Cost drivers of locally advanced rectal cancer treatment-An analysis of a leading healthcare insurer.

To evaluate the economic burden of locally advanced rectal cancer (LARC) treatment from a society perspective through analysis of health insurance-derived data of commercially insured and Medicare Advantage (MA) patients. Retrospective cost analysis of patients undergoing rectal resection within a multimodal (neoadjuvant chemoradiation + adjuvant chemotherapy) treatment strategy between January 1, 2010 and October 31, 2018, using the claims OptumLabs Data Warehouse database. In total, 1738 (935 commercial and 803 MA) patients were included. Overall treatment costs totaled $230,881,746 (on average$183 653 ± 82 384 per commercially insured and $73 681 ± 32 917 per MA patient). Cost distribution according to category (commercially insured patients) was: 29.92% related to outpatient care (follow-up visits/diagnostics), radiotherapy: 21.83%, index resection: 20.62%, chemotherapy: 17.44%, surgical inpatient: 6.32%, medical inpatient: 3.28%, emergency room: 0.58%. Relative cost distribution of the index resection itself differed marginally between the three approaches and was 21.49% for open, 19.30% for laparoscopic, and 20.93% for robotic surgery. Relative cost distributions of neoadjuvant, adjuvant, and outpatient treatments remained unchanged, independently of the surgical approach. This representation was similar in MA patients. Index-surgery related costs were outweighed by costs related to oncological and outpatient workup/follow-up treatments independently of both surgical approach and insurance type

Trends of complications and innovative techniques' utilization for colectomies in the United States.

Despite an increasing trend towards utilization of minimally invasive approaches (MIS), results regarding their safety profile are contradictory. All patients who underwent elective colectomy for any underlying disease with an identifiable operative approach available from the targeted colectomy files of the ACS-NSQIP PUFs 2013 to 2018 were included. The trend of utilization and complication rates of the different operative approaches (open, laparoscopic, robotic) were assessed during the inclusion period. Furthermore, overall, surgical, and medical complications were compared between the three approaches. The study cohort included 78,987 patients. Of them, 12,335 (15.6%) patients underwent open, 57,874 (73.3%) laparoscopic, and 8,778 (11.1%) robotic surgery. There was an increasing trend towards the utilization of robotic surgery (2.5% increase per year) at the expense of the other approaches. With the increasing trend toward the utilization of the robotic approach, a decreasing trend in overall and surgical complications and length of stay was observed. After adjusting for the baseline confounders, robotic surgery was associated with shorter length of stay, lower rate of overall (OR 0.397; p < 0.05 compared to open and OR: 0.763; p < 0.05 compared to laparoscopy) and surgical complications (OR: 0.464; p < 0.05 compared to open and OR: 0.734; p < 0.05 compared to laparoscopy). This study revealed an increasing trend toward the utilization of MIS for elective colectomy in the US. Robotic surgery was associated with a decreasing trend in overall and surgical morbidity and length of stay

Oral Antibiotics Bowel Preparation Without Mechanical Preparation For Minimally Invasive Colorectal Surgeries: Current Practice And Future Prospects.

The efficacy of preoperative oral antibiotics alone compared to mechanical bowel preparation and oral antibiotics in minimally invasive surgery is still a matter of ongoing debate. This study aimed to assess the trend of surgical site infection rates in parallel to the utilization of bowel preparation modality over time for minimally invasive surgery colorectal surgeries in the United States. Retrospective analysis. The American College of Surgeons National Surgical Quality Improvement Program database. Adult patients who underwent elective colorectal surgery and reported bowel preparation modality. The trends and compare surgical site infection rates for mutually exclusive groups according to the underlying disease (colorectal cancer, inflammatory bowel disease, and diverticular disease) who underwent bowel preparation using oral antibiotics or combined mechanical bowel preparation and oral antibiotics. Patients who had rectal surgery were analyzed separately. A total of 30,939 patients were included. Of them, 12,417 (40%) had rectal resections. Over the seven-year study period, mechanical bowel preparation and oral antibiotics utilization has increased from 29.3% in 2012 to 64.0% in 2018; p<0.0001 at the expense of no preparation and mechanical bowel preparation alone. Similarly, oral antibiotics utilization has increased from 2.3% in 2012 to 5.5% in 2018; p<0.0001. For colon cancer patients, patients who had oral antibiotics alone had higher superficial surgical site infection rates compared to patients who had combined mechanical bowel preparation and oral antibiotics (1.9% vs. 1.1%; p=0.043). Superficial, deep and organ space surgical site infection rates were similar for all other comparative colon surgery groups (cancer, inflammatory bowel disease, and diverticular disease). Patients with rectal cancer who had oral antibiotics had higher rates of deep surgical site infection (0.9% vs. 0.1%; p=0.004). However, superficial, deep and organ space surgical site infection rates were similar for all other comparative rectal surgery groups. Retrospective nature of the analysis. This study revealed widespread adoption of mechanical bowel preparation and oral antibiotics mechanical bowel preparation and oral antibiotics and increased adoption of oral antibiotics over the study period. Surgical site infection rates appear to be similar from a clinical relevance standpoint among most comparative groups, questioning systematic preoperative addition of mechanical bowel preparation to oral antibiotics alone in all patients for minimally invasive colorectal surgery. See Video Abstract at http://links.lww.com/DCR/B828

