Decision For Surgical Intervention Research Articles

Emotional Reactivity and Regulation Relate to Surgical Treatment Decision Making Among Newly Diagnosed Women With Breast Cancer.

Despite bilateral mastectomy (BLM) for early-stage breast cancer (BC) showing no survival benefit and increased risk compared to breast conserving surgery, some patients still choose this treatment. This study examined whether emotion reactivity and regulation influence treatment decision making among newly diagnosed women with breast cancer. Cross-sectional survey data were analyzed as part of a larger study. Measures included the Contralateral Prophylactic Mastectomy (CPM) survey, PROMIS Anxiety scale, and Emotion Regulation Questionnaire (ERQ) Cognitive Reappraisal and Emotional Suppression subscales. Primary analysis included a logistic regression model predicting treatment choice (BLM vs. non-BLM). Participants (N = 137) with unilateral BC (Stages 0-III) were divided between BLM (n = 66) versus breast conserving surgery (i.e., non-BLM, n = 71) treatment groups. Compared to the non-BLM group, the BLM group was younger, more likely to be partnered, and had a higher household income. Women with high levels of BC-specific worry were 3.6 times more likely to choose BLM compared to women with low levels of worry (OR = 3.09, 95% CI: 1.07-0.8.93). Those who used cognitive reappraisal were 10% less likely to choose BLM compared to women who did not use cognitive reappraisal (OR = 0.90, 95% CI: 0.82-0.99). There were no group differences in levels of generalized anxiety (OR = 0.93, 95% CI: 0.87-0.99) or emotional suppression (OR = 1.02, 95% CI: 0.90-1.16). Findings suggest the choice of BLM may be due, in part, to negative emotional experiences after a BC diagnosis and lesser use of reappraisal to reframe cancer-related fears. These may be important targets of intervention to support women making BC treatment decisions.

Associations of the Need for Surgery in Emergency Department Patients with Small Bowel Obstructions

Objectives: Management strategies for small bowel obstruction (SBO) vary from conservative approaches to surgical intervention. A known complication of surgery is the subsequent adhesions that can cause recurrent SBOs, longer hospital stays, and higher treatment costs. Our primary outcome was to identify independent risk factors that are associated with the decision for surgical intervention, and our secondary outcome was to describe characteristics of visits associated with complications. Methods: This study was a single-center, retrospective chart review from a large, urban university hospital. We included adult patients admitted to the emergency department (ED) with the International Classification of Diseases, 10th Rev, codes for small bowel obstruction from June 1, 2017– May 30, 2019. Eligible covariates were demographics, radiological findings, clinical presentation, past medical history, and results of radiologic testing. We identified univariate associations of outcome and then performed a multivariate logistic regression to identify independent associations of each outcome. Finally, a backwards selection was used to determine the final model. We calculated odds ratios (OR) and 95%confidence intervals (CI) along with the area under the curve (AUC), as appropriate. Results: A total of 530 patients met the study criteria; 148 (27.9%) underwent surgery of whom 35 (6.6%) had complications. We identified seven independent associations for the decision of surgery: abdominal distension (OR 0.27, 95% CI 0.10–0.62); gastrografin (OR 0.41, 95% CI 0.20–0.81); previous SBO (OR 0.42, 95% CI 0.26–0.66); higher Charlson Comorbidity Index score (OR 0.87, 95% CI 0.80–0.95); nasogastric decompression (OR 2.04, 95% CI 1.25–3.39), initial systolic blood pressure <100 mm Hg (OR 2.65, 95% CI 1.05–6.53); free fluid or volvulus/closed-loop obstruction on computed tomography (OR 7.95, 95% CI 4.25–15.39), with the AUC for the predictive model equaling 0.73. Conclusion: We identified seven independent associations present in the ED associated with the decision for surgery. These associations are a step toward building better prediction models and improving decision-making in the ED, allowing for a more adequate treatment plan.

Ensuring goal-aligned care in a busy surgical practice

The US population is aging. Accordingly, older adults with multiple comorbidities and geriatric syndromes will present in increasing numbers for surgical consultation. Incorporating patient goals into surgical treatment decisions is recommended by a joint guideline from the American Geriatrics Society and American College of Surgeons, the American Society of Colon and Rectal Surgeons, the Geriatric Surgery Verification program, and the Institute for Healthcare Improvement as part of building Age-Friendly Health Systems, however uptake has been slow. The aim of this review is to provide a framework for how patient goals can be elicited and used in real-world surgical practices to achieve goal-aligned care.

Pediatric limbal stem cell deficiency: An overview of a rarely studied pathology.

