Lifetime Health and Economic Outcomes of Biparametric Magnetic Resonance Imaging as First-Line Screening for Prostate Cancer : A Decision Model Analysis.

BACKGROUND: Contemporary prostate cancer (PCa) screening uses first-line prostate-specific antigen (PSA) testing, possibly followed by multiparametric magnetic resonance imaging (mpMRI) for men with elevated PSA levels. First-line biparametric MRI (bpMRI) screening has been proposed as an alternative. OBJECTIVE: To evaluate the comparative effectiveness and cost-effectiveness of first-line bpMRI versus PSA-based screening. DESIGN: Decision analysis using a microsimulation model. DATA SOURCES: Surveillance, Epidemiology, and End Results database; randomized trials. TARGET POPULATION: U.S. men aged 55 years with no prior screening or PCa diagnosis. TIME HORIZON: Lifetime. PERSPECTIVE: U.S. health care system. INTERVENTION: Biennial screening to age 69 years using first-line PSA testing (test-positive threshold, 4 µg/L) with or without second-line mpMRI or first-line bpMRI (test-positive threshold, PI-RADS [Prostate Imaging Reporting and Data System] 3 to 5 or 4 to 5), followed by biopsy guided by MRI or MRI plus transrectal ultrasonography. OUTCOME MEASURES: Screening tests, biopsies, diagnoses, overdiagnoses, treatments, PCa deaths, quality-adjusted and unadjusted life-years saved, and costs. RESULTS OF BASE-CASE ANALYSIS: For 1000 men, first-line bpMRI versus first-line PSA testing prevented 2 to 3 PCa deaths and added 10 to 30 life-years (4 to 11 days per person) but increased the number of biopsies by 1506 to 4174 and the number of overdiagnoses by 38 to 124 depending on the biopsy imaging scheme. At conventional cost-effectiveness thresholds, first-line PSA testing with mpMRI followed by either biopsy approach for PI-RADS 4 to 5 produced the greatest net monetary benefits. RESULTS OF SENSITIVITY ANALYSIS: First-line PSA testing remained more cost-effective even if bpMRI was free, all men with low-risk PCa underwent surveillance, or screening was quadrennial. LIMITATION: Performance of first-line bpMRI was based on second-line mpMRI data. CONCLUSION: Decision analysis suggests that comparative effectiveness and cost-effectiveness of PCa screening are driven by false-positive results and overdiagnoses, favoring first-line PSA testing with mpMRI over first-line bpMRI. PRIMARY FUNDING SOURCE: National Cancer Institute.

Decision regret up to 6 years after sleeve gastrectomy.

BACKGROUND: Sleeve gastrectomy (SG) is one of the most popular types of weight loss surgery today but is neither risk-free nor universally effective. We previously demonstrated that 5% of Roux-en-Y gastric bypass (RYGB) patients and up to 20% of gastric banding patients report overall regret 4 years after surgery. This study explores patients' attitudes toward their decision to have SG and decision regret rates up to 6 years postoperatively. METHODS: We surveyed 185 patients who were at least 6 months post-SG (response rate 30%). We used a modified version of the Decision Regret Scale developed by Brehaut et al. We converted responses to a 0-100 scale so that higher scores (> 50) reflect greater regret. We characterized patients who expressed having overall decision regret (score > 50) vs. those who did not (≤ 50). Demographic and preoperative clinical information was extracted from the online medical records. RESULTS: Of 185 SG patients, only 13 (7%) reported regret scores > 50 (i.e. high decision regret). Mean time from SG to survey completion was 41 months (range 6-76 months). Unadjusted comparisons between the two groups revealed that patients with high regret scores had lower mean weight loss (32.1% vs. 48.9% EBMIL), and reported less improvement in quality-of-life (QoL), such as physical health (46.2% vs. 93.5% "somewhat" or "significantly" improved). The two groups were similar in short-term complications, but those reporting overall regret were more likely to report GI complaints such as bloating (61.5% vs. 30.4%). Finally, patients with regret scores > 50 were more likely to be further out from SG (median time since surgery 61.8 vs. 41.1 months). CONCLUSION: In our study, very few patients reported regret (7%) up to 6 years postoperatively, in line with prior reports after RYGB. Those with regret reported poorer QoL.

