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Background: Although various studies have documented increased life-sustaining treatments among racial minorities in medical patients, whether similar disparities exist in surgical patients is unknown. Methods: A retrospective cohort study using the Nationwide Inpatient Sample (2006 to 2011) examining patients older than 39 years who died after elective colectomy was performed. Primary predictor variable was race, and main outcome was the use of life-sustaining treatment. Results: In univariate analysis, significant differences existed in use of cardiopulmonary resuscitation (CPR; black, 35.9%; Hispanic, 29.0%; other, 24.5%; white, 11.7%; P = .002) and reintubation (Hispanic, 75.0%; other, 69.0%; black, 52.3%; white, 45.2%; P = .01). In multivariate analysis, black (odds ratio [OR], 3.67; P = .01) and Hispanic (OR, 4.21; P = .03) patients were more likely to have undergone CPR, and Hispanic patients (OR, 4.24; P = .01) were more likely to have been reintubated (reference: white). Conclusions: Blacks and Hispanics had increased odds of experiencing CPR, and Hispanics were more likely to have been reintubated before death after a major elective operation. These variations may imply worse quality of death and increased associated costs. [ABSTRACT FROM AUTHOR]

Abstract: Background: Although robot-assisted laparoscopic radical cystectomy (RARC) was first reported in 2003 and has gained popularity, comparisons with open radical cystectomy (ORC) are limited to reports from high-volume referral centers. Objective: To compare population-based perioperative outcomes and costs of ORC and RARC. Design, setting, and participants: A retrospective observational cohort study using the US Nationwide Inpatient Sample to characterize 2009 RARC compared with ORC use and outcomes. Outcome measurements and statistical analysis: Propensity score methods were used to compare inpatient morbidity and mortality, lengths of stay, and costs. Results and limitations: We identified 1444 ORCs and 224 RARCs. Women were less likely to undergo RARC than ORC (9.8% compared with 15.5%, p =0.048), and 95.7% of RARCs and 73.9% of ORCs were performed at teaching hospitals (p <0.001). In adjusted analyses, subjects undergoing RARC compared with ORC experienced fewer inpatient complications (49.1% and 63.8%, p =0.035) and fewer deaths (0% and 2.5%, p <0.001). RARC compared with ORC was associated with lower parenteral nutrition use (6.4% and 13.3%, p =0.046); however, there was no difference in length of stay. RARC compared with ORC was $3797 more costly (p =0.023). Limitations include retrospective design, absence of tumor characteristics, and lack of outcomes beyond hospital discharge. Conclusions: RARC is associated with lower parenteral nutrition use and fewer inpatient complications and deaths. However, lengths of stay are similar, and the robotic approach is significantly more costly. [Copyright &y& Elsevier]

Objectives. Retroperitoneal lymph node dissection (RPLND) outcomes for testis cancer originate mostly from single-center series. We characterized population-based utilization, costs, and outcomes and assessed whether higher volume affects outcomes. Methods and Materials. Using the US Nationwide Inpatient Sample from 2001-2008, we identified 993 RPLND and used propensity score methods to assess utilization, costs, and inpatient outcomes based on hospital surgical volume. Results. 51.6% of RPLND were performed at hospitals where there were two or fewer cases per year. RPLND was more commonly performed at large urban teaching hospitals, where men were younger, more likely to be white and earning incomes exceeding the 50th percentile (all P = .05). Higher hospital volumes were associated with fewer complications and more routine home discharges (all P = .047). However, higher volume hospitals had more transfusions (P = .004) and incurred $1,435 more in median costs (P < .001). Limitations include inability to adjust for tumor characteristics and absence of outpatient outcomes. Conclusions. Sociodemographic differences exist between high versus low volume RPLND hospitals. Although higher volume hospitals had more transfusions and higher costs, perhaps due to more complex cases, they experienced fewer complications. However, most RPLND are performed at hospitals where there were two or fewer cases per year. [ABSTRACT FROM AUTHOR]

