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BackgroundTextbook oncologic outcome (TOO) is a composite outcome measure realized when all desired short-term quality metrics are met after an oncologic operation. This study examined the incidence and impact of achieving a TOO among patients undergoing resection of gastric adenocarcinoma.MethodsThe 2004–2016 National Cancer Database was queried for patients who underwent curative gastrectomy. Textbook oncologic outcome was defined as having met five metrics: R0 resection, American Joint Committee on Cancer-compliant lymph node evaluation (n ≥ 15), no prolonged hospital stay (< 75th percentile by year), no 30-day readmission, and receipt of guideline-accordant systemic therapy.ResultsOf 34,688 patients identified, 8249 (23.8 %) achieved TOO. The patients for whom TOO was achieved were more likely to have traveled farther (p < 0.001) and received care in an academic (p < 0.001) or very high case-volume facility (p < 0.001). The TOO group had a significanty higher median overall survival (OS) than the non-TOO group (80.5 vs 35.3 months; p < 0.001). The Kaplan-Meier curve showed that at 12 months, the survival probability estimate was 92 % for the TOO group versus 77 % for the non-TOO group. At 60 months (long-term survival), survival probability estimates remained higher for the TOO group (57 % vs 38 %). The results of the multivariate Cox regression model found that TOO attainment was significantly associated with a reduced risk of death (hazard ratio, 0.82; p < 0.001).ConclusionThe TOO measure is associated with improved OS and reduced risk of death after gastrectomy for gastric adenocarcinoma. Unfortunately, in this study, TOO was obtained in only 23.8 % of cases.

The novel coronavirus disease 2019 (COVID-19) continues to be a major public health concern. The aim of this study was to describe the presenting characteristics, epidemiology and predictors of outcomes among confirmed COVID-19 cases seen at a large community healthcare system which serves the epicenter and diverse region of Florida. We conducted a retrospective analysis of individuals with lab-confirmed SARS-CoV-2 infection who were seen, from March 2, 2020 to May 31, 2020, at Memorial Healthcare System in South Florida. Data was extracted from a COVID-19 registry of patients with lab-confirmed SARS-CoV-2 infection. Univariate and backward stepwise multivariate logistic regression models were used to determine predictors of key study outcomes. There were a total of 1692 confirmed COVID-19 patients included in this study. Increasing age was found to be a significant predictor of hospitalization, 30-day readmission and death. Having a temperature of 38 °C or more and increasing comorbidity score were also associated with an increased risk of hospitalization. Significant predictors of ICU admission included having a saturated oxygen level less than 90%, hypertension, dementia, rheumatologic disease, having a respiratory rate greater than 24 breaths per minute. Being of Hispanic ethnicity and immunosuppressant utilization greatly increased the risk of 30-day readmission. Having an oxygen saturation less than 90% and an underlying neurological disorder were associated with an increased likelihood of death. Results show that a patient’s demographic, underlying condition and vitals at triage may increase or reduce their risk of hospitalization, ICU admission, 30-day readmission or death.

Context Cholangiocarcinoma (CCA), a malignancy of the biliary tract epithelium is of increasing importance due to its rising incidence worldwide. There is a lack of data on cirrhosis in intrahepatic CCA (iCCA) and how it affects overall survival and prognosis. Objectives The primary objective of this study was to examine if there were differences in survival outcomes between iCCA patients with concomitant cirrhosis and those without cirrhosis. Methods The National Cancer Database (NCDB) was used to identify and study patients with iCCA from 2004 to 2017. The presence of cirrhosis was defined using CS Site-Specific Factor 2 where 000 indicated no cirrhosis and 001 indicated the presence of cirrhosis. Descriptive statistics were utilized for patient demographics, disease staging, tumor, and treatment characteristics. Kaplan-Meier (KM) method with log-rank test and a multivariate logistic regression model was used to assess if the presence of cirrhosis in iCCA was associated with survival status and long-term survival (60 or more months after diagnosis). Results There were 33,160 patients with CCA in NCDB (2004–2017), of which 3644 patients were diagnosed with iCCA. One thousand fifty-two patients (28.9%) had cirrhosis as defined by Ishak Fibrosis score 5–6 on biopsy and 2592 patients (71.1%) did not meet the definition for cirrhosis. Although in univariate analyses using KM/log-rank tests showed a survival advantage for non-cirrhotic patients, there was no statistically significant association found between cirrhosis and survival status (OR = 0.82, p  = 0.405) or long-term survival (OR = 0.98, p  = 0.933) when multivariate analysis was used. iCCA patients with cirrhosis and Stage 1 tumor had the highest median OS (132 months) vs 73.7 months in the non-cirrhotic arm, while patients with stage IV disease who had cirrhosis had half the survival time of those without. Our data thus indicates that the presence of cirrhosis is not an independent prognostic factor for survival.

