Experiences and Lessons Learned From the RADx-UP Consortium Community Engagement Projects.

In this study, we used emerging community engagement frameworks to describe the structure and outcomes of a large-scale, community-engaged, research-to-practice initiative, RADx-UP. Qualitative methods were used to analyze survey and meeting data from 2022 for RADx-UP projects. Most projects had diverse partners, achieved moderate levels of community engagement, and experienced positive outcomes. Challenges related to engagement readiness and partnership functioning. These findings demonstrate that community engagement is measurable and valuable. However, additional support is needed to achieve the highest engagement. (Am J Public Health. Published online ahead of print March 28, 2024:e1-e5. https://doi.org/10.2105/AJPH.2024.307615).

Sarcopenia and frailty as predictors of surgical morbidity and oncologic outcomes in retroperitoneal sarcoma.

BACKGROUND: Retroperitoneal sarcomas (RPS) are rare tumors for which surgical resection is the principal treatment. There is no established model to predict perioperative risks for RPS. We evaluated the association between preoperative sarcopenia, frailty, and hypoalbuminemia with surgical and oncological outcomes. METHODS: We performed a prospective cohort analysis of 65 RPS patients who underwent surgical resection. Sarcopenia was defined as Total Psoas Area Index ≤ 1st quintile by sex. Frailty was estimated using the modified frailty index (mFI). Logistic regression models were used to assess predictors of 30-day postoperative morbidity. The Kaplan-Meier method with log-rank test was utilized to assess factors associated with overall (OS) and recurrence-free survival (RFS). RESULT: Sarcopenia was associated with worse OS with a median of 54 compared with 158 months (p = 0.04), but no differences in RFS (p > 0.05). Hypoalbuminemia was associated with worse OS with a median of 72 compared with 158 months (p < 0.01). MFI scores were not associated with OS or RFS (p > 0.05). Sarcopenia, mFI, and hypoalbuminemia were not associated with postoperative morbidity (p > 0.05). CONCLUSION: This study suggests that sarcopenia may be utilized as a measure of overall fitness, rather than a cancer-specific risk, and the mFI is a poor predictive measure of outcomes in RPS.

Long-term Survival of Grafts From Small and Very Small Pediatric Donors in Women vs Men With End-stage Kidney Disease.

This cohort study compares graft survival of kidneys from small and very small pediatric donors in women vs men with end-stage kidney disease.

Medicaid Expansion Under the Affordable Care Act and Pediatric Trauma Patient Insurance Coverage.

INTRODUCTION: Uninsured pediatric trauma patients are at increased risk of poor outcomes. The impact of the Patient Protection and Affordable Care Act (ACA) on pediatric trauma patients has not been studied. We hypothesized that the expansion of Medicaid coverage under the ACA was associated with increased insurance coverage and improved outcomes. METHODS: Retrospective review of patients <18 y old presenting to a level 1 pediatric trauma center 2009-2019. An interrupted time series analysis was performed to assess the impact of Medicaid expansion under the ACA in January 2014. The primary outcome was rate of insurance coverage. Secondary outcomes included in-hospital mortality, disposition, 30-day readmission, length of stay (LOS), and intensive care unit (ICU) LOS. RESULTS: A total of 5645 patients were evaluated, (pre-ACA n = 2,243, post-ACA n = 3402). Expansion of Medicaid was associated with minimal changes on insurance coverage. There a decrease in mortality (RR = 0.96, P = 0.0355) and a slight increase in disposition to a rehabilitation facility (RR = 1.02, P = 0.0341). There was no association with 30-day readmission (RR = 1.02, P = 0.3498). Similarly, expansion of Medicaid was not associated with change in LOS (estimate = -0.00, P = 0.8893). There was a slight decrease in ICU LOS (estimate = -0.03, P < 0.0001). CONCLUSIONS: Medicaid expansion was associated with marginal changes in insurance coverage among pediatric trauma patients. We did not identify significant impacts on patient outcomes.