A Single Institution Multi-disciplinary Approach to Power-assisted Liposuction for the Management of Lymphedema.

OBJECTIVE: To implement and evaluate outcomes from a comprehensive, multi-disciplinary debulking program in the United States. SUMMARY OF BACKGROUND DATA: Interest in and access to surgical treatment for chronic lymphedema (LE) in the United States have increased in recent years, yet there remains little attention on liposuction, or debulking, as an effective treatment option. In some other countries, debulking is a common procedure for the surgical treatment of LE, is covered by insurance, and has demonstrated excellent, reproducible outcomes. In this study we describe our experience implementing a debulking technique from Sweden in the United States. METHODS: Patients who presented with chronic LE followed a systematic multi-disciplinary work-up. For debulking with power assisted liposuction, the surgical protocol was modeled after that developed by Håkan Brorson. A retrospective review of consecutive patients who underwent debulking at our institution was conducted. RESULTS: Between December 2017 and January 2020, 39 patients underwent 41 debulking procedures with power assisted liposuction, including 23 upper and 18 lower extremities. Mean patient age was 58 years and 85% of patients had LE secondary to cancer, the majority of which (64%) was breast cancer. Patients experienced excess volume reductions of 116% and 115% in the upper and lower extremities, respectively, at 1 year postoperatively. Overall quality of life (LYMQOL) improved by a mean of 33%. Finally, patients reported a decreased incidence of cellulitis and decreased reliance on conservative therapy modalities postoperatively. CONCLUSIONS: Debulking with power assisted liposuction is an effective treatment for patients with chronic extremity LE. The operation addresses patient goals and improves quality of life, and additionally reduces extremity volumes, infection rates and reliance on outpatient therapy. A comprehensive, multi-disciplinary debulking program can be successfully implemented in the United States healthcare system.

Comparing Clinician Consensus Recommendations to Patient-reported Opioid Use Across Multiple Hospital Systems.

OBJECTIVE: We compare consensus recommendations for 5 surgical procedures to prospectively collected patient consumption data. To address local variation, we combined data from multiple hospitals across the country. SUMMARY OF BACKGROUND DATA: One approach to address the opioid epidemic has been to create prescribing consensus reports for common surgical procedures. However, it is unclear how these guidelines compare to patient-reported data from multiple hospital systems. METHODS: Prospective observational studies of surgery patients were completed between 3/2017 and 12/2018. Data were collected utilizing post-discharge surveys and chart reviews from 5 hospitals (representing 3 hospital systems) in 5 states across the USA. Prescribing recommendations for 5 common surgical procedures identified in 2 recent consensus reports were compared to the prospectively collected aggregated data. Surgeries included: laparoscopic cholecystectomy, open inguinal hernia repair, laparoscopic inguinal hernia repair, partial mastectomy without sentinel lymph node biopsy, and partial mastectomy with sentinel lymph node biopsy. RESULTS: Eight hundred forty-seven opioid-naïve patients who underwent 1 of the 5 studied procedures reported counts of unused opioid pills after discharge. Forty-one percent did not take any opioid medications, and across all surgeries, the median consumption was 3 5 mg oxycodone pills or less. Generally, consensus reports recommended opioid quantities that were greater than the 75th percentile of consumption, and for 2 procedures, recommendations exceeded the 90th percentile of consumption. CONCLUSIONS: Although consensus recommendations were an important first step to address opioid prescribing, our data suggests that following these recommendations would result in 47%-56% of pills prescribed remaining unused. Future multi-institutional efforts should be directed toward refining and personalizing prescribing recommendations.

Perioperative Aspirin Use Is Associated with Bleeding Complications during Robotic Partial Nephrectomy.

