The Influence of Disparities on Prostate Cancer at Diagnosis in the Charlotte Metropolitan Area.

INTRODUCTION: Prostate cancer (PCa) is the most diagnosed noncutaneous malignancy and second leading-cause of cancer death in men, yet screening is decreasing. As PCa screening has become controversial, socioeconomic disparities in PCa diagnosis and outcomes widen. This study was designed to determine the current disparities influencing PCa diagnosis in Charlotte, NC. METHODS: The Levine Cancer Institute database was queried for patients with PCa, living in metropolitan Charlotte. Socioeconomic status (SES) was determined by the Area Deprivation Index (ADI); higher ADI indicated lower SES. Patients were compared by their National Comprehensive Cancer Network risk stratification. Artificial intelligence predictive models were trained and heatmaps were created, demonstrating the geographic and socioeconomic disparities in late-stage PCa. RESULTS: Of the 802 patients assessed, 202 (25.2%) with high-risk PCa at diagnosis were compared with 198 (24.7%) with low-risk PCa. High-risk PCa patients were older (69.8 ± 9.0 vs. 64.0 ± 7.9 years; p < 0.001) with lower SES (ADI block: 98.4 ± 20.9 vs. 92.1 ± 19.8; p = 0.004) and more commonly African-American (White: 66.2% vs. 78.3%, African-American: 31.3% vs. 20.7%; p = 0.009). On regression, ADI block was an independent predictor (odds ratio [OR] = 1.013, 95% confidence interval [CI] 1.002-1.024; p = 0.024) of high-risk PCa at diagnosis, whereas race was not (OR = 1.312, 95% CI 0.782-2.201; p = 0.848). A separate regression demonstrated higher ADI (OR = 1.016, 95% CI 1.004-1.027; p = 0.006) and older age (OR = 1.083, 95% CI 1.054-1.114; p < 0.001) were independent predictors for high-risk PCa. Findings, depicted in heatmaps, demonstrated the geographic locations where men with PCa were predicted to have high-risk disease based on their age and SES. CONCLUSIONS: Socioeconomic status was more closely associated with high-risk PCa at diagnosis than race. Although, of any variable, age was most predictive. The heatmaps identified areas that would benefit from increased awareness, education, and screening to facilitate an earlier PCa diagnosis.

Deep learning model utilizing clinical data alone outperforms image-based model for hernia recurrence following abdominal wall reconstruction with long-term follow up.

BACKGROUND: Deep learning models (DLMs) using preoperative computed tomography (CT) imaging have shown promise in predicting outcomes following abdominal wall reconstruction (AWR), including component separation, wound complications, and pulmonary failure. This study aimed to apply these methods in predicting hernia recurrence and to evaluate if incorporating additional clinical data would improve the DLM's predictive ability. METHODS: Patients were identified from a prospectively maintained single-institution database. Those who underwent AWR with available preoperative CTs were included, and those with < 18 months of follow up were excluded. Patients were separated into a training (80%) set and a testing (20%) set. A DLM was trained on the images only, and another DLM was trained on demographics only: age, sex, BMI, diabetes, and history of tobacco use. A mixed-value DLM incorporated data from both. The DLMs were evaluated by the area under the curve (AUC) in predicting recurrence. RESULTS: The models evaluated data from 190 AWR patients with a 14.7% recurrence rate after an average follow up of more than 7 years (mean ± SD: 86 ± 39 months; median [Q1, Q3]: 85.4 [56.1, 113.1]). Patients had a mean age of 57.5 ± 12.3 years and were majority (65.8%) female with a BMI of 34.2 ± 7.9 kg/m2. There were 28.9% with diabetes and 16.8% with a history of tobacco use. The AUCs for the imaging DLM, clinical DLM, and combined DLM were 0.500, 0.667, and 0.604, respectively. CONCLUSIONS: The clinical-only DLM outperformed both the image-only DLM and the mixed-value DLM in predicting recurrence. While all three models were poorly predictive of recurrence, the clinical-only DLM was the most predictive. These findings may indicate that imaging characteristics are not as useful for predicting recurrence as they have been for other AWR outcomes. Further research should focus on understanding the imaging characteristics that are identified by these DLMs and expanding the demographic information incorporated in the clinical-only DLM to further enhance the predictive ability of this model.

Disparate potential for readmission prevention exists among inpatient and outpatient procedures in a minimally invasive surgery practice.