Critical limb ischemia (CLI) is a frequent and major vascular problem and can lead to amputation and death despite surgical revascularization. Women have been shown to have 3 to 4 per cent lower revascularization rates for CLI compared with men as well as inferior outcomes. We hypothesize that this difference is a result of women being more likely admitted to low-volume hospitals, which in turn perform fewer revascularizations. Prospective cohort study. Data from the Nationwide Inpatient Sample 2007 to 2010 were used to identify admissions with primary International Classification of Diseases-9 codes for CLI (International Classification of Diseases-9 codes: 440.22, 440.23, 440.24, 707.1, 707.10-707.15, or 707.19). Hospitals were grouped in quintiles by annual revascularization procedures. Bivariate analyses were performed and multivariable logistic regression was used to analyze the odds of revascularization, amputation, and mortality while controlling for patient and hospital-level factors. Of 113,631 admissions, 54,370 (47.8%) were women, who were more likely admitted to low-volume hospitals (very low: 49.6% vs very high: 47.1%; P < 0.001). Revascularization rates were lower in women (31.6% vs 35.1%, P < 0.001) across all volume quintiles, whereas the difference was greatest in the use of open surgical revascularization (12.5% vs 16.0%, P < 0.001). In multivariable analysis, female gender [odds ratio (OR) 0.87, 95% confidence interval (CI) 0.83-0.92, P < 0.001] and very-low hospital volume (OR 0.21, 95% CI 0.17-0.26, P < 0.001) were both significantly associated with lower rates of revascularization. Women had lower odds of major amputation compared with men (OR 0.75, 95% CI 0.69-0.82, P < 0.001), whereas treatment in a very high-volume hospital was associated with increased odds for amputation (OR 1.37, 95% CI 1.09-1.73, P = 0.008). Neither gender nor hospital volume were independently associated with in-hospital mortality in the multivariable regression model. Women are more likely to be admitted to low-volume hospitals for treatment of CLI. Because of this, they are less likely to undergo revascularization, although they also had lower rates of major amputation. [ABSTRACT FROM AUTHOR]

Introduction: Analysis of large complex survey databases is an important research tool for health services researchers in Surgery. Missing data elements are challenging as reasons they are missing are multi-factorial, especially variables with multiple categories such as race. We simulated missing data for race and analyzed the bias from five missing data methods used in predicting major amputation in patients with critical limb ischemia (CLI). Methods: Discharges with fully observed data containing lower extremity revascularization or major amputation and CLI were selected from the 2003-2007 Nationwide Inpatient Sample, a complex survey database (weighted N=684,057). Considering random and non-random missing data schemes, we simulated missing data for race to compare five missing data methods (complete case analysis (CCA), missing indicator variable (MIV), single imputation with mean frequencies, re-weighted estimating equations (RWEEs), and multiple imputation). Bias was determined by comparing mean regression coefficients estimated from 100 simulated datasets (B_miss) to those estimated from the fully observed dataset (B_full), with relative bias calculated as (B_full–B_miss/B_full)*100%. Results: Our results demonstrate that RWEEs produce the least biased and MIV the most biased coefficients. CCA, single imputation, and multiple imputation resulted in moderate bias. Sensitivity analysis demonstrated that optimal method choice depends on quantity and type of missing data encountered. Conclusions: Missing data is an important analytical topic in research with large databases. RWEEs are flexible and provided the least biased coefficients. The commonly used MIV method introduces the most bias and should be used with caution. We present empirical evidence to guide method selection for handling missing data. [ABSTRACT FROM AUTHOR]