PURPOSE: Daily aspirin use following cardiovascular intervention is commonplace and creates concern regarding bleeding risk in patients undergoing surgery. Despite its cardio-protective role, aspirin is often discontinued 5-7 days prior to major surgery due to bleeding concerns. Single institution studies have investigated perioperative outcomes of aspirin use in robotic partial nephrectomy (RPN). We sought to evaluate the outcomes of perioperative aspirin (pASA) use during RPN in a multicenter setting. MATERIALS AND METHODS: We performed a retrospective evaluation of patients undergoing RPN at 5 high volume RPN institutions. We compared perioperative outcomes of patients taking pASA (81 mg) to those not on aspirin. We analyzed the association between pASA use and perioperative transfusion. RESULTS: Of 1,565 patients undergoing RPN, 228 (14.5%) patients continued pASA and were older (62.8 vs 56.8 years, p <0.001) with higher Charlson scores (mean 3 vs 2, p <0.001). pASA was associated with increased perioperative blood transfusions (11% vs 4%, p <0.001) and major complications (10% vs 3%, p <0.001). On multivariable analysis, pASA was associated with increased transfusion risk (OR 1.94, 1.10-3.45, 95% CI). CONCLUSIONS: In experienced hands, perioperative aspirin 81 mg use during RPN is reasonable and safe; however, there is a higher risk of blood transfusions and major complications. Future studies are needed to clarify the role of antiplatelet therapy in RPN patients requiring pASA for primary or secondary prevention of cardiovascular events.

Immunohistochemical analysis of Tn antigen expression in colorectal adenocarcinoma and precursor lesions.

BACKGROUND: The Tn antigen (CD175) is an O-glycan expressed in various types of human adenocarcinomas, including colorectal cancer (CRC), though prior studies have relied heavily upon poorly characterized in-house generated antibodies and lectins. In this study, we explored Tn expression in CRC using ReBaGs6, a well-characterized recombinant murine antibody with high specificity for clustered Tn antigen. METHODS: Using well-defined monoclonal antibodies, expression patterns of Tn and sialylated Tn (STn) antigens were characterized by immunostaining in CRC, in matched peritumoral [transitional margin (TM)] mucosa, and in normal colonic mucosa distant from the tumor, as well as in adenomas. Vicia villosa agglutinin lectin was used to detect terminal GalNAc expression. Histo-scoring (H scoring) of staining was carried out, and pairwise comparisons of staining levels between tissue types were performed using paired samples Wilcoxon rank sum tests, with statistical significance set at 0.05. RESULTS: While minimal intracellular Tn staining was seen in normal mucosa, significantly higher expression was observed in both TM mucosa (p < 0.001) and adenocarcinoma (p < 0.001). This pattern was reflected to a lesser degree by STn expression in these tissue types. Interestingly, TM mucosa demonstrates a Tn expression level even higher than that of the adenocarcinoma itself (p = 0.019). Colorectal adenomas demonstrated greater Tn and STn expression relative to normal mucosa (p < 0.001 and p = 0.012, respectively). CONCLUSIONS: In summary, CRC is characterized by alterations in Tn/STn antigen expression in neoplastic epithelium as well as peritumoral benign mucosa. Tn/STn antigens are seldom expressed in normal mucosa. This suggests that TM mucosa, in addition to CRC itself, represents a source of glycoproteins rich in Tn that may offer future biomarker targets.

Willingness of Kidney and Liver Transplant Candidates to Receive HCV-Infected Organs.

INTRODUCTION: Transplantation of organs exposed to hepatitis C virus (HCV) into uninfected patients has yielded excellent outcomes and more widespread adoption may lead to fewer discarded organs and more transplants. Patient perceptions may shed light on acceptability and likely the uptake of HCV+/HCV- transplantation, gaps in understanding, and perceived benefits/risks. METHODS: We surveyed 435 uninfected kidney and liver transplant candidates at four centers about their attitude towards HCV-infected organs. RESULTS: The percentage of patients willing to accept HCV-infected organs increased from 58% at baseline, to 86% following education about HCV, direct-acting antiviral agents (DAAs), and HCV+/HCV- transplantation benefits/risks. More willingness to accept an organ from an intravenous drug user (P < 0.001), age >50 y old (P = 0.02), longer waiting time (P = 0.02), more trust in the transplant system (P = 0.03), and previous awareness of DAAs (P = 0.04) were associated with higher willingness to accept an HCV-infected organ. The most important reasons for accepting an HCV-infected organ were a decrease in waiting time (65%), lower mortality and morbidity risk while on the waiting list (63%), effectiveness of DAAs (54%), and a quicker return to higher functional status (51%). CONCLUSIONS: Presenting patients with information about HCV+/HCV- transplantation in small doses that are calibrated to account for varying levels of health and numerical literacy is recommended.

Apolipoprotein L1 Opinions of African American Living Kidney Donors, Kidney Transplant Patients, and Nonpatients.

