The Impact of Frailty on Patients Undergoing Liver Resection for Colorectal Liver Metastasis.

BACKGROUND: The aim of this study is to assess the impact of frailty on short-term outcomes after hepatectomy for colorectal liver metastasis (CRLM). METHODS: Patients were identified using the National Surgical Quality Improvement Program (NSQIP). Patients were divided into 3 categories using the 5-item Modified Frailty Index (mFI). RESULTS: There were 5230 patients included. 52%, 35%, and 13% had mFI scores of 0, 1, and ≥ 2 respectively. Patients with a ≥ 2 mFI score were more likely to experience minor complication (OR 1.34, 95% CI 1.06-1.69), major complication (OR 1.56, 95% CI 1.15-2.12), readmission (OR 1.55, 95% CI 1.12-2.14), unfavorable discharge (OR 2.48, 95% CI 1.62-3.80), 30-day mortality (OR 3.02, 95% CI 1.02-8.95), prolonged length of stay (OR 1.47, 95% CI 1.18-1.83), and bile leak (OR 1.51, 95% CI 1.02-2.24). CONCLUSION: Frailty is associated with increased post-operative complications. The 5-item mFI can guide risk stratification, optimization, and counseling.

Does Preoperative Estimated Glomerular Filtration Rate (eGFR) Predict Short-Term Surgical Outcomes in Patients Undergoing Pancreatic Resections?

INTRODUCTION: Preoperative eGFR has been found to be a reliable predictor of post-operative outcomes in patients with normal creatinine levels who undergo surgery. The aim of our study was to evaluate the impact of preoperative eGFR levels on short-term post-operative outcomes in patients undergoing pancreatectomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) pancreatectomy file (2014-2017) was queried for all adult patients (age ≥ 18) who underwent pancreatic resection. Patients were stratified into two groups based on their preoperative eGFR (eGFR < 60 mL/min/1.73m2 and eGFR ≥ 60 mL/min/1.73m2). Outcome measures included post-operative pancreatic fistula, discharge disposition, hospital length of stay, 30-day readmission rate, and 30-day morbidity and mortality. Multivariate logistic regression analysis was performed. RESULTS: A total of 21,148 were included in the study of which 12% (n = 2256) had preoperative eGFR < 60 mL/min/1.73m2. Patients in the eGFR < 60 group had prolonged length of stay, were less likely to be discharged home, had higher minor and major complication rates, and higher rates of mortality. On logistic regression analysis, lower preoperative eGFR (< 60 mL/min/1.73m2) was associated with higher odds of prolonged length of stay [aOR: 1.294 (1.166-1.436)], adverse discharge disposition [aOR: 1.860 (1.644-2.103)], minor [aOR: 1.460 (1.321-1.613)] and major complications [aOR: 1.214 (1.086-1.358)], bleeding requiring transfusion [aOR: 1.861 (1.656-2.091)], and mortality [aOR: 2.064 (1.523-2.797)]. CONCLUSION: Preoperative decreased renal function measured by eGFR is associated with adverse outcomes in patients undergoing pancreatic resection. The results of this study may be valuable in improving preoperative risk stratification and post-operative expectations.

Survival after Margin-Positive Resection in the Era of Modern Chemotherapy for Pancreatic Cancer: Do Patients Still Benefit?

