The Incidence of Complications Following Scarf Osteotomy for the Treatment of Hallux Valgus: A Systematic Review With Meta-Analysis.

The Scarf osteotomy is a surgical procedure performed to correct a hallux valgus deformity. Multiple studies have supported use of the procedure with favorable outcomes. In contrast, there have been studies showing a significant complication rate with the procedure. Incidence of complications remains underreported in the literature. We performed a systemic review and meta-analysis examining a wide range of reported complications and associated clinical outcomes from the Scarf osteotomy. One hundred and sixteen publications were identified and 25 (21.6%) met our inclusion criteria. A total of 1583 Scarf procedures were included. Weighted mean follow-up was 26.4 months [range 12-168 months]. We found a 5.1% rate of recurrence, 3.5% rate of troughing, 1.0% rate of avascular necrosis, 1.8% rate of nonunion, 2.7% rate of malunion, 2.4% rate of infection, 5.3% rate of complex regional pain syndrome, and 3.4% rate of hallux varus. An average decrease in intermetatarsal angle of 6.3° was observed. No statistical difference was found in outcomes when comparing Scarf versus Scarf with additional procedure performed at time of surgery. To our knowledge, this systematic review and meta-analysis contains the highest number of Scarf procedures analyzed and presents complication rates on multiple adverse outcomes.

Infant Vaccinations among Mothers with Substance-Use Disorders: A Comparative Study.

Introduction: Infants of mothers with substance use disorder (SUD) are exposed to complex social environments and increased childhood health risks that can lead to adverse consequences throughout the lifespan. GunderKids, a voluntary, specialized, comprehensive pediatric care management program, was developed to mitigate many of these adverse consequences. Our organization is evaluating several clinical outcomes related to health and development in children born to women with SUD. The current study addressed the timeliness of vaccination coverage among these infants.Methods: This descriptive comparative preliminary study evaluated data of infants and their mothers with SUD who were previously identified during prenatal care visits either by self-report or by positive urine screens. Sociodemographic and vaccination data were extracted from a longitudinal master dataset of variables developed and maintained through retrospective review of electronic health records (EHRs) of these mothers and their infants. Timeliness of vaccination coverage of SUD-exposed infants participating in GunderKids was compared with that of SUD-exposed infants receiving standard pediatric care and was determined using a cumulative vaccinations method.Results: Overall, infants in the GunderKids group (n=50) had more timely vaccination coverage than those receiving standard pediatric care (n=20). Examples of timelier coverage included Haemophilus influenzae type b (Hib) at 4 months (P = .01; OR 4.3, 95% CI 1.4-13.4), for pneumococcal (P = .004; OR 6.6, 95% CI 1.8-23.8) and Hib (P = .004; OR 5.8, 95% CI 1.6-21.9) vaccinations at 15 months. More than 77% of GunderKids received all 6-month vaccinations in a timely manner compared with less than 45% of the standard care group; odds ratios suggest that GunderKids had 4.0-5.6 higher odds of receiving 6-month vaccinations.Conclusion: Vaccination coverage of infants participating in GunderKids was timelier than that of infants receiving standard pediatric care. Results suggest that specialized programs like GunderKids may assist in mitigating adverse health consequences and timeliness of vaccination coverage might be used as a proxy for measuring program effectiveness. Further investigation is recommended to determine clinical, individual, and organizational factors that influence parental behaviors and pediatric outcomes within SUD-exposed families.

Lack of Correlation Between Subjective and Objective Measures of Gastroesophageal Reflux Disease: Call for a Novel Validated Assessment Tool.