The cornea is the outermost transparent layer of the eye, and the continuous renewal of the corneal epithelium is important for its transparency. This process is primarily facilitated by corneal stem cells, most of which are found at the limbus. However, any deterioration or damage in this region leads to corneal conjunctivalization and consequent limbal stem cell deficiency (LSCD), which compromises corneal transparency. LSCD is an important condition, especially in the pediatric population, as it can lead to corneal vascularization, opacity and ultimately loss of vision and subsequent amblyopia, unlike adults. Although pediatric LSCD is often due to chemical injuries, as in adults, it is also caused by conditions such as congenital aniridia, Steven Johnson Syndrome and various other immunological disorders. Appropriate and timely treatment in pediatric LSCD is of particular importance in preventing progression to amblyopia, unlike adults. Accurate staging of the disease is essential for the necessary medical and surgical treatment decision. While medical approaches are at the forefront to eliminate the causative agent and improve the ocular surface in reversible cases, it is essential to replace the limbal stem cells lost in advanced disease. For these replacement procedures, it is noteworthy that there is a tendency for minimally invasive methods compared to adults to avoid possible complications due to long life expectancy in children. In conclusion, although there are various reviews on limbal stem cell deficiency (LSCD) in adults, we believe that this review for childhood LSCD will make an important contribution to the literature, since the relevant literature currently reported for the pediatric population is limited.

UNDERSTANDING THE MANAGEMENT OF MALIGNANT GLIOMAS DURING COVID-19 PANDEMIC IN A HIGH VOLUME TERTIARY GOVERNMENT HOSPITAL IN THE PHILIPPINES

Abstract AIMS Malignant glioma is a common primary brain tumor with a great burden of disease. When COVID-19 set in, it became a challenge to manage an already difficult treatment process in low-resource-setting centers. Despite this, conventional recommendations and standard treatment protocols are followed. However, outcomes were perceived to deviate from the convention, hence the reason for this study which is to understand the nature of outcomes in the management of malignant gliomas during the COVID-19 pandemic in Southern Philippines Medical Center (SPMC), the largest government tertiary hospital in the Philippines. METHOD A retrospective chart review of nine clinically and histologically diagnosed cases of malignant gliomas admitted in SPMC between April 2020 to September 2021 was performed. The clinical presentations, image correlation, and outcomes were listed. Then, classified as desirable, undesirable but acceptable, or unacceptable based on factors identified. Qualitative analysis by deduction including outcomes determining possible modifications in treatment of future cases was done. RESULTS Of the nine cases, one was listed as desirable, one with unacceptable outcome due to management complications, and the rest were labeled as undesirable but acceptable either because of advanced disease or poor KPS score. Three major factors were determined: the roles of pre-hospital and initial treatment delays, the decision for surgical treatment, and the COVID-19 pandemic. CONCLUSION The shift in the outcomes of malignant gliomas during COVID-19 shows the management challenge in low resource centers. There is an increase in highly malignant cases with guarded prognosis due to lack of education, support, and resources in terms of early diagnosis, treatment, and post-surgical care. This was aggravated by the restrictions imposed by the pandemic and financial crisis, especially for patients below the poverty line. Delays in management show a significant influence on prognosis regardless of treatment. As such, possible modifications in the current treatment algorithm are hereby recommended.

Utilizing computed tomography-based renal parenchymal volumes to calculate split renal function in patients with ureteral stricture disease.

Evaluation of split renal function (SRF) is critical for guiding surgical treatment decisions for patients with ureteral stricture disease (USD). We aimed to determine whether computed tomography (CT)-based renal parenchymal volumes may be used to predict SRF in patients with USD. We retrospectively reviewed all patients undergoing surgical management for USD at a single institution from October 2021 to January 2024. Patients who had preoperative nuclear medicine scan (NMS) and CT scan with intravenous contrast that were obtained within six weeks of each other were included. Interval between NMS and CT could be longer if the affected renal unit was drained with ureteral stent and/or percutaneous nephrostomy. Volume measurements were obtained using the 3D Region of Interest (ROI) Tool on Visage®7 Enterprise Imaging Platform (Visage Inc., San Diego, USA) by two investigators that were blinded to NMS derived SRF. Intraclass correlation coefficient (ICC) was used to assess consistency between investigators. Predictive accuracy was assessed using Pearson correlation coefficient (r) and linear regression. 40 of 160 patients met inclusion criteria. There was excellent reliability in calculating renal parenchymal volume between raters (ICC = 0.990). There was a strong linear correlation between estimated CT SRF and NMS SRF (r = 0.912, p < 0.00001). A linear regression model found RObservedSRF = -0.013 + 1.015(REstimatedSRF), with r2 = 0.832. CT-derived parenchymal volume analysis may be used to estimate SRF in patients with USD. This may obviate the need to obtain preoperative renal scans for SRF measurement in selected patients when assessing surgical management options.