BACKGROUND: R0 resection for pancreatic cancer is considered standard of care, but is not always achieved. This study looks at R1/R2 resection outcomes compared with chemotherapy alone. Our hypothesis is that patients with margin-positive disease have better outcomes than those receiving chemotherapy alone. STUDY DESIGN: Stage II pancreatic cancer patients who underwent R1/R2 surgery with/without neoadjuvant chemotherapy, from the National Cancer Database (NCDB) 2010 to 2017 were identified and compared with similar staged patients who received chemotherapy alone. The surgical group was then analyzed by subset based on receipt of chemotherapy: upfront surgery (+/- adjuvant therapy) and neoadjuvant therapy followed by surgery (+/- adjuvant therapy). RESULTS: There were 11,699 Stage II pancreatic cancer patients included, 9,521 (81.4%) of whom were treated with chemotherapy alone, 15.7% (n = 1,836) had upfront surgery, and 2.9% (n = 342) had neoadjuvant therapy with surgery. R1/R2 neoadjuvant patients had the best overall survival at a mean of 19.75 months (95% CI 17.91, 22.28) compared with the upfront surgery group (17.77 months, 95% CI 15.64, 19.55) and the chemotherapy alone group (10.12 months, 95% CI 8.97, 11.50) (hazard ratio [HR] 0.46 upfront surgery and 0.32 neoadjuvant group, respectively, p < 0.0001). Even with R2 resection, survival was better in surgical patients compared with patients who underwent chemotherapy only (15.76 mo vs 10.22 mo, p = 0.06). Patients with R1/R2 resections had improved survival if they received neoadjuvant/adjuvant chemotherapy, though the survival rates were significantly lower than those with standard R0 resections (n = 16,129). CONCLUSIONS: R1 resection has benefit over chemotherapy alone in pancreatic cancer. Pancreatic cancer patients who are left with microscopic R1 disease have better survival than without surgery, particularly in the setting of neoadjuvant therapy.

Do General Surgery Residency Program Websites Feature Diversity?

OBJECTIVE: This study assesses ways in which General Surgery residency program websites demonstrate diversity. DESIGN: Literature review and diversity expert opinion informed selection of diversity elements. We limited our evaluation to residency program-specific webpages. We identified 8 program website elements that demonstrate programmatic commitment to diversity: (1) standard nondiscrimination statement; (2) program-specific diversity and inclusion message; (3) community demographics; (4) personalized biographies of faculty, (5) personalized biographies of residents; (6) individual photographs of faculty; (7) individual photographs of residents; and (8) list of additional resources available for trainees. We evaluated the impact of program type (university, independent, or military); city population; region; program director gender and ethnicity; and program size on incorporation of these eight elements. We dichotomized programs that had ≥4 of these elements on their website and determined association with the above factors using chi-square or Fisher's exact test. SETTING: Website review July to December 2019. PARTICIPANTS: All nonmilitary-based general surgery residency program members of the Association of Program Directors in Surgery (APDS) (n = 242/251). RESULTS: General Surgery residency program websites included a mean of 2.7 ± 1.5 elements that showcase diversity. Most program websites (n = 215, 89%) featured ≤4 elements (range 1-4), while 15 (6.2%) had none. When stratified by programs having 4 or more elements on their website, university-based program (p < 0.001) was the only factor associated. Resident photos (n = 147, 61%), resources available to trainees (n = 146, 60%), faculty photos (n = 139, 57%), and community demographics (n = 93, 38%) were the most common of the 8 website elements. CONCLUSIONS: Residency program websites are vital to recruiting applicants. Featuring specific elements on the General Surgery residency website that display a program's commitment to diversity and inclusion may be important in attracting a diverse candidate pool. This research highlights opportunities programs may use to demonstrate more effectively a residency program's commitment to diversity and inclusion.

Expanding Recognition of Rickettsia parkeri Rickettsiosis in Southern Arizona, 2016-2017.

