The Cost Does Not Outweigh the Benefit: Pathologic Evaluation of Wrist Ganglion Cysts Should Not Be Routine.

BACKGROUND: As health care costs in the United States continue to rise, there is increasing attention on cost-saving measures. One area of investigation is the utility of pathologic examination of specimens from routine procedures with a suspected benign pathology. We assessed the utility and cost of routine pathologic analysis for wrist ganglion cyst excision. METHODS: A retrospective cohort study of all wrist ganglion cyst excisions performed by seven hand surgeons was conducted from 2015 to 2019 at Penn State Hershey Medical Center. Preoperative and intraoperative diagnoses, pathologic diagnosis, and pathology cost were assessed. RESULTS: A total of 407 patients underwent ganglion cyst excision, with 318 (78.1%) specimens sent for pathologic review. Of the 318, 317 (99.6%) specimens were concordant with the preoperative or intraoperative diagnosis of ganglion cyst. One specimen (0.3%) resulted as a benign cystic vascular malformation. The charge per specimen was $258, totaling $81,786 spent confirming benign pathology that was clinically correctly diagnosed by the operating surgeon in 99.6% of cases. CONCLUSIONS: Routine pathologic analysis is not indicated in cases in which surgeons have a high clinical suspicion for ganglion cyst based on preoperative and intraoperative findings. Pathologic review should be reserved for cases with atypical presentations or intraoperative findings.

Breast Cancer Survival in Eastern Region of Ghana.

Objective: Five-year overall survival rate of breast cancer in low-income countries (LICs) is significantly lower than in high-resource countries. This study explored clinical and pathological factors influencing mortality in the Eastern region of Ghana. Methods: We performed a retrospective medical chart review for patients undergoing surgery and chemotherapy for breast cancer at a regional hospital in Ghana from January 2014 to January 2017. Descriptive and survival analysis was done. Results: One hundred and twenty-nine patients were included in the study. The median age at presentation was 51 years. Sixty percent of patients presented with poorly differential histological grade III. The most common histological type was invasive ductal carcinoma (83%). Based on stage assessment using only tumor size and lymph node status, 60% presented at stage 3. Only 25% were tested for hormone receptor proteins and HER2 status. Of these, 57% had triple-negative breast cancer (TNBC). The 3-year overall survival rate was only 52%. Conclusion: The cumulative 3-year survival was 52%. Despite success in reducing cancer mortality in northern Africa, survival in sub-Saharan Africa remains poor. A significantly higher percentage of GIII and TNBC is found in breast cancers seen in Ghana. When combined with limited capacity for accurate diagnosis, cancer subtype analysis, adequate therapy, and follow-up, late-stage presentation leads to poor outcomes. Future studies should emphasize the identification of barriers to care and opportunities for cost-effective and sustainable improvements in diagnosing and treating breast cancer in LICs.

Morphological Analysis of Metacarpal Shafts With Respect to Retrograde Intramedullary Headless Screw Fixation.

Background: The use of retrograde intramedullary headless compression screw fixation for metacarpal neck and shaft fractures has been described in the literature. The purpose of this study was to perform a computed tomography (CT)-based morphological analysis of metacarpal size to help surgeons anticipate expected hardware needs. Methods: In all, 108 consecutive hand CT scans were evaluated for the medullary diameter in the volar-dorsal and radial-ulnar planes at the narrowest point of the canal, as well as for the distance from the articular surface to this point. Results were then analyzed by finger and by sex. Results: The ring finger had the smallest average medullary canal diameter for both men and women (2.7 and 2.6 mm, respectively); the small finger had the largest average diameter (3.9 mm) for men and the middle finger (3.6 mm) for women. Radial-ulnar was the rate-limiting dimension in the index, middle, and ring fingers, whereas volar-dorsal was the smallest dimension in the small finger, regardless of sex. Medullary diameter tended to be larger in patients aged more than 50 years. More than 50% of fingers have diameters >3.0 mm, and at least 40% of index, middle, and small fingers have diameters >3.5 mm, which are common diameters of commercially available headless compression screws. Conclusions: When preparing to perform open reduction internal fixation of a metacarpal using retrograde intramedullary headless compression screws, the surgeon needs to be prepared with screws of larger diameters to optimize fixation. Screws of larger diameters are needed to achieve endosteal purchase, regardless of sex.