Abstract B128: Underlying factors influencing kidney cancer surgical treatment disparities: Patients, non-patient community members and urologists’ perspectives

Abstract Background: Racial and ethnic minority patients often delay or forgo kidney cancer (KCa) surgical treatment and have an invasive surgical treatment. This study aimed to understand the underlying factors of KCa surgical treatment disparities through interviews with KCa patients and non-patients from racial and ethnic minority communities in Arizona and online surveys with urologists who practice in the U.S. Methods: We conducted phone interviews with KCa patients (n=13) and interviews at health events with community members without KCa (n=61). Online surveys were conducted with urologists (n=54). Results: Many interview participants had healthcare access issues with 22% reporting not having a primary care doctor and 12% reporting that there was a time when they could not see a doctor because of cost. Almost 50% reported that they had delayed care because they could not get an appointment soon enough. Among 10 patients who responded to a question about diagnosis delay, 4 answered that they waited over a year to see their doctor when they had health issues before their diagnosis. A quarter of community participants (25%) and about a third of patients (31%) reported that cultural values or religious beliefs influenced their choice of treatment. When community participants were asked what they knew about KCa symptoms and treatments, many did not provide relevant or correct information. Only 51% of non-patients reported that they trusted their doctor’s judgements about their medical care, but 92% of patients reported that they trusted their doctor’s judgement. About 30% of urologists reported that patients from racial and ethnic minority backgrounds often have healthcare access challenges, but only 9% responded that NHW patients often have challenges. They did not report that racial and ethnic differences in treatment exist. About 10% of urologists reported socioeconomic backgrounds of patients affect treatment decision and timeliness often or all the time. Only 46% reported that they refer patients to necessary services all the time, when patients express concerns of finance and healthcare access challenges. Many urologists strongly or slightly agreed that treatment decisions should be made by the treating clinicians (82%) and based on clinical information (87%). Many also strongly or slightly agreed that patients and their family members should contribute to decision-making (98%), while 46% strongly or slightly agreed that patients’ cultural and religious backgrounds often affect their treatment choices. In open-ended questions, urologists responded that work and family obligations, healthcare access, and health literacy rather than race and ethnicity are factors influencing treatment, while mistrust was identified as one of factors influencing treatment delay. Conclusions: Barriers to healthcare access, lack of knowledge, and mistrust before diagnosis may be underlying factors among patients, while urologists view healthcare access, social and economic factors, and mistrust influence KCa surgical treatment decision and delay. Citation Format: Ken Batai, Alex Cruz, Juan Adrover, Daphne Larose, D'Andre Gomez, Francine C. Gachupin, Jacquanette R. Slowtalker, Benjamin R. Lee, Juan Chipollini. Underlying factors influencing kidney cancer surgical treatment disparities: Patients, non-patient community members and urologists’ perspectives [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr B128.

Glenohumeral Joint Volume Measurement in Patients with Shoulder Instability: A 3D Volumetric Magnetic Resonance Arthrographic Study.

Background and Objectives: This study aimed to compare capsular volume in patients with shoulder instability to that in control subjects without instability using magnetic resonance (MR) arthrography. The objective was to develop a reliable screening method with which to assess shoulder volume. Materials and Methods: In 21 patients with atraumatic shoulder instability and 21 controls, thin-slice 3D volumetric MR arthrography sequences were obtained. MR arthrography images were uploaded to 3D reconstruction, and 3D images were generated. From the 3D reconstructed images, volumetric measurements of rotator interval (RI), anterior and posterior capsular (AC, PC) recesses, biceps tendon sheath (BS), axillary recess (AR), and total glenohumeral joint (TGJ) were performed. Individuals with any extra-articular contrast leakage were also recorded. Results: A retrospective study analyzed a patient group of 21 individuals with shoulder instability (mean age 29.52 ± 12.83 years) and a control group of 21 individuals without instability (mean age 35.71 ± 12.77 years). No statistically significant differences were identified between the groups with regard to age, gender, or side distribution. The mean total joint volume was significantly higher in the instability group (29.85 ± 6.40 cm3) compared to the control group (23.15 ± 3.48 cm3, p = 0.0001). Additionally, the mean volumes of the RI, AC, PC, BS, and AR were all significantly greater in the patient group compared to the control group. Conclusions: 3D volumetric MR arthrographic measurements of the shoulder joint capacity can provide valuable insights for clinical follow-up and guide surgical treatment decisions in cases of atraumatic shoulder instability.

Longitudinal health-related quality of life in people with thoracic aortic aneurysms.

