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Pancreatic adenocarcinoma (PDAC) is a challenging malignancy with known disparities in outcomes across ethnicities. Studies specifically investigating PDAC in Asian populations are sparse, overlooking the rich diversity within this group. This research seeks to fill that gap by examining survival differences across the broad spectrum of Asian ethnicities, acknowledging the complexity and varied experiences within these communities. Utilizing the National Cancer Database from 2004 to 2019, we categorized patients into East Asian, Southeast Asian, South Asian, and Pacific Islander groups. Non-Asian or Pacific Islanders were excluded. Overall Survival was analyzed using a Cox hazards model. The study consisted of 13,254 patients. Most patients were East Asian (59.4%, n=7,866). Southeast Asians exhibited the poorest survival in unadjusted analysis (HR: 1.32, 95%CI: 1.23-1.42, p<0.001) compared to South Asians who had the best. Multivariable analysis revealed significantly worse survival for East Asians and Pacific Islanders relative to South Asians, while Southeast Asians' results were not significantly different. Asian subgroup differences notably affect PDAC outcomes. Research on genetic and cultural aspects, especially in Southeast Asians, and tackling health disparities, is crucial for enhancing survival in this diverse disease.
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Background: Neoadjuvant chemoradiotherapy (nCRT) is the standard treatment for locally advanced rectal cancer, but only 20-40% of patients completely respond to this treatment. Methods: To define the molecular features that are associated with response to nCRT, we generated and collected genomic and transcriptomic data from 712 cancers prior to treatment from our own data and from publicly available data. Results: We found that patients with a complete response have decreased risk of both local recurrence and future metastasis. We identified multiple differences in DNA mutations and transcripts between complete and incomplete responders. Complete responder tumors have a higher tumor mutation burden and more significant co-occurring mutations than the incomplete responder tumors. In addition, mutations in DNA repair genes (across multiple mechanisms of repair) were enriched in complete responders and they also had lower expression of these genes indicating that defective DNA repair is associated with complete response to nCRT. Using logistic regression, we identified three significant predictors of complete response: tumor size, mutations within specific network genes, and the existence of three or more specific co-occurrent mutations. In incompletely responder tumors, abnormal cell-cell interaction and increased cancer associated fibroblasts were associated with recurrence. Additionally, gene expression analysis identified a subset of immune hot tumors with worse outcomes and upregulated of immune checkpoint proteins. Conclusions: Overall, our study provides a comprehensive understanding of the molecular features associated with response to nCRT and the molecular differences in non-responder tumors that later reoccur. This knowledge may provide critical insight for the development of precision therapy for rectal cancer.
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Background: Hyperparathyroidism is common with African American patients historically experiencing disparate outcomes. With a comprehensive outreach program and systematic treatment plans, we sought to evaluate our institution's ability to reduce disparities in hyperparathyroidism. Methods: We performed a retrospective review of prospectively collected data at a single medical center for all patients undergoing parathyroidectomy by endocrine surgeons from 2015 to 2021 for primary (PHPT) and tertiary (THPT) hyperparathyroidism. Patient demographics, pre-and post-operative clinical and biochemical data were collected and analyzed by race. Results: Of the 757 patients included, 675 patients had PHPT with 135 (20 %) African-American (AA) and 528(78 %) female. Of 82 patients with THPT, 44 (53 %) were AA and 34 (32 %) were female. AA patients were younger than Caucasian (CA) patients with a mean age (±SD) of 56 ± 15 vs 60 ± 14 years in PHPT (p < 0.01) and 50 ± 10 vs 55 ± 10 years in THPT (p = 0.02).Median (IQR) preoperative PTH was higher in AA with PHPT 134 (97-190) vs 102 (75-144) pg/mL (p < 0.01) and in AA with THPT 285 (189-544) vs 218 (145-293) (p = 0.01) pg/mL. AA PHPT patients had significantly higher preoperative mean (±SD) calcium levels 10.9 ± 0.8 vs 10.6 ± 0.8 mg/dL(p < 0.001). Biochemical cure rates at 6 months and complication rates were not different between races. Conclusions: AA patients with PHPT and THPT disease experienced similar cure rates to their CA counterparts despite having a more severe biochemical disease. Health care disparities may be ameliorated with treatment by high volume surgeons embedded in a comprehensive health care system.