Epidemiology and Perioperative Mortality of Exploratory Laparotomy in Rural Ghana.

Background: Perioperative mortality rate (POMR) has been identified as an important measure of access to safe surgical and anesthesia care in global surgery. There has been limited study on this measure in rural Ghana. In order to identify areas for future quality improvement efforts, we aimed to assess the epidemiology of exploratory laparotomy and to investigate POMR as a benchmark quality measure. Methods: Surgical records were reviewed at a regional referral hospital in Eastern Region, Ghana to identify cases of exploratory laparotomy from July 2017 through June 2018. Patient demographics, health information, and outcomes data were collected. Logistic regression was used to identify predictors of perioperative mortality. Findings: The study included operations for 286 adult and 60 pediatric patients. Only 60% of patients were covered by National Health Insurance (NHI). The overall POMR was 11.5% (12.6% adults; 6.7% pediatric). Sixty percent of mortalities were referrals from outside hospitals and the mortality rate for referrals was 13.5%. Odds of mortality was 13 times greater with perforated peptic ulcer disease (OR = 13.1, p = 0.025) and 12 times greater with trauma (OR = 11.7, p = 0.042) when compared to the most common operation. Female sex (OR = 0.3, p = 0.016) and NHI (OR = 0.4, p = 0.031) were protective variables. Individuals 60 years and older (OR = 3.3, p = 0.016) had higher mortality. Conclusion: POMR can be an important outcome and quality indicator for rural populations. Interventions aimed at decreasing emergent hernia repair, preventing perforation of peptic ulcer disease, improving rural infrastructure for response to major trauma, and increasing NHI coverage may improve POMR in rural Ghana.

Regional, racial, gender, and tumor biology disparities in breast cancer survival rates in Africa: A systematic review and meta-analysis.

BACKGROUND: The survival rates from breast cancer in Africa are poor and yet the incidence rates are on the rise. In this study, we hypothesized that, in Africa, a continent with great disparities in socio-economic status, race, tumor biology, and cultural characteristics, the survival rates from breast cancer vary greatly based on region, tumor biology (hormone receptor), gender, and race. We aimed to conduct the first comprehensive systematic review and meta-analysis on region, gender, tumor-biology and race-specific 5-year breast cancer survival rates in Africa and compared them to 20-year survival trends in the United States. METHODS: We searched MEDLINE, EMBASE, and Cochrane Library to identify studies on breast cancer survival in African published before October 17, 2018. Pooled 5-year survival rates of breast cancer were estimated by random-effects models. We explored sources of heterogeneity through subgroup meta-analyses and meta-regression. Results were reported as absolute difference (AD) in percentages. We compared the survival rates of breast cancer in Africa and the United States. FINDINGS: There were 54 studies included, consisting of 18,970 breast cancer cases. There was substantial heterogeneity in the survival rates (mean 52.9%, range 7-91%, I2 = 99.1%; p for heterogeneity <0.0001). Meta-regression analyses suggested that age and gender-adjusted 5-year survival rates were lower in sub-Saharan Africa compared to north Africa (AD: -25.4%; 95% CI: -34.9 - -15.82%), and in predominantly black populations compared to predominantly non-black populations (AD: -25.9%; 95% CI: 35.40 - -16.43%). Survival rates were 10 percentage points higher in the female population compared to male, but the difference was not significant. Progesterone and estrogen receptor-positive breast cancer subtypes were positively associated with survival (r = 0.39, p = 0.08 and r = 0.24, p = 0.29 respectively), but triple-negative breast cancer was negatively associated with survival. Survival rates are increasing over time more in non-black Africans (55% in 2000 versus 65% in 2018) compared to black Africans (33% in 2000 versus 40% in 2018); but, the survival rates for Africans are still significantly lower when compared to black (76% in 2015) and white (90% in 2015) populations in the United States. CONCLUSION: Regional, sub-regional, gender, and racial disparities exist, influencing the survival rates of breast cancer in Africa. Therefore, region and race-specific public health interventions coupled with prospective genetic studies are urgently needed to improve breast cancer survival in this region.