To assess the evolving standards of care for hyperparathyroidism in kidney transplant candidates. An 11-question, Institutional Review Board-approved survey was designed and reviewed by multiple institutions. The questionnaire was made available to the American Society of Transplantation's Kidney Pancreas Community of Practice membership via their online hub from April through July 2019. Twenty percent (n = 41) of kidney transplant centers responded out of 202 programs in the United States. Forty-one percent (n = 17) of respondents believed medical literature supports the concept that a serum parathyroid hormone level greater than 800 pg/mL could endanger the survival of a transplanted kidney and therefore makes transplantation in an affected patient relatively or absolutely contraindicated. Sixty-six percent (n = 27) said they occasionally recommend parathyroidectomy for secondary hyperparathyroidism prior to transplantation, and 66% (n = 27) recommend parathyroidectomy after transplantation based on persistent, unsatisfactory posttransplantation parathyroid hormone levels. Forty-six percent (n = 19) prefer subtotal parathyroidectomy as their choice; 44% (n = 18) had no standard preference. Endocrine surgery and otolaryngology were the most common surgical specialties consulted to perform parathyroidectomy in kidney transplant candidates. The majority of respondents (71%, n = 29) do not involve endocrinologists in the management of kidney transplantation candidates. Our survey shows wide divergence of clinical practice in the area of surgical management of kidney transplantation candidates with hyperparathyroidism. We suggest that medical/surgical societies involved in the transplantation care spectrum convene a multidisciplinary group of experts to create a new section in the kidney transplantation guidelines addressing the collaborative management of parathyroid disease in transplantation candidates. = American Association of Clinical Endocrinologists; = American Association of Endocrine Surgeons; = American Head and Neck Society; = chronic kidney disease; = chronic kidney disease-mineral and bone disorder; = end-stage renal disease; = hyperparathyroidism; = Kidney Disease Improving Global Outcomes; = kidney transplantation; = kidney transplant candidate; = parathyroid hormone; = parathyroidectomy; = ultrasonography.

AbstractObjectiveUnlike randomized controlled trials, practical real‐world studies can offer important information about implementation of prehospital interventions, particularly in community settings where there may be reluctance to adopt new practices. We present the results of a natural experiment that was driven by mandated COVID‐19 pandemic‐driven shift from endotracheal intubation (ETI) to the i‐gel® supraglottic airway (SGA) as a primary advanced airway management device in the prehospital setting to reduce emergency medical services (EMS) personnel exposure to potentially infectious secretions. The objective was to compare first‐pass success and timing to successful airway placement between ETI and the i‐gel® SGA under extenuating circumstances. MethodsThis pre/post study compared airway placement metrics in prehospital patients requiring advance airway management for non‐trauma‐related conditions. Data from EMS records were extracted over 2 years, 12 months pre‐pandemic, and 12 months post‐pandemic. During the pre‐COVID‐19 year, the EMS protocols utilized ETI as the primary advanced airway device (ETI group). Post‐pandemic paramedics were mandated to utilize i‐gel® SGA as the primary advanced airway device to reduce exposure to secretions (SGA group). ResultsThere were 199 adult patients, 83 (42%) in the ETI group and 116 (58%) in the SGA group. First‐pass success was significantly higher with SGA 96% (92%–99%) than ETI 68% (57%–78%) with paramedics citing the inability to visualize the airway in 52% of ETI cases. Time to first‐pass success was significantly shorter in the SGA group (5.9 min [5.1–6.7 min]) than in the ETI group (8.3 min [6.9–9.6 min]), as was time to overall successful placement at 6.0 min (5.1–6.8 min) versus 9.6 min (8.2–11.1 min), respectively. Multiple placement attempts were required in 26% of ETI cases and 1% of the SGA cases. There were no statistically significant differences in the number and types of complications between the cohorts. Return of spontaneous circulation (on/before emergency department [ED] arrival), mortality at 28 days, intensive care unit length of stay, or ventilator‐free days between the groups were not statistically different between the groups. ConclusionIn this natural experiment, the SGA performed significantly better than ETI in first‐pass airway device placement success and was significantly faster in achieving first‐pass success, and overall airway placement, thus potentially reducing exposure to respiratory pathogens. Practical real‐world studies can offer important information about implementation of prehospital interventions, particularly in community settings and in systems with a low frequency of tracheal intubations.