Background. Objective measures including the DeMeester score, lower esophageal sphincter (LES) pressure, acid exposure time, and body mass index (BMI) are used to determine gastroesophageal reflux disease (GERD) severity and eligibility for various antireflux surgical procedures. The GERD Health-Related Quality of Life (GERD-HRQL) survey is widely used to evaluate patients' subjective severity of symptoms and GERD-related quality of life. The purpose of this project was to identify whether or not the subjective measure (GERD-HRQL) correlated with objective measures (DeMeester score, LES, acid exposure time, and BMI) of GERD severity. Methods. A retrospective review of the medical records of patients who underwent antireflux surgery from 2013-2018 was completed. Patients' GERD severity was measured preoperatively and postoperatively using the GERD-HRQL. Statistical analysis included the calculation of Spearman correlation coefficients, Wilcoxon rank sum, sign, and chi-square tests. Results. 151 patients were included in the study; 64% were female. The mean age and BMI were 54.6 ± 14.6 years and 30.1 ± 4.1 kg/m2, respectively. The mean preoperative DeMeester score was 43.1 ± 36.1, LES pressure was 19.9 ± 18.4 mmHg, and acid exposure time was 11.4 ± 9.6. Mean GERD-HRQL scores decreased from 27.3 ± 9.2 preoperative to 5.3 ± 4.5 postoperative; P < .0001. Preoperative GERD-HRQL scores were not correlated with the DeMeester score (r = .11; P = .389), LES pressure (r = -.20; P = .089), acid exposure time (r = .05; P = .755), BMI (r = .10; P = .329), or age (r = -.16; P = .118). Conclusions. Total GERD-HRQL scores significantly decreased from pre- to postoperative. There was no correlation between subjective and objective GERD scoring. These data indicate the need for both physiologic evaluation and subjective assessment of patient symptoms during preoperative workup. There is a need for a contemporary, validated GERD questionnaire that correlates with objective pH testing.

Correction to: Factors Associated with Reoperation in Breast-Conserving Surgery for Cancer: A Prospective Study of American Society of Breast Surgeon Members.

The Disclosures in the original article are incomplete. Not included is the following information.

Factors Associated with Reoperation in Breast-Conserving Surgery for Cancer: A Prospective Study of American Society of Breast Surgeon Members.

BACKGROUND: More than 20% of patients undergoing initial breast-conserving surgery (BCS) for cancer require reoperation. To address this concern, the American Society of Breast Surgeons (ASBrS) endorsed 10 processes of care (tools) in 2015 to be considered by surgeons to de-escalate reoperations. In a planned follow-up, we sought to determine which tools were associated with fewer reoperations. METHODS: A cohort of ASBrS member surgeons prospectively entered data into the ASBrS Mastery® registry on consecutive patients undergoing BCS in 2017. The association between tools and reoperations was estimated via multivariate and hierarchical ranking analyses. RESULTS: Seventy-one surgeons reported reoperations in 486 (12.3%) of 3954 cases (mean 12.7% [standard deviation (SD) 7.7%], median 11.5% [range 0-32%]). There was an eightfold difference between surgeons in the 10th and 90th percentile performance groups. Actionable factors associated with fewer reoperations included routine planned cavity side-wall shaves, surgeon use of ultrasound (US), neoadjuvant chemotherapy, intra-operative pathologic margin assessment, and use of a pre-operative diagnostic imaging modality beyond conventional 2D mammography. For patients with invasive cancer, ≥ 24% of those who underwent reexcision did so for reported margins of < 1 or 2 mm, representing noncompliance with the SSO-ASTRO margin guideline. CONCLUSIONS: Although ASBrS member surgeons had some of the lowest rates of reoperation reported in any registry, significant intersurgeon variability persisted. Further efforts to lower rates are therefore warranted. Opportunities to do so were identified by adopting those processes of care, including improved compliance with the SSO-ASTRO margin guideline, which were associated with fewer reoperations.

Comparison of nonscheduled, postinsertion adjustment visits for complete dentures fabricated with conventional and CAD-CAM protocols: A clinical study.