Surgical intervention for thoracic aortic aneurysms is high risk. Understanding changes in health-related quality of life before and after endovascular stent grafting and open surgical repair can aid treatment decision-making. The Effective Treatments for Thoracic Aortic Aneurysms ('ETTAA') study (ISRCTN04044627) was a longitudinal, observational study. Adults with new/existing arch or descending thoracic aortic aneurysms greater than or equal to 4 cm in diameter were followed from 2014 to 2022. Five domains of health-related quality of life (Mobility, Self-Care, Usual Activities, Pain/Discomfort, and Anxiety/Depression) were recorded using the EuroQoL, five dimensions, five levels ('EQ-5D-5L') questionnaire and analysed using a range of longitudinal mixed models. Of 886 thoracic aortic aneurysm participants, 824 completed at least 2 questionnaires. Patients had slightly worse health-related quality of life than age-matched norms. Without surgery, deterioration occurred over time in Mobility (0.072/year (95% c.i. 0.042 to 0.101), P < 0.001) and Self-Care (0.039/year (95% c.i. 0.018 to 0.061), P < 0.001) in both sexes and Pain/Discomfort in women (0.069/year (95% c.i. 0.020 to 0.118), P = 0.005). For 6 weeks after endovascular stent grafting, there was a significant impairment in Self-Care (0.214 (95% c.i. 0.112 to 0.316), P < 0.001) and (for women only) in Usual Activities (0.625 (95% c.i. 0.338 to 0.911), P < 0.001), which then returned to pre-endovascular stent grafting levels. Six weeks after open surgical repair, the impairment in health-related quality of life was greater (Mobility 0.492 (95% c.i. 0.314 to 0.669), Self-Care 0.474 (95% c.i. 0.364 to 0.583), Usual Activities 1.469 (95% c.i. 1.042 to 1.896), and Pain/Discomfort 0.561 (95% c.i. 0.363 to 0.760), all P < 0.001) and took longer to return to pre-open surgical repair levels, partly due to increased complications and longer hospitalization. Anxiety/Depression decreased after open surgical repair (-0.214 (95% c.i. -0.326 to -0.101), P < 0.001). Age, sex, frailty, smoking, New York Heart Association class, and chronic obstructive pulmonary disease were significantly associated with health-related quality of life. Without intervention, health-related quality of life declines as age increases. Changes in health-related quality of life should contribute to surgical treatment decision-making.

Management of BRCA-associated breast cancer patients in low and middle-income countries: a review.

Breast cancer poses a significant global health challenge, with higher incidence rates in developed countries. However, low- and middle-income countries (LMICs) suffer from higher mortality rates due to various factors, including limited screening programs, delayed diagnosis and inadequate access to healthcare and advanced treatments. Approximately 5%-10% of breast cancer cases stem from germline mutations in BRCA-1/2 genes. A positive BRCA1/2 status obtained through genetic testing significantly influences surgical and medical treatment decisions. Therefore, genetic counseling, proper surveillance and customized interventions for BRCA1/2 carriers are essential to maximizing the benefits of monitoring, chemoprevention and risk-reducing surgeries for breast and ovarian cancers. Identification of BRCA mutations also impacts treatment strategies, leading to the integration of chemotherapeutic agents like platinum-based chemotherapy and PARP inhibitors. However, implementing these advanced treatment guidelines in LMICs with complex, fragmented and underfunded healthcare systems presents numerous challenges. In this review, we explore the current status and obstacles associated with managing BRCA1/2-associated breast cancer in LMICs.

Preoperative, Intraoperative and Post-Operative Optical Coherence Tomography for Pediatric Epiretinal Membranes Presenting with Strabismus

Abstract Purpose To highlight the value of optical coherence tomography (OCT) in the surgical decision making process of pediatric epiretinal membranes (ERMs). Methods A retrospective interventional case series that included the review of records of pediatric cases with ERMs presenting with strabismus who underwent pars plana vitrectomy by a single surgeon from March 2018 till June 2022. Demographic, clinical, and surgical details were extracted, as well as follow-up visits and outcomes. Results Five eyes of 5 cases with unilateral squint secondary to ERM were included. Age at presentation ranged from 2-7 years (mean 3.6 +/- 1.9), The male to female ration was 4:1. Two cases (40%) were idiopathic, 2 (40%) were secondary to familial exudative vitreoretinopathy (FEVR) and 1 (20%) was secondary to traumatic rupture globe. Preoperative and postoperative OCT was obtained in all cases, while preoperative fundus fluorescein angiography was obtained in 4 cases (80%). Intraoperative OCT was used in 4 cases (80%) to confirm complete release of the membrane from the fovea, and ILM was peeled in 3 cases (60%). The decision for surgical intervention and plan of surgery was totally dependent on preoperative OCT to confirm the extent of the ERM and the plane of cleavage. Intraoperative OCT helped assess areas of strong adherence of the membrane to avoid iatrogenic retinal injury. Initial restoration of the foveal anatomy with appearance of the fovea was seen after 3.6 +/- 2.8 months from the surgery with a range of 1-8 months. Squint improvement was seen in all cases. Time range to squint improvement was 1-4 months (mean 2.8 +/- 1.6). One case (20%) continued 4 years of follow up and two cases (40%) terminated follow up at 6 months due to squint improvement. Only one case (20%) showed progressive myopia post-surgery and one case did not achieve complete restoration of the fovea. Conclusion Surgical removal of pediatric epiretinal membranes presenting with strabismus leads to squint and visual improvement even if complete restoration of the foveal anatomy has not been reached yet. Combined use of preoperative, intraoperative and postoperative OCT in those cases helps better surgical and anatomical outcomes.

