Healthier Patients Research Articles

Active Cancer Patients Presenting to the Emergency Department with Acute Venous Thromboembolism: A Retrospective Cohort Study on Risks and Outcomes.

There is no prior study that has documented emergency department (ED) outcomes or stratified mortality risks of cancer patients presenting with an acute venous thromboembolism (VTE). To evaluate ED treatment of these patients, to document their outcomes, and to identify risk factors associated with death. A retrospective cohort study was performed on active cancer patients presenting with deep venous thrombosis or pulmonary embolism to two academic EDs between July 2012 and June 2016. Key outcomes included mortality, ED revisit, and admission within 30 days. The patient cohort was characterized; crosstabs and regression analysis were performed to assess relative risks (RRs) and mitigating factors associated with 30-day mortality. Of 355 patients, 9% died and 38% had one or more ED revisits or admissions. Recent immobility (RR 2.341, 95% CI 1.227-4.465), poor functional status (RR 2.090, 95% CI 1.028-4.248), recent admission (RR 2.441, 95% CI 1.276-4.669), and metastatic cancer (RR 4.669, 95% CI 1.456-14.979) were major risk factors for mortality. ED-provided anticoagulation reduced the overall mortality risk (RR 0.274, 95% CI 0.146-0.515) and mitigated the risk from recent immobility (RR 1.250, 95% CI 0.462-3.381), especially among patients with good or fair functional status. Immobility and cancer morbidity are key risk factors for mortality after an acute VTE, but ED-provided anticoagulation mitigates the risk of immobility among healthier patients. Eastern Cooperative Oncology Group performance status can help clinicians risk stratify these patients at presentation.

PD02-06 EFFECT OF RESIDENT INVOLVEMENT IN UROLOGICAL SURGERY ON SHORT-TERM PATIENT OUTCOMES: A META-ANALYSIS AND SYSTEMATIC REVIEW

You have accessJournal of UrologyEducation Research I (PD02)1 Sep 2021PD02-06 EFFECT OF RESIDENT INVOLVEMENT IN UROLOGICAL SURGERY ON SHORT-TERM PATIENT OUTCOMES: A META-ANALYSIS AND SYSTEMATIC REVIEW Nazia Hossain, Hussien Mohamed, and Avi-Chai Robinson Nazia HossainNazia Hossain More articles by this author , Hussien MohamedHussien Mohamed More articles by this author , and Avi-Chai RobinsonAvi-Chai Robinson More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001966.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The effect on patient outcomes with and without resident involvement in urological surgery remains controversial. This study aims to systematically determine the effect of resident involvement on patient outcomes in urological surgery. METHODS: This paper followed the Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines. Two independent reviewers searched PubMed, Embase, and the Cochrane Library to find studies assessing the impact of resident involvement on patient outcomes in urology cases. Eight patient variables were compared between cohorts to investigate participant similarity. Fifteen outcome variables potentially impacted by resident involvement were compared via meta-analysis. Study quality was assessed using the Newcastle-Ottawa Scale for cohort analysis and given a quality label based on Agency for Healthcare Research and Quality standards. Several papers relied on data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), which reports 30-day patient outcomes. Sensitivity analysis was done to assess for patient overlap between papers that used ACS-NSQIP data. RESULTS: Fifteen studies were included in the meta-analysis, comprising a total of 95,326 patients. The resident-involved group had an overall lower amount of patients with diabetes (odds ratio [OR], 0.84; [95% CI], [0.74, 0.94]), hypertension ([OR], 0.84; [95% CI], [0.82, 0.87]) and smoking ([OR], 0.81; [95% CI], [0.76, 0.86]). Residents were also less involved in operations where patients had a Class 3 or 4 American Society of Anesthesiologists (ASA) scores ([OR], 0.96; [95% CI], [0.93, 1.00]). However, the resident-involved group had more negative post-operative outcomes. The resident-involved surgery group had higher rates of postoperative septic ([OR], 1.37; [95% CI], [1.16, 1.62]) and deep vein thrombosis (DVT) ([OR], 1.36; [95% CI], [1.07, 1.74]). The resident group also had longer operative times when results were reported dichotomously ([OR], 1.78; [95% CI], [1.64, 1.93]). CONCLUSIONS: Based on the results, resident involvement in urological surgery seems to have a negative effect on patient outcomes, specifically increased rates of septic shock, DVT and longer operative time despite resident involvement in cases with healthier patients. However, the data is limited due to the lack of high-quality, propensity-scored studies. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e39-e39 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nazia Hossain More articles by this author Hussien Mohamed More articles by this author Avi-Chai Robinson More articles by this author Expand All Advertisement Loading ...

Assessing Goals-of-Care Documentation during the COVID-19 Patient Surge in an Academic Safety-Net Medical Center.