STATEMENT OF PROBLEM: Unscheduled denture-adjustment visits may disrupt both patients and clinicians. Denture-adjustment visits have not been correlated with denture-processing methods. PURPOSE: The purpose of this clinical study was to identify differences in the number of unscheduled postinsertion-adjustment visits of patients with complete dentures fabricated by injection molding (IM) versus dentures fabricated by computer-aided design and computer-aided manufacturing (CAD-CAM). MATERIAL AND METHODS: One hundred six participants were evaluated in the study. They were consecutively treated in a private practice setting and followed up for 1 year after the insertion of new complete dentures. The first 33 received dentures fabricated using an IM system, and the other 73 were milled using a CAD-CAM system. All participants had been edentulous for at least 1 year. Participant ages ranged from 29 to 83 years. IM dentures were fabricated by a commercial dental laboratory; CAD-CAM dentures were milled by a commercial manufacturer. All participants were scheduled for 1- or 2-week postinsertion office visits. Further adjustment visits were scheduled according to participant request. The results were tabulated, and univariable tests of association were performed including chi-square and the Fisher exact tests for categorical comparisons and the Wilcoxon rank sum test for comparison of ordinal continuous data. A multivariable logistic regression model was used to control for the influence of multiple predictor variables on the outcome of interest. RESULTS: Edentulous years ranged from 1 to 60. Approximately one half (n=56) of all participants returned for scheduled postinsertion visits approximately 1 to 2 weeks after insertion of the dentures. No significant demographic or clinical differences were noted between participants receiving CAD-CAM or conventional dentures. Return visits for unscheduled adjustments were not associated with the method of denture fabrication or any other demographic features (P=.55). CONCLUSIONS: Based on the results of this study, there were no significant differences in the number of unscheduled, postinsertion visits for participants whose dentures were fabricated following IM or CAD-CAM milling protocols. Clinicians may choose to fabricate complete dentures with either protocol and expect similar clinical results in terms of the number of unscheduled postinsertion visits.

Benchmarking the American Society of Breast Surgeon Member Performance for More Than a Million Quality Measure-Patient Encounters.

BACKGROUND: Nine breast cancer quality measures (QM) were selected by the American Society of Breast Surgeons (ASBrS) for the Centers for Medicare and Medicaid Services (CMS) Quality Payment Programs (QPP) and other performance improvement programs. We report member performance. STUDY DESIGN: Surgeons entered QM data into an electronic registry. For each QM, aggregate "performance met" (PM) was reported (median, range and percentiles) and benchmarks (target goals) were calculated by CMS methodology, specifically, the Achievable Benchmark of Care™ (ABC) method. RESULTS: A total of 1,286,011 QM encounters were captured from 2011-2015. For 7 QM, first and last PM rates were as follows: (1) needle biopsy (95.8, 98.5%), (2) specimen imaging (97.9, 98.8%), (3) specimen orientation (98.5, 98.3%), (4) sentinel node use (95.1, 93.4%), (5) antibiotic selection (98.0, 99.4%), (6) antibiotic duration (99.0, 99.8%), and (7) no surgical site infection (98.8, 98.9%); all p values < 0.001 for trends. Variability and reasons for noncompliance by surgeon for each QM were identified. The CMS-calculated target goals (ABC™ benchmarks) for PM for 6 QM were 100%, suggesting that not meeting performance is a "never should occur" event. CONCLUSIONS: Surgeons self-reported a large number of specialty-specific patient-measure encounters into a registry for self-assessment and participation in QPP. Despite high levels of performance demonstrated initially in 2011 with minimal subsequent change, the ASBrS concluded "perfect" performance was not a realistic goal for QPP. Thus, after review of our normative performance data, the ASBrS recommended different benchmarks than CMS for each QM.

A US Registry-Based Assessment of Use and Impact of Chemotherapy in Stage I HER2-Positive Breast Cancer.