BACKGROUND: Administrators have focused on decreasing postoperative readmissions for cost reduction without fully understanding their preventability. This study describes the development and implementation of a surgeon-led readmission review process that assessed preventability. METHODS: A gastrointestinal surgical group at a tertiary referral hospital developed and implemented a template to analyze inpatient and outpatient readmissions. Monthly stakeholder assessments reviewed and categorized readmissions as potentially preventable or not preventable. Continuous variables were examined by the Student's t test and reported as means and standard deviations. Categorical variables were examined by the Pearson χ2 statistic and Fisher's exact test. RESULTS: There were 61 readmission events after 849 inpatient operations (7.2%) and 16 after 856 outpatient operations (1.9%), the latter of which were all classified as potentially preventable. Colorectal procedures represented 65.6% of readmissions despite being only 37.2% of all cases. The majority (67.2%) of readmission events were not preventable. Compared to the not-preventable group, the potentially preventable group experienced more dehydration (30.0% vs 9.8%, P = .045) and ileostomy creation (78.6% vs 33.3%, P = .017). The potential for outpatient management to prevent readmission was significantly higher in the potentially preventable group (40.0% vs 0.0%, P < .001), as was premature discharge prevention (35.0% vs 0.0%, P < .001). CONCLUSION: The use of the standardized template developed for analyzing readmission events after inpatient and outpatient procedures identified a disparate potential for readmission prevention. This finding suggests that a singular focus on readmission reduction is misguided, with further work needed to evaluate and implement appropriate quality-based strategies.

FlatWire Sternal Closure System technique for median sternotomy closure.

Sternal closure after median sternotomy traditionally uses a stainless steel wire cerclage. Sternal wires are placed through or around the sternum, and the wire ends are twisted together to bring the sternum back together. Complications of this technique include sternal instability, dehiscence, non-union, and increased pain. Compared to traditional wire cerclage, the Figure 8 FlatWire Sternal Closure System has been demonstrated to be stronger and significantly reduce sternal cut-through and postoperative pain. There was no significant difference in hospital length of stay or mean hospitalization cost. Operative time was slightly longer in the FlatWire group, but this difference has been attributed to the learning curve of mastering the FlatWire technique. This article and supplemental video will demonstrate the technique of FlatWire Sternal Closure System. Briefly, the FlatWire is placed around the sternum, and the FlatWire end is fed through the security box. Once all of the wires are placed, the Figure 8 tensioning device is used to tighten each wire through the security box to the appropriate tensile force. Next, the FlatWires are rotated 90 degrees to hold the sternal position temporarily. Once sternal approximation is achieved, each FlatWire is twisted 120 degrees, and any excess length of the FlatWire is clipped.

Early warning: End-tidal carbon dioxide is associated with central venous oxygenation under continuous cardiorespiratory monitoring in a porcine model of hemorrhagic shock and resuscitation.

BACKGROUND: End-tidal carbon dioxide (ETCO2) has previously shown promise as a predictor of shock severity and mortality in trauma. ETCO2 monitoring is non-invasive, real-time, and readily available in prehospital settings, but the temporal relationship of ETCO2 to systemic oxygen transport has not been thoroughly investigated in the context of hemorrhagic shock. METHODS: A validated porcine model of hemorrhagic shock and resuscitation was used in male Yorkshire swine (N â€‹= â€‹7). Both ETCO2 and central venous oxygenation (SCVO2) were monitored and recorded continuously in addition to other traditional hemodynamic variables. RESULTS: Linear regression analysis showed that ETCO2 was associated with ScvO2 both throughout the experiment (ߠ​= â€‹1.783, 95% confidence interval (CI) [1.552-2.014], p â€‹< â€‹0.001) and during the period of most rapid hemorrhage (ߠ​= â€‹4.896, 95% CI [2.416-7.377], p â€‹< â€‹0.001) when there was a marked decrease in ETCO2. CONCLUSIONS: ETCO2 and ScvO2 were closely associated during rapid hemorrhage and continued to be temporally associated throughout shock and resuscitation.

Prospective, international analysis of quality of life outcomes in recurrent versus primary ventral hernia repairs.

BACKGROUND: Quality of life (QOL) has become a key outcome measure following ventral hernia repair (VHR), but recurrent and primary VHR have not been compared in this context previously. METHODS: The International Hernia Mesh Registry (2008-2019) was used to identify patients with QOL data scored by the Carolinas Comfort Scale preoperatively and postoperatively at 1 year. RESULTS: Repairs were performed in 227 recurrent and 1,122 primary VHs. Recurrent patients had a higher BMI, larger defects, and were more likely to have preoperative pain, but other comorbidities were equal. Recurrence rates at 1 year were equivalent. Recurrent patients had a greater improvement in pain (-6.3 ± 10.2 vs -4.3 ± 8.3,p = 0.002) and movement limitation (-5.5 ± 10.0 vs -3.2 ± 7.2,p < 0.001) compared to primary patients, but they had increased postoperative mesh sensation (4.6 ± 7.7 vs 2.7 ± 5.5,p < 0.001). CONCLUSIONS: Recurrent VHRs led to improved pain and movement limitation, but increased mesh sensation. These findings may be useful for preoperative counseling in the elective setting.