Context/Objectives: It is paramount that clinicians assess and document patients' priorities to guide goal-concordant interventions, especially during a public health crisis. Design: Retrospective chart review. Setting: Academic safety-net medical center in central Massachusetts, United States. Methods: We examined electronic medical records (EMRs) to discern goals-of-care (GOC) conversations with COVID-19 patients seen at some point by palliative care during their hospitalization, and all clinicians' use of a structured note template during the peak incidence of COVID-19 from March to May 2020. Patients were grouped based on comorbidities and preadmission living situation. GOC discussions were categorized into three types: code status decisions, other treatment decisions, and no treatment decisions. Results: Nearly all (97%) patients had GOC documentation within 48 hours of admission. Forty-four percent of first GOC conversations incorporated the template. Patients with dementia living in nursing facilities had GOC documentation within hours of hospital admission, whereas healthier patients had their first GOC conversation at one week of hospitalization. Decisions about code status predominated in the first (83%) and second (49%) discussions, followed by a focus on other treatment decisions in subsequent discussions (44%-57%). Many did not require a treatment decision (19%-27%) but focused on quality-of-life definitions. Nearly all survivors were discharged to a facility and only four patients returned home. Many survivors died within three months (case fatality rate: 77%). Conclusions: GOC documentation using a structured template combined with easy EMR retrievability and clinician training holds promise for aligning patients' values with real-time medical decisions, during and after the pandemic.

How long does it take patients to find a new primary care physician when theirs retires: a population-based, longitudinal study

BackgroundThe retirement of a family physician can represent a challenge in accessibility and continuity of care for patients. In this population-based, longitudinal cohort study, we assess whether and how long it takes for patients to find a new majority source of primary care (MSOC) when theirs retires, and we investigate the effect of demographic and clinical characteristics on this process.MethodsWe used provincial health insurance records to identify the complete cohort of patients whose majority source of care left clinical practice in either 2007/2008 or 2008/2009 and then calculated the number of days between their last visit with their original MSOC and their first visit with their new one. We compared the clinical and sociodemographic characteristics of patients who did and did not find a new MSOC in the three years following their original physician’s retirement using Chi-square and Fisher’s exact test. We also used Cox proportional hazards models to determine the adjusted association between patient age, sex, socioeconomic status, location and morbidity level (measured using Johns Hopkins’ Aggregated Diagnostic Groupings), and time to finding a new primary care physician. We produce survival curves stratified by patient age, sex, income and morbidity.ResultsFifty-four percent of patients found a new MSOC within the first 12 months following their physician’s retirement. Six percent of patients still had not found a new physician after 36 months. Patients who were older and had higher levels of morbidity were more likely to find a new MSOC and found one faster than younger, healthier patients. Patients located in more urban regional health authorities also took longer to find a new MSOC compared to those in rural areas.ConclusionsPrimary care physician retirements represent a potential threat to accessibility; patients followed in this study took more than a year on average to find a new MSOC after their physician retired. Providing programmatic support to retiring physicians and their patients, as well as addressing shortages of longitudinal primary care more broadly could help to ensure smoother retirement transitions.

Does Frailty or Age Increase the Risk of Postoperative Complications Following Cochlear Implantation?

ObjectiveTo evaluate whether frailty or age increases the risk of postoperative complications following cochlear implant (CI) surgery.Study DesignRetrospective cohort study.SettingTertiary academic center.MethodsAn evaluation of all adult patients undergoing cochlear implantation between 2006 and 2020 was performed. The 5-item Modified Frailty Index (mFI-5, comprising preoperative history of pulmonary disease, heart failure, hypertension, diabetes, and partially/totally dependent functional status) was calculated for all patients included in analysis in addition to demographic characteristics. The primary outcome was postoperative complications following CI within a 3-month period. Major complications included myocardial infarction, bleeding, and cerebrospinal fluid leak, among others. Predictors of postoperative complications were examined using multivariable logistic regression reporting odds ratios (ORs) and 95% CIs.ResultsThere were 520 patients included for review with a median age of 68 (range, 18-94) years and a slight male predominance (n = 283, 54.4%). There were 340 patients (65.4%) who were robust (nonfrail) with an mFI of 0, while 180 (34.6%) had an mFI of ≥1. There were 20 patients who experienced a postoperative complication (3.85%). There was no statistically significant association between postoperative complications as a result of preoperative frailty (OR, 1.56; 95% CI, 0.98-2.48, P = .06) or age as a continuous variable (OR, 0.99; 95% CI, 0.97-1.02, P = .51).ConclusionsCI is safe for elderly and frail patients and carries no additional risk of complications when compared to younger, healthier patients. While medical comorbidities should always be considered perioperatively, this study supports the notion that implantation is low risk in older, frail patients.