INTRODUCTION: The discovery of apolipoprotein L1 (ApoL1) has raised important ethical and clinical questions about genetic testing in the context of living and deceased kidney donation. Largely missing from this discussion are the perspectives of those African Americans (AA) most likely to be impacted by ApoL1 testing. METHODS: We surveyed 331 AA potential and former living kidney donors (LKDs), kidney transplant candidates and recipients, and nonpatients at three United States transplant programs about their ApoL1 testing attitudes. RESULTS: Overall, 72% felt that transplant programs should offer ApoL1 testing to AA potential LKDs. If a potential LKD has the high-risk genotype, 79% felt that the LKD should be allowed to make their own donation decision or participate in shared decision-making with transplant doctors. More than half of the potential LKDs (58%) would undergo ApoL1 testing and 81% of former LKDs would take the test now if offered. Most transplant candidates expressed a low likelihood of accepting a kidney from a LKD (79%) or a deceased donor (67%) with the high-risk genotype. CONCLUSIONS: There is strong support among LKDs and transplant patients for ApoL1 testing when evaluating potential kidney donors of African ancestry. Inclusion of AA stakeholders in developing guidelines and educational programs for ApoL1 testing is critical.

Single black men have the worst prognosis with localized prostate cancer.

INTRODUCTION: To determine whether marital status combined with race serve as prognostic factors for survival in localized prostate cancer. MATERIALS AND METHODS: Patients with localized prostate cancer were retrospectively extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Chi-square test was used to investigate the association between marital status combined with race and other variables. Gray's test was used to compare the cumulative incidence function of different variables. Multivariable analysis was conducted to assess prognostic factors after adjusting for other variables. RESULTS: A total of 207,219 patients with localized prostate cancer from the SEER database from 2010 to 2016 were eligible. We found that black or single patients had the highest risk of mortality (p < 0.001). When marital status and race were combined, single black patients had the worst prognosis after adjusting for other variables (hazard ratio = 1.93, 95% confidence interval: 1.58-2.35; p < 0.001). Married status had a prognostic advantage in all races. In the same marital groups, whites and Asians had lower risk of prostate cancer-specific mortality and other-cause mortality than blacks with married and single status (p < 0.001). CONCLUSIONS: Marital status and race serve as prognostic factors for localized prostate cancer. Blacks or single individuals had higher risk of mortality when considered independently, and single black patients had the worst prognosis. Furthermore, married status was an advantage in the same race group, and whites and Asians had lower risk than blacks with married and single status. Accordingly, the interaction between race and marital status on prostate cancer prognosis in clinical practice should be assessed carefully.

Evaluation of U.S. state opioid prescribing restrictions using patient opioid consumption patterns from a single, urban, academic institution.

Background: Since 2017, states, insurers, and pharmacies have placed blanket limits on the duration and quantity of opioid prescriptions. In many states, overlapping duration and daily dose limits yield maximum prescription limits of 150-350 morphine milligram equivalents (MMEs). There is limited knowledge of how these restrictions compare with actual patient opioid consumption; while changes in prescription patterns and opioid misuse rates have been studied, these are, at best, weak proxies for actual pain control consumption. We sought to determine how patients undergoing surgery would be affected by opioid prescribing restrictions using actual patient opioid consumption data. Methods: We constructed a prospective database of post-discharge opioid consumption: patients undergoing surgery at one institution were called after discharge to collect opioid consumption data. Patients whose opioid consumption exceeded 150 and 350 MME were identified. Results: Two thousand nine hundred and seventy-one patients undergoing 54 common surgical procedures were included in our study. Twenty-one percent of patients consumed more than the 150 MME limit. Only 7% of patients consumed above the 350 MME limit. Typical (non-outlier) opioid consumption, defined as less than the 75th percentile of consumption for any given procedure, exceeded the 150 MME and 350 MME limits for 41 and 7% of procedures, respectively. Orthopedic, spinal/neurosurgical, and complex abdominal procedures most commonly exceeded these limits. Conclusions: While most patients undergoing surgery are unaffected by recent blanket prescribing limits, those undergoing a specific subset of procedures are likely to require more opioids than the restrictions permit; providers should be aware that these patients may require a refill to adequately control post-surgical pain. Real consumption data should be used to guide these restrictions and inform future interventions so the risk of worsened pain control (and its troublesome effects on opioid misuse) is minimized. Procedure-specific prescribing limits may be one approach to prevent misuse, while also optimizing post-operative pain control.