What's known on the subject? and What does the study add? Retrospective data have suggested an increased survival benefit for patients undergoing partial nephrectomy compared to radical nephrectomy, possibly as a result of the avoidance of long-term renalin sufficiency and subsequent sequelae. However, recent level-one evidence has questioned this benefit. Both retrospective studies and randomized controlled trials are not without limitations., There are few population-based data available with respect to the outcomes of partial nephrectomy vs radical nephrectomy. Additionally, there are no population-based studies analyzing the surgical approach (minimally-invasive vs open), as well as other modalities, such as ablation and surveillance. Finally, there is very little information available on the potential differences in cost for each approach. The present study comprises the first comprehensive population-based analysis of the trends, outcomes and costs of all treatment modalities for T1a renal masses from 2005 to 2007., Objective To perform a comprehensive analysis of the outcomes and costs for treatments for small renal masses ( SRM) using a population-based approach. Partial nephrectomy may be associated with improved survival, although level-one evidence has questioned this survival advantage., Patients and Methods Using Surveillance, Epidemiology and End Results- Medicare data, we identified 1682 subjects who were diagnosed with SRM from 2005 to 2007., Treatment included open radical nephrectomy ( ORN; n = 404), minimally-invasive radical nephrectomy ( MIRN; n = 535), open partial nephrectomy ( OPN; n = 330), minimally-invasive partial nephrectomy ( MIPN; n = 160), ablation ( n = 211) and surveillance ( n = 42)., Postoperative complications, renal insufficiency diagnosis, overall mortality, cancer-specific mortality and postoperative costs were compared., Covariates were balanced before outcomes analysis using propensity score methods., Results Although the use of nephron-sparing surgery ( NSS) increased over the study period, radical nephrectomy remained the predominant approach for SRM in 2007., Minimally-invasive approaches had shorter lengths of stay ( P < 0.001), whereas open approaches had more overall complications, respiratory complications and intensive care unit admissions (all P < 0.003)., MIRN and ORN were associated with more peri-operative medical complications, acute renal failure, haemodialysis use and long-term chronic renal insufficiency diagnosis vs NSS (all P < 0.001)., Ablation, MIRN and ORN were associated with the highest overall mortality rates ( P < 0.001), whereas MIRN and ORN were associated with the highest cancer-specific mortality rates ( P < 0.001)., Treatment costs were lowest for surveillance ($2911) followed by ablation ($10 730), MIRN ($15 373), MIPN ($15 695), OPN ($16 986) and ORN ($17 803)., Conclusions Although not the predominant treatment approach for SRM over the study period, the use of NSS increased and was associated with improved survival, fewer complications and less renal insufficiency., Minimally-invasive approaches confer lower costs. [ABSTRACT FROM AUTHOR]

Abstract: Background: While radical prostatectomy surgeon learning curves have characterized less blood loss, shorter operative times, and fewer positive margins, there is a dearth of studies characterizing learning curves for improving sexual function. Additionally, while learning curve studies often define volume thresholds for improvement, few of these studies demonstrate specific technical modifications that allow reproducibility of improved outcomes. Objective: Demonstrate and quantify the learning curve for improving sexual function outcomes based on technical refinements that reduce neurovascular bundle displacement during nerve-sparing robot-assisted radical prostatectomy (RARP). Design, setting, and participants: We performed a retrospective study of 400 consecutive RARPs, categorized into groups of 50, performed after elimination of continuous surgeon/assistant neurovascular bundle countertraction. Surgical procedure: Our approach to RARP has been described previously. A single-console robotic system was used for all cases. Outcome measurements and statistical analysis: Expanded Prostate Cancer Index Composite sexual function was measured within 1 yr of RARP. Linear regression was performed to determine factors influencing the recovery of sexual function. Results and limitations: Greater surgeon experience was associated with better 5-mo sexual function (p =0.007) and a trend for better 12-mo sexual function (p =0.061), with improvement plateauing after 250–300 cases. Additionally, younger patient age (both p <0.02) and better preoperative sexual function (<0.001) were associated with better 5- and 12-mo sexual function. Moreover, trainee robotic console time during nerve sparing was associated with worse 12-mo sexual function (p =0.021), while unilateral nerve sparing/non–nerve sparing was associated with worse 5-mo sexual function (p =0.009). Limitations include the retrospective single-surgeon design. Conclusions: With greater surgeon experience, attenuating lateral displacement of the neurovascular bundle and resultant neurapraxia improve postoperative sexual function. However, to maximize outcomes, appropriate patient selection must be exercised when allowing trainee nerve-sparing involvement. [Copyright &y& Elsevier]

Purpose: We describe the feasibility of partial arterial clamping (PAC) during robot-assisted partial nephrectomy (RAPN). Patients and Methods: We undertook a retrospective study of five patients who underwent PAC vs 17 who underwent complete hilar clamping (CHC). Estimated blood loss (EBL), transfusion rate, operative/console time, warm ischemia time (WIT), pathology, and postoperative glomerular filtration rate (GFR) were compared. Results: PAC patients were older ( P=0.002) and more likely to have had previous abdominal surgeries ( P=0.032). PAC vs CHC was associated with higher median EBL (350 mL vs 75 mL, P=0.026), although there were no differences in blood transfusions ( P=0.250). PAC was associated with shorter WIT (14 min vs 21 min, P=0.023). Positive margin rate and GFR change were similar. Conclusions: PAC offers a simple and reproducible technique that limits WIT during RAPN. PAC was not associated with more transfusions or positive margins. Further study is warranted to determine the utility of PAC with larger tumor size as well as the long-term benefits on renal function. [ABSTRACT FROM AUTHOR]