Observational cohort study in older women with early breast cancer: Use of radiation therapy and impact on health-related quality of life and mortality

BackgroundRadiotherapy reduces in-breast recurrence risk in early breast cancer (EBC) in older women. This benefit may be small and should be balanced against treatment effect and holistic patient assessment. This study described treatment patterns according to fitness and impact on health-related quality-of-life (HRQoL). MethodsA multicentre, observational study of EBC patients aged ≥ 70 years, undergoing breast-conserving surgery (BCS) or mastectomy, was undertaken. Associations between radiotherapy use, surgery, clinico-pathological parameters, fitness based on geriatric parameters and treatment centre were determined. HRQoL was measured using the European Organisation for the Research and Treatment of Cancer (EORTC) questionnaires. ResultsIn 2013–2018 2811 women in 56 UK study centres underwent surgery with a median follow-up of 52 months. On multivariable analysis, age and tumour risk predicted radiotherapy use. Among healthier patients (based on geriatric assessments) with high-risk tumours, 534/613 (87.1%) having BCS and 185/341 (54.2%) having mastectomy received radiotherapy. In less fit individuals with low-risk tumours undergoing BCS, 149/207 (72.0%) received radiotherapy. Radiotherapy effects on HRQoL domains, including breast symptoms and fatigue were seen, resolving by 18 months. ConclusionRadiotherapy use in EBC patients ≥ 70 years is affected by age and recurrence risk, whereas geriatric parameters have limited impact regardless of type of surgery. There was geographical variation in treatment, with some fit older women with high-risk tumours not receiving radiotherapy, and some older, low-risk, EBC patients receiving radiotherapy after BCS despite evidence of limited benefit. The impact on HRQoL is transient.

Sleep Diagnostics for Home Monitoring of Sleep Apnea Patients.

Objectives: Sleep time information is essential for monitoring of obstructive sleep apnea (OSA), as the severity assessment depends on the number of breathing disturbances per hour of sleep. However, clinical procedures for sleep monitoring rely on numerous uncomfortable sensors, which could affect sleeping patterns. Therefore, an automated method to identify sleep intervals from unobtrusive data is required. However, most unobtrusive sensors suffer from data loss and sensitivity to movement artifacts. Thus, current sleep detection methods are inadequate, as these require long intervals of good quality. Moreover, sleep monitoring of OSA patients is often less reliable due to heart rate disturbances, movement and sleep fragmentation. The primary aim was to develop a sleep-wake classifier for sleep time estimation of suspected OSA patients, based on single short-term segments of their cardiac and respiratory signals. The secondary aim was to define metrics to detect OSA patients directly from their predicted sleep-wake pattern and prioritize them for clinical diagnosis.Methods: This study used a dataset of 183 suspected OSA patients, of which 36 test subjects. First, a convolutional neural network was designed for sleep-wake classification based on healthier patients (AHI < 10). It employed single 30 s epochs of electrocardiograms and respiratory inductance plethysmograms. Sleep information and Total Sleep Time (TST) was derived for all patients using the short-term segments. Next, OSA patients were detected based on the average confidence of sleep predictions and the percentage of sleep-wake transitions in the predicted sleep architecture.Results: Sleep-wake classification on healthy, mild and moderate patients resulted in moderate κ scores of 0.51, 0.49, and 0.48, respectively. However, TST estimates decreased in accuracy with increasing AHI. Nevertheless, severe patients were detected with a sensitivity of 78% and specificity of 89%, and prioritized for clinical diagnosis. As such, their inaccurate TST estimate becomes irrelevant. Excluding detected OSA patients resulted in an overall estimated TST with a mean bias error of 21.9 (± 55.7) min and Pearson correlation of 0.74 to the reference.Conclusion: The presented framework offered a realistic tool for unobtrusive sleep monitoring of suspected OSA patients. Moreover, it enabled fast prioritization of severe patients for clinical diagnosis.

Ten-year treatment complication outcomes of radical prostatectomy vs external beam radiation vs brachytherapy for 1503 patients with intermediate risk prostate cancer