Opinions of African American adults about the use of apolipoprotein L1 (ApoL1) genetic testing in living kidney donation and transplantation.

Apolipoprotein L1 (ApoL1) predictive genetic testing for kidney disease, and its emerging role in transplantation, remains controversial as it may exacerbate underlying disparities among African Americans (AAs) at increased risk. We conducted an online simulation among AAs (N = 585) about interest in ApoL1 testing and its cofactors, under 2 scenarios: as a potential living donor (PLD), and as a patient awaiting transplantation. Most respondents (61%) expressed high interest in genetic testing as a PLD: age ≥35 years (adjusted odds ratio [aOR], 1.75; 95% confidence interval [CI], 1.18, 2.60, P = .01), AA identity (aOR, 1.67; 95% CI, 1.02, 2.72, P = .04), perceived kidney disease risk following donation (aOR, 1.68; 95% CI, 1.03, 2.73, P = .03), interest in genetics (aOR, 2.89; 95% CI, 1.95, 4.29, P = .001), and genetics self-efficacy (aOR, 2.38; 95% CI, 1.54, 3.67, P = .001) were positively associated with ApoL1 test interest. If awaiting transplantation, most (89%) believed that ApoL1 testing should be done on AA deceased donors, and older age (aOR, 1.85; 95% CI, 1.03, 3.32, P = .04) and greater interest in genetics (aOR, 2.61; 95% CI, 1.41, 4.81, P = .002) were associated with interest in testing deceased donors. Findings highlight strong support for ApoL1 testing in AAs and the need to examine such opinions among PLDs and transplant patients to enhance patient education efforts.

Preventable Emergency Department Visits After Colorectal Surgery.

BACKGROUND: The emergency department plays a common and critical role in the treatment of postoperative patients. However, many quality improvement databases fail to record these interactions. As such, our understanding of the prevalence and etiology of postoperative emergency department visits in contemporary colorectal surgery is limited. Visits with potentially preventable etiologies represent a significant target for quality improvement, particularly in the current era of rapidly evolving postoperative and ambulatory care patterns. OBJECTIVE: We aimed to characterize postoperative emergency department visits and identify factors associated with these visits for potential intervention. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at an academic medical center. PATIENTS: Consecutive patients undergoing colectomy or proctectomy within the division of colorectal surgery at an academic medical center between 2014 and 2018 were included. MAIN OUTCOME MEASURES: Frequency and indication for emergency department visits, as well as clinical and sociodemographic factors associated with emergency department visits in the postoperative period, were included measures. RESULTS: From the 1763 individual operations, there were 207 emergency department visits from 199 patients (11%) within 30 days of discharge. Two thirds of emergency department visits led to readmission. Median (interquartile range) time to presentation was 8 days (4-16 d). Median time in the emergency department was 7.8 hours (6.0-10.1 h). One third of visits were identified as potentially preventable, most commonly for pain (17%) and stoma complications (excluding dehydration; 13%). A primary language other than English was associated with any postoperative emergency department visit risk ratio of 2.7 (95% CI, 1.3-5.3), as well as a preventable visit risk ratio of 3.6 (95% CI, 1.7-8.0). LIMITATIONS: This was a single-center study and a retrospective review. CONCLUSIONS: One third of emergency department visits after colorectal surgery are potentially preventable. Special attention should be directed toward those patients who do not speak English as a primary language. See Video Abstract at http://links.lww.com/DCR/B648. SE PUEDEN EVITAR LAS VISITAS AL SERVICIO DE URGENCIA DESPUS DE UNA CIRUGA COLORECTAL: ANTECEDENTES:Las unidades de emergencia tienen un rol fundamental en el periodo posterior a una cirugía. Sin embargo muchos de los registros en las bases de datos de estas secciones no son de buena calidad. Por esto analizar la prevalencia y etiología de las visitas postoperatorias en cirugía colorectal resulta ser bastante limitada. Para lograr una mejoría en la calidad es fundamental analizar las causas potencialmente evitables, especialmente al considerer la rapida evolucion de los parametros de medición actuales.OBJETIVO:Nuestro objetivo es caracterizar las visitas postoperatorias al servicio de urgencias e identificar los factores asociados potencialmente evitables.DISEÑO:Estudio de cohorte retrospectivo.AJUSTE:Centro médico académico, 2014-2018.PACIENTES:Pacientes consecutivos sometidos a colectomía o proctectomía dentro de la división de cirugía colorrectal en un centro médico académico entre 2014 y 2018.PRINCIPALES MEDIDAS DE RESULTADO:Frecuencia e indicación de las visitas al servicio de urgencias en el period postoperatorio: factores clínicos y sociodemográficos.RESULTADOS:De 1763 operaciones individuales, hubo 207 visitas al departamento de emergencias de 199 pacientes (11%) en los 30 días posteriores al alta. Dos tercios de las visitas al servicio de urgencias dieron lugar a readmisiones. La mediana [rango intercuartílico] de tiempo hasta la presentación fue de 8 [4-16] días. La mediana de tiempo en el servicio de urgencias fue de 7,8 [6-10,1] horas. Un tercio de las visitas se identificaron como potencialmente evitables, más comúnmente dolor (17%) y complicaciones del estoma (excluida la deshidratación) (13%). En los pacientes con poco manejo del inglés se asoció con una mayor frecuencia razón de visitas al departamento de emergencias posoperatorias [IC del 95%] 2,7 [1,3-5,3], así como opetancialmente evitables con un RR de 3,6 [1,7-8,0].LIMITACIONES:Estudio de un solo centro y revisión retrospectiva.CONCLUSIÓN:Al menos un tercio de las visitas al servicio de urgencias después de una cirugía colorrectal son potencialmente evitables. Se debe prestar especial atención a los pacientes que no hablan inglés como idioma materno. Consulte Video Resumen en http://links.lww.com/DCR/B648.