Anxiety During the COVID-19 Pandemic: A Web-Based Survey of Thyroid Cancer Survivors.

OBJECTIVE: Cancer patients and survivors may be disproportionately affected by COVID-19. We sought to determine the effects of the pandemic on thyroid cancer survivors' health care interactions and quality of life. METHODS: An anonymous survey including questions about COVID-19 and the Patient-Reported Outcomes Measurement Information System profile (PROMIS-29, version 2.0) was hosted on the Thyroid Cancer Survivors' Association, Inc website. PROMIS scores were compared to previously published data. Factors associated with greater anxiety were evaluated with univariable and multivariable logistic regression. RESULTS: From May 6, 2020, to October 8, 2020, 413 participants consented to take the survey; 378 (92%) met the inclusion criteria: diagnosed with thyroid cancer or noninvasive follicular neoplasm with papillary-like nuclear features, located within the United States, and completed all sections of the survey. The mean age was 53 years, 89% were women, and 74% had papillary thyroid cancer. Most respondents agreed/strongly agreed (83%) that their lives were very different during the COVID-19 pandemic, as were their interactions with doctors (79%). A minority (43%) were satisfied with the information from their doctor regarding COVID-19 changes. Compared to pre-COVID-19, PROMIS scores were higher for anxiety (57.8 vs 56.5; P < .05) and lower for the ability to participate in social activities (46.2 vs 48.1; P < .01), fatigue (55.8 vs 57.9; P < .01), and sleep disturbance (54.7 vs 56.1; P < .01). After adjusting for confounders, higher anxiety was associated with younger age (P < .01) and change in treatment plan (P = .04). CONCLUSION: During the COVID-19 pandemic, thyroid cancer survivors reported increased anxiety compared to a pre-COVID cohort. To deliver comprehensive care, providers must better understand patient concerns and improve communication about potential changes to treatment plans.

Strain and sex differences in somatosensation and sociability during experimental autoimmune encephalomyelitis.

Multiple Sclerosis (MS) is an immune-mediated disease that results in major locomotor deficits. However, recent studies have revealed that fatigue, slow processing speed, and memory impairment are the top variables impacting employment status for MS patients. These suggest that cognitive effects may have a greater impact on productivity, lifestyle, and quality of life than do disease-related motor deficits. However, these debilitating non-locomotive effects have been largely overlooked in rodent models of the disease, such as experimental autoimmune encephalomyelitis (EAE). We hypothesized that murine EAE can also be used to assess non-locomotive dysfunctions (mood, sociability, muscle strength, and balance), as well as potential biases in these dysfunctions due to sex and/or strain. We actively immunized male and female C57BL/6 (B6) and SJL mice for EAE and evaluated their performance on the Deacon's weight grip test, Kondziela's inverted screen test, Hall's rope grip test, manual von Frey test for somatic nociception, and a three-chamber social preference paradigm. We hypothesized that EAE progression is associated with changes in muscle strength, balance, pain, and sociability and that these variations are linked to sex and/or strain. Our results indicate that strain but not sex influenced differences in muscle strength and balance during EAE, and both sex and strain have an impact on mechanical nociception, regardless of EAE disease status. Furthermore, both sex and strain had complex effects on differences in sociability. In conclusion, testing these additional modalities during EAE helps to unveil other signs and symptoms that could be used to determine the efficacy of a drug or treatment in the modulation of a MS-like behavior.

Treatment Outcomes of Intracranial Myeloid Sarcomas: A Meta-Analysis.