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Importance: A competency-based assessment framework using entrustable professional activities (EPAs) was endorsed by the American Board of Surgery following a 2-year feasibility pilot study. Pilot study programs' clinical competency committees (CCCs) rated residents on EPA entrustment semiannually using this newly developed assessment tool, but factors associated with their decision-making are not yet known. Objective: To identify factors associated with variation in decision-making confidence of CCCs in EPA summative entrustment decisions. Design, Setting, and Participants: This cohort study used deidentified data from the EPA Pilot Study, with participating sites at 28 general surgery residency programs, prospectively collected from July 1, 2018, to June 30, 2020. Data were analyzed from September 27, 2022, to February 15, 2023. Exposure: Microassessments of resident entrustment for pilot EPAs (gallbladder disease, inguinal hernia, right lower quadrant pain, trauma, and consultation) collected within the course of routine clinical care across four 6-month study cycles. Summative entrustment ratings were then determined by program CCCs for each study cycle. Main Outcomes and Measures: The primary outcome was CCC decision-making confidence rating (high, moderate, slight, or no confidence) for summative entrustment decisions, with a secondary outcome of number of EPA microassessments received per summative entrustment decision. Bivariate tests and mixed-effects regression modeling were used to evaluate factors associated with CCC confidence. Results: Among 565 residents receiving at least 1 EPA microassessment, 1765 summative entrustment decisions were reported. Overall, 72.5% (1279 of 1765) of summative entrustment decisions were made with moderate or high confidence. Confidence ratings increased with increasing mean number of EPA microassessments, with 1.7 (95% CI, 1.4-2.0) at no confidence, 1.9 (95% CI, 1.7-2.1) at slight confidence, 2.9 (95% CI, 2.6-3.2) at moderate confidence, and 4.1 (95% CI, 3.8-4.4) at high confidence. Increasing number of EPA microassessments was associated with increased likelihood of higher CCC confidence for all except 1 EPA phase after controlling for program effects (odds ratio range: 1.21 [95% CI, 1.07-1.37] for intraoperative EPA-4 to 2.93 [95% CI, 1.64-5.85] for postoperative EPA-2); for preoperative EPA-3, there was no association. Conclusions and Relevance: In this cohort study, the CCC confidence in EPA summative entrustment decisions increased as the number of EPA microassessments increased, and CCCs endorsed moderate to high confidence in most entrustment decisions. These findings provide early validity evidence for this novel assessment framework and may inform program practices as EPAs are implemented nationally.
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Competência Clínica , Tomada de Decisões , Cirurgia Geral , Internato e Residência , Humanos , Cirurgia Geral/educação , Projetos Piloto , Masculino , Educação Baseada em Competências , Feminino , Estados UnidosRESUMO
BACKGROUND: While males present with more adverse clinicopathologic features in papillary thyroid carcinoma (PTC), younger age has previously been shown to be a favorable prognostic factor. We examined the combined effect of male sex and young age on PTC outcomes. METHODS: We conducted a retrospective analysis of a prospectively maintained database of thyroid cancer surgery patients (2000-2020) at a single quaternary care institution. We included papillary thyroid carcinoma cases and excluded those with prior cancer-related thyroid surgery. We examined demographics, cancer stage, surgical outcomes, and complications by age and sex, analyzing groups below and above the age of 40 years. RESULTS: A total of 680 patients with PTC were included. Females constituted 68% (age ≥40 years: 44% and <40 years: 24%) and males 32% (≥40 years: 24% and <40 years: 8%). A significant difference (p < 0.001) of N1 disease distribution was found between the groups. N1a metastasis was greater in patients younger than 40 regardless of sex ((M < 40 (15%), F < 40 (15%), M ≥ 40 (12%), and F ≥ 40 (9%)). While, M < 40 had greater N1b metastasis (36%) than all other groups (M ≥ 40 (28%), F < 40 (22%), and F ≥ 40 (10%)). There was no significant difference in the distribution of T stages between groups. Groups showed no differences in 30-day outcomes, recurrence at 1 year, reoperation, mortality, nerve injury, or hypocalcemia. CONCLUSIONS: Young males with PTC face increased occurrence of nodal metastasis yet experience similar recurrence rates as their female and older counterparts. Subgroup analysis underscores the predictive role of sex and age in advanced PTC cases.
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Câncer Papilífero da Tireoide , Neoplasias da Glândula Tireoide , Tireoidectomia , Humanos , Masculino , Adulto , Câncer Papilífero da Tireoide/cirurgia , Câncer Papilífero da Tireoide/patologia , Câncer Papilífero da Tireoide/mortalidade , Feminino , Estudos Retrospectivos , Neoplasias da Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/mortalidade , Tireoidectomia/métodos , Pessoa de Meia-Idade , Fatores Etários , Fatores Sexuais , Estadiamento de Neoplasias , Resultado do Tratamento , Idoso , Complicações Pós-Operatórias/epidemiologia , Prognóstico , Recidiva Local de Neoplasia/epidemiologiaRESUMO
INTRODUCTION: The influence of time to surgery on racial/ethnic disparities in papillary thyroid carcinoma (PTC) survival remains unstudied. MATERIALS AND METHODS: The National Cancer Database (2004-2017) was queried for patients with localized PTC. Survival data was compared by time to surgery, patient demographics, and multivariable Cox regression was performed. RESULTS: Of 126,708 patients included, 5% were Black, 10% Hispanic. Of all patients, 85% had no comorbidities. Non-Hispanic White (NHW) patients had a shorter median time to surgery than Black and Hispanic patients (36 vs. 43 vs. 42 days, respectively p â< â0.001). In multivariable analysis, longer time to surgery (>90 days vs â< â30 days) and Black race vs NHW, were associated with worse survival (HR: 1.56, (95%CI, 1.43-1.70), p â< â0.001 and HR: 1.21, (1.08-1.36), p â= â0.001), respectively. CONCLUSION: Delaying surgery for thyroid cancer is associated with worse survival. However, independent of time to surgery and other confounders, there remains a disparity as black patients have poorer outcomes.
