A DIEP Dive into Patient Risk Factors for Hernia and Bulge Development: A Meta-regression.

BACKGROUND: This meta-regression aims to investigate risk factors for abdominal hernia and bulge in patients undergoing deep inferior epigastric perforator (DIEP) flaps and the effect of prophylactic mesh placement on postoperative complications. METHODS: A systematic search was conducted in July of 2022 in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Seventy-four studies published between 2000 and 2022 met the inclusion criteria. Sixty-four studies were included in the analysis for bulge and 71 studies were included in the analysis for hernia. Meta-regressions were run on the proportion of patients experiencing hernia or bulge to assess for patient risk factors and the role of prophylactic mesh placement. Proportions were transformed using the Freeman-Tukey double arcsine method. RESULTS: The average rates of hernia and bulge after DIEP flaps were found to be 0.18% and 1.26%, respectively. Increased age (ß = 0.0059, p = 0.0117), prior abdominal surgery (ß = 0.0008, p = 0.046), and pregnancy history (ß = -0.0015, p = 0.0001) were significantly associated with hernia. Active smoking (ß = 0.0032, p = 0.0262) and pregnancy history (ß = 0.0019, p < 0.0001) were significantly associated with bulge. Neither the perforator vessel laterality nor the number of perforator vessels harvested had any association with hernia or bulge. Prophylactic mesh placement was not associated with hernia or bulge. CONCLUSION: Understanding the comorbidities associated with hernia or bulge following DIEP flap breast reconstruction, such as advanced age, prior abdominal surgery, pregnancy history, and active smoking status, allows surgeons to proactively identify and educate high-risk patients. Future studies may further explore whether prophylactic mesh placement offers patients any benefit.

Optical manipulation of the charge-density-wave state in RbV3Sb5.

Broken time-reversal symmetry in the absence of spin order indicates the presence of unusual phases such as orbital magnetism and loop currents1-4. The recently discovered kagome superconductors AV3Sb5 (where A is K, Rb or Cs)5,6 display an exotic charge-density-wave (CDW) state and have emerged as a strong candidate for materials hosting a loop current phase. The idea that the CDW breaks time-reversal symmetry7-14 is, however, being intensely debated due to conflicting experimental data15-17. Here we use laser-coupled scanning tunnelling microscopy to study RbV3Sb5. By applying linearly polarized light along high-symmetry directions, we show that the relative intensities of the CDW peaks can be reversibly switched, implying a substantial electro-striction response, indicative of strong nonlinear electron-phonon coupling. A similar CDW intensity switching is observed with perpendicular magnetic fields, which implies an unusual piezo-magnetic response that, in turn, requires time-reversal symmetry breaking. We show that the simplest CDW that satisfies these constraints is an out-of-phase combination of bond charge order and loop currents that we dub a congruent CDW flux phase. Our laser scanning tunnelling microscopy data open the door to the possibility of dynamic optical control of complex quantum phenomenon in correlated materials.

Written communication and the ICU team experience (WRITE): A pre-post intervention study.

OBJECTIVE: Families of critically ill patients may benefit from receiving a written update of patient care each day. Our objective was to develop a system to facilitate care provider creation of written updates and to determine the effect of implementing this process on the care provider experience. DESIGN: The experiences of ICU care providers (nurses, advanced practice providers, and physicians) were measured monthly during a 3-month pre-intervention and a 3-month intervention period. During the intervention period, written updates were sent to families each day and posted in the electronic medical record. Study investigators assisted by editing and distributing the written communication to families. SETTING: An urban academic medical center in the United States. MAIN OUTCOME MEASURES: Nurse-Physician Collaboration Scale (NPCS) and Maslach Burnout Inventory (MBI). RESULTS: Over the 3-month intervention period, care providers created written communication for families of 152 patients (average 5 ICU days per family). NPCS scores among the 65 participating care providers were significantly lower, indicating greater collaboration during the intervention vs. pre-intervention period: 49.9 (95 % CI 46.4-53.6) vs. 55.4 (95 % CI 51.5-59.3), p = 0.002. MBI scores were similar during the intervention vs. pre-intervention periods. A subset of care providers participated in individual interviews. Care providers reported that the process of creating written communication was acceptable and had clear benefits for both families and the medical team. CONCLUSIONS: Use of written communication as a supplement to verbal communication improves collaboration among ICU care providers without affecting symptoms of burnout. IMPLICATIONS FOR PRACTICE: We created a system to facilitate written communication with ICU families that was acceptable to care providers and improved aspects of their experience. In the future, use of written communication can be enhanced with refinements to the process that reduce the time spent creating written updates while highlighting the benefits to families and care providers.