Successful implementation of handheld reflectance confocal microscopy as the standard of care in the (surgical) management of lentigo maligna (melanoma).

Reflectance confocal microscopy (RCM) has shown promise in predicting surgical outcomes by non-invasively detecting subclinical lentigo maligna (melanoma) (LM/LMM). To assess the effects of presurgical mapping using handheld RCM (HH-RCM) on surgical treatment, follow-up outcomes and management decisions. A total of 117 consecutive LM/LMM cases (2015-2023) were included. The diagnostic accuracy of HH-RCM in detecting subclinical LM and invasive components was evaluated. The primary endpoints included histological margin status and changes in management based on the outcomes of the HH-RCM mapping procedure. Margin and follow-up outcomes were compared to a historical cohort before HH-RCM was introduced in our center (n = 94) (2003-2014). HH-RCM detected subclinical LM in 60% (n = 60) of cases. The median mapping duration was 14 min (range 4-50). In 27% (n = 33), the mapping procedure resulted in modified management, the majority consisting of limited surgery with adjuvant imiquimod (n = 15) or imiquimod monotherapy (n = 14). The remaining cases (n = 84) underwent HH-RCM-assisted surgery. Histological margins were cleared in 96.5% of the patients with a median histological margin of 3.0 mm, significantly higher than 81% in the historical cohort (median 2.0 mm) (p = 0.001). The sensitivity and specificity for detecting the extent of subclinical LM were 94% (95% CI 80.4-99.3) and 84% (95% CI 70.3-92.7), respectively. The negative predictive value for the detection of LMM was 94% (95% CI 84.4-97.7), and 75% of the initially missed LMM (n = 12) were identified during the HH-RCM mapping procedure. The study cohort had a 1.6% local recurrence rate compared with 25% in the historical cohort. Integrating HH-RCM as the standard of care could lead to more personalized treatment strategies for LM/LMM and allows for the selection of patients suitable for nonsurgical treatment.

Abstract PO5-26-12: Optimizing Treatment Decisions in Microinvasive Ductal Carcinoma in Situ: Evaluating the Need for Surgical Axillary Staging

Abstract Background: Surgical axillary staging is often debated in patients with microinvasive ductal carcinoma in situ (T1mi) due to the low occurrence of nodal metastasis. Axillary surgery (ASx) is associated with risks like seroma, wound complications, lymphedema, and sensory deficits. This study aims to assess the utility of surgical axillary staging in clinically node-negative (cN0) T1mi breast cancer patients and provide insights for optimizing high value surgical treatment and subsequent decision-making. Methods: This retrospective cohort study analyzed data from the National Cancer Database (NCDB) to investigate axillary status of patients with cT1mi breast cancer between 2012 and 2019. Patient demographics, clinical characteristics, treatment methods and pathologic findings were collected. Comparisons were made between those who did and did not undergo ASx, and of those who did, between patients who were pathologically node-positive (pN+) vs. node-negative (pN-). Results: Of 10,843 patients analyzed, 9,220 (85.0%) underwent ASx while 1,623 (15.0%) did not. Mean age of patients undergoing ASx and those who did not was 59.2±11.2 and 66.3±12.8 years, respectively (p&amp;lt; 0.001). On univariate analysis, other factors associated with undergoing ASx were having private insurance, fewer medical comorbidities, having a HER2+ or triple negative phenotype, higher grade, presence of lymphovascular invasion and undergoing mastectomy (all p&amp;lt; 0.05). Sentinel lymphadenectomy was performed in 83% of patients while axillary lymph node dissection (ALND) was performed in 17% of patients. Final pathology demonstrated an upgrade to a true invasive cancer (T1 or greater) in 29.3% of cases. Of 9,069 patients who underwent ASx with known pathologic nodal status, 8,512 (93.9%) were pN- and 557 (6.1%) were pN+. Factors independently associated with increased odds of having positive nodes were younger age (OR 1.02, 95% CI 1.01-1.03, p&amp;lt; 0.001), Black race (OR 1.51, 95% CI 1.12-2.10, p=0.007), lymphovascular invasion (OR 13.72, 95% CI 10.25-18.36, p&amp;lt; 0.001), and undergoing mastectomy (OR 1.98, 95% CI 1.57-2.51, p&amp;lt; 0.001). Among the pN+ patients, only 64 (0.7%) had ≥3 total positive nodes and would require ALND. On subset analysis of the 4,190 patients undergoing mastectomy, 244 (5.8%) did not undergo ASx, while 3,946 (94.2%) did, of whom 373 (9%) were pN+. Regarding adjuvant treatments in this group, more patients who underwent ASx received chemotherapy (12% v. 8%, p&amp;lt; 0.001), and among those who did undergo surgery those who were pN+ were much more likely to receive chemotherapy (58% v. 12%, p&amp;lt; 0.001). However, similar proportions of patients who did and did not undergo ASx received adjuvant radiation (5% v. 4%, p=0.65), while, as expected, among those undergoing ASx, a higher proportion who were pN+ underwent radiation (32% v. 5%, p&amp;lt; 0.001). Conclusion: Surgical axillary staging for T1mi breast cancer is common, but many patients are node-negative. More patients are undergoing ALND than necessary based on pathology. Nodal status influences adjuvant therapy decisions. Identifying factors linked to upgrade and higher pN+ probabilities can enable personalized surgical treatments, reducing morbidity for most patients. Citation Format: Christian Lava, Karen Li, Lauren Berger, Daisy Spoer, Lindy Rosal, Austin Williams, Monika Masanam, Ian Greenwalt, Jennifer Son, Lucy De La Cruz. Optimizing Treatment Decisions in Microinvasive Ductal Carcinoma in Situ: Evaluating the Need for Surgical Axillary Staging [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-26-12.