Social Dimensions of Urban Flood Experience, Exposure, and Concern

With growing urban populations and climate change, urban flooding is an important global issue, even in dryland regions. Flood risk assessments are usually used to identify vulnerable locations and populations, flooding experience patterns, or levels of concern about flooding, but rarely are all of these approaches combined. Furthermore, the social dynamics of flood concerns, exposure, and experience are underexplored. We combined geographic and survey data on household‐level measures of flood experience, concern, and exposure in Utah\u27s urbanizing Wasatch Front. We asked: (1) Are socially vulnerable groups more likely to be exposed to flood risk? (2) How common are flooding experiences among urban residents, and how are these experiences related to sociodemographic characteristics and exposure? and (3) How concerned are urban residents about flooding, and does concern vary by exposure, flood experience, and sociodemographic characteristics? Although floodplain residents were more likely to be White and have higher incomes, respondents who were of a racial/ethnic minority, were older, had less education, and were living in floodplains were more likely to report flood experiences and concern about flooding. Flood risk management approaches need to address social as well as physical sources of vulnerability to floods and recognize social sources of variation in flood experiences and concern

Survival impact of adjuvant chemotherapy in patients with stage IIA colon cancer: Analysis of the National Cancer Database.

Utility of adjuvant chemotherapy for stage II cancer remains a matter of debate. Clinical guidelines suggest adjuvant chemotherapy for stage II tumors with high-risk features, in particular T4 tumors. However, limited consensus exists regarding the importance of other high-risk features (lymphovascular or perineural invasion, microsatellite instability). Our study aimed to investigate the impact of adjuvant chemotherapy for stage IIA (T3N0) colon cancer patients. Patients who underwent colectomy for stage IIA colon adenocarcinoma (2010-2015) were identified in the National Cancer Database (NCDB) and divided in two groups based on receipt of adjuvant chemotherapy vs observation. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox proportional hazards regression analyses were performed to compare overall survival between the two groups. Subgroup analysis of patients with specific high-risk features LVI, PNI and MSI was performed. Among 46 688 surgical patients with stage IIA colon adenocarcinoma 5937 (12.7%) received adjuvant chemotherapy, while 40 751 (87.3%) were observed. Five-year IPTW-adjusted survival was higher in the adjuvant chemotherapy group (79.7% [95% CI 79.1, 80.2]) compared to the observation group (70.3% [95% CI 69.7, 70.9]). Patients with high-risk pathological features showed an estimated 5-year survival benefit of 11.3% (78.2% [95% CI 77.4, 79.1] vs 66.9% [95% CI 65.9, 67.8]) when treated with adjuvant chemotherapy. This NCDB analysis revealed a survival benefit for patients with stage IIA colon adenocarcinoma and high-risk features that were treated with adjuvant chemotherapy

Readmissions Within 48 Hours of Discharge: Reasons, Risk Factors, and Potential Improvements.