Low-energy electronic structure in the unconventional charge-ordered state of ScV6Sn6.

Kagome vanadates AV3Sb5 display unusual low-temperature electronic properties including charge density waves (CDW), whose microscopic origin remains unsettled. Recently, CDW order has been discovered in a new material ScV6Sn6, providing an opportunity to explore whether the onset of CDW leads to unusual electronic properties. Here, we study this question using angle-resolved photoemission spectroscopy (ARPES) and scanning tunneling microscopy (STM). The ARPES measurements show minimal changes to the electronic structure after the onset of CDW. However, STM quasiparticle interference (QPI) measurements show strong dispersing features related to the CDW ordering vectors. A plausible explanation is the presence of a strong momentum-dependent scattering potential peaked at the CDW wavevector, associated with the existence of competing CDW instabilities. Our STM results further indicate that the bands most affected by the CDW are near vHS, analogous to the case of AV3Sb5 despite very different CDW wavevectors.

Sebaceous carcinoma of the trunk and extremities: Epidemiology and treatment patterns in the United States.

Background: Sebaceous carcinoma is a rare cancer, and little is known about its current epidemiology and treatment. This is particularly true for sebaceous carcinomas of the trunk and extremities. Objective: We present a database analysis of sebaceous carcinoma cases to further delineate demographics, location, tumor characteristics, and treatment modalities among patients diagnosed with these tumors. Methods: The National Cancer Database was queried for cases of sebaceous carcinoma between 2004 and 2016. 3211 cases were analyzed for descriptive and comparative statistics. Results: Twenty-six percent of sebaceous carcinomas were found on the trunk and extremities. Tumors on the trunk and extremities were more likely to be larger than tumors on the head and neck, with 8% being greater than 50 mm (P < .001). Tumors on the trunk and extremities were more likely to be well differentiated (P < .001) and have fewer lymph node metastases (P < .001). Surgery was the primary treatment modality for tumors, followed by radiotherapy and rarely chemotherapy. Conclusions: Sebaceous cancer is a poorly understood entity. We demonstrated that trunk and extremity tumors tend to be larger and more differentiated than those of the head and neck. Treatment practices are varied at this time, but surgery is the primary modality.

Platelet-Rich Plasma, Bone Marrow Aspirate Concentrate, and Hyaluronic Acid Injections Outperform Corticosteroids in Pain and Function Scores at a Minimum of 6 Months as Intra-Articular Injections for Knee Osteoarthritis: A Systematic Review and Network Meta-analysis.

