Nontasters were more likely to be infected with SARS-CoV-2 than the other 2 groups, suggesting enhanced innate immune protection against SARS-CoV-2.

Digital Epidemiologic Research on Multilevel Risks for HIV Acquisition and Other Health Outcomes Among Transgender Women in Eastern and Southern United States: Protocol for an Online Cohort.

BACKGROUND: The HIV epidemic disproportionately impacts transgender women in the United States. Cohort studies identify unique risks for affected populations, but use of facility-based methods may bias findings towards individuals living in research catchment areas, more engaged in health services, or, in the case of transgender populations, those who are open about their transgender identity. Digital clinical trials and other online research methods are increasingly common, providing opportunity to reach those not commonly engaged in research. Simultaneously, there is a need to understand potential biases associated with digital research, how these methods perform, and whether they are accepted across populations. OBJECTIVE: This study aims to assess the feasibility of developing and implementing an online cohort of transgender women to assess risks for HIV acquisition and other health experiences. Further, this study aims to evaluate how an online cohort compares to a site-based, technology-enhanced cohort for epidemiologic research. The overarching goal is to estimate incidence of HIV and other health outcomes among transgender women in eastern and southern United States. METHODS: This substudy is part of a larger multisite prospective cohort (LITE) conducted among transgender women, which also includes a site-based, technology-enhanced cohort in 6 eastern and southern US cities. The online cohort was launched to enroll and follow participants across 72 cities in the same region and with similar demographic characteristics as the site-based cohort. Participants are followed for 24 months. Adult transgender women are recruited via convenience sampling (eg, peer referrals, social media, and dating apps). Participants reporting negative or unknown HIV status are enrolled in a baseline study visit, complete a sociobehavioral survey, and provide oral fluid specimens to test for HIV. Participants not living with HIV (lab-confirmed) at baseline are offered enrollment into the cohort; follow-up assessments occur every 6 months. RESULTS: Enrollment into the online cohort launched in January 2019. Active recruitment stopped in May 2019, and enrollment officially closed in August 2020. A total of 580 participants enrolled into and are followed in the cohort. A recruitment-enrollment cascade was observed across screening, consent, and completion of study activities. Implementation experiences with HIV test kits highlight the need for heavy staff engagement to support participant engagement, visit completion, and retention, even with automated digital procedures. CONCLUSIONS: This study is responsive to increasing research interest in digital observational and intervention research, particularly for populations who are most affected by the HIV epidemic and for those who may otherwise not participate in person. The progression across stages of the recruitment-enrollment cascade provides useful insight for implementation of cohort studies in the online environment. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/29152.

Rhinologic Procedures in the Era of COVID-19: Health-care Provider Protection Protocol.

INTRODUCTION: SARS-CoV-2 has been identified as the pathogen causing the outbreak of Coronavirus Disease 2019 (COVID-19) that started in Wuhan, China, in December 2019. SARS-CoV-2 has human-to-human transmission ability and universally contagious to all populations. The main transmission patterns are respiratory droplets transmission and contact transmission. The purpose of this study is to propose a protocol that may be used as a guide to reduce the incidence of COVID-19 infections among otolaryngology care teams. METHODS: A prospective cohort study was conducted to show the efficacy of our protocol to prevent transmission to health-care providers from March 11, 2020 through April 14, 2020. The protocol consisted of a series of protective measures that we applied to all health-care providers, then testing of our providers for COVID-19 using reverse transcription polymerase chain reaction along with immunoglobulin M (IgM) and immunoglobulin G (IgG) testing at the end of the study period to ensure effectiveness. RESULTS: Our protocol resulted in zero transmissions to our health-care providers during the duration of the initial study. We were involved in greater than 150 sinonasal, skull base, open airway, and endoscopy procedures during this study. At the conclusion of the initial 5 weeks, we had no health-care providers test positive for SARS-CoV-2. CONCLUSION: According to our proposed protocol, we were able to provide care for all patients in clinic, hospital, emergent, intensive, and surgical settings with no transmission of SARS-CoV-2 by symptomatology and post evaluation testing.