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Disparidades em Assistência à Saúde , Câncer Papilífero da Tireoide , Neoplasias da Glândula Tireoide , Tempo para o Tratamento , Humanos , Masculino , Feminino , Neoplasias da Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/mortalidade , Neoplasias da Glândula Tireoide/etnologia , Pessoa de Meia-Idade , Disparidades em Assistência à Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Câncer Papilífero da Tireoide/cirurgia , Câncer Papilífero da Tireoide/mortalidade , Câncer Papilífero da Tireoide/etnologia , Estados Unidos/epidemiologia , Tempo para o Tratamento/estatística & dados numéricos , Hispânico ou Latino/estatística & dados numéricos , Tireoidectomia/estatística & dados numéricos , Adulto , Idoso , População Branca/estatística & dados numéricos , Negro ou Afro-Americano/estatística & dados numéricos , Taxa de Sobrevida , Estudos RetrospectivosRESUMO
INTRODUCTION: Colorectal cancer is the third most common cause of cancer death. Rectal cancer makes up a third of all colorectal cases. Treatment for locally advanced rectal cancer includes chemoradiation followed by surgery. We have previously identified ST6GAL1 as a cause of resistance to chemoradiation in vitro and hypothesized that it would be correlated with poor response in human derived models and human tissues. METHODS: Five organoid models were created from primary human rectal cancers and ST6GAL1 was knocked down via lentivirus transduction in one model. ST6GAL1 and Cleaved Caspase-3 (CC3) were assessed after chemoradiation via immunostaining. A tissue microarray (TMA) was created from twenty-six patients who underwent chemoradiation and had pre- and post-treatment specimens of rectal adenocarcinoma available at our institution. Immunohistochemistry was performed for ST6GAL1 and percent positive cancer cell staining was assessed and correlation with pathological grade of response was measured. RESULTS: Organoid models were treated with chemoradiation and both ST6GAL1 mRNA and protein significantly increased after treatment. The organoid model targeted with ST6GAL1 knockdown was found to have increased CC3 after treatment. In the tissue microarray, 42 percent of patient samples had an increase in percent tumor cell staining for ST6GAL1 after treatment. Post-treatment percent staining was associated with a worse grade of treatment response (p = 0.01) and increased staining post-treatment compared to pre-treatment was also associated with a worse response (p = 0.01). CONCLUSION: ST6GAL1 is associated with resistance to treatment in human rectal cancer and knockdown in an organoid model abrogated resistance to apoptosis caused by chemoradiation.
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Quimiorradioterapia , Neoplasias Retais , beta-D-Galactosídeo alfa 2-6-Sialiltransferase , Humanos , Antígenos CD , beta-D-Galactosídeo alfa 2-6-Sialiltransferase/efeitos dos fármacos , beta-D-Galactosídeo alfa 2-6-Sialiltransferase/metabolismo , beta-D-Galactosídeo alfa 2-6-Sialiltransferase/efeitos da radiação , Estadiamento de Neoplasias , Neoplasias Retais/tratamento farmacológico , Neoplasias Retais/genética , Neoplasias Retais/radioterapiaRESUMO
BACKGROUND: The American Board of Surgery has endorsed competency-based education as vital to the assessment of surgical training. From 2018 to 2020, a national pilot study was conducted at 28 general surgery programs to evaluate feasibility of implementing entrustable professional activities (EPAs) for 5 common general surgical conditions. ACGME core competency Milestones were also rated for each resident by program clinical competency committees. This study aimed to evaluate the validity of general surgery EPAs compared with Milestones. STUDY DESIGN: Prospectively collected, de-identified EPA Pilot Study data were analyzed. EPAs studied were EPA-1 (gallbladder), EPA-2 (inguinal hernia), EPA-3 (right lower quadrant pain), EPA-4 (trauma), and EPA-5 (consult). Variables abstracted included levels of EPA entrustment (1 to 5) and corresponding ACGME Milestone subcompetency ratings (1 to 5) for the same study cycle. Spearman's correlations were used to evaluate the relationship between summative EPA scores and corresponding Milestone ratings. RESULTS: A total of 493 unique residents received a summative entrustment decision. EPA summative entrustment scores had moderate-to-strong positive correlation with mapped Milestone subcompetencies, with median rho value of 0.703. Among operation-focused EPAs, median rho values were similar between EPA-1 (0.688) and EPA-2 (0.661), but higher for EPA-3 (0.833). EPA-4 showed a strong positive correlation with diagnosis and communication competencies (0.724), whereas EPA-5, mapped to the most Milestone subcompetencies, had the lowest median rho value (0.455). CONCLUSIONS: Moderate-to-strong positive correlation was noted between EPAs and patient care, medical knowledge, and communication Milestones. These findings support the validity of EPAs in general surgery and suggest that EPA assessments can be used to inform Milestone ratings by clinical competency committees.
