A tool to predict disparities in the timeliness of surgical treatment for breast cancer patients in the USA.

PURPOSE: Breast cancer outcomes are impaired by both delays and disparities in treatment. This study was performed to assess their relationship and to provide a tool to predict patient socioeconomic factors associated with risk for delay. METHODS: The National Cancer Database was reviewed between 2004 and 2017 for patients with non-metastatic breast cancer managed with upfront surgery. Times to treatment were measured from the date of diagnosis. Patient, tumor, and treatment factors were assessed with attention paid to sociodemographic variables. RESULTS: 514,187 patients remained after exclusions, with 84.3% White, 10.8% Black, 3.7% Asian, and Hispanics comprising 5.6% of the cohort. Medicaid and uninsured patients had longer mean adjusted time to surgery (≥ 46 days) versus private (36.7 days), Medicare (35.9 days), or other governmental insurance (39.8 days). After adjustment, Black race and Hispanic ethnicity were most impactful, adding 6.0 and 6.4 preoperative days, 10.9 and 11.5 days to chemotherapy, 11.1 and 9.1 days to radiation, and 12.5 and 8.9 days to endocrine therapy, respectively. Income, education, and insurance, among other factors, also affected delay. A nomogram, including race and sociodemographic factors, was created to predict the risk of preoperative delay. CONCLUSION:  Significant disparities exist in timeliness of care for factors, including but not limited to, race and ethnicity. Although exact causes cannot be discerned, these data indicate population subsets whose intervals of care risk being longer than those specified by national quality standards. The nomogram created here may help direct resources to those at highest risk of incurring a treatment delay.

Medical-grade Honey as an Alternative to Surgery: A Case Series.

INTRODUCTION: Modern wound management continues to present new challenges. Many patients elect to forego operative debridement secondary to high risk, fear, cost concerns, and personal ideologies on healing. Although operative debridement has long been a tenet of proper wound care, alternative innovative approaches to wound management must be considered. OBJECTIVE: This case series describes the successful outcomes of 12 patients with dissimilar wounds who were managed with medical-grade honey (active Leptospermum honey [ALH]) as an alternative to surgery. MATERIALS AND METHODS: A case series was identified from clinical experience, chart review, and photographic documentation of all patients evaluated by the acute wound care service. To be included, patients had to decline the recommendation of operative debridement or skin grafting, utilize ALH as an alternative to surgery, and have regular follow-up visits. RESULTS: Twelve patients with complex wounds were identified and included in this case series. Five patients were considered high risk for surgery due to comorbidities. Seven patients were at low risk for surgery but desired to avoid operative procedures. The use of ALH facilitated autolytic debridement and healing without surgery or hospital readmission. CONCLUSIONS: The properties of ALH include autolytic debridement, bacterial growth inhibition, anti-inflammatory mediation, and cytokine release, making it a viable option for wound management for patients with contraindications to surgery. However, surgical debridement should remain a tenet of wound care in appropriate patients.

Combination therapy with PTH and DBM cannot heal a critical sized murine femoral defect.

Orthopaedic surgeons continue to search for cost-effective bone graft substitutes to enhance bone repair. Teriparatide (PTH 1-34) and demineralized bone matrix (DBM) have been used in patients to promote bone healing. We evaluated the efficacy of PTH and DBM in healing a critical sized femoral defect in three lineage-specific transgenic mice expressing Col3.6GFPtopaz (pre-osteoblastic marker), Col2.3GFPemerald (osteoblastic marker) and α-SMA-Cherry (pericyte/myofibroblast marker). Mid-diaphyseal defects measuring 2 mm in length were created in the central 1/3 of mice femora using a circular saw and stabilized with an alveolar distractor device and cerclage wires. Three groups were evaluated: Group I, PTH 30 µg/kg injection daily, Group II, PTH 30 µg/kg injection daily + DBM, and Group III, DBM + 30µL saline injection. PTH was given for 28 days or until the time of sacrifice. Animals were sacrificed at 7, 14, 28, and 56 days. Radiographs at the time of sacrifice were evaluated using a 5-point scaled scoring system. Radiographs showed a lack of healing across all treatment groups at all time points: Group I, 1.57 +/- 0.68; Group II, 3.00 +/- 1.29; and Group III, 2.90 +/- 1.03. Bone formation in the defect as measured by radiographic healing score was significantly better at 56 days in Groups II (p = 0.01) and III (p < 0.01) compared to Group I. Across all treatment groups and time points the defects were largely absent of osteoprogenitor cells based on gross observation of frozen histology and quantitation of cellular based histomorphometric parameters. Quantitation of frozen histologic slides showed a limited osteoprogenitor response to PTH and DBM. Our results suggest that the anabolic agent teriparatide is unable to induce healing in a critical sized mouse femoral defect when given alone or in combination with the DBM preparation we used as a local bone graft substitute.