Hip Fracture Treatment and Outcomes Among Community-Dwelling People Living With Dementia

The decision for surgical vs nonsurgical treatment for hip fracture can be complicated among community-dwelling people living with dementia. To compare outcomes of community-dwelling people living with dementia treated surgically and nonsurgically for hip fracture. This retrospective cross-sectional study undertook a population-based analysis of national Medicare fee-for-service data. Participants included community-dwelling Medicare beneficiaries with dementia and an inpatient claim for hip fracture from January 1, 2017, to June 30, 2018. Analyses were conducted from November 10, 2022, to October 17, 2023. Surgical vs nonsurgical treatment for hip fracture. The primary outcome was mortality within 30, 90, and 180 days. Secondary outcomes consisted of selected post-acute care services. Of 56 209 patients identified with hip fracture (73.0% women; mean [SD] age, 86.4 [7.0] years), 33 142 (59.0%) were treated surgically and 23 067 (41.0%) were treated nonsurgically. Among patients treated surgically, 73.3% had a fracture of the femoral head and neck and 40.2% had moderate to severe dementia (MSD). Among patients with MSD and femoral head and neck fracture, 180-day mortality was 31.8% (surgical treatment) vs 45.7% (nonsurgical treatment). For patients with MSD treated surgically vs nonsurgically, the unadjusted odds ratio (OR) of 180-day mortality was 0.56 (95% CI, 0.49-0.62; P < .001) and the adjusted OR was 0.59 (95% CI, 0.53-0.66; P < .001). Among patients with mild dementia and femoral head and neck fracture, 180-day mortality was 26.5% (surgical treatment) vs 34.9% (nonsurgical treatment). For patients with mild dementia who were treated surgically vs nonsurgically for femoral head and neck fracture, the unadjusted OR of 180-day mortality was 0.67 (95% CI, 0.60-0.76; P < .001) and the adjusted OR was 0.71 (95% CI, 0.63-0.79; P < .001). For patients with femoral head and neck fracture, there was no difference in admission to a nursing home within 180 days when treated surgically vs nonsurgically. In this cohort study of community-dwelling patients with dementia and fracture of the femoral head and neck, patients with MSD and mild dementia treated surgically experienced lower odds of death compared with patients treated nonsurgically. Although avoiding nursing home admission is important to persons living with dementia, being treated surgically for hip fracture did not necessarily confer a benefit in that regard. These data can help inform discussions around values and goals with patients and caregivers when determining the optimal treatment approach.

Extent of Resection Thresholds in Molecular Subgroups of Newly Diagnosed Isocitrate Dehydrogenase-Wildtype Glioblastoma.

Maximizing the extent of resection (EOR) improves outcomes in glioblastoma (GBM). However, previous GBM studies have not addressed the EOR impact in molecular subgroups beyond IDH1/IDH2 status. In the current article, we evaluate whether EOR confers a benefit in all GBM subtypes or only in particular molecular subgroups. A retrospective cohort of newly diagnosed GBM isocitrate dehydrogenase (IDH)-wildtype undergoing resection were prospectively included in a database (n = 138). EOR and residual tumor volume (RTV) were quantified with semiautomated software. Formalin-fixed paraffin-embedded tumor tissues were analyzed by targeted next-generation sequencing. The association between recurrent genomic alterations and EOR/RTV was evaluated using a recursive partitioning analysis to identify thresholds of EOR or RTV that may predict survival. The Kaplan-Meier methods and multivariable Cox proportional hazards regression methods were applied for survival analysis. Patients with EOR ≥88% experienced 44% prolonged overall survival (OS) in multivariable analysis (hazard ratio: 0.56, P = .030). Patients with alterations in the TP53 pathway and EOR <89% showed reduced OS compared to TP53 pathway altered patients with EOR>89% (10.5 vs 18.8 months; HR: 2.78, P = .013); however, EOR/RTV was not associated with OS in patients without alterations in the TP53 pathway. Meanwhile, in all patients with EOR <88%, PTEN -altered had significantly worse OS than PTEN -wildtype (9.5 vs 15.4 months; HR: 4.53, P < .001). Our results suggest that a subset of molecularly defined GBM IDH-wildtype may benefit more from aggressive resections. Re-resections to optimize EOR might be beneficial in a subset of molecularly defined GBMs. Molecular alterations should be taken into consideration for surgical treatment decisions in GBM IDH-wildtype.