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Internato e Residência , Humanos , Projetos Piloto , Educação de Pós-Graduação em Medicina , Competência Clínica , Educação Baseada em CompetênciasRESUMO
BACKGROUND: High-grade soft tissue sarcoma is rare and associated with poor prognosis. This study examines racial and ethnic variation in presentation and outcomes at a Southeastern US cancer center. METHODS: Among an institutional cohort of patients seen between January 2016-December 2021, racial and ethnic differences were evaluated using chi-squared tests, Kaplan Meier curves, and Cox proportional hazards models. RESULTS: There were 295 patients (71 â% Non-Hispanic White, 24 â% Black, 3 â% Hispanic White, 2 â% Other). Black representation was greater than national cohorts (24 â% vs. 12 â%). Histological subtype varied by race/ethnicity (p â= â0.007). Adjusting for histology and stage, survival was worse for Black vs. White patients (HR 1.71, 95 â% CI 1.07-2.76) and those with metastatic disease (5.47, 3.54-8.44). In non-metastatic patients, survival differences for Black vs. White patients were attenuated by receipt of multi-modal treatment (1.53, 0.82-2.88). CONCLUSION: Observed racial disparities in survival of high-grade sarcoma may be addressed by early, multidisciplinary management.
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Disparidades nos Níveis de Saúde , Sarcoma , Humanos , Etnicidade , Modelos de Riscos Proporcionais , Sarcoma/etnologia , Sarcoma/terapia , Sudeste dos Estados Unidos/epidemiologia , Estados Unidos/epidemiologia , Grupos RaciaisRESUMO
Purpose: Black women are less likely to receive screening mammograms and are at a higher lifetime risk for developing breast cancer compared to their White counterparts. Affordable Care Act (ACA) provisions decreased cost sharing for women's preventive screening, potentially mitigating screening disparities. We examined enrollment of a high-risk screening program before and after ACA implementation stratified by race. Methods: This retrospective, quasi-experimental study examined the ACA's impact on patient demographics at a high-risk breast cancer screening clinic from 02/28/2003-02/28/2019. Patient demographic data were abstracted from electronic medical records and descriptively compared in the pre- and post-ACA time periods. Interrupted time series (ITS) analysis using Poisson regression assessed yearly clinic enrollment rates by race using incidence rate ratios (IRR) and 95% confidence intervals (CI). Results: 2,767 patients enrolled in the clinic. On average, patients were 46 years old (SD, ± 12), 82% were commercially insured, and 8% lived in a highly disadvantaged neighborhood. In ITS models accounting for trends over time, Prior to ACA implementation, White patient enrollment was stable (IRR 1.01, 95% CI 1.00-1.02) while Black patient enrollment increased at 13% per year (IRR 1.13, 95% CI 1.05-1.22). Compared to the pre-ACA enrollment period, the post-ACA enrollment rate remained unchanged for White patients (IRR 0.99, 95% CI 0.97-1.01) but decreased by 17% for Black patients (IRR 0.83, 95% CI 0.74-0.92). Conclusion: Black patient enrollment decreased at a high-risk breast cancer screening clinic post-ACA compared to the pre-ACA period, indicating a need to identify factors contributing to racial disparities in clinic enrollment.
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INTRODUCTION: Liver allocation changes have led to increased travel and expenditures, highlighting the need to efficiently identify marginal livers suitable for transplant. We evaluated the validity of existing non-invasive liver quality tests and a novel machine learning-based model at predicting deceased donor macrosteatosis >30%. METHODS: We compared previously-validated non-invasive tests and a novel machine learning-based model to biopsies in predicting macrosteatosis >30%. We also tested them in populations enriched for macrosteatosis. RESULTS: The Hepatic Steatosis Index area-under-the-curve (AUC) was 0.56. At the threshold identified by Youden's J statistic, sensitivity, specificity, positive, and negative predictive values were 49.6%, 58.9%, 14.0%, and 89.7%. Other tests demonstrated comparable results. Machine learning produced the highest AUC (0.71). Even in populations enriched for macrosteatosis, no test was sufficiently predictive. CONCLUSION: Commonly used clinical scoring systems and a novel machine learning-based model were not clinically useful, highlighting the importance of pre-procurement biopsies to facilitate allocation.