To compare 10-year late complications of radical prostatectomy (RP) versus external-beam-radiation-therapy (EBRT) versus brachytherapy (BT). Retrospective analysis was performed on 1503 intermediate-risk-prostate-cancer patients treated from 2004 to 2007, using univariate comparisons. Eight hundred and nineteen underwent RP, 574 EBRT, and 110 BT. RP urinary and rectal complications were graded severe if patients required ≥3 pads/diapers per day, chronic condom catheter or penile clamp, daily clean-intermittent-catheterization, sling, artificial-urinary-sphincter, or rectal fistula. Complications for EBRT/BT were severe if graded 3/4 on the Radiation-Therapy-Oncology-Group scale for late effects. The prevalence of erectile-dysfunction-devices (EDD) of injections, pumps and/or penile implants were compared. Median follow-up for RP versus EBRT versus BT were 10.0, 9.6, and 9.8 years. Median age were 62.1, 70.8, 65.3, p < 0.0001. The 10-year prevalence of severe urinary complications for RP versus EBRT versus BT were 10.1%, 12.5%, 4.6%, p = 0.03, and were less for RP <64 years, p = 0.03, and lower Charlson score, p = 0.05. Pretreatment American-Urological-Association (AUA) score existed for 7.3%, 11.5%, 97.3% of RP versus EBRT versus BT, p < 0.0001, and the 10-year prevalence of EDD were 24.3%, 6.6%, 8.2%, respectively, p< 0.0001. Severe rectal complications were slightly higher for EBRT, p = 0.06. BT had lower prevalence of severe urinary complications, possibly by using AUA score to avoid patients with obstructive uropathy. Urinary complications may be reduced by limiting RP to younger, healthier patients, and by avoiding EBRT/BT with obstructive symptoms. RP had higher prevalence of EDD, despite having younger, healthier patients.

Improving Safety of Bilateral Knee Arthroplasty: Impact of Selection Criteria on Perioperative Outcome.

Background: Bilateral total knee arthroplasty (BTKA) procedures are associated with an increased risk of complications when compared with unilateral approaches. In 2006, in an attempt to reduce this risk, our institution implemented selection criteria that specified younger and healthier patients as candidates for BTKA. Questions/Purpose: We sought to investigate the effect of these selection criteria on perioperative outcomes. Methods: In a retrospective cohort study, we used institutional data to identify patients who underwent BTKA between 1998 and 2014. Patients were divided into 2 groups: those who underwent surgery before the 2006 introduction of our selection criteria (1998-2006) and those who underwent surgery after (2007-2014). Groups were compared in terms of demographics, comorbidity burden, and incidence of perioperative complications. Regression analysis was performed, calculating incidence rate ratios to evaluate changes in complication rates. Results: Before the selection criteria were implemented in 2006, patients who underwent BTKA were older and had a higher comorbidity burden. The rate of major complications per 1000 hospital days decreased from 31.5 in 1998 to 7.9 in 2014. A reduction in cardiac complications was the most significant contributor to this decrease in major complications. Conclusion: After stringent criteria for BTKA candidates were implemented at our institution, selection of younger patients with lower comorbidity burden was accompanied by a reduction in the incidence of operative complications. This suggests that introducing such criteria can be associated with a reduction in adverse perioperative outcomes.

Outcomes of pancreatic ductal adenocarcinoma (PDAC) patients treated with neoadjuvant stereotactic body radiation therapy (SBRT) or conventionally fractionated radiation therapy (CFRT).

e16209 Background: Hypothesis: Neoadjuvant SBRT can improve survival when compared to CFRT in PDAC patients who received chemotherapy. Past retrospective studies have shown improved outcomes of definitive SBRT when compared to CFRT without accounting for chemotherapy.1 We aim to study the outcomes of neoadjuvant SBRT vs CFRT accounting for chemotherapy. Methods: The National Cancer Database (NCDB) was queried for cases of PDAC from 2004-2015. Patients who received surgery and chemotherapy were included. Exclusion criteria were prior hormonal therapy or immunotherapy, lack of pathological confirmation or lack of information about chemotherapy. Log-rank test and Cox proportional hazards model were used to compare survival by radiation modalities. Predictors for overall survival (OS) were identified. Propensity score-matched (PSM) analysis balancing for different variables including type of chemotherapy was conducted. Results: Among 1604 patients, 223 (13.9%) had SBRT, and 1381 (86.1%) had CFRT. The median survivals were 30.0 and 26.0 months ( P = 0.010), while the 2-year survival rates were 63.4% and 53.7% for SBRT and CFRT patients, respectively. SBRT tended to be offered to older patients (age≥65: 56.1% vs 47.3%, P = 0.018), healthier patients (CCI=0: 72.2% vs 63.6%, P = 0.016), patients with worse cT staging (cT3 and cT4: 80.7% vs 69.7%, P = 0.008) and patients who got more multi-agent chemotherapy (89.2% vs 50.5%, P &lt; 0.001). In the cohort with positive clinical lymph nodes (cN+), CFRT tended to decrease the pN staging more when compared to SBRT ( P = 0.032) (Table). In multivariate analysis, multi-agent chemotherapy (HR, 0.72; P &lt; 0.001) was associated with better OS. SBRT did not show significantly better OS when compared to CFRT (HR, 0.81; P = 0.13) after accounting for other covariates including chemotherapy. PSM (1:1 match) analysis matched 223 pairs. SBRT did not show significant OS benefit (HR, 0.80; P = 0.17) when compared to CFRT. Conclusions: SBRT may be superior to CFRT in univariate analysis. However, after accounting for multi-agent chemotherapy, there is no significant survival difference between neoadjuvant SBRT and CFRT. Studies with larger sample size are desired. Neoadjuvant CFRT offers more significant nodal down-staging in patients with clinically positive lymph nodes (cN+) when compared to SBRT. Reference: Zhong J, Patel K, Switchenko J, et al. Outcomes for patients with locally advanced pancreatic adenocarcinoma treated with stereotacticbody radiation therapy versus conventionally fractionated radiation. Cancer2017 Sep 15;123(18):3486-3493. pN staging of cN+ cohort[Table: see text]