OBJECTIVE: Intracranial myeloid sarcomas (IMS) are rare central nervous system manifestations of malignant hematopoietic neoplasms of myeloid origin such as acute myeloid leukemia and chronic myeloid leukemia. Reported cases in the literature are limited to primarily case reports. We present a systematic review of this rare central nervous system tumor, characterizing the clinical presentation, tumor location, histopathology, and available treatment modalities. We correlate these variables with mortality, recurrence, and complications to suggest optimal management strategies for IMS. METHODS: A systematic literature search was performed across Ovid MEDLINE, Scopus, and Embase using 14 search terms in accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This systematic review examines variables such as patient age, tumor location, size, presenting symptoms, treatment modality, extent of resection, and mortality. We performed descriptive analyses to identify bivariate associations between patient characteristics, treatment, and outcomes. RESULTS: The mean age at diagnosis was 34.8 years, and the most common etiology was acute myeloid leukemia (68.8%). The most common presenting symptoms were headache (45.5%), vision complaints (27.3%), and weakness/motor symptoms (21.2%). IMS were most commonly located in the temporal lobe (10.1%), cerebellum (10.1%), or falcine/parasagittal (10.1%) region. Patients who received radiotherapy (P < 0.001) or chemotherapy (P < 0.001) had lower rates of mortality versus those who did not. Surgical treatment and extent of resection were not significantly associated with mortality (P > 0.05). CONCLUSION: The use of adjuvant radiotherapy or chemotherapy for IMS significantly reduces mortality, confirming IMS as a cranial manifestation of a systemic disease. Although surgical treatment is indicated for histopathologic diagnosis and to relieve mass effect, the extent of resection does not predict overall survival.

Is minimally invasive surgery of lesions in the right superior segments of the liver justified? A multi-institutional study of 245 patients.

BACKGROUND: Controversy exists regarding the safety and feasibility of minimally invasive resection for lesions in segments 7 or 8. We compare outcomes of minimally invasive surgery (MIS) and Open parenchymal sparing liver resections at two high-volume centers. METHODS: From 2003 to 2016 we identified patients who underwent MIS or Open resections for lesions in segments 7 or 8 at two institutions (MSKCC and SGH). Outcomes were compared using univariate and multivariate analyses. RESULTS: Two-hundred and forty-five patients underwent resection of lesions in segments 7 or 8 (MIS 30% and Open 70%). Compared to the Open group, the MIS group had longer operative time (223 ± 88 vs 188 ± 72 minutes, P = .003), lower blood loss (297 ± 287 vs 448 ± 670 mL, P = .03), and shorter mean length of stay (5.2 ± 7.4 vs 8.3 ± 11.7 days, P < .001), which remained significant on multivariate analysis. No differences in Pringle time, rate of postoperative complications, or R0 resections were detected. CONCLUSIONS: With appropriately selected patients treated by experienced MIS hepatopancreatobiliary surgeons, MIS resection of segments 7 or 8 is safe with similar rates of complications and R0 resections, with significantly less blood loss and shorter length of stay.

Development of transfusion guidelines for injured children using a Modified Delphi Consensus Process.

BACKGROUND: There is wide variability of transfusion practices for children with hemorrhagic injuries across trauma centers. We are planning a multicenter, randomized clinical trial evaluating tranexamic acid in children with hemorrhage. Standardization of transfusion practices across sites is important to minimize confounding. Therefore, we sought to generate consensus-based transfusion guidelines for the trial. METHODS: We used a modified Delphi process utilizing a multi-site, multi-disciplinary panel of experts to develop our transfusion guidelines. A survey of 23 clinical categories on various aspects of transfusion practices was developed and distributed via SurveyMonkey®. Statements were graded on a 5-point Likert scale ("Strongly agree" to "This intervention may be harmful"). Statements were accepted if ≥ 80% of the panelists rated the statement as "Strongly agree" or "Agree". After each round, the responses were calculated and the results included on subsequent rounds. RESULTS: 35 panelists from four pediatric trauma centers participated in the study, including 11 (31%) pediatric EM physicians, 8 (23%) pediatric trauma surgeons, 5 (14%) transfusionists, 5 (14%) pediatric anesthesiologists, and 6 (17%) pediatric critical care physicians (range of 8 to 10 from each clinical site). Four survey iterations were performed. In total 176 statements were rated and 39 were accepted by criteria across all 23 categories. An rational algorithm for transfusion in trauma was then developed. CONCLUSIONS: We successfully developed transfusion guidelines for various aspects of the management of children with hemorrhagic injuries using a modified Delphi process with broad interdisciplinary participation. We anticipate implementation of these guidelines will help minimize heterogeneity of transfusion practices across clinical sites for the upcoming clinical trial evaluating tranexamic acid in children with hemorrhage.