Defining surgical risk in octogenarians undergoing paraesophageal hernia repair.

BACKGROUND: With an aging population, the utility of surgery in elderly patients, particularly octogenarians, is of increasing interest. The goal of this study was to analyze outcomes of octogenarians versus non-octogenarians undergoing paraesophageal hernia repair (PEHR). METHODS: The Nationwide Readmission Database was queried for patients > 18 years old who underwent PEHR from 2016 to 2018. Exclusion criteria included a diagnosis of gastrointestinal malignancy or a concurrent bariatric procedure. Patients ≥ 80 were compared to those 18-79 years old using standard statistical methods, and subgroup analyses of elective and non-elective PEHRs were performed. RESULTS: From 2016 to 2018, 46,450 patients were identified with 5425 (11.7%) octogenarians and 41,025 (88.3%) non-octogenarians. Octogenarians were more likely to have a non-elective operation (46.3% vs 18.2%, p < 0.001), and those undergoing non-elective PEHR had a higher mortality (5.5% vs 1.2%, p < 0.001). Outcomes were improved with elective PEHR, but octogenarians still had higher mortality (1.3% vs 0.2%, p < 0.001), longer LOS (3[2, 5] vs 2[1, 3] days, p < 0.001), and higher readmission rates within 30 days (11.1% vs 6.5%, p < 0.001) compared to non-octogenarian elective patients. Multivariable logistic regression showed that being an octogenarian was not independently predictive of mortality (odds ratio (OR) 1.373[95% confidence interval 0.962-1.959], p = 0.081), but a non-elective operation was (OR 3.180[2.492-4.057], p < 0.001). Being an octogenarian was a risk factor for readmission within 30 days (OR 1.512[1.348-1.697], p < 0.001). CONCLUSIONS: Octogenarians represented a substantial proportion of patients undergoing PEHR and were more likely to undergo a non-elective operation. Being an octogenarian was not an independent predictor of perioperative mortality, but a non-elective operation was. Octogenarians' morbidity and mortality was reduced in elective procedures but was still higher than non-octogenarians. Elective PEHR in octogenarians is reasonable but should involve a thorough risk-benefit analysis.

Platelet Aggregation, Mitochondrial Function and Morphology in Cold Storage: Impact of Resveratrol and Cytochrome c Supplementation.

Donated platelets are critical components of hemostasis management. Extending platelet storage beyond the recommended guidelines (5 days, 22 °C) is of clinical significance. Platelet coagulation function can be prolonged with resveratrol (Res) or cytochrome c (Cyt c) at 4 °C. We hypothesized that storage under these conditions is associated with maintained aggregation function, decreased reactive oxygen species (ROS) production, increased mitochondrial respiratory function, and preserved morphology. Donated platelets were stored at 22 °C or 4 °C supplemented with 50 µM Res or 100 µM Cyt c and assayed on days 0 (baseline), 5, 7 and 10 for platelet aggregation, morphology, intracellular ROS, and mitochondrial function. Declining platelet function and increased intracellular ROS were maintained by Res and Cyt c. Platelet respiratory control ratio declined during storage using complex I + II (CI + CII) or CIV substrates. No temperature-dependent differences (4 °C versus 22 °C) in respiratory function were observed. Altered platelet morphology was observed after 7 days at 22 °C, effects that were blunted at 4 °C independent of exposure to Res or Cyt c. Storage of platelets at 4 °C with Res and Cyt c modulates ROS generation and platelet structural integrity.

Multidisciplinary Management of an Aorto-esophageal Injury Caused by Foreign Body Ingestion.

A 37-year-old incarcerated male ingested a complex "X-shaped" foreign body that resulted in a penetrating aorto-esophageal injury. A primary esophagotomy with retrieval of the foreign body and muscle flap closure was performed simultaneously with thoracic endovascular aortic repair. This multidisciplinary surgical approach controls for both immediate exsanguination and postoperative complications to improve patient outcome.

Novel Modification of HeartMate 3 Implantation.

We have modified the HeartMate 3 (Abbott, Abbott Park, IL) implantation technique to better suit our patient population. This modification optimizes the placement of the HeartMate 3 sewing cuff and allows passage of the suture transmurally from endocardium to epicardium in a "cut then sew" technique. We believe this affords a superior seal and protection from tearing friable myocardium.