A narrative review of esophageal tissue engineering and replacement: where are we?

Long-gap esophageal defects, whether congenital or acquired, are very difficult to manage. Any significant surgical peri-esophageal dissection that is performed to allow for potential stretching of two ends of a defect interrupts the esophageal blood supply and leads to complications such as leak and stricture, even in the youngest, healthiest patients. The term “congenital” applied to these defects refers mainly to long-gap esophageal atresia (LGA). Causes of acquired long-segment esophageal disruption include recurrent leaks and fistulae after primary repair, refractory GERD, caustic ingestions, cancer, and strictures. 5,000–10,000 patients per year in the US require esophageal replacement. Gastric, colonic, and jejunal pull-up surgeries are fraught with high rates of both short and long term complications thus creating a space for a better option. Since the 1970’s many groups around the world have been unsuccessfully attempting esophageal replacement with tissue-engineered grafts in various animal models. But, recent advances in these models are now combining novel technologic advances in materials bioscience, stem-cell therapies, and transplantation and are showing increasing promise to human translational application. Transplantation has been heretofore unsuccessful, but given modern improvements in transplant microsurgery and immunosuppressive medications, pioneering trials in animal models are being undertaken now. These rapidly evolving medical innovations will be reviewed here.

Treatment patterns and outcomes in real-world transplant-ineligible patients newly diagnosed with multiple myeloma.

Despite the significant proportion of older patients with newly diagnosed multiple myeloma (MM), most clinical trials driving therapeutic decisions in routine practice include younger and presumably healthier patients than those in the real world. Furthermore, longitudinal studies suggest that elderly, transplant-ineligible patients with MM are not benefitting enough from new anti-MM agents. We retrospectively analyzed the profile of and treatment patterns and outcomes in 675 transplant-ineligible patients with MM who started frontline therapy in routine practice. The mean (SD) age was 75.6 (6.7) years; 152 (47.4%) had Eastern Cooperative Oncology Group performance status (ECOG PS) 2-4, and 73 (25.1%) had high cytogenetic risk. The most frequent frontline therapy was non-VMP bortezomib-based regimens (n=207; 30.7%), which were more frequent among patients with ECOG PS 0/1 and higher risk (e.g., international staging system (ISS) stage III, severely impaired glomerular filtrate rate (GFR), high lactate dehydrogenase (LDH), and high-risk cytogenetics); 185 patients (27.4%) started an attenuated (lite) VMP regimen, and 159 (23.6%) a VMP (VISTA) regimen. Median progression-free survival and overall survival (OS) were 15.3 months (95%CI 14.0-16.9) and 33.5 months (95%CI 29.1-37.2), respectively; 405 patients (78.2%) achieved partial response or better. Age, ECOG PS, ISS stage, serum LDH, GFR, cytogenetic risk, and treatment regimen significantly influenced OS. In this study, a remarkable proportion of transplant-ineligible patients with MM were older, frontline regimens were highly heterogeneous, and patients at higher risk often received less efficacious combinations. These findings suggest that clinicians have limited objective criteria for therapeutic decisions for this patient group.

Systemic Determinants in Surgery: Nonclinical Factors Affecting Time to Operation for Incarcerated Ventral Hernias.