Rickettsia parkeri rickettsiosis is an emerging, tick-borne disease in the United States (US), transmitted by the bite of Amblyomma maculatum group ticks. Clinical manifestations include fever, headache, myalgia, maculopapular rash, and a characteristic eschar that forms at the site of the tick bite. Arizona's index case of R. parkeri rickettsiosis was reported in 2014. Seven additional confirmed and probable cases were identified during 2016-2017 through routine investigation of electronic laboratory reports and by self-reporting to public health authorities. Serum samples were evaluated for immunoglobulin G antibodies reactive with antigens of Rickettsia rickettsii (the agent of Rocky Mountain spotted fever [RMSF]) and R. parkeri using indirect immunofluorescence antibody tests. Eschar swab specimens were evaluated using Rickettsia genus-specific and R. parkeri-specific real-time PCR assays. Patients (six male, one female) ranged in age from 29 to 69 years (median of 41 years), and became ill between July 2016 and September 2017. Fever (6/7), myalgia (5/7), and arthralgia (5/7) were most commonly reported and 5/7 patients had a documented eschar. All patients reported a tick bite acquired in southern Arizona within 2-8 days before illness onset. Four patients worked as U.S. Border Patrol agents. Antibodies reactive to R. rickettsii, R. parkeri, or to both antigens were detected in all patients. Seroconversions between acute and convalescent-phase samples were identified for two patients and DNA of R. parkeri was identified in eschar swab samples from two patients. R. parkeri rickettsiosis is endemic to a region of the southwestern United States and presents an occupational risk that could be lessened by prevention messaging to Border Patrol agents. RMSF, a closely related and more severe spotted fever rickettsiosis, is also endemic to Arizona. Public health agencies can assist clinicians in distinguishing these two infections clinically through education and accessing species-specific diagnostic assays that can improve surveillance efforts for both diseases.

Finding what works: Predicting health or social service linkage in drug using, African American, female sex workers in Miami, FL.

Female sex workers (FSWs) encounter numerous challenges in accessing health and social services. In this study of drug using, African American FSWs, the authors examine specific factors associated with health or social service linkage among participants in a randomized intervention trial. Respondent linkage was significantly associated with individual factors (living alone, severe internal mental distress, and traumatic victimization) and project-related variables (attending five case management sessions and client engagement rating). In the multivariate model, higher client engagement and session attendance remained significant. The researchers conclude by discussing the importance of intervention attendance and engagement as key contributors to health and social service linkage among FSWs.

The Demand for Antiretroviral Drugs in the Illicit Marketplace: Implications for HIV Disease Management Among Vulnerable Populations.

The diversion of antiretroviral medications (ARVs) has implications for the integrity and success of HIV care, however little is known about the ARV illicit market. This paper aimed to identify the motivations for buying illicit ARVs and to describe market dynamics. Semi-structured interviews (n = 44) were conducted with substance-involved individuals living with HIV who have a history of purchasing ARVs on the street. Grounded theory was used to code and analyze interviews. Motivations for buying ARVs on the illicit market were: to repurchase ARVs after having diverted them for money or drugs; having limited access or low quality health care; to replace lost or ruined ARVs; and to buy a back-up stock of ARVs. This study identified various structural barriers to HIV treatment and ARV adherence that incentivized ARV diversion. Findings highlight the need to improve patient-provider relationships, ensure continuity of care, and integrate services to engage and retain high-needs populations.

Medication adherence challenges among HIV positive substance abusers: the role of food and housing insecurity.

This study examines the prevalence of food/housing insecurity and its association with psychological, behavioral, and environmental factors impacting antiretroviral (ARV) medication adherence and diversion among substance using HIV+ patients in South Florida. Five hundred and three HIV+ substance abusers were recruited through targeted sampling. Participants completed a standardized instrument assessing demographics, mental health status, sex risk behaviors, HIV diagnosis, treatment history and access, ARV adherence and diversion, and attitudes toward health-care providers. Chi-square and t-tests were used to examine differences by food/housing status and a multivariate linear regression model examined food/housing insecurity and its associations to ARV adherence. Food/housing insecurity was reported by 43.3% of the sample and was associated with higher likelihood of severe psychological distress and substance dependence. Nearly 60% reported recent ARV diversion; only 47.2% achieved 95% medication adherence over one week. Food/housing insecure participants had deficits in their HIV care, including less time in consistent care, lower access to medical care, and less favorable attitudes toward care providers. Multivariate linear regression showed food/housing insecurity demonstrated significant main effects on adherence, including lower past week adherence. Medication diversion was also associated with reduced adherence. Our findings suggest that food/housing insecurity operates as a significant driver of ARV non-adherence and diversion in this population. In the pursuit of better long-term health outcomes for vulnerable HIV+ individuals, it is essential for providers to understand the role of food and housing insecurity as a stressor that negatively impacts ARV adherence and treatment access, while also significantly contributing to higher levels of distress and substance dependence.

