Sex differences and racial/ethnic disparities in the presentation and treatment of medullary thyroid cancer.

BACKGROUND: This study assessed for disparities in the presentation and management of medullary thyroid cancer (MTC). METHODS: Patients with MTC (2010-2020) were identified from the National Cancer Database. Differences in disease presentation and likelihood of guideline-concordant surgical management (total thyroidectomy and resection of ≥1 lymph node) were assessed by sex and race/ethnicity. RESULTS: Of 6154 patients, 68.2% underwent guideline-concordant surgery. Tumors >4 â€‹cm were more likely in men (vs. women: OR 2.47, p â€‹< â€‹0.001) and Hispanic patients (vs. White patients: OR 1.52, p â€‹= â€‹0.001). Non-White patients were more likely to have distant metastases (Black: OR 1.63, p â€‹= â€‹0.002; Hispanic: OR 1.44, p â€‹= â€‹0.038) and experienced longer time to surgery (Black: HR 0.66, p â€‹< â€‹0.001; Hispanic: HR 0.71, p â€‹< â€‹0.001). Black patients were less likely to undergo guideline-concordant surgery (OR 0.70, p â€‹= â€‹0.022). CONCLUSIONS: Male and non-White patients with MTC more frequently present with advanced disease, and Black patients are less likely to undergo guideline-concordant surgery.

Validation of the GERAADA score to predict 30-day mortality in acute type A aortic dissection in a single high-volume aortic centre.

OBJECTIVES: This study aimed to evaluate employing the German Registry of Acute Aortic Dissection Type A (GERAADA) score to predict 30-day mortality in an aortic centre in the USA. METHODS: Between January 2010 and June 2021, 689 consecutive patients underwent surgery for acute type A dissection at a single institution. Excluded were patients with missing clinical data (N = 4). The GERAADA risk score was retrospectively calculated via a web-based application. Model discrimination power was calculated with c-statistics from logistic regression and reported as the area under the receiver operating characteristic curve with 95% confidence intervals. The calibration was measured by calculating the observed versus estimated mortality ratio. The Brier score was used for the overall model evaluation. RESULTS: Included were 685 patients [mean age 60.6 years (SD: 13.5), 64.8% male] who underwent surgery for acute type A aortic dissection. The 30-day mortality rate was 12.0%. The GERAADA score demonstrated very good discrimination power with an area under the receiver operating characteristic curve of 0.762 (95% confidence interval 0.703-0.821). The entire cohort's observed versus estimated mortality ratio was 0.543 (0.439-0.648), indicating an overestimation of the model-calculated risk. The Brier score was 0.010, thus revealing the model's acceptable overall performance. CONCLUSIONS: The GERAADA score is a practical and easily accessible tool for reliably estimating the 30-day mortality risk of patients undergoing surgery for acute type A aortic dissection. This model may naturally overestimate risk in patients undergoing surgery in experienced aortic centres.

Development of a risk-prediction model for primary aldosteronism in veterans with hypertension.

BACKGROUND: Rates of screening for primary aldosteronism in patients who meet the criteria are exceedingly low (1%-3%). To help clinicians prioritize screening in patients most likely to benefit, we developed a risk-prediction model. METHODS: Using national Veterans Health Administration data, we identified patients who met the criteria for primary aldosteronism screening between 2000 and 2019. We performed multivariable logistic regression to identify characteristics associated with positive primary aldosteronism testing before generating a risk-scoring system based on the coefficients (0< ß < 0.5 = 1 pt, 0.5 ≤ ß < 1 = 2 pts, 1 ≤ ß < 1.5 = 3 pts) and then tested the system performance using an internal validation cohort. RESULTS: We identified 502,190 patients who met primary aldosteronism screening criteria, of whom 1.6% were screened and 15% tested positive. Based on the regression model, we generated a risk-scoring system based on a total of 9 possible points in which age under 50, absence of smoking history, and resistant hypertension each scored 1 point; elevated serum sodium 2 points; and hypokalemia 3 points. Rates of positive screening increased with risk score, with 5.6% to 6.7% of those scoring 0 points testing positive; 7.9% to 9.0% 1 point; 8.6% to 10% 2 points; 13% to 14% 3 points; 21% 4 points; 22% to 38% 5 points; 27% to 38% 6 points; 42% to 49% 7 points; and 50% to 51% ≥8 points. CONCLUSION: In hypertensive patients who meet the criteria for primary aldosteronism screening, rates of positive screening range from 5.6% to 51%. Use of our risk-predication model incorporating these factors can identify patients most likely to benefit from testing.

The Penn Classification System for Malperfusion in Acute Type A Dissection: A 25-Year Experience.

BACKGROUND: The University of Pennsylvania classification system (Penn class) of acute type A aortic dissection (aTAAD) is used to evaluate the impact of malperfusion on surgical outcomes. The purpose of this analysis was to determine the validity of Penn class in a larger and more contemporary cohort and to compare its performance with other classification systems. METHODS: This was a retrospective study of patients who underwent aTAAD repair at our institution from 1993 to 2020. Patients were assigned to Penn class on the basis of burden of preoperative malperfusion syndrome. The association of Penn class and 30-day mortality was evaluated by multivariable regression. The discriminatory ability of Penn class for mortality was determined by a bootstrapped C statistic. RESULTS: There were 1192 patients, of whom 50% were assigned to Penn class A (no ischemia), 21% (253/1192) to class B (local ischemia), 14% (171/1192) to class C (generalized ischemia), and 14% (167/1192) to class B-C (combined ischemia). The incidence of mortality rose significantly with increasing Penn class from 5% (31/601) in class A to 35% (59/167) in class B-C (P < .001). After adjustment, 30-day mortality increased significantly with class B (odds ratio [OR], 2.43; 95% CI, 1.38-4.27), class C (OR, 3.39; 95% CI, 1.90-6.03), and class B-C (OR, 13.08; 95% CI, 7.90-22.15) compared with class A. The C statistic was 0.77 (95% CI, 0.72-0.80) and was significantly higher than for models featuring alternative classification systems (P < .05). CONCLUSIONS: Penn class provides excellent discrimination for 30-day mortality after repair of aTAAD.

Populational Perceptions Regarding Decision to Visit the Emergency Room with Chest Pain During COVID-19.

INTRODUCTION: A significant decrease in emergency presentations of acute cardiac conditions has been observed during the COVID-19 pandemic. We aimed to understand perceptions that influence people's decisions whether to present to the emergency department (ED) with symptoms related to acute cardiovascular events to inform necessary medical communication. METHODS: We recruited users of Amazon Mechanical Turk (Seattle, WA) to participate in a survey to elucidate perceptions of COVID-19 risk associated with a visit to the ED. A conjoint analysis was designed based on commonly reported factors associated with people's decisions to present to the ED during the pandemic to calculate preference utilities. RESULTS: After exclusions, 1003 participants completed the survey between 12/5/2020 and 12/6/2020. Participants ranked the perceived risk of contracting COVID-19 at the ED as one of the highest, only second to that at bars and restaurants. Only 68% (685/1003) were willing to present to the ED immediately with severe chest pain. Fear of further transmitting the virus to loved ones was the most frequently cited reason for not presenting. Conjoint analysis demonstrated severe chest pain to be the dominant factor in the decision to present to the ED. CONCLUSIONS: The risk of contracting COVID-19 while presenting to the ED for a life-threatening cardiovascular symptom is overestimated and is strongly affected by social factors.