Abstract: Background: Although subtle technical variation affects potency preservation during robot-assisted laparoscopic radical prostatectomy (RARP), most prostatectomy studies focus on achieving the optimal anatomic nerve-sparing dissection plane. However, the impact of active assistant/surgeon neurovascular bundle (NVB) countertraction on sexual function outcomes has not been studied or quantified. Objective: To illustrate technique and compare sexual function outcomes for nerve sparing without (NS-0C) versus with (NS-C) assistant and/or surgeon NVB countertraction. Design, setting, and participants: This is a retrospective study of 342 NS-0C versus 268 NS-C RARP procedures performed between August 2008 and February 2011. Surgical procedure: RARP. Measurements: We used the Expanded Prostate Cancer Index Composite (EPIC) sexual function and potency scores, estimated blood loss (EBL), operative time, and positive surgical margin (PSM). Results and limitations: In unadjusted analysis, men undergoing NS-0C versus NS-C were older, had worse baseline sexual function, higher biopsy and pathologic Gleason grade, and higher preoperative prostate-specific antigen (PSA) levels (all p ≤0.023). However, NS-0C versus NS-C was associated with higher 5-mo sexual function scores (20 vs 10; p <0.001), and this difference was accentuated for bilateral intrafascial nerve sparing in preoperatively potent men (35.8 vs 16.6; p <0.001). Similarly, 5-mo potency for preoperatively potent men was better with bilateral intrafascial NS-0C versus NS-C (45.0% vs 28.4%; p =0.039). However, no difference in sexual function or potency was observed at 12 mo. In adjusted analyses, NS-0C versus NS-C was associated with improved 5-mo sexual function (parameter estimate: 10.90; standard error: 2.16; p <0.001) and potency (odds ratio: 1.69; 95% confidence interval, 1.01–2.83; p =0.046). NS-0C versus NS-WC was associated with shorter operative times (p =0.001) and higher EBL (p =0.001); however, there were no significant differences in PSM. Limitations include the retrospective, single-surgeon study design and smaller numbers for 12-mo comparison. Conclusions: Reliance on countertraction to facilitate dissecting NVB away from the prostate leads to neuropraxia and delayed recovery of sexual function and potency. Subtle technical modification to dissect the prostate away from the NVB without countertraction enables earlier return of sexual function and potency. [Copyright &y& Elsevier]

Objective: To evaluate contemporary national practice pattern trends in the use of thermal ablation (radiofrequency ablation and cryoablation) in the management of stage I renal cell carcinoma (RCC), and the factors that lead to using thermal ablation (TA) vs partial (PN) or radical nephrectomy (RN) in the United States. Methods: Within the Surveillance, Epidemiology and End Results (SEER) database, we identified subjects with T1-N0M0 RCC treated with either PN, RN, or TA between 2004 and 2007. Proportions, trends, and multivariable logistic regression models tested the predictors of the use of TA. Results: In total, 15,145 patients underwent a procedure for an RCC that was organ-confined and ≤7 cm. Of these, 578 underwent TA, 4402 underwent PN, and 10,165 underwent RN. On unadjusted analyses, patients who received TA were more likely to be older, single, have smaller tumor size, be diagnosed in more recent years, and have more unspecified histologic subtype and tumor grade. In multivariable adjusted analyses, single status (P = .02), male gender (P = .01), increasing age (P <.01), year of diagnosis (P <.01), and smaller tumor size (P <.01) were strong independent predictors of TA use compared with surgery (PN or RN). Further adjusted analyses showed no statistical difference in cancer-specific or overall survival between TA vs PN or RN. Conclusions: TA use for stage I RCC increased over a relatively short period and was performed more commonly in patients of older age and with smaller tumor size. Longer follow-up is needed to assess the comparative effectiveness of TA vs surgery. [ABSTRACT FROM AUTHOR]