PURPOSE: To compare the efficacy of common intra-articular injections used in the treatment of knee osteoarthritis, including corticosteroid (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), and bone marrow aspirate concentrate (BMAC), with a minimum follow-up of 6-months. METHODS: A literature search was conducted using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in August 2022 in the following databases: PubMed/MEDLINE, Scopus, Cochrane Database of Controlled Trials, and the Cochrane Database of Systematic Reviews. Level I to II randomized clinical trials with a minimum follow-up of 6 months that investigated the treatments of interest were included. Patient-reported outcome scores for pain and function at baseline and at latest follow-up were extracted, and the change in scores was converted to uniform 0 to 100 scales. Arm-based Bayesian network meta-analysis using a random-effects model was created to compare the treatment arms in pain and function. RESULTS: Forty-eight studies comprising a total of 9,338 knees were included. The most studied intra-articular injection was HA (40.9%), followed by placebo (26.2%), PRP (21.5%), CS (8.8%), and then BMAC (2.5%). HA and PRP both led to a significant improvement in pain compared with placebo. HA, PRP, and BMAC all led to a significant improvement in function scores when compared with placebo. Surface under the cumulative ranking curves (SUCRAs) of the interventions revealed that PRP, BMAC, and HA were the treatments with the highest likelihood of improvement in both pain and function, with overall SUCRA scores of 91.54, 76.46, and 53.12, respectively. The overall SUCRA scores for CS and placebo were 15.18 and 13.70, respectively. CONCLUSIONS: At a minimum 6-month follow-up, PRP demonstrated significantly improved pain and function for patients with knee osteoarthritis compared with placebo. Additionally, PRP exhibited the highest SUCRA values for these outcomes when compared with BMAC, HA, and CS. LEVEL OF EVIDENCE: Level II, meta-analysis of Level I to II studies.

Patients With Autoimmune Hepatitis and Nonalcoholic Fatty Liver Disease: Characteristics, Treatment, and Outcomes.

GOAL: The objective of this study was to characterize an autoimmune hepatitis (AIH)/nonalcoholic fatty liver disease (NAFLD) overlap cohort, determine if they received standard of care treatment, and delineate their outcomes in comparison with patients with AIH or NAFLD alone. BACKGROUND: AIH is a relatively rare and heterogeneously presenting liver disease of unknown etiology. NAFLD is a leading cause of liver disease worldwide. AIH treatment includes steroids, which have adverse metabolic effects that can worsen NAFLD. No treatment guidelines are available to mitigate this side on AIH/NAFLD overlap patients. Few studies to date have examined these patients' characteristics, management practices, and outcomes. MATERIALS AND METHODS: A single-center, retrospective chart review study examining biopsy-proven AIH/NAFLD, AIH, and NAFLD patients. Characteristics, treatment, and 1- and 3-year outcomes (all-cause mortality, need for liver transplantation, or decompensated cirrhosis) were evaluated. RESULTS: A total of 72 patients (36.1% AIH/NAFLD, 34.7% AIH, and 29.2% NAFLD) were included. AIH/NAFLD patients were found to be more often Hispanic/Latino, female, and with lower liver aminotransaminases, immunoglobulin G, and anti-smooth muscle antibody positivity. AIH/NAFLD patients were less likely to receive standard of care treatment. No significant differences in outcomes were seen between AIH/NAFLD and either AIH or NAFLD. CONCLUSIONS: Our study demonstrated that AIH/NAFLD patients have unique characteristics and are less likely to receive standard of care treatment compared with patients with AIH alone. Despite this, no difference in outcomes (all-cause mortality, need for liver transplantation, or decompensated cirrhosis) was seen. Given NAFLD's rising prevalence, AIH/NAFLD cases will likely increase, and may benefit from alternative treatment guidelines to prevent worsening of NAFLD.

A nationwide analysis of salvage surgery for laryngeal cancer in the elderly.

BACKGROUND: We aim to describe outcomes of elderly patients undergoing salvage surgery for laryngeal cancer and to characterize the interplay of age with various other factors in this growing population. METHODS: Using the National Cancer Database, we identified cases of salvage laryngectomy in patients who failed chemoradiation. An age cutoff of 70 years was used to separate subjects into two groups. Various factors were compared. RESULTS: Of the 825 patients included, 166 (20.1%) were elderly. Elderly patients had worse overall survival (p = 0.001), higher 30-day and 90-day mortality (p = 0.006, p < 0.001), and a longer length of stay (LOS) (p = 0.015). LOS over 1 week was associated with worse survival (p = 0.032). CONCLUSION: Elderly patients had worse overall perioperative survival than their younger counterparts. LOS and 30-day readmissions were associated with higher risk of mortality in this group. We provide a contemporary set of relevant information for head and neck cancer providers to consider in this growing population.