Open risk assessment.

As criminal justice actors increasingly seek to rely on more evidence-informed practices, including risk assessment instruments, they often lack adequate information about the evidence that informed the development of the practice or the tool. Open science practices, including making scientific research and data accessible and public, have not typically been followed in the development of tools designed for law enforcement, judges, probation, and others. This is in contrast to other government agencies, which often open their processes to public notice and comment. Lack of transparency has become pressing in the area of risk assessment, as entire judicial systems have adopted some type of risk assessment scheme. While the types of information used in a risk tool may be made public, often the underlying methods, validation data, and studies are not - nor are the assumptions behind how a level of risk gets categorized as "high" or "low." We discuss why those concerns are relevant and important to the new risk assessment tool now being used in federal prisons, as part of the First Step Act. We conclude that a number of key assumptions and policy choices made in the design of that tool are not verifiable or are inadequately supported, including the choice of risk thresholds and the validation data itself. Unfortunately, as a result, the federal risk assessment effort has not been the hoped-for model for open risk assessment.

Impact of Draf III, Draf IIb, and Draf IIa frontal sinus surgery on nasal irrigation distribution.

BACKGROUND: Delivery of topical pharmacotherapy to the paranasal sinuses remains integral to the management of chronic rhinosinusitis. The frontal sinus remains a difficult access site for irrigations, often limited by its position relative to the nostril and ethmoid sinus. In view of the previous demonstration of improved frontal sinus irrigation with Draf III vs Draf IIa, in this work we sought to evaluate topical access of Draf IIb relative to Draf IIa and Draf III modification of the frontal sinus outflow tract. METHODS: Unfixed human cadaver heads were dissected using Draf IIa, Draf IIb, and Draf III frontal sinusotomies. Draf IIa, Draf IIb, and Draf III frontal sinusotomies were performed in progressive sequence on each cadaver head. Nasal irrigation fluid access to the frontal sinus was tested after each successive frontal sinus intervention. Irrigations were performed using Frankfort horizontal and vertex positioning. Blinded reviewers were then asked to evaluate nasal irrigation access based on an ordinal scale. RESULTS: Eight cadaveric specimens (age, 78 ± 12.3 years; 62.5% female) were assessed. The greatest distribution scores were recorded by Draf III, then IIb, and then IIa (90.7% vs 81.3% vs 50.1%; p < 0.001). Similarly, the rate of lavage was greatest with Draf III (50% vs 12.5% vs 12.5%). Vertex positioning and increasing volume trended toward improved distribution but did not reach statistical significance. CONCLUSION: Adequate delivery of topical therapy to the paranasal sinuses by nasal irrigation remains critical in the postoperative state. Although increasing the dimensions of the frontal recess improves nasal irrigation delivery, the Draf III procedure provides the optimal delivery of pharmacotherapy in those with frontal sinus disease.

Adjuvant Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for patients at High-Risk of Peritoneal Metastases.

BACKGROUND: Selection of patients for hyperthermic intraperitoneal chemotherapy (HIPEC) continues to evolve. We hypothesized that adjuvant HIPEC for patients at high-risk of peritoneal progression is safe and associated with favorable outcomes. METHODS: The institutional database of a high-volume center was queried for patients with high-risk disease undergoing HIPEC with a peritoneal carcinomatosis index (PCI) of 0. High-risk patients were defined as those with ruptured primary tumors or locally advanced (T4) disease. RESULTS: 37 patients underwent adjuvant HIPEC, with a median follow-up of 5.2 years. 54% had low-grade (LG) tumors while 46% had high-grade (HG) tumors. No patients underwent neoadjuvant chemotherapy, while eleven patients (32.4%) received adjuvant chemotherapy. There were no perioperative mortalities, and the overall complication rate was 43%. For the entire cohort, five year recurrence-free survival (RFS) and overall survival (OS) were 77% and 100%, respectively. Five year RFS and OS were 75% and 100% for LG patients and 81% and 100% for HG patients, respectively. CONCLUSIONS: Adjuvant HIPEC for patients at high-risk of peritoneal progression, with PCI 0, is safe and associated with favorable long-term survival. Additional prospective investigation is needed to identify patient populations who may benefit most from HIPEC.

