Search

The American College of Surgeons Oncology Group Z0011 (ACOSOG Z0011) trial demonstrated no survival advantage for women with clinical T1-T2 invasive breast cancer with 1-2 positive sentinel lymph nodes (SLN) who received whole-breast radiation, and no further axillary surgery when compared to women who did undergo axillary lymph node dissection (ALND). We used the National Cancer Database (NCDB) to study changes in utilization of ALND after the publication of this trial. NCDB was queried for female patients from 2012 to 2015 who met Z0011 criteria. Patients were divided into four groups based on Commission on Cancer facility accreditation. Outcome measures include the rate of ALND (nonadherence to Z0011) and the average number of nodes retrieved with ALND. 27,635 patients were identified, with no significant differences in T stage and receptor profiles between groups. Overall rate of ALND decreased from 34.0% in 2012 to 22.7% in 2015. Nonadherence was lowest in Academic Programs (decreasing from 30.1% in 2012 to 20.5% in 2015) and was highest in Community Cancer Programs (41.2% in 2012 to 29.1% in 2015). Median number of positive SLN did not differ between groups (p = .563). Median number of nodes retrieved on ALND decreased from 9 (IQR 5-14) in 2012 to 7 (IQR 4-12) in 2015 (p < .001). In patients who met the ACOSOG Z11 trial guidelines, rates of ALND have decreased over time. However, rates of nonadherence to Z0011 are significantly higher in Community Cancer Programs compared to Academic Programs. more...

Background Although ejections from motor vehicles are considered a marker of a significant mechanism and a predictor of severe injuries and mortality, scant recent data exist to validate these outcomes. This study investigates whether ejections increase the mortality risk following a motor vehicle crash using data that reflect the introduction of new vehicles to the streets of a large city in the United States. Methods The Trauma and Emergency Medicine Information System of Los Angeles County was queried for patients ≥ 16 years old admitted following a motor vehicle crash between 2002 and 2012. Ejected patients were compared to nonejected. Primary outcome was mortality. A logistic regression model was used to identify predictors of mortality and severe trauma. Results A total of 9,742 (6.8%) met inclusion criteria. Of these, 449 (4.6%) were ejected; 368 (82.0%) were passengers and 81 (18.0%) were drivers. The rate of ejection decreased linearly (6.1% in 2002 to 3.4% in 2012). Compared to nonejected patients, ejected patients were more likely to require intensive care unit admission (43.7% vs 22.1%, P 25) (24.2% vs 7.3%, P 25) with adjusted odds ratio of 2.48 (P, Highlights • The rate of ejection during a motor vehicle crash has decreased since 2002. • Ejected patients had a significantly higher mortality compared to nonejected. • Ejection was a predictor of both critical injuries and mortality. more...

Current guidelines support cancer-directed surgery, chemotherapy, or active surveillance for clinical stages 1 to 3 of epithelial malignant pleural mesothelioma (MPM). Definitive chemotherapy is recommended for sarcomatoid/biphasic histologies. Our objective is to assess compliance with recommendations, measuring their impact on overall survival.The National Cancer Database participant user file (2004 to 2014) was queried for patients diagnosed with MPM clinical stages 1 to 3. Multivariable logistic regression model identified factors independently associated with guideline compliance. Kaplan-Meier analysis and Cox proportional hazards were used for overall survival comparison with histologic subgroup analysis.A total of 3419 patients with clinical stages 1 to 3 met criteria for analysis and comprised epithelial (68.5%), sarcomatoid (17.2%), and biphasic subtypes (14.3%). Cancer-directed surgery was significantly underutilized in epithelial MPM, with 29.3% having no treatment. On multivariable analysis, insurance status and facility type were the strongest predictors of guideline compliance. High-volume hospitals were the most compliant with guidelines (odds ratio 3.58, 95% confidence interval (CI), 2.34 to 5.49, P.001). Median survival estimates for no treatment, chemotherapy alone, surgery plus chemotherapy, and trimodal therapy were 10.2, 15.4, 21.1, and 21.7 months, respectively (log rank P.001). In epithelial MPM, a significant increase in overall survival was observed in surgery plus chemotherapy (hazard ratio 0.62, 95% CI, 0.53 to 0.73, P.001) and trimodality (hazard ratio 0.61, 95% CI, 0.49 to 0.76, P.001; reference: no treatment).There is a suboptimal compliance with national guidelines for the treatment of MPM, particularly in low-volume nonacademic settings. Adherence to recommended surgery-based multimodal therapy is associated with an overall survival improvement. more...