We explore nonclinical factors affecting the amount of time from admission to the operating room for patients requiring nonelective repair of ventral hernias. Using the 2005-2012 Nationwide Inpatient Sample, we identified adult patients with a primary diagnosis of ventral hernia without obstruction/gangrene, who underwent nonelective repair. The outcome variable of interest was time from admission to surgery. We performed univariate and multivariable analyses using negative binomial regression, adjusting for age, sex, race, income, insurance, admission day, comorbidity status (van Walraven score), diagnosis, procedure, hospital size, location/teaching status, and region. 7,253 patients met criteria, of which majority were women (n = 4,615) and white (n = 5,394). The majority of patients had private insurance (n = 3,015) followed by Medicare (n = 2,737). Median time to operation was 0days. Univariate analysis comparing operation <1day to ≥1day identified significant differences in race, day of admission, insurance, length of stay, comorbidity status, hospital location, type, and size. Negative binomial regression showed that weekday admission (IRR 4.42, P < .0001), private insurance (IRR 1.53-2.66, P < .0001), rural location (IRR 1.39-1.76, P < .01), small hospital size (IRR 1.26-1.36, P < .05), white race (IRR 1.30-1.34, P < .01), healthier patients (van Walraven score IRR 1.05, P < .0001), and use of mesh (IRR 0.39-0.56, P < .02) were associated with shorter time until procedure. Shorter time from admission to the operating room was associated with several nonclinical factors, which suggest disparities may exist. Further prospective studies are warranted to elucidate these disparities affecting patient care.

Challenges and opportunities to developing a frailty index using electronic health record data

Older adults represent the majority of patients diagnosed with cancer yet remain under-represented in clinical trials [ [1] Ludmir E.B. Mainwaring W. Lin T.A. et al. Factors associated with age disparities among Cancer clinical trial participants. JAMA Oncol. 2019; 5: 1769-1773 Crossref PubMed Scopus (60) Google Scholar ]. The reasons for this are multifaceted and include clinician bias against recommending trial participation to older adults, trial unavailability, patient ineligibility, and other social and cultural barriers [ [2] Hurria A. Levit L.A. Dale W. et al. Improving the evidence base for treating older adults with Cancer: American society of clinical oncology statement. J Clin Oncol. 2015; 33: 3826-3833 Crossref PubMed Scopus (227) Google Scholar ]. Underrepresentation leads to a lack of evidence to guide management recommendations for older adults, forcing clinicians to extrapolate from data generated in potentially younger, healthier patients. The American Society of Clinical Oncology (ASCO) has repeatedly identified research using real-world data as a mechanism to fill this evidence gap. A 2015 ASCO research statement recommended that developers of research and clinical databases ensure that their systems collect geriatric assessment (GA) data and have the functionality to support real-world data studies designed to improve the evidence base supporting the treatment of older adults [ [2] Hurria A. Levit L.A. Dale W. et al. Improving the evidence base for treating older adults with Cancer: American society of clinical oncology statement. J Clin Oncol. 2015; 33: 3826-3833 Crossref PubMed Scopus (227) Google Scholar ]. Similarly, action items from a 2017 ASCO-U.S. Food and Drug Administration (FDA) co-sponsored workshop included standardizing and enhancing the quality of data recorded in electronic health records (EHRs) to facilitate better geriatric oncology research [ [3] Levit L.A. Singh H. Klepin H.D. et al. Expanding the evidence base in geriatric oncology: action items from an FDA-ASCO workshop. J Natl Cancer Inst. 2018; 110: 1163-1170 Crossref PubMed Scopus (35) Google Scholar ].