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Fígado Gorduroso , Transplante de Fígado , Humanos , Doadores de Tecidos , Testes de Função HepáticaRESUMO
OBJECTIVE: Hyperparathyroidism (HPT) is nearly universal in patients with end-stage kidney disease. Kidney transplantation (KT) reverses HPT in many patients, but most studies have only focused on following calcium and not parathyroid hormone (PTH) levels. We sought to study the prevalence of persistent HPT post-KT at our center and its effect on graft survival. METHODS: Patients who underwent KT from January 2015 to August 2021 were included and characterized by post-KT HPT status at the most recent follow-up: resolved (achieving normal PTH post-KT) versus persistent HPT. Those with persistent HPT were further stratified by the occurrence of hypercalcemia (normocalcemic versus hypercalcemic HPT). Patient demographics, donor kidney quality, PTH and calcium levels, and allograft function were compared between groups. Multivariable logistic regression and Cox regression with propensity score matching were conducted. RESULTS: Of 1554 patients, only 390 (25.1%) patients had resolution of renal HPT post-KT with a mean (±SD) follow-up length of 40±23 months. The median (IQR) length of HPT resolution was 5 (0-16) months. Of the remaining 1164 patients with persistent HPT post-KT, 806 (69.2%) patients had high PTH and normal calcium levels, while 358 (30.8%) patients had high calcium and high PTH levels. Patients with persistent HPT had higher parathyroid hormone (PTH) at the time of KT [403 (243-659) versus 277 (163-454) pg/mL, P <0.001] and were more likely to have received cinacalcet treatment before KT (34.9% vs. 12.3%, P <0.001). Only 6.3% of patients with persistent HPT received parathyroidectomy. Multivariable logistic regression showed race, cinacalcet use pre-KT, dialysis before KT, receiving an organ from a deceased donor, high PTH, and calcium levels at KT were associated with persistent HPT post-KT. After adjusting for patient demographics and donor kidney quality by propensity score matching, persistent HPT (HR 2.5, 95% CI 1.1-5.7, P =0.033) was associated with a higher risk of allograft failure. Sub-analysis showed that both hypercalcemic HPT (HR 2.6, 95% CI 1.1-6.5, P =0.045) and normocalcemic HPT (HR 2.5, 95% CI 1.3-5.5, P =0.021) were associated with increased risk of allograft failure when compared with patients with resolved HPT. CONCLUSION: Persistent HPT is common (75%) after KT and is associated with a higher risk of allograft failure. PTH levels should be closely monitored after kidney transplantation so that patients with persistent HPT can be treated appropriately.
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Hipercalcemia , Hiperparatireoidismo Secundário , Transplante de Rim , Humanos , Cinacalcete/uso terapêutico , Cálcio , Transplante de Rim/efeitos adversos , Sobrevivência de Enxerto , Estudos Retrospectivos , Hiperparatireoidismo Secundário/etiologia , Hiperparatireoidismo Secundário/cirurgia , Hormônio Paratireóideo , Hipercalcemia/complicações , ParatireoidectomiaRESUMO
BACKGROUND: Despite the known influences of both race- and aging-related factors in colorectal cancer outcomes and mortality, limited literature is available on the intersection between race and aging-related impairments. OBJECTIVE: To explore racial differences in frailty and geriatric deficit subdomains among patients with colorectal cancer. DESIGN: Retrospective study using data from the Cancer and Aging Resilience Evaluation registry. SETTINGS: A comprehensive cancer center in the Deep South. PATIENTS: Older adults (aged ≥60 years) with colorectal cancer. MAIN OUTCOME MEASURES: Measure of frailty and geriatric assessment subdomains of physical function, functional status, cognitive complaints, psychological function, and health-related quality of life. RESULTS: Black patients lived in areas with a higher social vulnerability index compared to White patients (0.69 vs 0.49; p < 0.01) and had limited social support more often (54.5% vs 34.9%; p = 0.01). After adjustment for age, cancer stage, comorbidities, and social vulnerability index, Black patients were found to have a higher rate of frailty than White patients (adjusted OR 3.77; 95% CI, 1.76-8.18; p = 0.01). In addition, Black patients had more physical limitations (walking 1 block: adjusted OR 1.93; 95% CI, 1.02-3.69; p = 0.04), functional limitations (activities of daily living: adjusted OR 3.21; 95% CI, 1.42-7.24; p = 0.01), and deficits in health-related quality of life (poor global self-reported health: adjusted OR 2.45; 95% CI, 1.23-5.13; p = 0.01). Similar findings were shown after stratification by stage I to III vs IV. LIMITATIONS: Retrospective study at a single institution. CONCLUSIONS: Among older patients with colorectal cancer, Black patients were more likely to be frail than White patients, with deficits observed specifically in physical function, functional status, and health-related quality of life. Geriatric assessment may provide an important tool in addressing racial inequities in colorectal cancer. DIFERENCIAS RACIALES EN LOS DFICITS RELACIONADOS CON EL ENVEJECIMIENTO ENTRE ADULTOS MAYORES CON CNCER COLORRECTAL: ANTECEDENTES: A pesar de las influencias conocidas de los factores relacionados con la raza y el envejecimiento en los resultados y la mortalidad del cáncer colorectal, hay muy poca literatura sobre la intersección entre los impedimentos relacionados con la raza y el envejecimiento.OBJETIVO: El objetivo era explorar las diferencias raciales en los subdominios de fragilidad y déficit geriátrico entre los pacientes