Bundled Payment Models in Spine Surgery: Current Challenges and Opportunities, a Systematic Review.

BACKGROUND: Bundled payments offer a lump sum for management of particular conditions over a specified period that has the potential to reduce health care payments. In addition, bundled payments represent a shift toward patient-centered reimbursement, which has the upside of improved care coordination among providers and may lead to improved outcomes. OBJECTIVE: To review the challenges and sources of payment variation and opportunities for restructuring bundled payments plans in the context of spine surgery. METHODS: We reviewed episodes of care over the past 10 years. We completed a search using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and the PICOS (Participants, Intervention, Comparison, Outcomes, Study Design) model in PubMed and Ovid databases to identify studies that met our search criteria. RESULTS: Ten studies met the search criteria, which were retrospective in design. The primary recipient of reimbursement was the hospital associated with the index procedure (59.7%-77% of the bundled payment), followed by surgeon reimbursement (12.8%-14%) and post-acute care rehabilitation (3.6%-7.3%). On average, the index hospitalization was $32,467, ranging from $11,880 to $107,642, depending on number of levels fused, complications, and malignancy. Readmission was shown to increase the 90-day payment by 50%-200% for uncomplicated fusion. CONCLUSIONS: The implementation of spine surgery in bundled payment models offers opportunity for health care cost reduction. Patient heterogeneity, complications, and index hospitalization pricing are among factors that contribute to the challenge of payment variation. Development of standard care pathways, multidisciplinary coordination between inpatient and outpatient postoperative care, and empowerment of patients are also key elements of progress in the evolution of bundled payments in spine surgery. We anticipate more individualized risk-adjusted prediction models of payment for spine surgery, contributing to more manageable variation in payment and favorable models of bundled payments for payers and providers.

Variability in the utility of predictive models in predicting patient-reported outcomes following spine surgery for degenerative conditions: a systematic review.

OBJECTIVEThere is increasing emphasis on patient-reported outcomes (PROs) to quantitatively evaluate quality outcomes from degenerative spine surgery. However, accurate prediction of PROs is challenging due to heterogeneity in outcome measures, patient characteristics, treatment characteristics, and methodological characteristics. The purpose of this study was to evaluate the current landscape of independently validated predictive models for PROs in elective degenerative spinal surgery with respect to study design and model generation, training, accuracy, reliability, variance, and utility.METHODSThe authors analyzed the current predictive models in PROs by performing a search of the PubMed and Ovid databases using PRISMA guidelines and a PICOS (participants, intervention, comparison, outcomes, study design) model. They assessed the common outcomes and variables used across models as well as the study design and internal validation methods.RESULTSA total of 7 articles met the inclusion criteria, including a total of 17 validated predictive models of PROs after adult degenerative spine surgery. National registry databases were used in 4 of the studies. Validation cohorts were used in 2 studies for model verification and 5 studies used other methods, including random sample bootstrapping techniques. Reported c-index values ranged from 0.47 to 0.79. Two studies report the area under the curve (0.71-0.83) and one reports a misclassification rate (9.9%). Several positive predictors, including high baseline pain intensity and disability, demonstrated high likelihood of favorable PROs.CONCLUSIONSA limited but effective cohort of validated predictive models of spine surgical outcomes had proven good predictability for PROs. Instruments with predictive accuracy can enhance shared decision-making, improve rehabilitation, and inform best practices in the setting of heterogeneous patient characteristics and surgical factors.

Factors predicting opioid dependence in patients undergoing surgery for degenerative spondylolisthesis: analysis from the MarketScan databases.