Abstract: Background: Large prostate size, median lobes, and prior benign prostatic hyperplasia (BPH) surgery may pose technical challenges during robot-assisted laparoscopic prostatectomy (RALP). Objective: To describe technical modifications to overcome BPH sequelae and associated outcomes. Design, settings, and participants: A retrospective study of prospective data on 951 RALP procedures performed from September 2005 to November 2010 was conducted. Outcomes were analyzed by prostate weight, prior BPH surgical intervention (n =59), and median lobes >1cm (n =42). Surgical procedure: RALP. Measurements: Estimated blood loss (EBL), blood transfusions, operative time, positive surgical margin (PSM), and urinary and sexual function were measured. Results and limitations: In unadjusted analysis, men with larger prostates and median lobes experienced higher EBL (213.5 vs 176.5ml; p <0.001 and 236.4 vs 193.3ml; p =0.002), and larger prostates were associated with more transfusions (4 vs 1; p =0.037). Operative times were longer for men with larger prostates (164.2 vs 149.1min; p =0.002), median lobes (185.8 vs 155.0min; p =0.004), and prior BPH surgical interventions (170.2 vs 155.4min; p =0.004). Men with prior BPH interventions experienced more prostate base PSM (5.1% vs 1.2%; p =0.018) but similar overall PSM. In adjusted analyses, the presence of median lobes increased both EBL (p =0.006) and operative times (p <0.001), while prior BPH interventions also prolonged operative times (p =0.014). However, prostate size did not affect EBL, PSM, or recovery of urinary or sexual function. Conclusions: Although BPH characteristics prolonged RALP procedure times and increased EBL, prostate size did not affect PSM or urinary and sexual function. [Copyright &y& Elsevier]

Introduction. Pharmacotherapies improve sexual function following treatments for localized prostate cancer; however, patterns of care remain unknown. Aim. To ascertain post-treatment utilization of pharmacotherapies for erectile dysfunction (ED) using a population-based approach. Methods. We identified 38,958 men who underwent definitive treatment for localized prostate cancer during 2003–2006 from the MarketScan Medstat data. Main Outcome Measures. We compared the use of ED pharmacotherapy at baseline (up to 3 months prior) and up to 30 months following radical prostatectomy (RP) or radiotherapy (RT) for localized prostate cancer by utilizing National Drug Classification codes for phosphodiesterase-5 inhibitors (PDE5I), intracavernosal injectable therapies (IT), urethral suppositories and vacuum erection devices (VED). In adjusted analyses, we controlled for the effect of age, comorbidity, type of treatment, health plan and use of adjuvant hormone therapy on the use of pharmacotherapies. Results. Men undergoing RP vs. RT were younger with less co-morbid conditions. Utilization of PDE5I was up to three times greater for men undergoing RP vs. RT, 25.6% vs. 8.8%, ( P < 0.0001) in the first post-treatment year, and usage of these agents was greatest for men undergoing minimally-invasive RP procedures. A higher percentage of men also used IT, suppositories and VED after RP vs. RT ( P < 0.001). However, more men in the RT group received adjuvant hormonal therapy (39.53% vs. 5.25% for RP, P < 0.01). In adjusted analyses, men undergoing RP vs. RT were more than two times likely (OR 2.1, 95% CI 1.98, 2.26) to use PDE5I post-treatment while men on adjuvant hormonal therapy were less likely to use PDE5I (OR 0.74, 95% CI 0.70–0.79, P < 0.0001). Conclusion. Men undergoing RP vs. RT, particularly minimally-invasive RP, are more likely to employ IT, suppositories, VED, and PDE5I pharmacotherapy post-treatment. Prasad MM, Prasad SM, Hevlone ND, Gu X, Weinberg AC, Lipsitz SR, Palapattu GS, and Hu JC. Utilization of pharmacotherapy for erectile dysfunction following treatment for prostate cancer. J Sex Med 2010;7:1062–1073. [ABSTRACT FROM AUTHOR]