Is an Incidental Meckel's Diverticulum Truly Benign?

Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract and it is found to affect nearly 2 percent of the population. Interestingly, the surgical management of an asymptomatic Meckel's diverticulum remains widely controversial in the adult population. Review of the literature finds the overall risk of Meckel's diverticulum becoming symptomatic to be low; however, the risk accompanying its resection also proves to be minimal thus perpetuating the question of its proper management. We report our experience with an elderly patient who required an emergent operative intervention and was incidentally found to have Meckel's diverticulum. Review of final pathology found Meckel's diverticulum to contain a carcinoid tumor. In our review, the presence of a carcinoid tumor within Meckel's diverticulum is a rare finding, but its incidence may further support the resection of incidentally found asymptomatic Meckel's diverticulum in patients of all ages.

Utility of early postoperative radiographs after posterior spinal fusion for adolescent idiopathic scoliosis.

STUDY DESIGN: Retrospective. OBJECTIVE: Evaluate the ability of serial full-length spine radiographs to detect clinically significant implant-related (IR) and non-implant-related (NIR) radiographical abnormalities in the first 6 months after routine posterior spinal fusion for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Patients with AIS are exposed to repeated doses of ionizing radiation during the course of their treatment with potential consequences for their long-term health. Postoperative algorithms for AIS often involve frequent standing plain radiographs during the first 6 months after surgery to detect IR and NIR abnormalities that may impact a patient's clinical course. However, the actual clinical utility of such repeated spine radiographs has not been studied. METHODS: Retrospective chart and radiographical review was conducted at a single institution for patients with AIS after posterior spinal fusion between 2007 and 2012. Radiographical abnormalities identified on full-length spine radiographs or additional imaging modalities in the first 6 postoperative months were grouped into IR or NIR findings. The findings were considered clinically significant if they resulted in a deviation from an anticipated postoperative course or additional interventions. RESULTS: For 129 patients, 761 full-length spine radiographs were obtained in the first 6 postoperative months. Eight patients (11 radiographs) had IR or NIR abnormalities, with only 2 of these considered clinically significant. Seven of the remaining 121 were identified to have IR or NIR abnormalities using other imaging modalities, with 2 considered clinically significant. The sensitivity and specificity of a full-length spine radiograph for detecting a clinically significant abnormality was 50% and 95%, respectively. CONCLUSION: Routine full-length spine radiographs used with high frequency in the first 6 months after posterior spinal fusion rarely detected a radiographical abnormality that resulted in a meaningful change to a patient's clinical management. Blanket postoperative screening algorithms should be reconsidered to minimize patient radiation exposure.

Conformational analysis of 6α- and 6ß-naltrexol and derivatives and relationship to opioid receptor affinity.

Naltrexol and its C6 α and ß desoxy, iodo, mesyl, tosyl, trifyl, dimethylcarbamyl, and diphenylcarbamyl derivatives were studied in their energy-minimized C ring chair-like and boat-like conformations using B3LYP/6-31G** and SM5.4/A to estimate aqueous solvation free energy. The results were compared to experimental opioid receptor binding affinities. The total energy difference between ß conformers correlated well with MOR binding affinity, while the aqueous solvation free energy correlated well with the KOR binding affinity.