Basic principles of surgical treatment of distal radius fractures

Distal radius fractures are one of the most frequent fractures of the upper extremities. The decision for conservative or surgical treatment is made after appropriate diagnostics using conventional radiographic and usually computed tomography imaging examinations. If the indications for surgical treatment are present, various options for reduction and fixation are available. The spectrum ranges from closed to open procedures up to accompanying arthroscopic support. Appropriate preoperative patient education about the procedure and the planned postinterventional treatment is essential. The goal of treatment is to restore wrist function while maintaining mobility and strength with alow risk of complications. All surgical procedures share the principle of reduction to restore anatomical relationship followed by fixation. Closed procedures include fixation with Kirschner wires and the construction of an external fixator. Volar locking plate osteosynthesis has become established in recent years as the method of choice for the majority of the fractures to be treated. For special fracture patterns and the treatment of accompanying injuries, arthroscopic support can be indicated. There is no uniform consensus on the best choice of procedure. This article discusses the possible procedures including the approaches, fixation techniques and specific follow-up treatment.

Usability of an Automated System for Real-Time Monitoring of Shared Decision-Making for Surgery: Mixed Methods Evaluation.

Improving shared decision-making (SDM) for patients has become a health policy priority in many countries. Achieving high-quality SDM is particularly important for approximately 313 million surgical treatment decisions patients make globally every year. Large-scale monitoring of surgical patients' experience of SDM in real time is needed to identify the failings of SDM before surgery is performed. We developed a novel approach to automating real-time data collection using an electronic measurement system to address this. Examining usability will facilitate its optimization and wider implementation to inform interventions aimed at improving SDM. This study examined the usability of an electronic real-time measurement system to monitor surgical patients' experience of SDM. We aimed to evaluate the metrics and indicators relevant to system effectiveness, system efficiency, and user satisfaction. We performed a mixed methods usability evaluation using multiple participant cohorts. The measurement system was implemented in a large UK hospital to measure patients' experience of SDM electronically before surgery using 2 validated measures (CollaboRATE and SDM-Q-9). Quantitative data (collected between April 1 and December 31, 2021) provided measurement system metrics to assess system effectiveness and efficiency. We included adult patients booked for urgent and elective surgery across 7 specialties and excluded patients without the capacity to consent for medical procedures, those without access to an internet-enabled device, and those undergoing emergency or endoscopic procedures. Additional groups of service users (group 1: public members who had not engaged with the system; group 2: a subset of patients who completed the measurement system) completed user-testing sessions and semistructured interviews to assess system effectiveness and user satisfaction. We conducted quantitative data analysis using descriptive statistics and calculated the task completion rate and survey response rate (system effectiveness) as well as the task completion time, task efficiency, and relative efficiency (system efficiency). Qualitative thematic analysis identified indicators of and barriers to good usability (user satisfaction). A total of 2254 completed surveys were returned to the measurement system. A total of 25 service users (group 1: n=9; group 2: n=16) participated in user-testing sessions and interviews. The task completion rate was high (169/171, 98.8%) and the survey response rate was good (2254/5794, 38.9%). The median task completion time was 3 (IQR 2-13) minutes, suggesting good system efficiency and effectiveness. The qualitative findings emphasized good user satisfaction. The identified themes suggested that the measurement system is acceptable, easy to use, and easy to access. Service users identified potential barriers and solutions to acceptability and ease of access. A mixed methods evaluation of an electronic measurement system for automated, real-time monitoring of patients' experience of SDM showed that usability among patients was high. Future pilot work will optimize the system for wider implementation to ultimately inform intervention development to improve SDM. RR2-10.1136/bmjopen-2023-079155.

Nap polysomnography in infants with laryngomalacia as a tool to predict treatment strategy.