Objectives Organised medicine mandates that professionalism be taught during specialty training. This study’s primary objective was to determine the relative importance that doctors in different specialties place on different attributes of a medical professional. Methods Attending staff and resident doctors in acute care (anaesthesia, emergency medicine, surgery) and longitudinal care (internal medicine, psychiatry) specialties at a large academic hospital completed an anonymous, web-based survey. The forced-choice format required respondents to narrow down 25 professional attributes to three. The main outcome measure was the number of doctors in the two specialty groups who chose one or more attributes in each of six underlying categories. Results Almost two-thirds of respondents in both groups chose Moral and Ethical attributes. Significantly more longitudinal than acute care doctors chose Relationships with Patients attributes (76% versus 58%) and Communication Skills attributes (28% versus 18%), whereas significantly more acute care doctors chose Clinical Competence attributes (44% versus 29%). Specialty group was more important in choice of professional attributes than gender or position as a resident or attending staff doctor. Conclusions Most respondents chose attributes that the literature and organised medicine define as core elements of medical professionalism. The differences between specialty groups suggest that attributes in the Relationships with Patients and Communication Skills categories be emphasised for trainees in acute care specialties, and attributes in the Clinical Competence category be emphasised for trainees in longitudinal care specialties. [ABSTRACT FROM AUTHOR]

Atrophy of cortical and subcortical gray matter is apparent in Huntington's disease (HD) before symptoms manifest. We hypothesized that the white matter (WM) connecting cortical and subcortical regions must also be affected early and that select clinical symptoms were related to systems degeneration. We used diffusion tensor magnetic resonance imaging (DTI) to examine the regional nature of WM abnormalities in early HD, including the preclinical period, and to determine whether regional changes correlated with clinical features. We studied individuals in early stages (HD), presymptomatic individuals known to carry the genetic mutation that causes HD (Pre-HD), and matched healthy controls. DTI indices of tissue integrity were obtained from several regions of interest, including the corpus callosum (CC), internal capsule (IC), and basal ganglia, were compared across groups by t tests, and were correlated to cognitive and clinical measures. WM alterations were found throughout the CC, in the anterior and posterior limbs of the IC, and in frontal subcortical WM in HD subjects, supporting the selective involvement of the pyramidal tracts in HD; a similar distribution of changes was seen in Pre-HD subjects, supporting presymptomatic alterations. There was a significant relationship between select DTI measures and cognitive performance. Alterations in diffusion indices were also seen in the striatum that were independent of atrophy. Our findings support that WM alterations occur very early in HD. The distribution of the changes suggests that these changes contribute to the disruption of pyramidal and extrapyramidal circuits and also support a role of compromised cortical circuitry in early cognitive and subtle motor impairment during the preclinical stages of HD. © 2006 Movement Disorder Society [ABSTRACT FROM AUTHOR]

OBJECTIVE: • To determine differences in surgical outcomes by surgical approach during a period of rapid adoption of minimally invasive surgical approaches in radical prostatectomy. PATIENTS AND METHODS: • We identified 19 542 men undergoing minimally invasive (MIRP), perineal (PRP), and retropubic (RRP) radical prostatectomy from 2003 to 2006 from the MarketScan® Medstat database, a national employerbased administrative database. • We assessed for temporal trends in perioperative complications, use of postoperative cystography and anastomotic strictures by surgical approach. RESULTS: • Between 2003 and 2006, MIRP use increased 33.6% vs 31.8% and 1.7% decreases in RRP and PRP, respectively. During the 4-year study, median length of stay for MIRP decreased from 2.0 to 1.0 day ( P = 0.004) and overall perioperative complications decreased from 13.8 to 10.7%, ( P = 0.023). • These findings were driven by reductions in genitourinary complications (3.3 to 2.5%, P = 0.049), miscellaneous surgical complications (3.6 to 2.3%, P = 0.006) and intestinal injury (1.5 to 0.1%, P = 0.009). • Median length of stay for RRP decreased from 3.2 to 2.9 days, ( P < 0.001), overall perioperative complications decreased from 18.1 to 14.6%, ( P = 0.007), because of reductions in both wound/bleeding complications (2.0 to 1.1%, P = 0.002) and heterologous blood transfusions. • Men undergoing MIRP vs RRP were less likely to have perioperative complications (12.5 vs 17.1%, P < 0.001), blood transfusions (1.5 vs 8.9%, P < 0.001) and anastomotic strictures (6.3 vs 12.8%, P < 0.001), and they had shorter mean lengths of stay (1.8 vs 3.1 days, P < 0.001) during the study period. CONCLUSION: • The increased use of MIRP corresponds with a decreasing trend for complications, blood transfusions, lengths of stay and need for reoperation. Additionally, MIRP was found to have fewer associated complications compared with men undergoing open procedures. Further study is needed to assess the impact of tumour characteristics and surgeon volume on these perioperative outcomes as well as effects on long-term cancer control. [ABSTRACT FROM AUTHOR]

