Disparities in Care: Impact of Socioeconomic Factors on Pancreatic Surgery: Exploring the National Cancer Database.

Studies have shown high-volume institutions have decreased mortality and increased survival for pancreatectomy. However, not all patients can travel to high-volume centers. Socioeconomic factors may influence treatment decisions. The goal of this study is to examine socioeconomic factors that determine where a patient is treated and how that location affects outcome. This is a retrospective study of the National Cancer Database of patients diagnosed with pancreatic cancer from 2004 to 2014. The primary outcome was to examine socioeconomic factors that predicted where a patient underwent their pancreatectomy. Patients treated at academic programs (APs) had to travel a mean distance of 80.9 miles, whereas patients treated at community programs (CPs) had to travel 31.7 miles

Predictors of Utilization and Quality Assessment in Robotic Rectal Cancer Resection: A Review of the National Cancer Database.

Robotic surgery (RS) is a novel treatment for rectal cancer resection (RCR); however, this technology is not widely accessible. The objective of this study is to evaluate the utilization of RS in RCR compared with open and laparoscopic techniques and to assess the quality of resection. RCR from 2010 to 2012 were identified using the National Cancer Database and placed into categories: open, laparoscopic, and robotic. A total of 23,857 patients who received open, laparoscopic, and robotic RCR were included (n = 14,735 (61.8%); 7,185 (30.1%); 1,937 (8.1%), respectively). Patients over 70 had a lower likelihood of robotic RCR. Patients with insurance were 2 times more likely to have robotic RCR. Patients at an academic/research program were more likely to undergo RS compared with a community cancer program (OR 3.6, 95% CI [2.79, 4.78]; P \u3c 0.0001). Length of stay (LOS) was longer in open (7.9 ± 7.1) versus laparoscopic (6.6 ± 6.3) or robotic (6.8 ± 6.4) RCR (P \u3c 0.0001). Although there was an increased likelihood of positive surgical margins with open RCR (OR 1.3, 95% CI [1.09, 1.66]; P \u3c 0.0001), there was no difference in robotic and laparoscopic techniques. Younger insured patients at academic/research affiliated hospitals have a higher likelihood of receiving robotic RCR. Compared with open RCR, robotic RCR have a lower likelihood of positive surgical margins and shorter LOS

Severe complicated Clostridium difficile infection: Can the UPMC proposed scoring system predict the need for surgery?

INTRODUCTION: Clostridium difficile infection (CDI) is one of the most common health care-associated infections, and it continues to have significant morbidity and mortality. The onset of fulminant colitis often requires total abdominal colectomy with ileostomy, which has a mortality rate of 35% to 57%. University of Pittsburgh Medical Center (UPMC) developed a scoring system for severity and recommended surgical consultation for severe complicated disease. The aim of this study was to evaluate if the UPMC-proposed scoring system for severe complicated CDI can predict the need for surgical intervention. METHODS: This is a retrospective review of all patients who developed severe complicated CDI at Geisinger Medical Center between January 2007 and December 2012 as defined by the UPMC scoring system. Main outcomes were the need for surgical intervention and 30-day mortality. RESULTS: Eighty-eight patients had severe complicated CDI based on the UPMC scoring system. Fifty-nine patients (67%) required surgery and 29 did not. All patients had a diagnosis of CDI as shown by positive toxin assays. There was no difference between the groups with respect to age, sex, body mass index, or comorbidities. When comparing the surgical group to the nonsurgical cohort, the surgical cohort averaged 20 points on the scoring system compared to 9 in the nonoperative cohort. In patients with severe complicated CDI, 15 or more points predicted the need for surgery 75% of the time. Forty-two percent of the surgical cohort had respiratory failure requiring mechanical ventilation compared to 0% in the nonsurgical cohort (p \u3c 0.0001). Forty-nine percent of the surgical cohort required vasopressors for septic shock before surgery compared to 0% in the nonsurgical cohort (p \u3c 0.0001). Acute kidney injury was present in 92% of the surgical cohort versus 72% within the nonsurgical cohort (p = 0.026). Seventy-six percent of the surgical patients were admitted to the ICU before surgery. Within the nonsurgical cohort, only 24% of patients required ICU stay during admission. Overall, 30-day mortality in the surgical cohort was 30%, and there was no mortality in the nonsurgical cohort. CONCLUSIONS: The UPMC scoring system for severe complicated CDI can help us predict patients who need a surgical consult and the need for surgical intervention. In patients with severe complicated CDI, evidence of end-organ failure predicts surgical intervention. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic study, level IV

How important is consent in maternal serum screening for Down syndrome in France? Information and consent evaluation in maternal serum screening for Down syndrome: a French study.

OBJECTIVES: To evaluate the level of information and informed consent for maternal serum screening (MSS) for Down syndrome (DS) in the second trimester of pregnancy and analyse the exercise of autonomy towards the test by the women concerned. METHODS: We studied the population of pregnant women attending obstetric consultations in two French hospitals over a 3-month period. The women were assigned to three groups according to MSS results for DS: women at high risk of having a child with DS (group 1), women at low risk (group 2) and women who did not undergo the test (group 3). A questionnaire was completed before the medical consultation, to assess the quality of consent before amniocentesis for the group at high risk and before the second-trimester ultrasound scan for the other two groups. RESULTS: We analysed 305 questionnaires for 89, 137 and 79 women belonging to groups 1, 2 and 3 respectively. In total, 123 women (40.3% [IC 95%, 35-46%]) were considered to be well informed; 33 (10%, [IC 95%, 8-12%]) had a high level of knowledge, but made choices not consistent with their stated attitude, and 149 (49.7% [IC 95%, 45-56%]) were considered uninformed. Logistic regression analysis showed that maternal consent depended on three independent components: The score attributed to the doctor for information about MSS (t = 4.216, p < 0.001).Whether the patient belonged to group 1 (t = -2.631, p < 0.009).Educational level (< high-school diploma, high-school diploma or at least two years of higher education after high school) (t = 2.324, p < 0.02). The rate of consent increased with educational level and was highest for the women in group 1 and for those whose doctor had a high information score. CONCLUSIONS: Our findings clearly show that women are provided with insufficient information concerning MSS screening for DS in the second trimester of pregnancy for real and valid consent to be obtained. Copyright (c) 2007 John Wiley & Sons, Ltd