Patterns and predictors of fatigue following living donor nephrectomy: Findings from the KDOC Study.

This study sought to identify the prevalence, pattern, and predictors of clinical fatigue in 193 living kidney donors (LKDs) and 20 healthy controls (HCs) assessed at predonation and 1, 6, 12, and 24 months postdonation. Relative to HCs, LKDs had significantly higher fatigue severity (P = .01), interference (P = .03), frequency (P = .002), and intensity (P = .01), and lower vitality (P < .001), at 1-month postdonation. Using published criteria, significantly more LKDs experienced clinical fatigue at 1 month postdonation, compared to HCs, on both the Fatigue Symptom Inventory (60% vs. 37%, P < .001) and SF-36 Vitality scale (67% vs. 16%, P < .001). No differences in fatigue scores or clinical prevalence were observed at other time points. Nearly half (47%) reported persistent clinical fatigue from 1 to 6 months postdonation. Multivariable analyses demonstrated that LKDs presenting for evaluation with a history of affective disorder and low vitality, those with clinical mood disturbance and anxiety about future kidney failure after donation, and those with less physical activity engagement were at highest risk for persistent clinical fatigue 6 months postdonation. Findings confirm inclusion of fatigue risk in existing OPTN informed consent requirements, have important clinical implications in the care of LKDs, and underscore the need for further scientific examination in this population.

Pain expectancy, prevalence, severity, and patterns following donor nephrectomy: Findings from the KDOC Study.

Postoperative pain is an outcome of importance to potential living kidney donors (LKDs). We prospectively characterized the prevalence, severity, and patterns of acute or chronic postoperative pain in 193 LKDs at six transplant programs. Three pain measurements were obtained from donors on postoperative Day (POD) 1, 3, 7, 14, 21, 28, 35, 41, 49, and 56. The median pain rating total was highest on POD1 and declined from each assessment to the next until reaching a median pain-free score of 0 on POD49. In generalized linear mixed-model analysis, the mean pain score decreased at each pain assessment compared to the POD3 assessment. Pre-donation history of mood disorder (adjusted ratio of means [95% confidence interval (CI)]: 1.40 [0.99, 1.98]), reporting "severe" on any POD1 pain descriptors (adjusted ratio of means [95% CI]: 1.47 [1.12, 1.93]) and open nephrectomy (adjusted ratio of means [95% CI]: 2.61 [1.03, 6.62]) were associated with higher pain scores across time. Of the 179 LKDs who completed the final pain assessment, 74 (41%) met criteria for chronic postsurgical pain (CPSP), that is, any donation-related pain on POD56. Study findings have potential implications for LKD education, surgical consent, postdonation care, and outcome measurements.