This study aimed to investigate the role of nap polysomnography (NPSG) in predicting treatment strategies for infants with moderate to severe laryngomalacia and to explore the association between obstructive sleep apnea (OSA) severity, weight gain, and laryngomalacia severity. A retrospective analysis was conducted on infants diagnosed with moderate to severe laryngomalacia who underwent NPSG between January 2019 and June 2023. Clinical variables, NPSG parameters, and treatment decisions were collected. Weight gain rate and its correlation with NPSG indices were assessed. Logistic regression analyses were performed to predict treatment strategies based on NPSG findings. Of the 39 infants included (median age: 3.3months), 77% exhibited OSA, with 69% having moderate to severe OSA [apnea-hypopnea index (AHI) > 5/h]. Weight gain rate correlated negatively with indices of OSA severity, including the hypopnea index (HI) and the AHI. In a multiple logistic regression analysis incorporating the severity of OSA (AHI), weight gain rate, and laryngomalacia severity, only AHI predicted the decision for surgical or non-invasive ventilation treatment (OR = 2.1, CI95 [1.6; 2.8], p ≤ 10-4). The weight gain rate was predicted (r2 = 0.28) by the AHI and the presence of retractions of auxiliary inspiratory muscles. This study underscores the importance of NPSG in assessing infants with moderate to severe laryngomalacia. The AHI from NPSG emerged as a potential predictor for treatment decisions and weight gain rate, emphasizing its clinical relevance. These findings advocate incorporating NPSG into the diagnostic and management process for infants with laryngomalacia.

Perioperative textbook outcomes of minimally invasive pancreatoduodenectomy: a multicenter retrospective cohort analysis in a Korean minimally invasive pancreatic surgery registry.

The aim of this study is to investigate the perioperative composite textbook outcomes of pancreatic surgery after minimally invasive pancreatoduodenectomy (MIPD). The cohort study was conducted across 10 institutions and included 1552 patients who underwent MIPD registered with the Korean Study Group on Minimally Invasive Pancreatic Surgery between May 2007 and April 2020. We analyzed perioperative textbook outcomes of pancreatic surgery after MIPD. Subgroup analyses were performed to assess outcomes based on the hospital volume of MIPD. Among all patients, 21.8% underwent robotic pancreatoduodenectomy. High-volume centers (performing >20 MIPD/year) performed 88.1% of the procedures. The incidence of clinically relevant postoperative pancreatic fistula was 11.5%. Severe complications (Clavien-Dindo grade ≥IIIa) occurred in 15.1% of the cases. The 90-day mortality rate was 0.8%. The mean hospital stay was 13.7 days. Textbook outcomes of pancreatic surgery success were achieved in 60.4% of patients, with higher rates observed in high-volume centers than in low-volume centers (62.2% vs. 44.7%, P <0.001). High-volume centers exhibited significantly lower conversion rates (5.4% vs. 12.5%, P =0.001), lower 90-day mortality (0.5% vs. 2.7%, P =0.001), and lower 90-day readmission rates (4.5% vs. 9.6%, P =0.006) than those low-volume centers. MIPD could be performed safely with permissible perioperative outcomes, including textbook outcomes of pancreatic surgery, particularly in experienced centers. The findings of this study provided valuable insights for guiding surgical treatment decisions in periampullary disease.

Extent of Resection Thresholds in Molecular Subgroups of IDH-Wildtype Glioblastoma

INTRODUCTION: Maximizing the extent of resection (EOR) improves outcomes in glioblastoma (GBM). However, prior GBM studies have not addressed the impact of EOR in molecular subgroups of GBM beyond IDH1/IDH2 status. Therefore, it remains unclear whether EOR confers a benefit in all GBM subtypes or only in particular molecular subgroups. METHODS: Patients with newly diagnosed GBM IDH-wildtype undergoing resection were prospectively included in a database (n=138). EOR and RTV were quantified with semi-automated software. Formalin-fixed paraffin-embedded tumor tissues were analyzed by targeted next-generation sequencing. The association between recurrent genomic alterations and EOR/RTV was evaluated using a recursive partitioning analysis (RPA) to identify thresholds of EOR or RTV that may predict survival. The Kaplan-Meier methods and multivariable Cox proportional hazards regression methods were applied for survival analysis. RESULTS: Patients with EOR = 95.9% and younger than 67.5 years experienced improved survival compared to older patients with EOR &lt;95.9% (Hazard ratio [HR] 5.85, p &lt; 0.002). Patients with alterations in the TP53 pathway and EOR &lt;88.72% showed reduced OS (mOS: 10.5 vs. 18.8 months; HR: 2.78, p = 0.013). However, EOR/RTV was not associated with OS in patients without alterations in the TP53 pathway. Among patients with EOR &lt;87.69%, PTEN altered had significantly worse overall survival than PTEN wildtype (9.5 vs. 15.4 months; HR: 4.53, p &lt; 0.001). CONCLUSIONS: Our results suggest that a subset of molecularly defined GBMs IDH-wildtype may benefit more from aggressive resections. Re-resections to optimize EOR might be beneficial in a subset of molecularly defined GBMs. Molecular alterations should be taken into consideration for surgical treatment decisions in GBM IDH-wildtype.