OBJECTIVE The opioid crisis is identified as a national emergency and epidemic in the United States. The aim of this study was to identify risk factors associated with opioid dependence in patients undergoing surgery for degenerative spondylolisthesis (DS). METHODS The authors queried MarketScan databases to investigate the factors affecting postsurgery opioid use in patients with DS between 2000 and 2012. The outcome of interest was opioid dependence, which was defined as continued opioid use, > 10 opioid prescriptions, or diagnosis of or prescription for opioid dependence disorder in the period of 1 year before or 3-15 months after the procedure. Comparisons of outcomes were performed using nonparametric 2-group tests and generalized regression models. RESULTS A cohort of 10,708 patients was identified from the database. The median patient age was 61 years (interquartile range 54-69 years), and 65.1% were female (n = 6975). A majority of patients had decompression with fusion (n = 10,068; 94%) and underwent multilevel procedures (n = 8123; 75.9%). Of 10,708 patients, 14.85% (n = 1591) were identified as having opioid dependence within 12 months prior to the index surgical procedure and 9.90% (n = 1060) were identified as having opioid dependence within 3-15 months after the procedure. Of all the variables, prior opioid dependence (OR 16.29, 95% CI 14.10-18.81, p < 0.001) and younger age (1-year increase in age: OR 0.972, 95% CI 0.963-0.980, p < 0.001) were independent predictors of opioid dependence following surgery for DS. The use of fusion was not associated with opioid dependence following the procedure (p = 0.8396). Following surgery for DS, patients were more likely to become opioid independent than they were to become opioid dependent (8.54% vs 3.58%, p < 0.001). CONCLUSIONS The majority of patients underwent fusion for DS. Surgical decompression with fusion was not associated with increased risk of postsurgery opioid dependence in patients with DS. Overall, opioid dependence was reduced by 4.96% after surgery for DS. Prior opioid dependence is associated with increased risk and increasing age is associated with decreased risk of opioid dependence following surgery for DS.

Phase I trial of a multi-epitope-pulsed dendritic cell vaccine for patients with newly diagnosed glioblastoma.

BACKGROUND: This study evaluated the safety and immune responses to an autologous dendritic cell vaccine pulsed with class I peptides from tumor-associated antigens (TAA) expressed on gliomas and overexpressed in their cancer stem cell population (ICT-107). METHODS: TAA epitopes included HER2, TRP-2, gp100, MAGE-1, IL13Rα2, and AIM-2. HLA-A1- and/or HLA-A2-positive patients with glioblastoma (GBM) were eligible. Mononuclear cells from leukapheresis were differentiated into dendritic cells, pulsed with TAA peptides, and administered intradermally three times at two-week intervals. RESULTS: Twenty-one patients were enrolled with 17 newly diagnosed (ND-GBM) and three recurrent GBM patients and one brainstem glioma. Immune response data on 15 newly diagnosed patients showed 33 % responders. TAA expression by qRT-PCR from fresh-frozen tumor samples showed all patient tumors expressed at least three TAA, with 75 % expressing all six. Correlations of increased PFS and OS with quantitative expression of MAGE1 and AIM-2 were observed, and a trend for longer survival was observed with gp100 and HER2 antigens. Target antigens gp100, HER1, and IL13Rα2 were downregulated in recurrent tumors from 4 HLA-A2+ patients. A decrease in or absence of CD133 expression was seen in five patients who underwent a second resection. At a median follow-up of 40.1 months, six of 16 ND-GBM patients showed no evidence of tumor recurrence. Median PFS in newly diagnosed patients was 16.9 months, and median OS was 38.4 months. CONCLUSIONS: Expression of four ICT-107 targeted antigens in the pre-vaccine tumors correlated with prolonged overall survival and PFS in ND-GBM patients. The goal of targeting tumor antigens highly expressed on glioblastoma cancer stem cells is supported by the observation of decreased or absent CD133 expression in the recurrent areas of gadolinium-enhanced tumors.