Opioid Consumption After Gender-Affirming Mastectomy and Two Other Breast Surgeries.

BACKGROUND: There are few studies that evaluate patient-reported opioid consumption after discharge from surgery. In addition, there has been a call for "special care in prescribing opioids" for lesbian, gay, bisexual, transgender, questioning patients. Here, we evaluate if patients undergoing gender-affirming mastectomy (GAM) require different amounts of opioids for pain management after discharge compared alongside two surgeries with similar surgical exposure. MATERIALS AND METHODS: From October 2017 to July 2018, patients undergoing oncologic mastectomy without reconstruction, mammoplasty reduction, or gender-affirming mastectomy at a single institution were enrolled in a phone survey study to quantify opioids consumed after discharge from surgery. Patient information was captured from the medical record. A total of 170 patients were called between 14 and 30 d after discharge and were asked to count unused pills from their opioid prescription. RESULTS: A total of 99 patients participated and provided pill counts. There were differences between prescribed and consumed opioids within each surgery. Patients who underwent oncologic mastectomy were prescribed and consumed the lowest amounts of opioids. There were significantly more opioids prescribed to patients with GAM than mammoplasty reduction, but consumption was not statistically different. Patients with oncologic mastectomy, mammoplasty reduction, and GAM consumed a median of 0, 10, and 15 five mg oxycodone equivalent tablets, respectively. CONCLUSIONS: Despite similar approaches, surgeries had different opioid prescribing and use profiles. Generally, all patients were overprescribed opioids. Overprescribing may be especially problematic in patients with known higher risk of misuse and substance abuse. Granular data on patient consumption, demographics, and preoperative risk factors for opioid misuse may improve prescribing practices.

Delayed adjuvant hormonal therapy and its impact on mortality in women with breast cancer.

Adjuvant hormonal therapy (HT) is important for the management of hormone-sensitive breast cancer. However, the timeliness for adjuvant HT and the consequences of delayed initiation of treatment have not been analyzed. The purpose of this study was to characterize delays to HT and assess the impact on clinical outcomes. The study cohort consisted of female patients with invasive ductal and/or lobular, hormone receptor-positive breast cancer diagnosed between 2010 and 2015. Initiation of HT >6 months (180 days) after surgery was defined as delayed. Patients receiving chemotherapy were excluded from the study cohort. Multivariable logistic regression modeling was performed to establish associations between delayed HT and demographic, facility, and clinical factors. Survival analysis was performed using the Kaplan-Meier estimation and Cox proportional hazards regression to evaluate overall survival. Of 179 590 women assessed in the National Cancer Database, 3.2% had a delay in the initiation of adjuvant HT. Positive demographic-related risk factors were younger age, ethnic minority groups, and multiple comorbidities. Clinical factors significantly associated with delayed initiation of adjuvant HT were high-grade tumor, larger tumor size, greater lymph node involvement, having an unplanned readmission within 30 days of surgery, and positive final surgical margins. Adjusted survival analysis showed a survival disadvantage of delayed initiation of HT. Risk factors for delayed initiation of HT specific to demographic and clinical characteristics were identified. Delayed initiation of HT was associated with a survival detriment.

Assessing Burnout and Professional Fulfillment in Breast Surgery: Results From a National Survey of the American Society of Breast Surgeons.

BACKGROUND: Physician burnout is a well-recognized problem in health care that has a negative impact on professional well-being and quality of patient care. Rates of burnout in breast surgery are not well-defined. This study sought to understand the degree of burnout among breast surgeons and to identify factors that influence professional fulfillment. METHODS: All U.S. members of the American Society of Breast Surgeons with a valid email address were surveyed in October 2017. The results were anonymous, and the participants were blinded to the study hypothesis. The survey included 30 questions (16-item Professional Fulfillment Index [PFI] and 14-item demographics/practice patterns). Multivariable linear regressions were performed to assess overall burnout and high professional fulfillment. RESULTS: Of the 2568 surveys delivered, 708 surveys were initiated, and 660 were completed. Among breast surgeons, 270 (41.3%) expressed burnout, whereas 281 (42.5%) reported high professional fulfillment. In the multivariable analysis, years in practice was inversely associated with burnout and positively correlated with professional fulfillment. Working more than 60 h per week was positively associated with burnout, and having more than 50% of practice dedicated to breast surgery correlated positively with fulfillment. CONCLUSION: Approximately 4 of 10 breast surgeons have symptoms of burnout, whereas 4 of 10 surgeons report high professional fulfillment. Specific clinical practice conditions largely influence rates of burnout and professional fulfillment. The contributing factors identified in the study analysis may be useful in identifying breast surgeons at higher risk for burnout. The study findings also help to inform the design of interventions focused on the clinical practice environment to promote professional fulfillment and sustainability.