Age and Lymphovascular Invasion Accurately Predict Sentinel Lymph Node Metastasis in T2 Melanoma Patients.

BACKGROUND: The risk of sentinel lymph node (SLN) metastasis in melanoma is related directly to tumor thickness and inversely to age. The authors hypothesized that for T2 (thickness 1.1-2.0 mm) melanoma, age, and other factors may be able to identify a cohort of patients with a low risk of SLN metastases. METHODS: The authors developed logistic regression models to predict positive SLNs in patients undergoing SLN biopsy for T2 melanoma using the National Cancer Database. Classification and regression-tree analysis were used to identify groups of patients with high and low risk for SLN metastases. The prediction model then was applied to a separate data set from a multicenter randomized clinical trial. RESULTS: The study identified 12,918 patients with T2 melanoma undergoing SLN biopsy with clinically node-negative melanoma. In the multivariable analysis, increasing thickness, younger age, lymphovascular invasion (LVI), mitotic rate of 1/mm2 or more, axial location, and Clark level of 4 or 5 were independent risk factors for SLN metastases. A cohort based on age (> 56 years) and no LVI was identified with a relatively low risk (7.8%; 95% confidence interval 7.2-8.4%) of SLN metastases. The independent data set of 1531 patients with T2 melanoma confirmed these findings. Among elderly patients (age > 75 years) with melanoma 1.2 mm or smaller and no LVI, the risk of a positive SLN was 4.9% (95% confidence interval 3.3-7.1%). CONCLUSIONS: Younger age and LVI are powerful predictors of SLN metastases for patients with T2 melanoma. This prediction model can inform shared decision-making regarding whether to perform SLN biopsy for older patients with otherwise low-risk T2 melanoma.

Identifying risk factor for development of perioperative venous thromboembolism in patients with gastrointestinal malignancy.

BACKGROUND: Current data suggests that decreasing VTE incidence may require focus on other factors. This study aimed to identify perioperative risk factors for VTE in patients undergoing surgery for gastrointestinal (GI) malignancy. METHODS: Patients undergoing surgery for GI malignancy from 2013 to 2016 were grouped according to whether or not they developed a postoperative VTE, and groups were compared along demographic, perioperative, and outcome variables. RESULTS: Patients who developed VTE were more likely to be older (67 ±â€¯11 VTE vs. 61 ±â€¯10 no VTE, p = 0.04), male (92% vs. 59%, p = 0.02), and have a history of atrial fibrillation (39% vs. 11%, p = 0.01). They also experienced higher intraoperative blood loss (328 ±â€¯724 mL no VTE vs. 918 ±â€¯1885 mL VTE, p = 0.01). On multivariable analysis, history of atrial fibrillation was independently associated with development of postoperative VTE (odds ratio = 3.83, 95% confidence interval = 1.13-13.05, p = 0.03). CONCLUSION: A prior history of atrial fibrillation independently predicts increased risk of developing VTE after surgery for GI malignancy. Improving understanding of the underlying VTE pathophysiology in these patients can help guide effective prevention strategies.

Should Sentinel Lymph Node Biopsy Be Performed for All T1b Melanomas in the New 8th Edition American Joint Committee on Cancer Staging System?

