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After a stroke, poorly controlled blood pressure (BP) is associated with a higher risk of recurrent vascular events. Despite the importance of controlling BP to avert recurrent vascular events, fewer than half of stroke survivors in the United States achieve BP control. It is unclear to what extent insurance status affects BP levels after stroke. We assessed BP control among adults with a history of stroke who participated in the National Health and Nutrition Examination Surveys from 1999 through 2016. The relationship between insurance type and BP level (low normal: <120/80 mmHg and normal: <140/90 mmHg) were evaluated using logistic regression before and after adjusting for sociodemographic characteristics and medical comorbidities for those <65 years and ≥ 65 years. Among 1646 adult stroke survivors (weighted n = 5,586,417), 30% had BP in the low normal range while 64% had BP in the normal range. Among 613 stroke survivors <65 years (weighted n = 2,396,980), only those with other government insurance (CHAMPVA, CHAMPUS/TRICARE) had better BP control than the uninsured (adjusted HR 2.68, 95% CI 0.99–7.25). Among 1033 participants ≥65 years (weighted n = 3,189,437), those with private insurance plus Medicare trended toward better normal BP compared to Medicare alone (adjusted HR 1.34, 95% CI 0.94–1.90). Only stroke survivors with CHAMPVA, CHAMPUS/TRICARE government insurance in the United States have lower odds of controlled BP compared to no insurance among those <65 years. Insurance alone does not improve BP control among stroke survivors. • Blood pressure control is imperative among stroke survivors but data on insurance status is lacking. • Stroke survivors <65 years who had other government insurance (CHAMPVA, TRICARE) more often had BP control than the uninsured. • Insurance alone is not sufficient to achieve BP control. [ABSTRACT FROM AUTHOR]

The incidence of pancreatic cancer has increased threefold over the last 40 years with the greatest rate of growth occurring in the elderly. In the past it was suggested that elderly patients tolerated pancreaticoduodenectomy less well than younger patients with higher mortality rates. This single-institution experience examines the question of whether age is a significant factor in relation to morbidity and mortality in patients undergoing pancreaticoduodenectomy. Between 1994 and 1999 outcomes of 122 patients who underwent pancreaticoduodenectomy were reviewed. There were 48 patients 70 years of age and older and 74 patients less than 70 years of age. Both groups were compared with respect to preoperative clinical prognostic determinates and perioperative factors affecting morbidity and mortality. There was no significant difference between the two groups comparing their comorbidities, use of preoperative antibiotics, intraoperative blood loss, or length of hospital stay (11.9 and 10.8 days respectively). The two groups were also similar with regard to pathologic diagnosis with pancreatic adenocarcinoma being the most frequently encountered neoplasm. There was one death in the less-than-70-year-old group and none in the older group. No significant difference in the rate of complications was appreciated. These data demonstrate that pancreaticoduodenectomy can be performed safely in patients 70 years of age and older with morbidity and mortality rates similar to those of younger individuals. [ABSTRACT FROM AUTHOR]

Background: Patients with stroke in the United States can be transferred for higher level of care. Little is known about possible inequities in interhospital transfers (IHTs) for acute ischemic stroke. We hypothesized that historically marginalized populations would have lower odds of IHT., Methods: A cross-sectional analysis was done for adults with a primary diagnosis of acute ischemic stroke in 2010 to 2017; n=747 982 were identified in the National Inpatient Sample. Yearly rates for IHT were assessed and adjusted odds ratios (aORs) of IHT in 2014 to 2017 were compared with that of 2010 to 2013. Multinomial logistic regression was used to determine the aOR of IHT, adjusting for sociodemographic variables (model 1), sociodemographic and medical variables such as comorbidity and mortality risk (model 2), and sociodemographic, medical, and hospital variables (model 3)., Results: After adjusting for sociodemographic, medical, and hospital characteristics, there were no significant temporal differences in IHT from 2010 to 2017. Overall, women were less likely than men to be transferred in all models (model 3: aOR, 0.89 [0.86-0.92]). Compared with those who were White, individuals who were Black (aOR, 0.93 [0.88-0.99]), Hispanic (aOR, 0.90 [0.83-0.97]), other (aOR, 0.90 [0.82-0.99]), or of unknown race, ethnicity (aOR, 0.89 [0.80-1.00]) were less likely to be transferred (model 2), but these differences dissipated when further adjusting for hospital-level characteristics (model 3). Compared with those with private insurance, those with Medicaid (aOR, 0.86 [0.80-0.91]), self-pay (aOR, 0.64 [0.59-0.70]), and no charge (aOR, 0.64 [0.46-0.88]) were less likely to be transferred (model 3). Individuals with lower income were less likely to be transferred compared with those with higher income (model 3: aOR, 0.85 [0.80-0.90], third versus fourth quartile)., Conclusions: Adjusted odds of IHT for acute ischemic stroke remained stable from 2010 to 2017. There are numerous inequities in the rates of IHT by race, ethnicity, sex, insurance, and income. Further studies are needed to understand these inequities and develop policies and interventions to mitigate them.