Increasing Organ Donor Designation Rates in Adolescents: A Cluster Randomized Trial.

Objectives. To evaluate the effectiveness of video messaging on adolescent organ donor designation rates.Methods. We randomized adolescent driver education classes in Massachusetts, between July 2015 and February 2018, to receive 1 of 3 organ donation video messaging interventions (informational, testimonial, or blended). Adolescents completed questionnaires before and after the intervention and at 1-week follow-up; we compared their registration status at time of obtaining driver's license with that of a regionally matched historical comparison group.Results. Donor designation rates were higher for those exposed to video messaging than for the historical comparison group (60% vs 50%; P < .001). Testimonial (64%) and blended messaging (65%) yielded higher donor designation rates than informational messaging (51%; P = .013). There was a statistically significant messaging × time interaction effect for donation knowledge (P = .03), with blended and informational messaging showing more gains in knowledge from before to after the intervention (P < .001; d = 0.69 and P < .001; d = 0.45, respectively), compared with testimonial messaging (d = 0.09; P = .22).Conclusions. Testimonial messaging is most effective in producing a verifiable and demonstrable impact on donor designation rates among adolescents, and driver education classes are an efficient venue for disseminating organ donation messaging to youths.Trial Registration. ClinicalTrials.gov; identifier: NCT03013816.

Design and Implementation of an Infrastructure Program to Support Clinical Research in Surgery.

Barriers to active participation in clinical research among academic surgeons include insufficient research training and mentorship, increased clinical demands, lack of protected research time, limited access to resources, complex regulatory requirements, and a highly competitive research funding environment. We describe the development and implementation of a novel clinical research infrastructure program designed to attenuate these barriers and increase clinical research engagement and productivity in a large academic surgery department. Interim outcomes show a high utilization of program services across all divisions within the department, a substantial increase in new clinical research protocols, more applications submitted to funding agencies, and a high level of user satisfaction. We discuss how a departmental infrastructure program can simultaneously address barriers faced by surgeon clinical researchers and foster continuation of the longstanding tradition of innovation and discovery in academic surgery.

Surgical Risk Factors for the Delayed Initiation of Adjuvant Chemotherapy in Breast Cancer.

BACKGROUND: Timely administration of adjuvant chemotherapy for breast cancer is associated with a survival benefit. Specific elements of surgical management may lead to delays initiating chemotherapy, resulting in unfavorable outcomes. The purpose of this study was to determine the correlation between surgical factors and delayed chemotherapy in breast cancer patients. METHODS: A retrospective analysis of the National Cancer Database was performed. The study cohort consisted of female patients with stage 1-3 breast cancer diagnosed between 2010 and 2014. Initiation of chemotherapy beyond 90 days after surgery was defined as delayed. Multivariable logistic regression modeling was performed to establish associations between delayed chemotherapy and clinical and demographic factors of interest. Survival analysis was performed using the Kaplan-Meier estimation and Cox proportional hazards regression to evaluate potential 5-year overall survival disadvantage of delayed initiation of chemotherapy. RESULTS: Of 166,681 women assessed, 4.3% had a delay in the initiation of chemotherapy. Surgery-specific risk factors included unplanned readmission in the postoperative period, lower surgical volume, mastectomy with immediate autologous reconstruction, and positive surgical margins. Adjusted survival analysis showed a survival disadvantage of delayed initiation of chemotherapy (hazard ratio [HR] 1.46; p < 0.01). CONCLUSIONS: Risk factors for delayed initiation of chemotherapy specific to the surgical process were identified. Delayed initiation of adjuvant chemotherapy was associated with a survival detriment. Efforts should be made to address these surgical management issues and optimize the perioperative process to ensure timely patient treatment.