Background: Despite the paucity of evidence supporting chemotherapy in the treatment of node-negative, HER2-positive breast cancer measuring <2 cm, use of trastuzumab-based chemotherapy has increased over the past decade. Therefore, we used the National Cancer Database to evaluate the use and impact of chemotherapy on survival in this population. Methods: We identified female patients aged 18 to 70 years with node-negative, HER2-positive breast cancer measuring <2 cm. A propensity-matched cohort model was used to control for risk factors known to influence survival. Primary end points assessed were receipt of chemotherapy and overall survival (OS). Results: In our propensity-matched cohort model (n=8,222), adjuvant chemotherapy (ACT) was associated with a lower 5-year OS rate in T1mi breast cancer (n=626; 89.1% [95% CI, 81.8%-93.5%] vs 99.1% [96.6%-99.8%]), no significant effect in T1a disease (n=2,901; 95.4% [93.2%-96.9%] vs 96.9% [94.1%-98.3%]), and improved 5-year OS in T1b (n=2,340; 97.1% [95.1%-98.4%] vs 92.3% [88.5%-94.9%]) and T1c tumors (n=2,355; 95.9% [93.5%-97.5%] vs 91.5% [88.4%-93.9%]). In the entire cohort of 21,148 patients who met the inclusion criteria, ACT was associated with lower 5-year OS in T1mi (89.6% [83.7%-93.4%] vs 98.1% [96.6%-98.9%]) and T1a tumors (94.9% [92.9%-96.3%] vs 96.5% [94.6%-97.7%]), and improved 5-year OS in T1b (96.8% [95.6%-97.7%] vs 92.3% [88.7%-94.8%]) and T1c tumors (95.8% [94.9%-96.5%] vs 91.6% [88.5%-93.9%]). Increased use of ACT was observed over the study period. From 2010 to 2013, annual treatment rates were 71.5%, 72.4%, 73.3%, and 74.4%, respectively (trend test, P<.0001). Conclusions: Our data support the use of ACT for HER2-positive, node-negative T1b and T1c breast cancer, whereas no benefit was observed for ACT in T1mi and T1a HER2-positive, node-negative breast cancer. Although use of ACT is increasing in node-negative, HER2-positive breast cancer <2 cm, our findings caution against its use in the smallest of these tumors (T1mi and T1a) due to lack of survival benefit.

Are We on the Same Page? Patient and Provider Perceptions About Exercise in Cancer Care: A Focus Group Study.

Background: Physical activity (PA) during and after cancer treatment can help with symptom management and reduce the risk of cancer recurrence. However, it is unclear what constitutes an optimal exercise program. In addition, provider and patient barriers exist to the recommendation and adoption of exercise as part of a cancer treatment plan. The goal of this study was to determine how providers and patients feel about exercise during cancer treatment and explore what the barriers to implementing such a program might be. Patients and Methods: Focus groups and interviews were held with patients with malignancy, both metastatic and nonmetastatic, and oncology providers. In total, 20 patients participated in either a focus group or an individual interview and 9 providers contributed to the focus group. An equal number of patients (n=10) were interviewed as attended a focus group. Audiotaped sessions were transcribed verbatim. Theme identification was independently coded by 4 coders and synthesized as a group. Results: Neither patient group recalled PA instruction from oncology providers during their cancer treatment. Most participants (95%) felt exercise is important during cancer treatment, citing overall well-being benefits versus improved disease outcome. Most patients (80%) preferred a home-based exercise program provided by the oncologist. Fatigue was the most cited barrier to regular exercise during treatment (50%). All providers acknowledged benefits of PA to patients, but not universally for all. More than half of providers (55%) preferred a referral system for exercise programs. Clinic visit time constraints and a perceived lack of expertise in the area of PA were common barriers to making exercise recommendations a routine part of the treatment plan. Conclusions: Patients with cancer and oncologists recognize the benefits of PA during treatment. Disagreement exists between to whom, how, and where exercise plans should be disseminated and implemented.

Impact of Obesity on Cesarean Delivery Outcomes.

BACKGROUND: The rate of cesarean delivery has increased over the last 2 decades. Obesity is a risk factor for complications during pregnancy and cesarean procedures. The objective of this study was to evaluate cesarean delivery outcomes in patients with vs without obesity, and determine the impact of obesity on complications. METHODS: The medical records of patients who underwent a cesarean delivery from 2010 to 2014 were reviewed. Patients were grouped by body mass index (BMI) into obese (≥30kg/m²) and non-obese (<30kg/m²) cohorts for comparison. RESULTS: Nine hundred seventy-one patients were included; 432 whom had obesity, and 539 did not have obesity. The rate of gestational diabetes was increased among patients with vs without obesity (15.3% vs 5.8%; P<0.001). Obesity was associated with an increased incidence of surgical site infections (8.1% vs 2.4%; P<0.001), yeast infection (2.8% vs 0.2%; P<0.001), and seroma (2.8% vs 0.4%; P=0.002). Obesity was an independent risk factor for surgical site infections, regardless of wound closure technique (adjusted odds ratio=3.24, 95% CI, 1.66-6.32; P<0.001). CONCLUSIONS: Obesity is a risk factor for wound infections after a cesarean delivery. As obesity rates increase, it is important to be aware of these risks after performing a cesarean delivery.