Written Communication, Visitation Policies, and Awareness of Medical Issues Among Intensive Care Unit Families.

BACKGROUND: Open intensive care unit (ICU) visitation policies facilitate communication between clinicians and patients' families. Restrictive visitation policies (eg, during a pandemic) may reduce families' comprehension of information. OBJECTIVES: To determine whether written communication increased awareness of medical issues among ICU families and whether the effect size depended on the visitation policies in place when participants were enrolled. METHODS: Families of ICU patients were randomly assigned to receive usual care with or without daily written patient care updates from June 2019 to January 2021. Participants were asked whether patients had experienced 6 ICU problems at up to 2 time points during the ICU stay. Responses were compared with the study investigators' consensus. RESULTS: Of 219 participants, 131 (60%) were restricted from visiting. Participants in the written communication group were more likely than participants in the control group to correctly identify shock, renal failure, and weakness and were just as likely as participants in the control group to correctly identify respiratory failure, encephalopathy, and liver failure. Participants in the written communication group were more likely than participants in the control group to correctly identify the patient's ICU problems when all 6 were grouped as a composite outcome, with the adjusted odds ratio of correct identification tending to be higher among participants enrolled during restricted versus open visitation periods: 2.9 (95% CI, 1.9-4.2; P < .001) vs 1.8 (95% CI, 1.1-3.1; P = .02), P = .17 for difference. CONCLUSIONS: Written communication helps families correctly identify ICU issues. The benefit may be enhanced when families cannot visit the hospital. ClinicalTrials.gov Identifier: NCT03969810.

A new index, Respiratory Insufficiency index and Modified Early Warning Scores predict extubation failure.

Background: Extubation failure occurs in 5%-20% of patients and is associated with poor clinical outcomes. The primary aim of this project was to determine the predictive ability of the Respiratory Insufficiency (RI) index, Respiratory Oxygenation (ROX) index and Modified Early Warning Score (MEWS) in identifying extubation failure. Methods: This was a secondary analysis of a prior cross-sectional retrospective study conducted from February 2018 through December 2018 among adult subjects who received mechanical ventilation for more than 24 h. Extubation failure was defined as the need for reintubation or rescue non-invasive ventilation (NIV) within 48 h after planned extubation. Univariate analysis and logistic regression were used to identify the predictors and final model was validated using 10-fold cross validation. Nomogram was constructed based on the final model. Results: Of 216 enrolled subjects, 46 (21.3%) experienced extubation failure. The median RI index 1-h post extubation was 20 [interquartile range [IQR] 16.33-24.24] for success group and 27.02 [IQR 22.42-33.83] for the failure group (P<0.001). The median ROX index 1-h post extubation was 16.66 [IQR 12.57-19.84] for success group and 11.11 [IQR 8.09-14.67] for failure group (P<0.001). The median MEWS 1-h post extubation was 2 [IQR 1-3] for the success group and 4 [IQR 3-5] for the failure group (P<0.001). In multivariable analysis, age >60 years [OR 3.89 (95% CI 1.56-9.73); P=0.004], MEWS >4 [OR 4.01 (95% CI (1.59-10.14); P=0.003] and, RI index >20 [OR 4.50 (95% CI 1.43-14.21); P=0.010] were independently associated with extubation failure. Conclusion: In the present study, RI index and MEWS were independently associated with predicting extubation failure within 1 h of extubation. A prospective validation study is warranted to establish the role of these indices in predicting extubation outcome.

Disparities in Utilization of Same-Day Discharge Following Appendectomy in Children.