Pain treatment and antiretroviral medication adherence among vulnerable HIV-positive patients.

Pain represents a significant source of morbidity, function loss, and decreased quality of life among people living with HIV. The present study examined the associations among pain, pain treatment, and ARV adherence among indigent, HIV-positive substance abusers. Participants were recruited via targeted sampling strategies, and completed a one-time computer-assisted personal interview. ANOVA and chi-square tests were used to analyze differences in demographics, health and psychological status, health behaviors, by pain and pain treatment status; a multivariate logistic regression model was constructed to examine the contribution of pain/treatment status to recent ARV adherence. Results indicated that those with untreated pain had lower odds of achieving gold-standard 95% ARV adherence as compared to the pain-free and treated pain groups; higher substance dependence symptoms were also associated with significantly lower odds of 95% ARV adherence. Findings suggest that pain management is critical to the health of people living with HIV, specifically those with high levels of co-morbid health and psychological problems. The prevalence of untreated pain was elevated among this group, and contributed to reduced ARV adherence. Providers of clinical care to disadvantaged HIV-positive patients should emphasize routine assessment and appropriate treatment of pain in order to provide comprehensive HIV care.

HIV testing and engagement in care among highly vulnerable female sex workers: implications for treatment as prevention models.

BACKGROUND: Although emerging Treatment as Prevention models can be effective in reducing HIV incidence among high-risk populations, many HIV infected individuals remain undiagnosed or fail to engage in HIV care. METHODS: This study examined the factors associated with HIV testing and care among a population of substance using female sex workers. RESULTS: Recent HIV testing was associated with higher education level, having a regular health care provider or clinic, recent crack use, and higher sexual risk behaviors; HIV treatment utilization was associated with higher levels of social support, having a regular health care provider or clinic, housing stability and insurance coverage. Qualitative data revealed HIV-related stigma, denial, social isolation, and substance use as barriers to HIV testing and treatment; social support and accessibility of services were key enablers. CONCLUSIONS: Improving HIV testing and linkage to treatment among female sex workers will require structural initiatives to reduce stigma and increase service seeking support.

Nonmedical prescription drug users in private vs. public substance abuse treatment: a cross sectional comparison of demographic and HIV risk behavior profiles.

BACKGROUND: Little is known regarding the demographic and behavioral characteristics of nonmedical prescription drug users (NMPDUs) entering substance abuse treatment settings, and information on the HIV-related risk profiles of NMPDUs is especially lacking. Participation in substance abuse treatment provides a critical opportunity for HIV prevention and intervention, but successful initiatives will require services appropriately tailored for the needs of NMPDUs. METHODS: This paper compares the HIV risk profiles of NMPDUs in public (n = 246) and private (n = 249) treatment facilities. Participants included in the analysis reported five or more recent episodes of nonmedical prescription drug use, a prior HIV negative test result, and current enrollment in a substance abuse treatment facility. A standardized questionnaire was administered by trained interviewers with questions about demographics, HIV risk, and substance use. RESULTS: Private treatment clients were more likely to be non-Hispanic White, younger, and opioid and heroin users. Injection drug use was higher among private treatment clients, whereas public clients reported higher likelihood of trading or selling sex. Public treatment clients reported higher rates of HIV testing and availability at their treatment facilities compared to private clients. CONCLUSIONS: Findings suggest differing demographics, substance use patterns, profiles of HIV risk and access to HIV testing between the two treatment samples. Population tailored HIV interventions, and increased access to HIV testing in both public and private substance treatment centers, appear to be warranted.