ObjectiveThe aim of this study was to understand variation in intraoperative and postoperative utilization for common general surgery procedures.Summary background dataReducing surgical costs is paramount to the viability of hospitals.MethodsRetrospective analysis of electronic health record data for 7762 operations from 2 health systems. Adult patients undergoing laparoscopic cholecystectomy, appendectomy, and inguinal/femoral hernia repair between November 1, 2013 and November 30, 2017 were reviewed for 3 utilization measures: intraoperative disposable supply costs, procedure time, and postoperative length of stay (LOS). Crossed hierarchical regression models were fit to understand case-mixed adjusted variation in utilization across surgeons and locations and to rank surgeons.ResultsThe number of surgeons performing each type of operation ranged from 20 to 63. The variation explained by surgeons ranged from 8.9% to 38.2% for supply costs, from 15.1% to 54.6% for procedure time, and from 1.3% to 7.0% for postoperative LOS. The variation explained by location ranged from 12.1% to 26.3% for supply costs, from 0.2% to 2.5% for procedure time, and from 0.0% to 31.8% for postoperative LOS. There was a positive correlation (ρ = 0.49, P = 0.03) between surgeons' higher supply costs and longer procedure times for hernia repair, but there was no correlation between other utilization measures for hernia repair and no correlation between any of the utilization measures for laparoscopic appendectomy or cholecystectomy.ConclusionsSurgeons are significant drivers of variation in surgical supply costs and procedure time, but much less so for postoperative LOS. Intraoperative and postoperative utilization profiles can be generated for individual surgeons and may be an important tool for reducing surgical costs. more...

Background Firearm violence results in the death of thousands of children in the US annually. The effects of firearm legislation on gun violence are published but widely contested. Materials and Methods The Kid's Inpatient Database from 2000 to 2009 were queried to capture hospitalizations of children diagnosed with a firearm-related injury. Cases were categorized into five levels of firearm legislation strictness by Brady State Scorecard. Trends of injuries were explored in terms of legislative strength, age, and race. Results 27,566 children analyzed in the study. Most were adolescents aged 15–19 (87.3%), male (89.7%), and black (53.7%). The proportion of accidental injuries increased relative to state law leniency (R2 = 0.90), with highest percentage in lenient states (33.2%) compared to strict (16.7%). The proportion of suicide attempts were higher in states with lenient laws (4.4%) compared to strict (1.3%). Accidents were inversely related to age (59.3% in ages 0–4 compared to 22.0% in adolescents), while assaults were positively related to age (31.6% in ages 0–4 compared to 66.6% in adolescents). Whites were most likely to present with accidental injuries (44.6%), and Blacks and Hispanics with assaults (68.2% and 75.6%). Race (p = 0.009), age (p Conclusions Firearm-related injuries types in hospitalized children are associated with age, race, and state level legislation. Accidents are most prevalent in young children, Whites, and states with lenient gun laws, while suicide attempts are more common in adolescents, Whites, and states with lenient gun laws. Suicide attempts are also associated with the greatest odds of in-hospital mortality. To address firearm violence, consideration should be given to legislation that promote safe gun storage behaviors and restrict firearm accessibility to children. more...

This study surveys surgeons’ cost knowledge and ability to distinguish subtle price variations between surgical tools with similar functions or indications.

Author(s): Alban, Rodrigo F; Anania, Emily C; Cohen, Tara N; Fabri, Peter J; Gewertz, Bruce L; Jain, Monica; Jopling, Jeffrey K; Maggio, Paul M; Sanchez, Juan A; Sax, Harry C

Our objective was to determine how surgical approach impacts overall survival and postoperative outcomes when comparing robotic-assisted minimally invasive esophagectomy (RAMIE), minimally invasive esophagectomy (MIE), and open esophagectomy (OE).The National Cancer Database was queried for patients diagnosed with pathologic Stage 0 to III esophageal cancer from 2010 to 2015. Primary outcome measures evaluated were length of stay, 30-day unplanned readmissions, mortality rates at 30 and 90 days, and overall survival rates. The surgical cohorts underwent 1:1 propensity score matching, and Kaplan-Meier survival estimates were compared by surgical approach. Cox proportional hazards regression was utilized to estimate factors associated with overall survival.Of 5,553 patients that met criteria, 28.4% were MIE, 7.8% RAMIE, and 63.8% OE. From 2010 to 2015, an increasing trend was seen for both minimally invasive approaches, with MIE surpassing the number of OEs. Unplanned 30-day readmissions and 30-day and 90-day mortality rates were not significantly different between the different groups. Median length of stay was significantly shorter in MIE (9 [interquartile range (IQR), 8 to 14] days) and RAMIE (9 [IQR, 7 to 14] days), compared with OE (10 [IQR, 8 to 15] days; p0.001). MIE and RAMIE had comparable survival rates compared with OE, with no significant differences in median overall survival estimates after propensity score matching (log-rank p = 0.603), with a trend for increased survival in MIE (adjusted hazard ratio, 0.97; 95% confidence interval, 0.89 to 1.06; p = 0.530) and RAMIE (hazard ratio, 0.81; 95% confidence interval, 0.69 to 0.95; p = 0.012). Both minimally invasive approaches had a significantly higher median lymph node counts (MIE: 15 [IQR, 9 to 22]; RAMIE: 17 [IQR, 11 to 24]; OE: 13 [IQR, 8 to 20]), which may highlight important differences in postoperative upstaging.Trends in MIE use is surpassing the open approach. Minimally invasive approaches are becoming the preferred approach, with noninferior long-term results compared with OEs. A significantly higher lymph node yield was seen for RAMIE and MIE. more...