INTRODUCTION: Disparities in the delivery of pediatric surgical care exist for racial and ethnic minority groups. Utilization of same-day discharge (SDD) following appendectomy for acute, uncomplicated appendicitis is increasing; however, rates among diverse populations have not been explored to evaluate equitable care delivery and healthcare utilization. Our objective was to determine whether race and ethnicity are associated with rates of SDD and postdischarge healthcare utilization. We hypothesized that racial and ethnic minority groups would have lower rates of SDD. METHODS: This retrospective cohort study used data from the 2015-2019 American College of Surgeons National Surgical Quality Improvement Program-Pediatric clinical registry and included children who underwent appendectomy. Patients with complicated appendicitis were excluded. Primary exposure was racial or ethnic group. The primary outcome was SDD, and secondary outcomes included postdischarge emergency department visits and hospital readmissions. RESULTS: Of 37,579 simple appendicitis patients, SDD after appendectomy occurred in 10,012 (26.6%). On multivariable analysis, Black or African American race was associated with lower likelihood of SDD (adjusted odds ratio [aOR]: 0.85; 95% confidence interval [95% CI]:0.79-0.92; P < 0.0001). Hispanic ethnicity was associated with higher likelihood of SDD (aOR: 1.19; 95% CI: 1.12-1.25; P < 0.0001). Likelihood of postoperative emergency department visits was higher in Black or African American patients (aOR: 1.36; 95% CI: 1.14-1.62; P < 0.001) and Hispanic patients (aOR: 1.37; 95% CI: 1.12-1.58; P < 0.0001). Hospital readmission rates were similar across groups. CONCLUSIONS: Rates of SDD following appendectomy vary among racial and ethnic groups. Interventions to achieve equitable healthcare delivery including SDD after appendectomy are needed.

Understanding Opioid Prescribing Practices of Resident Physicians.

BACKGROUND: To compare opioid prescribing practices of resident physicians across a variety of surgical and nonsurgical specialties; to identify factors which influence prescribing practices; and to examine resident utilization of best practice supplemental resources. METHODS: An anonymous survey which assessed prescribing practices was completed by residents from one of several different subspecialties, including internal medicine, obstetrics and gynecology, general surgery, neurosurgery, orthopedic surgery, and urology. Fisher's exact test assessed differences in prescribing practices between specialties. RESULTS: Only 35% of residents reported receiving formal training in safe opioid prescribing. Overall, the most frequently reported influences on prescribing practices were the use of standardized order sets for specific procedures, attending preference, and patient's history of prescribed opioids. Resident physicians significantly underutilize best practice supplemental resources, such as counseling patients on pain expectations prior to prescribing opioid medication; contacting established pain specialists; screening patients for opioid abuse; referring to the Prescription Monitoring Program; and counseling patients on safe disposal of unused pills (P < .001). DISCUSSION: The incorporation of comprehensive prescribing education into resident training and the utilization of standardized order sets can promote safe opioid prescribing.

Defining diverticular fistula through inpatient admissions: a population study.

BACKGROUND: Diverticular fistula, a pathologic connection from the colon to the skin or another organ, is an uncommon sequela of diverticular disease. It is generally considered an indication for surgery. The current literature is limited in terms of defining the epidemiology of this disease process. This analysis defines the demographics of fistulous diverticular disease on a national level. METHODS: A retrospective review of the 2018 National Inpatient Sample (NIS) was conducted, using ICD-10 codes for diverticular disease, diverticular-associated fistulas, and associated surgeries. Demographic factors were compared between groups, and several sub-group analyses were performed. RESULTS: A total of 7,105,498 discharges were recorded: 119,115 (1.68%) with non-fistulizing diverticular disease and 3,843 (0.05%) with diverticular fistula. Patients with diverticular fistula were more likely to be younger (64.7 v 68.2 years, p < .0001) and female (57.3% v 55.4%, p = 0.028) than patients with non-fistulizing disease. They were also more likely to undergo surgery (64.9% v 25.7%, p < .0001), to be admitted electively (44.7% v 12.0%, p < .0001), and to have a longer length of stay (LOS) (mean 8.07 v 5.20 days, p < .0001). Diverticular fistula patients that underwent surgery were more likely to be male (44.8% v 39.0%, p = 0.003), to be admitted electively (65.3% v 6.7%, p < .0001), and to have longer LOS (mean 8.74 v 6.81 days, p < .0001) than those who received medical treatment alone. CONCLUSION: Diverticular fistula is a rare diagnosis, accounting for 0.05% of total admissions and 3.12% of admissions for diverticular disease. However, this is more common than the previously reported rate of < 0.1% of diverticular disease admissions. While surgery is generally indicated for diverticular fistula, only 64.9% of patients underwent surgical treatment. Although this study is limited by its retrospective nature and use of administrative data, our findings elucidate the prevalence and patterns of inpatient admissions for diverticular fistula in the United States.