con cáncer colorectal.DISEÑO: Estudio retrospectivo utilizando datos del registro Cancer and Aging Resilience Evaluation.AJUSTES: Un centro oncológico integral en el Sur Profundo.PACIENTES: Adultos mayores (≥60 años) con cáncer colorrectal de raza Negra o Blanca.PRINCIPALES MEDIDAS DE RESULTADO: Medida compuesta de fragilidad y subdominios de evaluación geriátrica de función física, estado funcional, quejas cognitivas, función psicológica y calidad de vida relacionada con la salud.RESULTADOS: De los 304 pacientes incluidos, el 21,7% (n = 66) eran negros y la edad media era de 69 años. Los pacientes negros vivían en áreas con un índice de vulnerabilidad social (SVI) más alto en comparación con los pacientes blancos (SVI 0,69 vs 0,49; p < 0,01) y con mayor frecuencia tenían apoyo social limitado (54,5% vs 34,9%; p = 0,01). Después de ajustar por edad, estadio del cáncer, comorbilidades y SVI, los pacientes de raza negra tenían una mayor tasa de fragilidad en comparación con los pacientes de raza blanca (ORa 3,77, IC del 95%: 1,76-8,18; p = 0,01). Además, los pacientes negros tenían más limitaciones físicas (caminar 1 cuadra: ORa 1,93, IC 95% 1,02-3,69; p = 0,04), limitaciones funcionales (actividades de la vida diaria: ORa 3,21, IC 95% 1,42-7,24; p = 0,01 ) y déficits en la calidad de vida relacionada con la salud (mala salud global autoinformada: ORa 2,45, IC 95% 1,23-5,13; p = 0,01). Las quejas cognitivas y las funciones psicológicas no difirieron según la raza (p > 0,05). Se mostraron hallazgos similares después de la estratificación por estadio I-III frente a IV.LIMITACIONES: Estudio retrospectivo en una sola institución.CONCLUSIONES: Entre los pacientes mayores con cáncer colorrectal, los pacientes negros tenían más probabilidades que los pacientes blancos de ser frágiles, observándose déficits específicamente en la función física, el estado funcional y la calidad de vida relacionada con la salud. La evaluación geriátrica puede proporcionar una herramienta importante para abordar las desigualdades raciales en el cáncer colorrectal.
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Neoplasias Colorretais , Fragilidade , Humanos , Idoso , Atividades Cotidianas , Qualidade de Vida , Fatores Raciais , Estudos Retrospectivos , EnvelhecimentoRESUMO
INTRODUCTION: Enhanced recovery programs (ERPs) reduce racial disparities in surgical outcomes for general colorectal surgery populations. It is unclear, however, if disparities in IBD populations are impacted by ERPs. METHODS: Retrospective study comparing IBD patients undergoing major elective colorectal operations before (2006-2014) and after (2015-2021) ERP implementation using ACS-NSQIP data. The primary outcome of length of stay (LOS) was analyzed by negative binomial regression, and secondary outcomes (complications and readmissions) by logistic regression. RESULTS: Of 466 IBD patients, 47% were pre-ERP and 53% were ERP patients. In multivariable analysis stratified by ERP period, Black race was associated with increased odds of complications in the pre-ERP (OR 3.6, 95%CI 1.4-9.3) and ERP groups (OR 3.1 95%CI 1.3-7.6). Race was not a predictor of LOS or readmission in either group. High social vulnerability was associated with increased odds of readmission pre-ERP (OR 15.1, 95%CI 2.1-136.3), but this disparity was mitigated under ERPs (OR 1.4, 95%CI 0.4-5.6). CONCLUSION: While ERPs mitigated some disparities by social vulnerability, racial disparities persist in IBD populations even under ERPs. Further work is needed to achieve surgical equity for IBD patients.
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Neoplasias Colorretais , Doenças Inflamatórias Intestinais , Humanos , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Doenças Inflamatórias Intestinais/cirurgia , Assistência Perioperatória , Tempo de InternaçãoRESUMO
BACKGROUND: As the obesity epidemic grows, the number of morbidly obese patients undergoing anterior cervical discectomy and fusion (ACDF) continues to increase. Despite the association of obesity with perioperative complications in anterior cervical surgery, the impact of morbid obesity on ACDF complications remains controversial, and studies examining morbidly obese cohorts are limited. METHODS: A single-institution, retrospective analysis of patients undergoing ACDF from September 2010 to February 2022 was performed. Demographic, intraoperative, and postoperative data were collected via review of the electronic medical record. Patients were categorized as nonobese (body mass index [BMI] <30), obese (BMI 30-39.9), or morbidly obese (BMI ≥40). Associations of BMI class with discharge disposition, length of surgery, and length of stay were assessed using multivariable logistic regression, multivariable linear regression, and negative binomial regression, respectively. RESULTS: The study included 670 patients undergoing single-level or multilevel ACDF: 413 (61.6%) nonobese, 226 (33.7%) obese, and 31 (4.6%) morbidly obese patients. BMI class was associated with prior history of deep venous thrombosis (P < 0.01), pulmonary thromboembolism (P < 0.05), and diabetes mellitus (P < 0.001). In bivariate analysis, there was no significant association between BMI class and reoperation or readmission rates at 30, 60, or 365 days postoperatively. In multivariable analysis, greater BMI class was associated with increased length of surgery (P = 0.03), but not length of stay or discharge disposition. CONCLUSIONS: For patients undergoing ACDF, greater BMI class was associated with increased length of surgery, but not reoperation rate, readmission rate, length of stay, or discharge disposition.