Patient satisfaction is a key metric used to measure quality in health care. However, patient satisfaction measures in the pediatric population are less studied and understood than in the adult population. The purpose of this study was to evaluate the impact of telephone follow-up on patient satisfaction in an outpatient pediatric neurosurgery clinic. A standardized telephone follow-up call was performed within 1 week of a child’s clinic visit. Pearson’s χ2 or Fisher’s exact tests were used to assess changes in patient satisfaction measures after implementation of the telephone follow-up call initiative. The proportion of overall “top-box” physician rating significantly increased from 85.5% in 2017 to 95.6% in 2018 (P = .04). There was also a nonsignificant upward trend in the proportion of respondents noting that they would recommend this provider, as well as in all measures of physician communication quality and office staff quality. A simple telephone call to new patients after an outpatient pediatric neurosurgery clinic visit resulted in statistically significant and clinically meaningful changes in patient satisfaction scores.

BACKGROUND: Therapeutic hypothermia (TH) protects the infant's brain after hypoxic ischemic injury. Ongoing developmental therapies help support the brain recovery process. Currently, there is no standard of care for the involvement of therapists during TH in infants. The parental perspective on how to introduce therapies has not been evaluated. AIMS: The objective of this study was to evaluate current therapy practices across the United States and the parental perspective on therapy involvement for infants with hypoxic ischemic encephalopathy (HIE). STUDY DESIGN: Participants were recruited from the National Association of Neonatal Therapists and the parent support group, Hope for HIE, to complete anonymous surveys. Participants included US neonatal therapists and parents of infants, aged 6 to 24 months, with HIE. RESULTS: A total of 63 parents participated. Almost 70% of parents reported that therapists first met with them after magnetic resonance imaging (MRI). Over 75% said therapists did not attend conferences to discuss imaging and 73% did not think therapists used imaging to design a treatment plan. Most parents would have wanted to meet earlier (63% during TH vs 37% after). A total of 115 therapists participated. The majority (67%) reported that their institution did not have a standardized protocol. Over 60% believe that MRI results could help with treatment planning. Both parents and therapists felt that written and video educational materials would be of most value. CONCLUSION: There is variability in neonatal therapy service for infants undergoing TH according to survey respondents. Therapists who responded feel that standardized guidelines could improve care, as well as developing written and video materials for parent education. Parents who participated would have wanted to meet therapists earlier in treatment. Further research in this space would be beneficial to optimize care practices and parent experience.

The objective of this study was to determine the incidence of textbook oncologic outcome (TOO) and its impact on overall survival (OS) among patients with invasive ductal carcinoma (IDC) following modified radical mastectomy (MRM) versus MRM with contralateral prophylactic mastectomy (MRM ​+ ​CPM). The 2004–2017 National Cancer Database was queried for patients with IDC who underwent MRM and MRM ​+ ​CPM. TOO was defined as: resection with negative margins, adequate lymphadenectomy, length of stay ≤50th percentile, and no 30-day readmission or mortality. 87,573 patients were identified, of which 14.3% underwent MRM ​+ ​CPM. Logistic regression models revealed that MRM ​+ ​CPM is independently associated with a reduced likelihood of achieving TOO (AOR ​= ​0.71; P ​< ​0.001). MRM patients who achieved TOO had a higher median OS compared to those who did not (164.6 vs.142.2 months, P ​< ​0.001). MRM ​+ ​CPM is associated with a lower incidence of TOO attainment compared to MRM. •Textbook oncologic outcome (TOO) is attained when all desired short-term quality metrics are met after oncologic surgery.•Modified radical mastectomy (MRM) ​+ ​contralateral prophylactic mastectomy is associated with a lower incidence of TOO.•MRM patients who achieved TOO had a higher median overall survival compared to those who did not.