Daily Written Care Summaries for Families of Critically Ill Patients: A Randomized Controlled Trial.

OBJECTIVES: To determine the effect of daily written updates on the satisfaction and psychologic symptoms of families of ICU patients. DESIGN: Randomized controlled trial. SETTING: Single, urban academic medical center. SUBJECTS: Surrogates of nondecisional, critically ill adults with high risk of mortality ( n = 252) enrolled from June 2019 to January 2021. INTERVENTIONS: Usual communication with the medical team with or without written communication detailing the suspected cause and management approach of each ICU problem, updated each day. MEASUREMENTS AND MAIN RESULTS: Participants completed surveys at three time points during the ICU stay: enrollment ( n = 252), 1 week ( n = 229), and 2 weeks ( n = 109) after enrollment. Satisfaction with care was measured using the Critical Care Family Needs Inventory (CCFNI). The presence of anxiety, depression, and acute stress were assessed using the Hospital Anxiety and Depression Scale (HADS) and Impact of Events Scale Revised (IES-R). CCFNI, HADS, and IES-R scores were similar among participants assigned to the intervention group and control group upon enrollment and during the first week after enrollment ( p > 0.05). From enrollment to the second week after enrollment, there was an improvement in CCFNI and HADS scores among participants assigned to the intervention group versus the control group. At week 2, CCFNI scores were significantly lower among participants in the intervention group versus the control group, indicating greater satisfaction with care: 15.1 (95% CI, 14.2-16.0) versus 16.4, (95% CI, 15.5-17.3); p = 0.04. In addition, 2 weeks after enrollment, the odds of symptoms of anxiety, depression, and acute stress among participants assigned to the intervention versus control group were 0.16 (95% CI, 0.03-0.82; p = 0.03); 0.15 (95% CI, 0.01-1.87; p = 0.14); and 0.27 (95% CI, 0.06-1.27; p = 0.10), respectively. CONCLUSIONS: Written communication improved satisfaction and the emotional well-being of families of critically ill patients, supporting its use as a supplement to traditional communication approaches.

Healthy lifestyle and life expectancy with and without Alzheimer's dementia: population based cohort study.

OBJECTIVE: To determine the impact of lifestyle factors on life expectancy lived with and without Alzheimer's dementia. DESIGN: Prospective cohort study. SETTING: The Chicago Health and Aging Project, a population based cohort study in the United States. PARTICIPANTS: 2449 men and women aged 65 years and older. MAIN EXPOSURE: A healthy lifestyle score was developed based on five modifiable lifestyle factors: a diet for brain health (Mediterranean-DASH Diet Intervention for Neurodegenerative Delay-MIND diet score in upper 40% of cohort distribution), late life cognitive activities (composite score in upper 40%), moderate or vigorous physical activity (≥150 min/week), no smoking, and light to moderate alcohol consumption (women 1-15 g/day; men 1-30 g/day). MAIN OUTCOME: Life expectancy with and without Alzheimer's dementia in women and men. RESULTS: Women aged 65 with four or five healthy factors had a life expectancy of 24.2 years (95% confidence interval 22.8 to 25.5) and lived 3.1 years longer than women aged 65 with zero or one healthy factor (life expectancy 21.1 years, 19.5 to 22.4). Of the total life expectancy at age 65, women with four or five healthy factors spent 10.8% (2.6 years, 2.0 to 3.3) of their remaining years with Alzheimer's dementia, whereas women with zero or one healthy factor spent 19.3% (4.1 years, 3.2 to 5.1) with the disease. Life expectancy for women aged 65 without Alzheimer's dementia and four or five healthy factors was 21.5 years (20.0 to 22.7), and for those with zero or one healthy factor it was 17.0 years (15.5 to 18.3). Men aged 65 with four or five healthy factors had a total life expectancy of 23.1 years (21.4 to 25.6), which is 5.7 years longer than men aged 65 with zero or one healthy factor (life expectancy 17.4 years, 15.8 to 20.1). Of the total life expectancy at age 65, men with four or five healthy factors spent 6.1% (1.4 years, 0.3 to 2.0) of their remaining years with Alzheimer's dementia, and those with zero or one healthy factor spent 12.0% (2.1 years, 0.2 to 3.0) with the disease. Life expectancy for men aged 65 without Alzheimer's dementia and four or five healthy factors was 21.7 years (19.7 to 24.9), and for those with zero or one healthy factor life expectancy was 15.3 years (13.4 to 19.1). CONCLUSION: A healthy lifestyle was associated with a longer life expectancy among men and women, and they lived a larger proportion of their remaining years without Alzheimer's dementia. The life expectancy estimates might help health professionals, policy makers, and stakeholders to plan future healthcare services, costs, and needs.