BACKGROUND: In the 8th edition of the American Joint Committee on Cancer melanoma staging system, the T1b category has been redefined based solely on thickness and ulceration. National Comprehensive Cancer Network guidelines recommend consideration of sentinel lymph node biopsy (SLNB) for all patients with T1b melanomas (0.8 to 1.0 mm thick). We hypothesized that the new staging system would lead to excessive use of SLNB in patients with non-ulcerated T1b melanomas with a low risk of positive sentinel lymph nodes. STUDY DESIGN: The National Cancer Database 2015 Melanoma Public Use File was used to select patients undergoing SLNB for thin T1 cutaneous melanoma from 2010 to 2015. Clinicopathologic risk factors for having a positive SLNB were evaluated. Univariable and multivariable logistic regression models and classification and regression tree analysis were performed to identify groups with high and low risk of positive SLNB. RESULTS: We selected patients undergoing SLNB without ulceration with thickness 0.75 to 1.04 mm, staged T1b in the new 8th edition American Joint Committee on Cancer by thickness criteria alone (6,894 patients). Independent risk factors for a positive sentinel lymph node were age 56 years or younger (odds ratio [OR] 1.74; 95% CI 1.38 to 2.17), thickness 1.0 vs 0.8 to 0.9 mm (OR 1.36; 95% CI 1.09 to 1.70), female sex (OR 1.36; 95% CI 1.09 to 1.69), and mitotic rate ≥1/mm2 (OR 2.01; 95% CI 1.54 to 2.64). Classification and regression tree analysis identified 2 groups based on age, mitotic rate, and thickness with a risk of positive SLNB <5%. These 2 groups made up 55% of T1b, nonulcerated melanoma patients who underwent SLNB. CONCLUSIONS: The new 8th edition American Joint Committee on Cancer melanoma staging system T1b category should not be used to determine use of SLNB in thin melanoma, as more than one half of T1b lesions without ulceration have a low risk of positive sentinel lymph nodes.

Evaluation of Probe Angles for Synchronous Waveform 915-MHz Microwave Ablation.

BACKGROUND: The purpose of this study is to compare the ablation performance between a synchronous microwave ablation (MWA) system and a commercially available asynchronous system in ex vivo bovine liver and evaluate the efficacy of ablation at varying entrance angles. MATERIALS AND METHODS: Two 915-MHz MWA systems were used in bench top ex vivo bovine livers with various conditions (synchronous versus asynchronous). Using synchronous technology ablations to liver, kidney, or lung at angles of 0, 15, 30, and 90° were evaluated. RESULTS: Synchronous and asynchronous MWA systems created mean ablation zone volumes of 26.4 and 15.8 cm3, 62.9 and 45.4 cm3, 90.8 and 56.4, and 75.7 and 54.8 cm3 with single, double (2 microwave probes in use simultaneous) (2 cm spacing), and triple (three probes in use simultaneously) (2 cm and 3 cm spacing) antennae configurations, respectively; adjusted P-values ≤ 0.006. Ablation defects were similar across all groups when evaluated for entrance angle. Specifically, when comparing 0-degree angle to all other angles, achieved zones of ablation (ZA) were similar (mean ± standard deviation for 0-degree versus all other angles: 8.72 ± 4.84 versus 9.38 ± 4.11 cm2, P = 0.75). The use of the long-tip probe resulted in a statistically significant increase in the achieved ZA when compared to the short tip probe (10.9 ± 4.3 versus 6.5 ± 2.4, respectively; P = 0.01). CONCLUSIONS: Newly developed synchronous microwave technology creates significantly larger ablation zones when compared to an existing asynchronous commercially available system. The angle of approach does not affect the resulting ZA. This is clinically relevant as true 0-degree angle is often difficult to obtain.

Algorithmic risk assessments and the double-edged sword of youth.

At sentencing, youth can be considered both a mitigating circumstance because of its association with diminished culpability, and an aggravating circumstance because of its association with crime risk. In theory, judges and parole boards can recognize this double-edged sword phenomenon and balance the mitigating and aggravating effects of youth. But when sentencing authorities rely on algorithmic risk assessments, a practice that is becoming increasingly common, this balancing process may never take place. Algorithmic risk assessments often place heavy weights on age in a manner that is not fully transparent - or, in the case of proprietary "black box" algorithms, not transparent at all. For instance, our analysis of one of the leading black-box tools, the COMPAS Violent Recidivism Risk Score, shows that roughly 60% of the risk score it produces is attributable to age. We argue that this type of fact must be disclosed to sentencing authorities in an easily interpretable manner so that they understand the role an offender's age plays in the risk calculation. Failing to reveal that a stigmatic label such as "high risk of violent crime" is due primarily to a defendant's young age could lead to improper condemnation of a youthful offender, especially given the close association between risk labels and perceptions of character and moral blameworthiness.