Pancreatic adenocarcinoma: effects of neoadjuvant therapy on post-pancreatectomy outcomes - an American College of Surgeons National Surgical Quality Improvement Program targeted variable review.

BACKGROUND: As the incidence of pancreatic adenocarcinoma increases, so has the utilization of neoadjuvant therapy. The objective of this study was to evaluate outcomes in patients undergoing neoadjuvant therapy or surgery first for pancreatic adenocarcinoma. METHODS: The ACS-NSQIP 2014-2015 targeted pancreatectomy variables were queried for patients with pancreatic adenocarcinoma who underwent resection. Outcomes of those receiving neoadjuvant therapy were compared to surgery first using a multivariate, logistic regression model. RESULTS: 3408 patients underwent pancreatectomy; 2596 proximal pancreatectomies, 741 distal pancreatectomies, 64 total pancreatectomies and 7 other pancreatic procedures were performed. Of the 3408 patients identified, 934 (27.5%) received neoadjuvant therapy: 496 chemotherapy alone, 28 radiation alone, and 410 combined chemotherapy/radiation therapy. Overall morbidity and mortality were similar between patients receiving neoadjuvant therapy versus those who underwent surgery first. Neoadjuvant treatment was associated with lower rates of pancreatic fistulas (10.2% vs. 13.2%, P = 0.017), but higher intra/postoperative transfusion rates (27.4% vs. 20.3%, P < 0.0001). CONCLUSIONS: Neoadjuvant therapy appeared to be safe prior to operative intervention as no difference in overall postoperative morbidity or mortality rates were identified. There were increased intra/postoperative transfusions in the neoadjuvant therapy group, but neoadjuvant therapy was associated with lower rates of pancreatic fistulas.

21-Gene recurrence score decreases receipt of chemotherapy in ER+ early-stage breast cancer: an analysis of the NCDB 2010-2013.

The purpose of this study was to determine if receipt of chemotherapy was associated with utilization of the 21-gene recurrence score assay (RS assay) or with recurrence score (RS) in eligible patients. Using the National Cancer Data Base (NCDB), we identified female patients eligible for RS assay based on National Comprehensive Cancer Network (NCCN) guidelines: age 18-70, ER-positive and HER2-negative early-stage breast cancer diagnosed during 2010-2013. We excluded patients not meeting testing guidelines. Inclusion required result of RS in patients who underwent RS assay and status for receipt of chemotherapy. Multivariable logistic regression models and propensity matched analysis were used to determine associations between RS assay and RS with receipt of chemotherapy. Among 129,765 patients who were eligible, 74,778 underwent RS assay and had results available. Of these, 59.5 % (44,505) had low-risk, 32.0 % (23,920) had intermediate-risk, and 8.5 % (6353) had high-risk RS. Patients with intermediate- and high-risk RS were more likely to receive chemotherapy [OR 12.9 (CI 12.2-13.6), p <0.001 and OR 87.2 (CI 79.6-95.6), p <0.0001], respectively. In both low- and intermediate-risk groups, increasing RS score was significantly associated with increasing odds of receiving chemotherapy [OR 1.10 (CI 1.09-1.12), p <0.0001 and OR 1.26 (CI 1.25-1.27), p <0.0001, respectively, for each point increase in RS]. Receipt of chemotherapy was more likely in patients who did not undergo RS assay compared to those who did, OR 1.21 (CI 1.175-1.249) p <0.0001. The utilization of RS assay and the RS were both strongly associated with chemotherapy receipt. Patients eligible for chemotherapy, based on NCCN criteria, were more likely to receive chemotherapy if they did not undergo RS assay or they had a high RS.

