Praful Ravi

Racial/ethnic disparities in perioperative outcomes of major procedures: Results from the national surgical quality improvement program

Objective: To determine the association between race/ethnicity and perioperative outcomes in individuals undergoing major oncologic and nononcologic surgical procedures in the United States. Background: Prior work has shown that there are significant racial/ethnic disparities in perioperative outcomes after several types of major cardiac, general, vascular, orthopedic, and cancer surgical procedures. However, recent evidence suggests attenuation of these racial/ethnic differences, particularly at academic institutions. Methods: We utilized the American College of Surgeons National Surgical Quality Improvement Program database to identify 142,344 patients undergoing one of the 16 major cancer and noncancer surgical procedures between 2005 and 2011. Results: Eighty-five percent of the cohort was white, with black and Hispanic individuals comprising 8% and 4%, respectively. In multivariable analyses, black patients had greater odds of experiencing prolonged length of stay after 10 of the 16 procedures studied (all P < 0.05), though there was no disparity in odds of 30-day mortality after any surgery. Hispanics were more likely to experience prolonged length of stay after 5 surgical procedures (all P < 0.04), and were at greater odds of dying within 30 days after colectomy, heart valve repair/replacement, or abdominal aortic aneurysm repair (all P < 0.03). Fewer disparities were observed for Hispanics, than for black patients, and also for cancer, than for noncancer surgical procedures. Conclusions: Important racial/ethnic disparities in perioperative outcomes were observed among patients undergoing major cancer and noncancer surgical procedures at American College of Surgeons National Surgical Quality Improvement Program institutions. There were fewer disparities among individuals undergoing cancer surgery, though black patients, in particular, were more likely to experience prolonged length of stay.

A population-based assessment of the burden of acute pancreatitis in the United States.

Objectives The aim of this study is to investigate the incidence and mortality of emergency department (ED) visits in the United States attributed to acute pancreatitis (AP) and quantify predictors of admission and mortality. Methods Using the nationwide ED sample, all ED visits between 2006 and 2009 for AP were extracted. Multivariable analyses were fitted for prediction of admission and mortality. Results A weighted sample of 1,224,121 patient visits with AP was captured. Of those, 75.4% resulted in admission and 0.7% died. Between 2006 and 2009, the incidence of AP ED visits increased from 9.9 to 10.6 per 10,000 person-years. Patients were more likely to be admitted if sicker (Charlson Comorbidity Index score ≥3; OR, 6.48; P < 0.001) and if the etiology of pancreatitis was alcoholic versus biliary (OR, 2.20; P < 0.001). They were more likely to die if sicker (Charlson Comorbidity Index score ≥3; OR, 1.51; P < 0.001) and covered with Medicare or Medicaid versus private insurance (OR, 1.40; P < 0.001 and OR, 1.45; P < 0.001, respectively). Conclusions Emergency department visits for AP represent a significant burden on US health care. Although mortality is lower than previously reported, significant disparities exist in patients presenting with AP with regard to admission and mortality rates. Further investigations are needed to assess these disparities.

Mental health outcomes in elderly men with prostate cancer

OBJECTIVE To examine the burden of mental health issues (MHI), namely anxiety, depressive disorders, and suicide, in a population-based cohort of older men with localized prostate cancer and to evaluate associations with primary treatment modality. PATIENTS AND METHODS A total of 50,856 men, who were 65 years of age or older with clinically localized prostate cancer diagnosed between 1992 and 2005 and without a diagnosis of mental illness at baseline, were abstracted from the Surveillance, Epidemiology, and End Results-Medicare database. The primary outcome of interest was the development of MHI (anxiety, major depressive disorder, depressive disorder not elsewhere classified, neurotic depression, adjustment disorder with depressed mood, and suicide) after the diagnosis of prostate cancer. RESULTS A total of 10,389 men (20.4%) developed MHI during the study period. Independent risk factors for MHI included age ≥ 75 years (hazard ratio [HR] = 1.29); higher comorbidity (Charlson comorbidity index ≥ 3, HR = 1.63); rural hospital location (HR = 1.14); being single, divorced, or widowed (HR = 1.12); later year of diagnosis (HR = 1.05); and urinary incontinence (HR = 1.47). Black race (HR = 0.79), very high-income status (HR = 0.87), and definitive treatment (radical prostatectomy [RP], HR = 0.79; radiotherapy [RT], HR= 0.85, all P<0.001) predicted a lower risk of MHI. The rates of MHI at 10 years were 29.7%, 29.0%, and 22.6% in men undergoing watchful waiting (WW), RT, and RP, respectively. CONCLUSION Older men with localized prostate cancer had a significant burden of MHI. Men treated with RP or RT were at a lower risk of developing MHI, compared with those undergoing WW, with median time to development of MHI being significantly greater in those undergoing RP compared with those undergoing RT or WW.