Bilateral Total Knee Arthroplasty Should Remain the Exception and Not the Rule

Commentary Transparent shared decision-making is the recommendation by Warren et al. in their article. The authors call on surgeons to make patients aware of the increased risk of complications with bilateral total knee arthroplasty (TKA) regardless of the degree of baseline health. Such a response might not be enough. Warren et al. used the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database to capture patients undergoing bilateral total knee arthroplasty (TKA) and then captured their ACS Morbidity Probability variable, which is derived from an extensive number of comorbidities and risk factors. These patients were matched to those undergoing unilateral TKA. Both groups of patients were stratified into 4 different levels of risk, and complication rates were compared within each level. The patients who underwent bilateral TKA had a higher complication rate regardless of the preoperative risk level. The authors admit the limitations of their study; the NSQIP is limited to 30-day follow-up, and defining bilateral procedures requires certain assumptions. Nonetheless, their reported incidence of bilateral TKA is supported by the 3.9% rate in Part A Medicare data1, and their methods are applied the same across all 4 stratifications of risk. Their findings refute previous studies that concluded that younger and healthier patients undergoing bilateral TKA have no higher risk of complications than those undergoing unilateral procedures. Simultaneous bilateral TKA is attractive to patients and surgeons for many reasons. The overall time in recovery is condensed and costs are reduced. Previous authors have demonstrated equal outcomes, but even advocates of the practice have noted increased rates of complications that led to the eventual working paradigm that it be reserved for younger patients with less risk2,3. This article is the first to examine that assumption with a robust model consisting of 4 levels of risk derived from multiple elements. The greater than threefold higher risk of complications even in the lowest risk level is derived from registry data across multiple hospitals. A bias toward reporting of positive outcomes is inevitable in published case series, which might not capture the true distribution of the complications. The added overall risk reported is compatible with other recent data-mining studies that show the same effect without the stratification of comorbidities4,5. Surgeons are inherently biased in terms of how they interpret the literature relative to their perception of their personal surgical outcomes. Complications after TKA are relatively rare and can occur sporadically, leaving the individual surgeon in a “prison of small numbers” that can lead to undue confidence recommending bilateral TKA. This report, based on data across multiple practices and thousands of patients, requires sober study by all surgeons. All surgeons are instinctively and correctly uncomfortable with cases with longer anesthesia times and wound exposure times, which are inherent to bilateral TKA. Most surgeons are aware of the increased risks of needing transfusion and needing a skilled nursing facility after discharge. Dorr et al. demonstrated the synergistic added impact of fat embolism in bilateral procedures >30 years ago6. However, surgeon perceptions of added risk are muted by self-confidence, trust in local protocols, and the desire to satisfy patient preferences for bilateral procedures. Surgeons are painfully aware of the difficulties and interruption of normal life that patients incur when undergoing complications from TKA. Patients are at risk for discounting warnings about complications unless they have sustained such complications themselves or observed family and/or friends experience them. Shared decision-making is an improvement over paternalistic direction from a surgeon, but it still allows for preconceived assumptions by the surgeon and patient in an unequal relationship of knowledge and personal experience. Given the reported added risk inherent to bilateral TKA that is shown in this article, even in the healthiest patients, is it enough for the surgeon to make that risk transparent to the patient, especially if the risk is discounted by the patient because of the time and economic concerns that cloud his or her choices? All surgeons should carefully study the added risks reported in this study when bilateral TKA is pursued rather than staged TKA. Further studies will be needed to support the frequently given assumption that patient selection neutralizes such added risk; at this time, evidence for such a counterargument is weak. Providing transparency about added risk does not reduce the increased incidence of complications. One of the basic tenets of medicine is primum non nocere (first do no harm); an argument can be made that bilateral TKA should be performed relatively rarely and surgeons should be more resistant to acquiescing to patient expectations.

Comparison between small renal masses 0-2 cm vs. 2.1-4 cm in size: A population-based study

BackgroundThe NCCN guidelines recommend active surveillance (AS) as an option for the initial management of cT1a 0-2 cm renal lesions. However, data about comparison between renal cell carcinoma (RCC) 0-2 cm vs. 2.1-4 cm are scarce. MethodsWithin the Surveillance, Epidemiology, and End Results database (2002–2016), 46,630 T1a NanyMany stage patients treated with nephrectomy were identified. Data were tabulated according to histological subtype, tumor grade (low [LG] vs. high [HG]), as well as age category and gender. Additionally, rates of synchronous metastases were quantified. ResultsOverall, 69.3 vs. 74.1% clear cell, 21.4 vs. 17.6% papillary, 6.9 vs. 6.8% chromophobe, 2.0 vs. 1.1% sarcomatoid dedifferentiation, 0.2 vs. 0.2% collecting duct histological subtype were identified for respectively 0-2 cm and 2.1-4 cm RCCs. In both groups, advanced age was associated with higher rate of HG clear cell and HG papillary histological subtype. In 0-2 cm vs. 2.1-4 cm RCCs, 13.8% vs. 20.2% individuals operated on harbored HG tumors and were more prevalent in males. Lower synchronous metastases rates were recorded in 0-2 cm RCC and ranged from 0 in respectively multilocular cystic to 0.9% in HG papillary histological subtype. The highest synchronous metastases rates were recorded in sarcomatoid dedifferentiation histological subtype (13.8% and 9.7%) in both groups. ConclusionsRelative to 2.1-4 cm RCCs, 0-2 cm RCCs harbored lower rates of HG tumors, lower rates of aggressive variant histology and lower rates of synchronous metastases. The indications and demographics of patients selected for AS may be expanded in the future to include younger and healthier patients.

Are Growing Rates of Total Joint Arthroplasty in Younger Patients of Concern?

Abstract Total joint arthroplasty (TJA) is being used more frequently now than in the past for younger patients who may not have radiographic evidence of severe osteoarthritis. This change is problematic. We will present evidence that younger patients, and those with early-stage osteoarthritis, benefit less from TJA than do older patients with late-stage osteoarthritis. The reasons for the increase in TJA among younger, healthier patients are complex and have economic and ethical implications. Outcomes of TJA are poorly studied in patients less than 55 years, and it is unclear whether many younger patients who undergo TJA have arthritis severe enough to warrant the procedure. TJA may be inappropriate for patients who have minimal pain and disability related to osteoarthritis and higher functional demands that stress the replaced joint. In this viewpoint, we discuss reasons for the increase in TJA among these patients and make ethics-based recommendations for avoiding inappropriate and costly TJA.