Postoperative complications in pediatric patients with cerebral palsy.

BACKGROUND/PURPOSE: To assess surgical outcomes of patients with cerebral palsy (CP) and if they differ from patients without CP. METHODS: The NSQIP-Pediatric database from 2012 to 2019 was used to compare differences in presenting characteristics and outcomes between patients with and without CP. Chi-square tests and multivariable logistic regression analysis were used to determine significance. RESULTS: 119,712 patients, 433 (0.4%) with CP, 119,279 (99.6%) without, were identified. Patients with CP had more postoperative complications (19.4% vs. 6.9%, p < 0.001) with an OR of 3.2, (95%CI 2.5-4.1, p < 0.001) on univariable analysis. They underwent fewer laparoscopic procedures (79.1% vs. 90.8%, p < 0.001), had more readmissions (10.2% vs. 3.8%, p < 0.001), reoperations (5.1% vs. 1.2%, p < 0.001), and longer length of stays (LOS) (median 3 versus 1 day, p < 0.001). On multivariable analysis, having CP did not increase the odds of postoperative morbidity (OR 0.99, 95% CI 0.7-1.3), but higher ASA class, congenital lung malformation, gastrointestinal disease, coagulopathy, preoperative inotropic support, oxygen use, nutritional support, and steroid use significantly increase the odds of morbidity, all of which were more common in patients with CP. CONCLUSION: Patients with CP have more postoperative complications, open procedures, and longer LOS. Patient complexity may account for these differences and risk-directed perioperative planning may improve outcomes. LEVEL OF EVIDENCE: Level IV.

Impact of Inequities on Delay in Breast Cancer Management in Women Undergoing Second Opinions.

BACKGROUND: Inequities in breast cancer treatment lead to delay in therapy, decreased survival and lower quality of life. This study aimed to examine demographics and clinical factors impacting time to treatment for second-opinion breast cancer patients. MATERIALS AND METHODS: We performed a retrospective chart review to analyze patients presenting to one academic institution for second opinion of breast imaging, diagnosis, or breast-related treatment. Data from women with stage I-III breast cancer who received treatment at this institution were evaluated to determine the impact of patient demographics and clinical characteristics on time to first treatment. RESULTS: Of the 1006 charts reviewed, 307 met inclusion criteria. Low-income patients averaged 58 days from diagnosis to surgery compared to 35 days for high-income patients (incidence rate ratio [IRR] 0.64, P<0.01). Black patients averaged 56 days from diagnosis to surgery compared to 42 days for White patients (IRR 1.37, P<0.01). Latina patients averaged 38 days from initial encounter to neoadjuvant chemotherapy compared to 20 days for White patients (IRR 1.69, P<0.05). CONCLUSION: Patients with low-income, of Black race and Latina ethnicity experienced increased time to treatment. Additionally, time to mastectomy with and without reconstruction was longer than time to partial mastectomy. Further exploration is needed to determine why certain factors lead to treatment delay and how inequities can be eliminated.

