Understanding Disparities in Breast Cancer Care in Memphis, Tennessee.

Although significant progress has been made in improving breast cancer survival, disparities among racial, ethnic, and underserved groups still exist. The goal of this investigation is to quantify racial disparities in the context of breast cancer care, examining the outcomes of recurrence and mortality in the city of Memphis. Patients with a biopsy-proven diagnosis of breast cancer from January 1, 2002, through December 31, 2012, were obtained from the tumor registry. Black patients were more likely to have advanced (II, III, or IV) clinical stage of breast cancer at diagnosis versus white patients. Black breast cancer patients had a two times higher odds of recurrence (95% confidence interval: 1.4, 3.0) after adjusting for race and clinical stage. Black breast cancer patients were 1.5 times more likely to die (95% confidence interval: 1.2, 1.8), after adjusting for race; age at diagnosis; clinical stage; ER, PR, HER2 status; and recurrence. Black women with stages 0, I, II, and III breast cancer all had a statistically significant longer median time from diagnosis to surgery than white women. Black patients were more likely to have advanced clinical stages of breast cancer at diagnosis versus white patients on a citywide level in Memphis. Black breast cancer patients have higher odds of recurrence and mortality when compared with white breast cancer patients, after adjusting for appropriate demographic and clinical attributes. More work is needed to develop, evaluate, and disseminate interventions to decrease inequities in timeliness of care for breast cancer patients.

Laparoscopic lumbar hernia repair.

Lumbar hernias are rare clinical entities that often pose a challenge for repair. Because of the surrounding anatomy, adequate surgical herniorraphy is often difficult. Minimally invasive surgery has become an option for these hernias. Herein, we describe two patients with lumbar hernias (one with a recurrent traumatic hernia and one with an incisional hernia). Both of these hernias were successfully repaired laparoscopically.

Routine follow-up imaging is unnecessary in the management of blunt hepatic injury.

BACKGROUND: Nonoperative management of hemodynamically stable patients with blunt hepatic injuries has become the standard of care over the past decade. However, controversy regarding the role of in-hospital follow-up computed tomographic (CT) scans as a part of this nonoperative management scheme is ongoing. Although many institutions, including our own, have advocated routine in-hospital follow-up scans, others have suggested a more selective policy. Over time, we have perceived a low yield from follow-up studies. The hypothesis for this study is that routine follow-up imaging of asymptomatic patients is unnecessary. METHODS: All patients selected for nonoperative management of blunt hepatic injury were evaluated for utility of follow-up CT scans over a 4-year period. RESULTS: There were 530 stable patients with hepatic injury on admission CT scans in which follow-up scans were obtained within a week of admission. All injuries were classified according to the revised American Association for the Surgery of Trauma Organ Injury Scale: 102 (19.2%) grade I, 181 (34.1%) grade II, 158 (29.8%) grade III, 74 (13.9%) grade IV, and 15 (2.8%) grade V. Follow-up scans showed that most injuries were either unchanged (51%) or improved (34.7%). Only three patients underwent intervention based on their follow-up scans: two patients had arteriography (one with therapeutic embolization) and one had percutaneous drainage. Each of those patients had clinical signs or symptoms that were indicative of ongoing hepatic abnormality. CONCLUSION: These data demonstrate that, regardless of injury grade, routine in-hospital follow-up scans are not indicated as part of the nonoperative management of blunt liver injuries. Follow-up scans are indicated for patients who develop signs or symptoms suggestive of hepatic abnormality.

Staged management of giant abdominal wall defects: acute and long-term results.

INTRODUCTION: Shock resuscitation leads to visceral edema often precluding abdominal wall closure. We have developed a staged approach encompassing acute management through definitive abdominal wall reconstruction. The purpose of this report is to analyze our experience with this technique applied to the treatment of patients with open abdomen and giant abdominal wall defects. METHODS: Our management scheme for giant abdominal wall defects consists of 3 stages: stage I, absorbable mesh insertion for temporary closure (if edema quickly resolves within 3-5 days, the mesh is gradually pleated, allowing delayed fascial closure); stage II, absorbable mesh removal in patients without edema resolution (2-3 weeks after insertion to allow for granulation and fixation of viscera) and formation of the planned ventral hernia with either split thickness skin graft or full thickness skin closure over the viscera; and stage III, definitive reconstruction after 6-12 months (allowing for inflammation and dense adhesion resolution) by using the modified components separation technique. Consecutive patients from 1993 to 2001 at a single institution were evaluated. Outcomes were analyzed by management stage, with emphasis on wound related morbidity and mortality, and fistula and recurrent hernia rates. RESULTS: Two hundred seventy four patients (35 with sepsis, 239 with hemorrhagic shock) were managed. There were 212 males (77%), and mean age was 37 (range, 12-88). The average size of the defects was 20 x 30 cm. In the stage I group, 108 died (92% of all deaths) because of shock. The remaining 166 had temporary closure with polyglactin 910 woven absorbable mesh. As visceral edema resolved, bedside pleating of the absorbable mesh allowed delayed fascial closure in 37 patients (22%). In the stage II group, 9 died (8% of all deaths) from multiple organ failure associated with their underlying disease process, and 96% of the remaining 120 had split-thickness skin graft placed over the viscera. No wound related mortality occurred. There were a total of 14 fistulae (5% of total, 8% of survivors). In the stage III group, to date, 73 of the 120 have had definitive abdominal wall reconstruction using the modified components separation technique. There were no deaths. Mean follow-up was 24 months, (range 2-60). Recurrent hernias developed in 4 of these patients (5%). CONCLUSIONS: The staged management of patients with giant abdominal wall defects without the use of permanent mesh results in a safe and consistent approach for both initial and definitive management with low morbidity and no technique-related mortality. Absorbable mesh provides effective temporary abdominal wall defect coverage with a low fistula rate. Because of the low recurrent hernia rate and avoidance of permanent mesh, the components separation technique is the procedure of choice for definitive abdominal wall reconstruction.