This cohort study assesses utilization patterns of continuous renal replacement therapy and attempts to establish evidence-based guidelines to standardize the process flow and to promote meaningful use. more...

Failure to rescue (FTR), defined as death after a major complication, is a metric increasingly being used to assess quality of care. Risk factors associated with FTR after esophagectomy have not been previously studied.The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent esophagectomy with gastric conduit between 2010 and 2014. Patients with at least one major postoperative complication were grouped according to inhospital mortality (FTR group) and survival to discharge (SUR group). A stepwise logistic regression model was used to identify predictors of FTR.A total of 1,730 patients comprised the study group, with 102 (5.9%) in the FTR group and 1,628 (94.1%) in the SUR group. The FTR patients were older (69.0 versus 64.0 years, p0.0001) compared with the SUR patients. There were no differences in sex, body mass index, preoperative weight loss, smoking status, operation type, or surgeon specialty between the two groups. Age greater than 75 years (adjusted odds ratio 2.68, p0.0001), black race (adjusted odds ratio 2.75, p = 0.001), American Society of Anesthesiologists class 4 or 5 (adjusted odds ratio 1.82, p = 0.02), and the occurrence of pneumonia, respiratory failure, acute renal failure, sepsis, or acute myocardial infarction were predictive of FTR based on multivariable logistic regression.Nearly 6% of patients who have a major complication after esophagectomy do not survive to discharge. Age greater than 75 years, black race, American Society of Anesthesiologists class 4 or 5, and complications related to major infection or organ failure predict FTR. Further research is necessary to investigate how these factors affect survival after complications in order to improve rescue efforts. more...

BACKGROUND Organ availability is a consistently limiting factor in transplant surgery. A primary driver of this limitation is donor conversion rate, which is defined as the percentage of eligible donors for whom procurement is actually performed. An alternative way to increase organ availability is through improved utilization of organs from donors after cardiac death (DCD). Recently, a concerted, multidisciplinary effort has been made within our system to improve conversion rates and DCD utilization, thus increasing organ availability. STUDY DESIGN Retrospective analysis of a prospectively collected database from TransLife, our local organ procurement organization (OPO), as well as the Orlando Regional Medical Center (ORMC) trauma registry, from 2009-2012 (up to 2013 for DCD). During which time, this organization implemented best practice guidelines to improve conversions and DCD utilization. We analyzed yearly conversion rates, DCD donations and population demographics before and after implementation of these policies. RESULTS During the study period, donor conversion rates significantly improved from 58% in 2009 to 82% percent in 2012 hospital-wide (P more...

Activin A, a homodimeric protein (βAβA) and a member of the TGF-β superfamily, is involved in the inflammatory repair process. Using cDNA microarray analysis, we discovered strong induction of the activin βA gene in human mast cells (MC) on stimulation with PMA and calcium ionophore (A23187). Activin βA mRNA was also highly induced in primary cultured murine bone marrow MC (BMMC) after stimulation by IgE receptor cross-linking. Secretion of activin A was evident in human mast cell-1 line cells 3 h after stimulation and progressively increased over time. Activin A was present in the cytoplasm of activated but not unstimulated murine bone marrow MC as demonstrated by immunofluorescence studies, suggesting that secretion of activin A by MC was due to de novo synthesis rather than secretion of preformed protein. Activin A also colocalized with human lung MC from patients with asthma by double-immunofluorescence staining. Furthermore, secretion of activin A was significantly increased in the airway of wild-type mice after OVA sensitization followed by intranasal challenge. Secretion of activin A, however, was greatly reduced in MC-deficient WBB6F1-W/Wv mice as compared with wild-type mice, indicating that MC are an important contributor of activin A in the airways of a murine asthma model. Additionally, activin A promoted the proliferation of human airway smooth muscle cells. Taken together, these data suggest that MC-derived activin A may play an important role in the process of airway remodeling by promoting the proliferation of airway smooth muscle. more...