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Obesidade Mórbida , Fusão Vertebral , Humanos , Estudos de Coortes , Estudos Retrospectivos , Obesidade Mórbida/complicações , Obesidade Mórbida/epidemiologia , Obesidade Mórbida/cirurgia , Fusão Vertebral/métodos , Complicações Pós-Operatórias/etiologia , Discotomia/métodos , Vértebras Cervicais/cirurgiaRESUMO
Importance: In January 2011, the US Food and Drug Administration (FDA) announced a mandate to limit acetaminophen (paracetamol) to 325 mg/tablet in combination acetaminophen and opioid medications, with manufacturer compliance required by March 2014. Objective: To assess the odds of hospitalization and the proportion of acute liver failure (ALF) cases with acetaminophen and opioid toxicity prior to and after the mandate. Design, Setting, and Participants: This interrupted time-series analysis used hospitalization data from 2007-2019 involving ICD-9/ICD-10 codes consistent with both acetaminophen and opioid toxicity from the National Inpatient Sample (NIS), a large US hospitalization database, and ALF cases from 1998-2019 involving acetaminophen and opioid products from the Acute Liver Failure Study Group (ALFSG), a cohort of 32 US medical centers. For comparison, hospitalizations and ALF cases consistent with acetaminophen toxicity alone were extracted from the NIS and ALFSG. Exposures: Time prior to and after the FDA mandate limiting acetaminophen to 325 mg in combination acetaminophen and opioid products. Main Outcomes and Measures: Odds of hospitalization involving acetaminophen and opioid toxicity and percentage of ALF cases from acetaminophen and opioid products prior to and after the mandate. Results: In the NIS, among 474â¯047â¯585 hospitalizations from Q1 2007 through Q4 2019, there were 39â¯606 hospitalizations involving acetaminophen and opioid toxicity; 66.8% of cases were among women; median age, 42.2 (IQR, 28.4-54.1). In the ALFSG, from Q1 1998 through Q3 2019, there were a total of 2631 ALF cases, of which 465 involved acetaminophen and opioid toxicity; 85.4% women; median age, 39.0 (IQR, 32.0-47.0). The predicted incidence of hospitalizations 1 day prior to the FDA announcement was 12.2 cases/100â¯000 hospitalizations (95% CI, 11.0-13.4); by Q4 2019, it was 4.4/100â¯000 hospitalizations (95% CI, 4.1-4.7) (absolute difference, 7.8/100â¯000 [95% CI, 6.6-9.0]; P < .001). The odds of hospitalizations with acetaminophen and opioid toxicity increased 11%/y prior to the announcement (odds ratio [OR], 1.11 [95% CI, 1.06-1.15]) and decreased 11%/y after the announcement (OR, 0.89 [95% CI, 0.88-0.90]). The predicted percentage of ALF cases involving acetaminophen and opioid toxicity 1 day prior to the FDA announcement was 27.4% (95% CI, 23.3%-31.9%); by Q3 2019, it was 5.3% (95% CI, 3.1%-8.8%) (absolute difference, 21.8% [95% CI, 15.5%-32.4%]; P < .001). The percentage of ALF cases involving acetaminophen and opioid toxicity increased 7% per year prior to the announcement (OR, 1.07 [95% CI, 1.03-1.1]; P < .001) and decreased 16% per year after the announcement (OR, 0.84 [95% CI, 0.77-0.92]; P < .001). Sensitivity analyses confirmed these findings. Conclusions and Relevance: The FDA mandate limiting acetaminophen dosage to 325 mg/tablet in prescription acetaminophen and opioid products was associated with a statistically significant decrease in the yearly rate of hospitalizations and proportion per year of ALF cases involving acetaminophen and opioid toxicity.
Assuntos
Acetaminofen , Analgésicos Opioides , Analgésicos , Hospitalização , Falência Hepática Aguda , Adulto , Feminino , Humanos , Masculino , Acetaminofen/administração & dosagem , Acetaminofen/efeitos adversos , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/efeitos adversos , Hospitalização/estatística & dados numéricos , Falência Hepática Aguda/induzido quimicamente , Falência Hepática Aguda/epidemiologia , Falência Hepática Aguda/terapia , Prescrições/estatística & dados numéricos , Estados Unidos/epidemiologia , United States Food and Drug Administration , Combinação de Medicamentos , Analgésicos/administração & dosagem , Analgésicos/efeitos adversos , Pessoa de Meia-IdadeRESUMO
INTRODUCTION: Total thyroidectomy (TT) has been shown to be a safe and effective treatment for Graves' disease. However, the time course for improvement of symptoms has not been defined. METHODS: With an institutional review board approval, we prospectively gathered survey data of all patients (n = 79) undergoing TT for Graves' disease at a single institution from 2019 to 2021. After informed consent was obtained, patients completed surveys preoperatively and at 2 wk followed by monthly postoperative visits/phone calls. Patient demographics and survey results were collected and analyzed. Symptom recovery time was evaluated using Kaplan-Meier analysis. RESULTS: A total of 50 patients completed the survey on postoperative follow-up (response rate 63%). Average age was 38 y (range 12-80 y) and 88% of patients were female. The most common preoperative symptoms were fatigue (90%) and heat/cold intolerance (88%). Tremor (median time to resolution: 1 wk; interquartile range [IQR] 1-3), diarrhea (median 1 wk [IQR 1-3]), and palpitations (median 1 wk [IQR 1-3]) resolved the most rapidly followed by eye symptoms (median 3 wk [IQR 1-6]), heat/cold intolerance (median 3 wk [IQR 3-30]), memory deficits (median 3 wk [IQR 1-undefined]), and fatigue (median: 3 wk [IQR 1-14]). There were no significant differences in time to resolution of symptoms by gender or age (less than versus 40 y and older). Those with uncontrolled Graves' had more severe symptoms but no difference in time to resolution from the euthyroid Graves' patients. CONCLUSIONS: Many Graves' disease symptoms improve rapidly following TT, with a median time to improvement of less than 1 mo.