Hospital readmission rate is an important quality metric and has been recognized as a key measure of hospital value-based purchasing programs. This study aimed to assess the risk factors for hospital readmission with a focus on potentially preventable early readmissions within 48 hours of discharge. This is a retrospective cohort study. This study was conducted at a tertiary academic facility with a standardized enhanced recovery pathway. Consecutive patients undergoing elective major colorectal resections between 2011 and 2016 were included. Univariable and multivariable risk factors for overall and early (<48 hours) readmissions were identified. Specific surgical and medical reasons for readmission were compared between early and late readmissions. In total, 526 of 4204 patients (12.5%) were readmitted within 30 days of discharge. Independent risk factors were ASA score (≥3; OR, 1.5; 95% CI, 1.1-2), excess perioperative weight gain (OR, 1.7; 95% CI, 1.3-2.3), ileostomy (OR, 1.4; 95% CI, 1-2), and transfusion (OR, 2; 95% CI, 1.4-3), or reoperation (OR, 11.4; 95% CI, 7.4-17.5) during the index stay. No potentially preventable risk factor for early readmission (128 patients, 24.3% of all readmissions, 3% of total cohort) was identified, and index hospital stay of ≤3 days was not associated with increased readmission (OR, 0.9; 95% CI, 0.7-1.2). Although ileus and small-bowel obstruction (early: 43.8% vs late: 15.5%, p < 0.001) were leading causes for early readmissions, deep infections (3.9% vs 16.3%, p < 0.001) and acute kidney injury (0% vs 5%, p = 0.006) were mainly observed during readmissions after 48 hours. Risk of underreporting due to loss of follow-up and the potential co-occurrence of complications were limitations of this study. Early hospital readmission was mainly due to ileus or bowel obstruction, whereas late readmissions were related to deep infections and acute kidney injury. A suspicious attitude toward potential ileus-related symptoms before discharge and dedicated education for ostomy patients are important. A short index hospital stay was not associated with increased readmission rates. See Video Abstract at http://links.lww.com/DCR/B237. REINGRESOS DENTRO DE LAS 48 HORAS POSTERIORES AL ALTA: RAZONES, FACTORES DE RIESGO Y POSIBLES MEJORAS: La tasa de reingreso hospitalario es una métrica de calidad importante y ha sido reconocida como una medida clave de los programas hospitalarios de compras basadas en el valor.Evaluar los factores de riesgo para el reingreso hospitalario con énfasis en reingresos tempranos potencialmente prevenibles dentro de las 48 horas posteriores al alta.Estudio de cohorte retrospectivo.Institución académica terciaria con programa de recuperación mejorada estandarizado.Pacientes consecutivos sometidos a resecciones colorrectales mayores electivas entre 2011 y 2016.Se identificaron factores de riesgo uni y multivariables para reingresos totales y tempranos (<48 horas). Se compararon razones médicas y quirúrgicas específicas para el reingreso entre reingresos tempranos y tardíos.En total, 526/4204 pacientes (12,5%) fueron readmitidos dentro de los 30 días posteriores al alta. Los factores de riesgo independientes fueron puntuación ASA (≥3, OR 1.5; IC 95% 1.1-2), aumento de peso perioperatorio excesivo (OR 1.7; IC 95% 1.3-2.3), ileostomía (OR 1.4, IC 95%: 1-2) y transfusión (OR 2, IC 95% 1.4-3) o reoperación (OR 11.4; IC 95% 7.4-17.5) durante la estadía índice. No se identificó ningún factor de riesgo potencialmente prevenible para el reingreso temprano (128 pacientes, 24.3% de todos los reingresos, 3% de la cohorte total), y la estadía hospitalaria índice de ≤ 3 días no se asoció con un aumento en el reingreso (OR 0.9; IC 95% 0.7-1.2) Mientras que el íleo / obstrucción del intestino delgado (temprano: 43.8% vs. tardío: 15.5%, p < 0.001) fueron las principales causas de reingresos tempranos, infecciones profundas (3.9% vs 16.3%, p < 0.001) y lesión renal aguda (0 vs 5%, p = 0.006) se observaron principalmente durante los reingresos después de 48 horas.Riesgo de subregistro debido a la pérdida en el seguimiento, posible co-ocurrencia de complicaciones.El reingreso hospitalario temprano se debió principalmente a íleo u obstrucción intestinal, mientras que los reingresos tardíos se relacionaron con infecciones profundas y lesión renal aguda. Es importante tener una actitud suspicaz hacia los posibles síntomas relacionados con el íleo antes del alta y una educación específica para los pacientes con ostomía. La estadía hospitalaria índice corta no se asoció con mayores tasas de reingreso. Consulte Video Resumen en http://links.lww.com/DCR/B237

Ordering a Normal Diet at the End of Surgery-Justified or Overhasty?

Early re-alimentation is advocated by enhanced recovery pathways (ERP). This study aimed to assess compliance to ERP-set early re-alimentation policy and to compare outcomes of early fed patients and patients in whom early feeding was withhold due to the independent decision making of the surgeon. For this purpose, demographic, surgical and outcome data of all consecutive elective colorectal surgical procedures (2011⁻2016) were retrieved from a prospectively maintained institutional ERP database. The primary endpoint was postoperative ileus (POI). Surgical 30-day outcome and length of stay were compared between patients undergoing the pathway-intended early re-alimentation pattern and patients in whom early re-alimentation was not compliant. Out of the 7103 patients included, 1241 (17.4%) were not compliant with ERP re-alimentation. Patients with delayed re-alimentation presented with more postoperative complications (37 vs. 21%, p < 0.001) and a prolonged length of hospital stay (8 ± 7 vs. 5 ± 4 days, p < 0.001). While male gender (odds ratio (OR) 1.24; 95% confidence interval (CI) 1.04⁻1.32), fluid overload (OR 1.38; 95% CI 1.16⁻1.65) and high American Society of Anaesthesiologists (ASA) score (OR 1.51; 95% CI 1.27⁻1.8) were independent risk factors for POI, laparoscopy (OR 0.51; 95% CI 0.38⁻0.68) and ERP compliant diet (OR 0.46; 95% CI 0.36⁻0.6) were both protective. Hence, this study provides further evidence of the beneficial effect of early oral feeding after colorectal surgery

Intraoperative Fluid Management a Modifiable Risk Factor for Surgical Quality - Improving Standardized Practice.