Background: Blood pressure variability (BPV) has emerged as a significant factor associated with clinical outcomes after intracerebral hemorrhage (ICH). Although hematoma expansion (HE) is associated with clinical outcomes, the relationship between BPV that encompasses prehospital data and HE is unknown. We hypothesized that BPV was positively associated with HE., Methods: We analyzed 268 patients with primary ICH enrolled in the National Institutes of Health-funded Field Administration of Stroke Therapy-Magnesium (FAST-MAG) study who received head computed tomography or magnetic resonance imaging on arrival to the emergency department (ED) and repeat imaging within 6-48 h. BPV was calculated by standard deviation (SD) and coefficient of variation (CV) from prehospital data as well as systolic blood pressure (SBP) measurements taken on ED arrival, 15 min post antihypertensive infusion start, 1 h post maintenance infusion start, and 4 h after ED arrival. HE was defined by hematoma volume expansion increase > 6 mL or by 33%. Univariate logistic regression was used for presence of HE in quintiles of SD and CV of SBP for demographics and clinical characteristics., Results: Of the 268 patients analyzed from the FAST-MAG study, 116 (43%) had HE. Proportions of patients with HE were not statistically significant in the higher quintiles of the SD and CV of SBP for either the hyperacute or the acute period. Presence of HE was significantly more common in patients on anticoagulation., Conclusions: Higher BPV was not found to be associated with occurrence of HE in the hyperacute or the acute period of spontaneous ICH. Further study is needed to determine the relationship., (© 2022. Springer Science+Business Media, LLC, part of Springer Nature and Neurocritical Care Society.)

Objective: Robot-assisted lobectomy is the fastest growing technique for pulmonary lobectomy, but the diversity of approaches has led to apprehension about port placement among learning surgeons. The aim of this study was to survey high-volume thoracic surgeons who perform robot-assisted lobectomy to understand and consolidate common themes of port placement., Methods: An electronic online survey was created, and the link was emailed to the 100 highest volume robotic thoracic surgeons in the United States. The survey included an interactive graphical interface, which allowed each respondent to mark the preferential robotic port placement in the chest wall for each of the 5 pulmonary lobectomies. Results were analyzed individually and in aggregate. A heat map was generated to show trends., Results: One hundred surgeons were surveyed (response rate: 62%). Most (90%) respondents utilized a 4-arm approach and 79% used a completely 4-arm portal approach with CO 2 insufflation. Exact locations for each robotic port were reported by 60% of the surveyed surgeons and the results varied; however, most surgeons generally used the seventh to ninth interspaces for the camera and instruments. The use of multiple different interspace levels was common. Ninety-four percent of respondents used an additional nonrobotic assistant port., Conclusions: There is not a universal port strategy for robot-assisted lobectomy. However, placement of the camera and robotic ports low in the seventh to ninth interspaces is the most common approach. There are some nuances of stapling port strategies and sequence of port placement, which are identified.

Objective: The postoperative handover is often compromised by reporting inconsistencies between different specialties. We describe a multidisciplinary quality improvement initiative to improve postoperative information reporting., Design: A quality improvement project with interrupted time-series data collection was undertaken in the postanesthesia care unit between January 2015 and August 2015. We utilized Six Sigma methodology to engage multispecialty stakeholders in identifying deficiencies in the existing postoperative handover process in January 2015. A standardized handover process including a checklist and electronic handover note was implemented within a postanesthesia care unit in June 2015. Direct observations of handovers were conducted to determine reporting accuracy, handover duration, and specialty representative attendance. Segmented linear and logistic regression analyses were used for interrupted time-series data., Setting: Single postanesthesia care unit at an academic tertiary referral center., Participants: Physician trainees in anesthesia (n = 82) and surgical subspecialties (n = 139), certified registered nurse anesthetists (n = 57), and recovery room registered nurses (n = 139)., Results: Cumulative handover scores increased by 18.3 points in the postimplementation period (n = 70) when compared to preimplementation handovers (n = 69), a finding which remained statistically significant after adjusting for preintervention time trends (difference 16 points; 95% confidence intervals 3-31; p = 0.021). No statistically significant difference in handover duration was seen between cohorts (6.8 minutes vs 6.1 minutes, difference 0.5 minutes; 95% confidence intervals -2.8 to 3.7; p = 0.78). Three years postimplementation, there was consistent use of a modified electronic handover note and surgical subspecialty attendance during handover., Conclusions: A standardized handover process was associated with improved information reporting among different surgical disciplines without significantly lengthening handover duration., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)