The article discusses a study about the patterns of care associated with the diagnosis of chronic lymphocytic leukemia (CLL). It describes CLL as a disease among older people in which its identification and diagnosis tend to be incidental and presumptive, respectively. Results show that women as well as urban residents are expected to experience a delay in diagnosis. It adds that no evidence has been obtained regarding the relationship between diagnostic delay and survival in CLL patients.

The article discusses the study of abnormality detection in the preoperative electrocardiograms for older patients who were susceptible to heart risk in the U.S. An assessment of several risk factors found through electrocardiogram were studied including the patients' age, gender, and surgical type. It notes that patients who are ages 65 years and above and patients with a heart disease history have the higher risk of electrocardiogram abnormality. It concludes that age remains to be a determining factor of preoperative electrocardiogram abnormalities.

Background: Transient receptor potential vanilloid 1 channels integrate nociceptive stimuli and are predominantly expressed by unmyelinated C-fiber nociceptors, but not low-threshold mechanoreceptive sensory or motor fibers. A recent report showed that the transient receptor potential vanilloid 1 channel agonist capsaicin allows a hydrophilic quaternary ammonium derivative of lidocaine, QX-314, to selectively block C fibers without motor block. The authors tested whether a similar differential block would be produced using amphipathic N-methyl amitriptyline, amitriptyline, bupivacaine, or lidocaine, either alone or together with 0.05% capsaicin, in a rat sciatic nerve block model.Methods: Rats (n = 8/group) were anesthetized with sevoflurane, and 0.2 ml of drug was injected either alone or with capsaicin (simultaneously or 10 min later) next to the sciatic nerve in the sciatic notch. Motor function was assessed by the extensor postural thrust. Nociception was evaluated by the nocifensive withdrawal reflex and vocalization evoked by pinch of a skin fold over the lateral metatarsus (cutaneous pain) with a serrated forceps.Results: N-Methyl amitriptyline, amitriptyline, bupivacaine, or lidocaine, followed by injection of capsaicin 10 min later, each elicited a predominantly nociceptive-specific blockade. In comparison, simultaneous application of each local anesthetic with capsaicin did not elicit a clinically significant differential block, with the exception of N-methyl amitriptyline.Conclusions: Both tertiary amine local anesthetics and their quaternary ammonium derivatives can elicit a predominantly sensory/nociceptor selective block when followed by injection of capsaicin. The combined application of transient receptor potential vanilloid 1 channel agonists and various local anesthetics or their quaternary ammonium derivatives is an appealing strategy to achieve a long-lasting differential block in regional analgesia. [ABSTRACT FROM AUTHOR]

Humans exhibit significant interindividual variability in behavioral reaction time (RT) performance yet the underlying neural mechanisms for this variability remain largely unknown. It has been proposed that interindividual variability in RT performance may be due to differences in white matter (WM) physiological properties, although such a relationship has never been demonstrated in cortical projection or association pathways in healthy young adults. Using diffusion tensor MRI (DTI), we sought to test whether diffusion tensor fractional anisotropy (FA), a measure of the orientational coherence of water self-diffusion, is regionally cor- related with RT on a visual self-paced choice RT (CRT) task. CRT was found to be significantly correlated with FA in projection and association pathways supporting visuospatial attention including the right optic radiation, right posterior thalamus, and right medial precuneus WM. Significant correlations were also observed in left superior temporal sulcus WM and the left parietal operculum. The lateralization of the CRT-FA correlation to right visual and parietal WM pathways is consistent with the specialization of right visual and parietal cortices for visuospatial attention. The localization of the CRT-FA correlations to predominately visual and parietal WM pathways, but not to motor pathways or the corpus callosum indicates that individual differences in visual CRT performance are associated with variations in the WM underlying the visuospatial attention network as opposed to pathways supporting motor movement or interhemispheric transmission. [ABSTRACT FROM AUTHOR]