Assuntos
Doença de Graves , Tireoidectomia , Humanos , Feminino , Adulto , Masculino , Tireoidectomia/efeitos adversos , Tireoidectomia/métodos , Doença de Graves/cirurgia , Resultado do Tratamento , FadigaRESUMO
BACKGROUND: Hyperparathyroidism is common in patients with end-stage kidney disease and may persist after kidney transplantation (KT). Parathyroidectomy (PTx) is curative, but whether PTx should be performed before or after KT remains controversial. There is concern that PTx can adversely affect renal allograft function if performed post-KT and result in persistent hypocalcemia. This study evaluated outcomes and postoperative complications of PTx before and after KT at our institution. METHODS: We performed a retrospective review of patients at our center (1/2012-2/2019) who had PTx either pre-KT or post-KT. Data on patient demographics, surgical outcomes, and postoperative complications of PTx were collected. RESULTS: Ninety-eight patients were included in this study, with 23 patients undergoing PTx before KT and 75 after KT. The length of follow-up after KT was 67.7 ± 25.5 months. In post-KT PTx patients, 30-day allograft function was unchanged after PTx. Calcium oxalate and phosphate crystals were less common on allograft biopsies in pre-KT PTx patients (10.0% vs. 34.8%, p = 0.038). Patients in the pre-KT group required more calcium supplementation after PTx than the post-KT group (p < 0.001). At one-year post-PTx, 17 (19.1%) patients required > 1000 mg elemental calcium per day and 7 (7.9%) patients required > 2000 mg/day. There was no difference in surgical success or postoperative complications between the two groups. CONCLUSIONS: Parathyroidectomy before or after kidney transplantation does not adversely affect allograft function. The incidence of persistent hypocalcemia was low. Parathyroidectomy is safe and effective either before or after kidney transplantation.
Assuntos
Hiperparatireoidismo Secundário , Hipocalcemia , Falência Renal Crônica , Transplante de Rim , Humanos , Hipocalcemia/epidemiologia , Cálcio , Paratireoidectomia , Estudos Retrospectivos , Falência Renal Crônica/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Hiperparatireoidismo Secundário/etiologia , Hiperparatireoidismo Secundário/cirurgiaRESUMO
OBJECTIVE: To examine whether body mass index (BMI) changes modify the association between kidney donation and incident hypertension. BACKGROUND: Obesity increases hypertension risk in both general and living kidney donor (LKD) populations. Donation-attributable risk in the context of obesity, and whether weight change modifies that risk, is unknown. METHODS: Nested case-control study among 1558 adult LKDs (1976-2020) with obesity (median follow-up: 3.6 years; interquartile range: 2.0-9.4) and 3783 adults with obesity in the Coronary Artery Risk Development in Young Adults (CARDIA) and Atherosclerosis Risk in Communities (ARIC) studies (9.2 y; interquartile range: 5.3-15.8). Hypertension incidence was compared by donor status using conditional logistic regression, with BMI change investigated for effect modification. RESULTS: Overall, LKDs and nondonors had similar hypertension incidence [incidence rate ratio (IRR): 1.16, 95% confidence interval (95% CI): 0.94-1.43, P =0.16], even after adjusting for BMI change (IRR: 1.25, 95% CI: 0.99-1.58, P =0.05). Although LKDs and nondonors who lost >5% BMI had comparable hypertension incidence (IRR: 0.78, 95% CI: 0.46-1.34, P =0.36), there was a significant interaction between donor and >5% BMI gain (multiplicative interaction IRR: 1.62, 95% CI: 1.15-2.29, P =0.006; relative excess risk due to interaction: 0.90, 95% CI: 0.24-1.56, P =0.007), such that LKDs who gained weight had higher hypertension incidence than similar nondonors (IRR: 1.83, 95% CI: 1.32-2.53, P <0.001). CONCLUSIONS: Overall, LKDs and nondonors with obesity had similar hypertension incidence. Weight stability and loss were associated with similar hypertension incidence by donor status. However, LKDs who gained >5% saw increased hypertension incidence versus similar nondonors, providing support for counseling potential LKDs with obesity on weight management postdonation.