A Prospective Comparison of Clinical, Radiographic, and Intraoperative Features of Hallux Rigidus: Long-Term Follow-Up and Analysis.

Forty-seven patients (50 feet) underwent surgical intervention for symptomatic hallux rigidus from February 1998 to April 1999. Thirty-eight patients (41 feet) returned at 1 year for a follow-up evaluation. Of these 38 patients, 20 (21 feet) returned for the 15-year follow-up evaluation. Subjective evaluations were performed using the modified American Orthopaedic Foot and Ankle Surgery hallux metatarsophalangeal-interphalangeal 100-point scale. Long-term postoperative objective physical examination and radiographic analysis were performed. These data were compared with the preoperative and short-term follow-up data. The subjective evaluation showed a statistically significant differing over the long term, with a mean increase of 27.6 points. The results of the physical examination and radiographic measurements were mixed. The long-term dorsal range of motion was not significant across surgery type. Radiographically, the procedure types resulted in similar changes, suggesting that neither joint preservation nor joint destructive procedures were more stable over time. Plantar transposition of the capital fragment, offsetting the longitudinal shortening of the first metatarsal, was not significant, confirming the short-term findings. For this patient population, the long-term results of surgical intervention for hallux rigidus, regardless of procedure type, provided subjective patient improvement but no statistically significant increase in first metatarsophalangeal joint function or dorsal range of motion.

Increasing Follow-up Outcomes of At-Risk Alcohol Patients Using Motivational Interviewing.

Our trauma division implemented a screening, brief intervention, and referral to treatment (SBIRT) program in 2009 and has maintained more than 92% screening rate for all inpatient admissions since inception. Brief interventions are proven to be more likely to effect and reinforce change if a follow-up contact is made with patients. This led to discussion regarding whether identified patients were more likely to follow up with our SBIRT wellness specialist using motivational interviewing or with our partners, exercise physiology, who use traditional interviewing techniques. We retrospectively reviewed more than 3,000 inpatient admissions in which screening for at-risk alcohol use were positive. Fifty-one percent of identified patients were referred for wellness specialist consultation with a follow-up rate of 52% compared with a follow-up rate of only 21% in the exercise physiology group. Motivational interviewing is more effective in encouraging at-risk alcohol users to participate in follow-up care.

Levetiracetam as adjunctive therapy for acute alcohol withdrawal syndrome in hospitalized patients.

BACKGROUND: Benzodiazepines are often considered the standard of care for managing symptoms of acute alcohol withdrawal syndrome. Because of potential adverse effects, other agents have been evaluated in this patient population. Previous studies have produced mixed results on the efficacy of levetiracetam in alcohol withdrawal. OBJECTIVE: The objective of this study was to determine whether adjunctive levetiracetam reduces the amount of symptom-triggered benzodiazepines required by patients experiencing symptoms of alcohol withdrawal. METHODS: We conducted a retrospective chart review of patients who experienced symptoms of alcohol withdrawal while hospitalized. The outcomes of patients who received adjunctive levetiracetam were compared with those of patients who received only the standard of care (control group). RESULTS: Two hundred fifty patients (125 in each cohort) were included. No significant differences were found in the benzodiazepine requirements of the 2 cohorts. The control group required a median average daily dose of 2.0 mg of lorazepam (range, 0.1-17 mg/d) compared with the levetiracetam group, which required a median average daily dose of 1.3 mg of lorazepam (range, 0.0-53.5 mg/d) (P = 0.09). The patients in the control group required a median total of 6 mg of lorazepam during their hospitalization compared with a median total of 5.5 mg in the levetiracetam group. Both cohorts had a median length of stay of 3 days, although those in the levetiracetam group had a shorter length of intensive care unit stay and spent less time mechanically ventilated. CONCLUSIONS: The adjunctive use of levetiracetam does not significantly reduce the benzodiazepine requirements of patients experiencing symptoms of alcohol withdrawal in the inpatient setting.