Peptide YY Levels across Pubertal Stages and Associations with Growth Hormone

CONTEXT Changes in appetite-regulating peptides may impact food intake during puberty and facilitate the pubertal growth spurt. Peptide YY (PYY) is an anorexigenic hormone that is high in anorexia nervosa and low in obesity, inhibits GnRH secretion, and is suppressed by GH administration. The relationship between PYY and GH has not been examined across puberty. OBJECTIVES We hypothesized that PYY would be inversely associated with GH in adolescents and would be lowest when GH is highest. DESIGN AND SETTING We conducted a cross-sectional study at a Clinical Research Center. SUBJECTS We studied 87 children, 46 boys and 41 girls ages 9-17 yr at Tanner stages 1-5 of puberty (10th-90th percentiles for body mass index). OUTCOME MEASURES We measured fasting PYY and nadir GH levels after administration of an oral glucose load. Leptin levels were also measured. RESULTS Fasting PYY was lowest and nadir GH highest in boys in Tanner stages 3-4 (P = 0.02) and in girls in Tanner stages 2-3 (P = 0.02). Leptin levels were highest in early pubertal boys and late pubertal girls. For the group as a whole and within genders, even after controlling for body mass index, log nadir GH correlated inversely with log PYY (P = 0.003, 0.07, and 0.02). PYY levels did not correlate with leptin levels. CONCLUSIONS During mid-puberty, at a time when GH levels are the highest, PYY is at a nadir, and these low PYY levels may facilitate pubertal progression and growth.

Evolving changes in disease biomarkers and risk of early progression in smoldering multiple myeloma

We studied 190 patients with smoldering multiple myeloma (SMM) at our institution between 1973 and 2014. Evolving change in monoclonal protein level (eMP) was defined as ⩾10% increase in serum monoclonal protein (M) and/or immunoglobulin (Ig) (M/Ig) within the first 6 months of diagnosis (only if M-protein ⩾3 g/dl) and/or ⩾25% increase in M/Ig within the first 12 months, with a minimum required increase of 0.5 g/dl in M-protein and/or 500 mg/dl in Ig. Evolving change in hemoglobin (eHb) was defined as ⩾0.5 g/dl decrease within 12 months of diagnosis. A total of 134 patients (70.5%) progressed to MM over a median follow-up of 10.4 years. On multivariable analysis adjusting for factors known to predict for progression to MM, bone marrow plasma cells ⩾20% (odds ratio (OR)=3.37 (1.30–8.77), P=0.013), eMP (OR=8.20 (3.19–21.05), P<0.001) and eHb (OR=5.86 (2.12–16.21), P=0.001) were independent predictors of progression within 2 years of SMM diagnosis. A risk model comprising these variables was constructed, with median time to progression of 12.3, 5.1, 2.0 and 1.0 years among patients with 0–3 risk factors respectively. The 2-year progression risk was 81.5% in individuals who demonstrated both eMP and eHb, and 90.5% in those with all three risk factors.

Trends of acute kidney injury after radical or partial nephrectomy for renal cell carcinoma

OBJECTIVES To investigate the prevalence, temporal trends, and predictors of postoperative acute kidney injury (AKI) in a large cohort of patients with renal cell carcinoma treated with radical or partial nephrectomy. METHODS Between January 1998 and December 2010, patients who underwent radical or partial tumor nephrectomy were identified within the Nationwide Inpatient Sample. First, prevalence and temporal trends of AKI were analyzed. Second, predictors of AKI were identified using multivariable regression analyses. Third, associations between AKI and in-hospital complications, length of stay, hospital costs, and in-hospital mortality were evaluated using logistic regression models adjusted for clustering. RESULTS Of total 253,046 patients, 5.5% (14,303 in radical and 3,525 in partial nephrectomy) experienced AKI. Rates of AKI significantly increased from 2.0% in 1998 to 10.4% in 2010 (P<0.001). Predictors of AKI included male sex, radical nephrectomy, more contemporary years (2004-2010), older age, black race, higher comorbidities, higher preoperative chronic kidney disease stage, Medicare insurance status, and nephrectomy at urban hospitals (all P<0.01). Postoperative AKI during hospitalization was associated with an increased rate of in-hospital mortality, any complications, transfusion, prolonged length of stay, and higher hospital costs (all P<0.001). CONCLUSIONS Rising rates of in-hospital AKI after radical and partial nephrectomy were observed. Increasing awareness of AKI, identification of patients at risk before surgery, early postoperative AKI diagnosis, collaboration with nephrologists, implementation of renoprotective strategies, long-term renal functional follow-up, and a well-designed prospective study, may be warranted.