We aimed to determine a safe zone of intraoperative fluid management associated with the lowest postoperative complication rates without increased acute kidney injury (AKI) risk for elective colorectal surgery patients. Elective colorectal surgeries between 2018 and 2020 were included. Unadjusted odds ratios for postoperative ileus, prolonged length of stay (LOS), and AKI were plotted against the rate of intraoperative ringer's lactate (RL) infusion (mL/kg/h) and total intraoperative volume. Binary logistic regression analysis, including fluid volumes as a confounder, was used to identify risk factors for postoperative complications. A total of 2,900 patients were identified. Of them, 503 (17.3%) patients had ileus, 772 (26.6%) patients had prolonged LOS, and 240 (8.3%) patients had AKI. The intraoperative fluid resuscitation rate (mg/kg/h) was less impactful on postoperative ileus, LOS, and AKI than the total amount of intraoperative fluid. A total fluid administration range between 300 mL and 2.7 L was associated with the lowest complication rate. Total intraoperative RL ≥2.7 L was independently associated with a higher risk of ileus (adjusted OR 1.465;95% CI 1.154-1.858) and prolonged LOS (adjusted OR 1.300;95% CI 1.047-1.613), but not AKI. Intraoperative RL≤300 ml was not associated with an increased risk of AKI. Total intraoperative RL≥2.7L was independently associated with postoperative ileus and prolonged LOS in elective colorectal surgery patients. A new potential standard for intraoperative fluids will require anesthesia case planning (complexity and duration) to ensure total fluid volume meets this new opportunity to improve care

Electroweak Supersymmetry around the Electroweak Scale

Inspired by the phenomenological constraints, LHC supersymmetry and Higgs searches, dark matter search as well as string model building, we propose the electroweak supersymmetry around the electroweak scale: the squarks and/or gluinos are around a few TeV while the sleptons, sneutrinos, bino and winos are within one TeV. The Higgsinos can be either heavy or light. We consider bino as the dominant component of dark matter candidate, and the observed dark matter relic density is achieved via the neutralino-stau coannihilations. Considering the Generalized Minimal Supergravity (GmSUGRA), we show explicitly that the electroweak supersymmetry can be realized, and the gauge coupling unification can be preserved. With two Scenarios, we study the viable parameter spaces that satisfy all the current phenomenological constraints, and we present the concrete benchmark points. Furthermore, we comment on the fine-tuning problem and LHC searches.Comment: RevTex4, 28 pages, 8 figures, 8 tables, version to appear in EPJ

Cluster Density and the IMF

Observed variations in the IMF are reviewed with an emphasis on environmental density. The remote field IMF studied in the LMC by several authors is clearly steeper than most cluster IMFs, which have slopes close to the Salpeter value. Local field regions of star formation, like Taurus, may have relatively steep IMFs too. Very dense and massive clusters, like super star clusters, could have flatter IMFs, or inner-truncated IMFs. We propose that these variations are the result of three distinct processes during star formation that affect the mass function in different ways depending on mass range. At solar to intermediate stellar masses, gas processes involving thermal pressure and supersonic turbulence determine the basic scale for stellar mass, starting with the observed pre-stellar condensations, and they define the mass function from several tenths to several solar masses. Brown dwarfs require extraordinarily high pressures for fragmentation from the gas, and presumably form inside the pre-stellar condensations during mutual collisions, secondary fragmentations, or in disks. High mass stars form in excess of the numbers expected from pure turbulent fragmentation as pre-stellar condensations coalesce and accrete with an enhanced gravitational cross section. Variations in the interaction rate, interaction strength, and accretion rate among the primary fragments formed by turbulence lead to variations in the relative proportions of brown dwarfs, solar to intermediate mass stars, and high mass stars.Comment: 14 pages, 3 figures, to be published in ``IMF@50: A Fest-Colloquium in honor of Edwin E. Salpeter,'' held at Abbazia di Spineto, Siena, Italy, May 16-20, 2004. Kluwer Academic Publishers; edited by E. Corbelli, F. Palla, and H. Zinnecke