Cancer incidence, type, and survival after bariatric surgery.

BACKGROUND: Many types of cancer have been found to be associated with being overweight or obese. Literature has demonstrated a reduction in cancer risk in patients who have undergone bariatric surgery. OBJECTIVES: To compare the incidence and types of new cancer diagnoses, cumulative cancer incidence, cancer risk, and overall survival in patients with obesity who underwent bariatric surgery with that of those who did not. SETTING: Community-based academic medical center. METHODS: We retrospectively compared the rates and types of new incident cancers in a bariatric surgery cohort (Bariatric group) with those of a non-surgical cohort (Comparison group). The Comparison group was chosen from patients who had a clinic visit in our health system within 30 days of each bariatric surgical operation and matched on age, sex, and body mass index. Patients who had a cancer diagnosis prior to having bariatric surgery were excluded from the Bariatric group and patients who had a cancer diagnosis prior to the clinic visit on which they were matched were excluded from the Comparison group. Relative risk of cancer by type was calculated. Chi-square and Fisher exact tests were used for categorical data analysis, and Wilcoxon rank-sum for continuous data. The Kaplan Meier estimator with the log-rank test was used to compare overall survival between groups, while competing risks survival analysis with the Gray test for equality was used to compare cancer incidence in the Surgery group with that in the Comparison group. RESULTS: After matching, the Bariatric group had 1593 patients and the Comparison group had 2156. The Bariatric and Comparison groups had 82 and 222 new incident cancer cases, respectively (P < .001). The 10-year incidence of any new cancer in the Bariatric group was 6.5%, compared with an incidence of 12.1% in the Comparison group (P < .001). Relative risk of cancer in the Bariatric group was lower than that of the Comparison group, with the greatest differences in endometrial (88.8%), kidney (77.4%), thyroid (72.9%), and ductal carcinoma in situ (71.2%) cancers. The 10-year overall survival rate was higher in the Bariatric group than in the Comparison group, 93.3% versus 80.6%, respectively (P < .001). CONCLUSIONS: Bariatric surgery reduces the risk for developing cancer and offers survival advantage when compared with similar patients who do not undergo bariatric surgery.

Postoperative Outcomes in the Plain Community Population of Western Wisconsin.

BACKGROUND: Residents of plain communities constitute an underserved minority population that is not reliably captured in contemporary surgical outcomes research. We hypothesized that plain communities (PC) patients would have higher postoperative complication rates than a general surgical population. METHODS: A retrospective review of 30-day postoperative outcomes for PC patients compared to a majority (non-PC) matched patient population from September 2014 to March 2020 was performed. The primary outcome measure was any complication within 30 days of surgery. RESULTS: 270 PC patients were matched with 493 non-PC patients. The 30-day complication rate was higher for the PC group (6.3% vs 3.7%, P = .09), though not statistically significant. There was significantly lower utilization of preventive care services, and postoperative follow-up among PC patients. DISCUSSION: Although our regional PC surgical patient population utilized preventive and postoperative health care services less than the non-PC population, there was no statistically significant difference in overall 30-day postoperative morbidity or mortality.

Temporal Artery Biopsy: When Is It Worth the Headache?

BACKGROUND: Temporal artery biopsy is ordered when clinical symptoms and an elevated C-reactive protein values and/or erythrocyte sedimentation rates suggest giant cell arteritis. The percentage of temporal artery biopsies positive for giant cell arteritis is low. The objectives of our study were to analyze the diagnostic yield of temporal artery biopsies at an independent academic medical center and to develop a risk stratification model for triaging patients for possible temporal artery biopsy. METHODS: We retrospectively reviewed the electronic health records of all patients who underwent temporal artery biopsy in our institution from January 2010 through February 2020. We compared clinical symptoms and inflammatory marker (C-reactive protein and erythrocyte sedimentation rate) values of patients whose specimens were positive for giant cell arteritis with those of patients with negative specimens. Statistical analysis included descriptive statistics, chi-square test, and multivariable logistic regression. A risk stratification tool, which included point assignments and measures of performance, was developed. RESULTS: Of 497 temporal artery biopsies for giant cell arteritis performed, 66 were positive and 431 were negative. Jaw/tongue claudication, elevated inflammatory marker values, and age were associated with a positive result. Using our risk stratification tool, 3.4% of low-risk patients, 14.5% of medium-risk patients, and 43.9% of high-risk patients were positive for giant cell arteritis. CONCLUSIONS: Jaw/tongue claudication, age, and elevated inflammatory markers were associated with positive biopsy results. Our diagnostic yield was much lower when compared with a benchmark yield determined in a published systematic review. A risk stratification tool was developed based on age and the presence of independent risk factors.