Relationship between androgen deprivation therapy and community-acquired respiratory infections in patients with prostate cancer.

To investigate the dose‐dependent effect of androgen deprivation therapy on community‐acquired respiratory infections in patients with localized prostate cancer.

Delay in Nephrectomy and Cancer Control Outcomes in Elderly Patients with Small Renal Masses

Objective: To examine the impact of nephrectomy delay on the survival of patients with small renal masses. Methods: Relying on the Surveillance, Epidemiology, and End Results Medicare-linked database, 6,237 patients with pT1a renal cell carcinoma who underwent radical or partial nephrectomy were identified (1988-2005). Nephrectomy delay was dichotomized as ≤3 vs. >3 months. Uni- and multivariate Cox regression analyses tested the effect of delayed nephrectomy on cancer-specific mortality (CSM). In sub-analyses, various other time from diagnosis to nephrectomy cut-offs were modelled: (a) ≤1 vs. >1 month, (b) ≤2 vs. >2 months, (c) ≤4 vs. >4 months, (d) ≤6 vs. >6 months, (e) ≤12 vs. >12 months or (f) continuously coded. Results: In univariate analyses, nephrectomy delay >3 months was associated with a higher risk of CSM (hazard ratio [HR]: 2.07; 95% confidence interval [CI]: 1.58-2.72; p < 0.001). However, after multivariate adjustment, a nephrectomy delay >3 months was not significantly associated with a higher risk of CSM (HR: 1.33; 95% CI: 0.96-1.86; p = 0.09). The lack of a relationship between nephrectomy delay and CSM after multivariate adjustment persisted even in various sub-analyses of other categorizations for nephrectomy delay. Conclusions: In the case of eventual nephrectomy delay among patients with small renal masses, CSM is unaffected.

Defining cure in multiple myeloma: a comparative study of outcomes of young individuals with myeloma and curable hematologic malignancies

Advances in therapy in recent years have led investigators to challenge the dogma that multiple myeloma (MM) is incurable. We assessed overall (OS) and progression-free survival (PFS) of young patients ( ≤ 50 years) with MM and compared outcomes with follicular lymphoma (FL), diffuse large B-cell lymphoma (DLBCL), and Hodgkin lymphoma (HL). All patients ≤ 50 years with newly diagnosed MM (n = 212), FL (n = 168), DLBCL (n = 195), and HL (n = 233) between 1 January 2005 and 31 December 2015 were included. Observed vs. expected survival was summarized by standardized mortality ratios (SMR). Compared to the background US population, excess mortality risk was seen at diagnosis in all four cancers, SMR 19.5 (15.2–24.5) in MM, 4.2 (2.3–7.2) in FL, 13.0 (9.2–18.4) in DLBCL, and 5.2 (2.6–9.3) in HL. We reasoned that cure would most likely occur in the first 3 years after diagnosis and be reflected by an overall survival probability similar to the background population. From the 36-month landmark, excess mortality risk was seen in MM (SMR 20.7 [14.7–28.3]) and FL (SMR 3.8 [1.5–7.8]), but not with DLBCL (SMR 3.1 [0.8–8.0]) or HL (SMR 0.9 [0.0–5.1]). MM patients have 20-fold excess mortality risk compared to the background population at diagnosis and at 3 years after diagnosis, suggesting that MM remains an incurable cancer.

Pneumonia after Major Cancer Surgery: Temporal Trends and Patterns of Care

Rationale. Pneumonia is a leading cause of postoperative complication. Objective. To examine trends, factors, and mortality of postoperative pneumonia following major cancer surgery (MCS). Methods. From 1999 to 2009, patients undergoing major forms of MCS were identified using the Nationwide Inpatient Sample (NIS), a Healthcare Cost and Utilization Project (HCUP) subset, resulting in weighted 2,508,916 patients. Measurements. Determinants were examined using logistic regression analysis adjusted for clustering using generalized estimating equations. Results. From 1999 to 2009, 87,867 patients experienced pneumonia following MCS and prevalence increased by 29.7%. The estimated annual percent change (EAPC) of mortality after MCS was −2.4% (95% CI: −2.9 to −2.0, P < 0.001); the EAPC of mortality associated with pneumonia after MCS was −2.2% (95% CI: −3.6 to 0.9, P = 0.01). Characteristics associated with higher odds of pneumonia included older age, male, comorbidities, nonprivate insurance, lower income, hospital volume, urban, Northeast region, and nonteaching status. Pneumonia conferred a 6.3-fold higher odd of mortality. Conclusions. Increasing prevalence of pneumonia after MCS, associated with stable mortality rates, may result from either increased diagnosis or more stringent coding. We identified characteristics associated with pneumonia after MCS which could help identify at-risk patients in order to reduce pneumonia after MCS, as it greatly increases the odds of mortality.