Patient Risk Factors Associated With Postoperative Complications After Common Hand Procedures.

Carpal tunnel syndrome (CTS), trigger finger (TF), and De Quervain tenosynovitis (DQ) are 3 common pathologies of the hand often treated with relatively simple surgical procedures. However, outcomes from these procedures can be compromised by postoperative complications. The aim of this study was to evaluate the association between diabetes, tobacco use, and obesity and the incidence of postoperative complications. We reviewed 597 patients treated surgically for CTS, TF, or DQ from 2010 to 2015. We used bivariate and multivariate analyses to assess independent associations between diabetes, tobacco use, obesity, and surgical complications and compared the incidences with healthier patients without these comorbidities. We also looked at patients with overlapping diagnoses of these comorbidities. Bivariate analysis showed that patients with diabetes and smokers were more likely to have a surgical complication. Multivariate analysis showed diabetes and tobacco use as independent predictors of complications. The disease states or combinations placing patients at the highest risk of a postoperative complication were the diabetic-smoker-obese, diabetic-smoker, diabetic-obese, diabetic, and smoker-obese groups. The diabetic-smoker-obese patient population had a 42.02% predicted rate of postoperative complications. Diabetes and tobacco use are independent risk factors for complications after operative treatment of CTS, TF, and DQ. Obesity when coexisting with diabetes mellitus (DM) and/or tobacco use increased the risk of complications. When the 3 patient factors evaluated, DM, obesity, and tobacco use, were present, the rate of complications was 42.02%. Careful assessment and discussion should occur before proceeding with operative treatment for simple hand conditions in patients with the risk factors studied.

The contemporary role of metastasectomy in the management of metastatic RCC

Metastasectomy was initially described in the 1970s as a therapeutic strategy for patients with metastatic renal cell carcinoma. Since that time, systemic therapy options have grown exponentially, most recently with the introduction of immunotherapy. We aimed to review the contemporary literature regarding the role of metastasectomy in the era of targeted therapy and immunotherapy. Historically, metastasectomy has benefited patients with small volume, single-organ metastases, with favorable outcomes amongst younger, healthier patients with metastases to specific sites. The interplay between the employment of metastasectomy and systemic therapy has been limited to small, retrospective series with significant patient selection bias. More recently, investigators have conducted randomized controlled trials exploring the use of targeted therapies in the adjuvant setting after metastasectomy. Initial randomized data suggested no benefit in using sorafenib in this setting, and a subsequent study demonstrated possible harm in using pazopanib after metastasectomy. However, the role of other novel systemic therapies, including immunotherapy, nor the timing of use, have been meaningfully explored. Metastasectomy appears to be a valuable therapeutic option in the properly selected patient, requiring a multi-disciplinary management strategy and, pending future trials, a multimodal treatment approach.

Bilateral Simultaneous Total Knee Arthroplasty May Not Be Safe Even in the Healthiest Patients.

Bilateral total knee arthroplasty (TKA) has been shown to increase both mortality and complications, but has potential benefits including decreased length of stay, rehabilitation time, and costs. The purpose of this study was to use data from a nationally representative database to identify if there is a population of patients undergoing TKA in whom bilateral TKA can be safely performed, by comparing 30-day mortality and complication rates with those of patients undergoing unilateral TKA. The National Surgical Quality Improvement Program (NSQIP) was queried to compare 30-day rates of mortality and any complication between bilateral TKA and unilateral TKA. A total of 8,291 patients who underwent bilateral TKA were matched 1:1 with a unilateral TKA control cohort (n = 315,219) by morbidity probability, which is a cumulative variable encompassing demographic characteristics, comorbidities, and laboratory values. Patients were divided into quartiles based on morbidity probability. Binary logistic regression comparing bilateral TKA and unilateral TKA for the same quartiles was performed to establish if any population could safely have bilateral TKA performed. Bilateral TKA had an increased risk for all complications (p < 0.001) and major complications (p < 0.001) when compared with unilateral TKA regardless of health status. For all complications, there was a greater than threefold increase for the first quartile (healthiest patients) (p < 0.001), a greater than fourfold increase for the second and third quartiles (p < 0.001), and a greater than threefold increase for the fourth quartile (least healthy patients) (p < 0.001). For major complications, there was a greater than twofold increase for the first quartile (p = 0.001) and the second quartile (p < 0.001), an almost threefold increase for the third quartile (p < 0.001), and a 57% increase for the fourth quartile (p = 0.005). This study will assist shared decision-making between orthopaedic surgeons and patients by suggesting that bilateral TKA may not be as safe an option for even healthy individuals compared with unilateral TKA. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.