Optimized infection control practices augment the robust protective effect of vaccination for ESRD patients during a hemodialysis facility SARS-CoV-2 outbreak.

BACKGROUND: While dialysis patients are at greater risk of serious SARS-CoV-2 complications, stringent infection prevention measures can help mitigate infection and transmission risks within dialysis facilities. We describe an outbreak of 14 cases diagnosed in a hospital-based outpatient ESRD facility over 13 days in the second quarter of 2021, and our coordinated use of epidemiology, viral genome sequencing, and infection control practices to quickly end the transmission cycle. METHODS: Symptomatic patients and staff members were diagnosed by RT-PCR. Facility-wide screening utilized SARS-CoV-2 antigen tests. SARS-CoV-2 genome sequences were obtained from residual diagnostic specimens. RESULTS: Of the 106 patients receiving dialysis in the facility, 10 were diagnosed with SARS-CoV-2 infection, as was 1 patient support person. Of 3 positive staff members, 2 were unvaccinated and had provided care for 6 and 4 of the affected patients, respectively. Sequencing demonstrated that all cases in the cluster shared an identical B.1.1.7./Alpha substrain. Attack rates were greatest among unvaccinated patients and staff. Vaccine effectiveness was 88% among patients. CONCLUSIONS: Prompt recognition of an infection cluster and rapid intervention efforts successfully ended the outbreak. Alongside consistent adherence to core infection prevention measures, vaccination was highly effective in reducing disease incidence and morbidity in this vulnerable population.

Epidemiology, Management, and Outcomes of Accidental Hypothermia: A Multicenter Study of Regional Care.

BACKGROUND: Hypothermia is an uncommon, potentially life-threatening condition. We hypothesized (1) advanced rewarming techniques were more frequent with increased hypothermia severity, (2) active rewarming is increasingly performed with smaller intravascular catheters and decreased cardiopulmonary bypass, and (3) mortality was associated with age, hypothermia severity, and type. METHODS: Trauma patients with temperatures <35°C at 4 ACS-verified trauma centers in Wisconsin and Minnesota from 2006 to 2016 were reviewed. Statistical analysis included chi-square and Fisher's exact tests. A P value < .05 was considered significant. RESULTS: 337 patients met inclusion criteria; primary hypothermia was identified in 127 (38%), secondary in 113 (34%), and mixed primary/secondary in 96 (28%) patients. Hypothermia was mild in 69%, moderate in 26%, and severe in 5% of patients. Intravascular rewarming catheter was the most frequent advanced modality (2%), used increasingly since 2014. Advanced techniques were used for primary (12%) vs. secondary (0%) and mixed (5%) (P = .0002); overall use increased with hypothermia severity but varied by institution. Dysrhythmia, acute kidney injury, and frostbite risk worsened with hypothermia severity (P < .0001, P = .031, and P < .0001, respectively). Mortality was greatest in patients with mixed hypothermia (39%, P = .0002) and age >65 years (33%, P = .03). Thirty-day mortality rates were similar among severe, moderate, and mild hypothermia (P = .44). CONCLUSION: Advanced rewarming techniques were used more frequently in severe and primary hypothermia but varied among institutions. Advanced rewarming was less common in mixed hypothermia; mortality was highest in this subgroup. Reliance on smaller intravascular catheters for advanced rewarming increased over time. Given inconsistencies in management, implementation of guidelines for hypothermia management appears necessary.