Does routine uniportal thoracoscopy during rib fixation identify more injuries and impact outcomes?

BACKGROUND: Flail chest and severely displaced rib fractures due to blunt trauma can be associated with intrathoracic injuries. At our institution, two thoracic surgeons perform all surgical stabilization of rib fractures (SSRF): one performs routine uniportal thoracoscopy (R-VATS) at the time of SSRF and the other for only select cases (S-VATS). In this pilot study, we hypothesized that R-VATS at the time of SSRF identifies and addresses intrathoracic injuries not seen on imaging and may impact patient outcomes. METHODS: A retrospective review of all patients who underwent SSRF from 2013-2019 at our institution was performed for severely displaced rib fractures or flail chest. Data collected included demographics, imaging results, treatment strategy, and operative findings. RESULTS: Ninety-nine patients underwent SSRF. Uniportal thoracoscopy was performed on 69% of these patients. When thoracoscopy was performed, 31 additional injuries were identified. R-VATS identified 23 additional intrathoracic findings at time of thoracoscopy not seen on CT scan compared to 8 findings in the S-VATS group (P=0.367). At 3 months follow-up, one empyema and one diaphragmatic hernia required reoperation-neither of which underwent thoracoscopy at time of SSRF. There were no differences in LOS, operative times, and overall mortality between the SSRF/thoracoscopy and SSRF only groups. CONCLUSIONS: R-VATS at the time of SSRF did not identify a statistically significant greater number of occult intrathoracic injuries compared to S-VATS. R-VATS was not associated with increased operative time, LOS, and mortality. Further study is needed to determine if there is benefit to R-VATS in patients meeting requirements for rib fracture repair.

Inflammatory State After Intrathoracic Breast Implant Placement for Postpneumonectomy Syndrome.

We describe a case of a 16-year-old patient who underwent right pneumonectomy for pulmonary vein atresia and developed postpneumonectomy syndrome. She had an 800-cm3 saline-filled silicone tissue expander placed in the right hemithorax with resolution of her postpneumonectomy syndrome. However, 2 years later, she developed fevers, night sweats, and arthralgias. Her medical workup was negative for vasculitis, inflammatory bowel disease, and infectious etiologies. She underwent tissue expander removal, resulting in resolution of her symptoms. This report describes a case of an inflammatory state created by a tissue expander placed for postpneumonectomy syndrome.

A High-Fidelity, Tissue-Based Simulation for Cardiac Transplantation.

Several operations in cardiothoracic surgery have been accurately modeled with tissue-based simulations. These have been shown to be beneficial in the training of residents. Cardiac transplantation has not been simulated. We describe a high-fidelity, tissue-based simulation that can be used to teach trainees to perform a cardiac transplant. We modified the existing Ramphal Cardiac Surgery Simulator to accommodate cardiac transplantation. An attending cardiac surgeon successfully performed the simulated transplant, demonstrating each of the component tasks of the operation. We believe our simulation will enhance the training of cardiothoracic surgery residents.

Decreased Time from 9-1-1 Call to PCI among Patients Experiencing STEMI Results in a Decreased One Year Mortality.

BACKGROUND: The impact on mortality due to prompt recognition of ST-segment Elevation Myocardial Infarction (STEMI) patients by EMS has not been well described. The objective of this study was to describe the association between the time interval, 9-1-1 call to percutaneous intervention (PCI), and mortality at one year. METHODS: This retrospective analysis included patients that were transported by EMS as a "code STEMI" and underwent PCI.  Total time from 9-1-1 call to PCI was calculated for each patient and was the independent variable of interest. Each patient's mortality status at one year was the outcome variable, collected by querying medical records and the national death index. Confounding variables were abstracted from hospital records. Logistic regression was conducted to determine the likelihood of survival given differences in time to PCI. RESULTS: A total of 550 patients were included in the analyses of which 68% were male with an average age 59.8 (SD 12.8). Mean reperfusion time was 81.8 min (SD 20.0) and was significantly lower in patients alive at one year (80.8 min, SD 19.7) vs. deceased at one year (93.9 min, SD 19.6), respectively. Odds of survival at one year decreased by 3% (OR 0.97; 95% CI 0.96-0.99) for every one minute increase in time to PCI. This relationship practically represents a 30% increase in mortality for every 10 minute delay from 9-1-1 call to PCI. CONCLUSION: The model produced suggests that a linear relationship exists between time to PCI and mortality in the prehospital environment with the probability of survival decreasing significantly as time to PCI increases.