Imposter Syndrome in Surgical Trainees: Clance Imposter Phenomenon Scale Assessment in General Surgery Residents.

BACKGROUND: Imposter syndrome occurs when high-achieving individuals have a pervasive sense of self-doubt combined with fear of being exposed as a fraud, despite objective measures of success. This threatens mental health and well-being. The prevalence and severity of imposter syndrome has not been studied among general surgery residents on a large scale. The primary outcomes of this study were the prevalence and severity of imposter syndrome. STUDY DESIGN: The Clance Impostor Phenomenon Scale was administered to residents at 6 academic general surgery residency programs. Multivariable analysis was performed to identify significant differences among groups and predictive characteristics of imposter syndrome. RESULTS: One hundred and forty-four residents completed the assessment (response rate 46.6%; 47.2% were male). Only 22.9% had "none to mild" or "moderate" imposter syndrome. A majority (76%) had "significant" or "severe" imposter syndrome. There were no significant differences in mean scores among male and female residents (p = 0.69). White residents had a mean score of 71.3 and non-White residents had a mean score of 68.3 (p = 0.24). There was no significant difference between PGY1 to PGY5 or research residents (p = 0.72). There were no significant differences based on US Medical Licensing Examination or American Board of Surgery In-Service Training Examination scores (p = 0.18 and p = 0.37, respectively). CONCLUSIONS: Imposter syndrome is prevalent among general surgery residents, with 76% of residents reporting either significant or severe imposter syndrome. There were no predictive characteristics based on demographics or academic achievement, suggesting that there is something either inherent to those choosing general surgery training or the general surgery training culture that leads to such substantive levels of imposter syndrome.

Neutrophil-to-Lymphocyte Ratio Is a Predictive Biomarker in Patients with Epidermal Growth Factor Receptor (EGFR) Mutated Advanced Non-Small Cell Lung Cancer (NSCLC) Treated with Tyrosine Kinase Inhibitor (TKI) Therapy.

BACKGROUND: First-line treatment for patients with non-small cell lung cancer (NSCLC) with a sensitizing epidermal growth factor receptor (EGFR) mutation is a tyrosine kinase inhibitor (TKI). Despite higher response rates and prolonged progression free survival (PFS) compared with platinum doublet chemotherapy, a subset of these patients do not receive prolonged benefit from these agents. We investigate if the neutrophil-to-lymphocyte ratio (NLR) and other markers of cachexia and chronic inflammation correlate with worse outcomes in these patients. METHODS: This study is a retrospective review of 137 patients with advanced EGFR-mutated NSCLC treated with TKIs at Rush University Medical Center and University of Chicago Medicine from August 2011 to July 2019, with outcomes followed through July 2020. The predictive value of NLR and body mass index (BMI) was assessed at the start of therapy, and after 6 and 12 weeks of treatment by univariable and multivariable analyses. RESULTS: On univariable analysis, NLR ≥ 5 or higher NLR on a continuous scale were both associated with significantly worse PFS and overall survival (OS) at treatment initiation, and after 6 or 12 weeks of treatment. On multivariable analysis, NLR ≥ 5 was associated with increased risk of death at 12 weeks of therapy (HR 3.002, 95% CI 1.282-7.029, p = 0.011), as was higher NLR on a continuous scale (HR 1.231, 95% CI 1.063-1.425, p = 0.0054). There was no difference in PFS and OS and amongst BMI categories though number of disease sites and Eastern Cooperative Oncology Group (ECOG) performance status was associated with worse PFS and OS. CONCLUSIONS: Patients with NLR ≥ 5 have a worse median PFS and median OS than patients with NLR < 5. NLR may have value as a predictive biomarker and may be useful for selecting patients for therapy intensification in the front-line setting either at diagnosis or after 12 weeks on therapy. NLR needs to be validated prospectively.