Shubhada Sansgiry

Intra-abdominal Fat Predicts Survival in Pancreatic Cancer

BackgroundBody mass index (BMI) has proven unreliable in predicting survival following pancreaticoduodenectomy for cancer. While measures of intra-abdominal fat correlate with medical and postoperative complications of obesity, the impact of intra-abdominal fat on pancreatic cancer survival is uncertain. We hypothesized that the quantity of intra-abdominal fat would predict survival following resection of pancreatic cancer.MethodsPreoperative CT imaging was used to measure intra-abdominal fat. Cox regression analyses were used to identify independent predictors of survival.ResultsSixty-one patients from 2000–2009 underwent pancreaticoduodenectomy for exocrine pancreatic adenocarcinoma. After adjusting for age and perineural invasion status, preoperative BMI did not predict overall survival (p < 0.827). Unlike BMI, quartile of intra-abdominal fat predicted survival. Relative to patients with the least intra-abdominal fat (lowest quartile), those with more intra-abdominal fat demonstrated worse overall survival, but in a non-linear fashion. Individuals in the second quartile showed a fourfold increase in likelihood of death (HR 4.018, 95% CI 1.099–14.687, p < 0.035) relative to the lowest quartile. Patients in the third (HR 2.124, 95% CI 0.278–16.222, p < 0.468) and fourth quartile (HR 1.354, 95% CI 0.296–6.190, p < 0.696) also showed greater risk of death.ConclusionsMeasuring intra-abdominal fat identifies a subset of patients with worse prognosis in pancreatic cancer.

Changes in Psychotherapy Utilization Among Veterans With Depression, Anxiety, and PTSD

OBJECTIVE Large-scale health care systems such as the Veterans Health Administration (VHA) have recently invested heavily in the expansion of psychotherapy services. This study examined longitudinal changes in use of psychotherapy at the VHA during a period of substantial programmatic change targeting increased availability and quality of mental health care. METHODS This retrospective cohort study used data from the VHA National Patient Care Database outpatient treatment files to identify patients with a new-onset diagnosis of depression, anxiety, or posttraumatic stress disorder during fiscal years (FYs) 2004 (N=424,428), 2007 (N=494,318), and 2010 (N=583,733). Use of psychotherapy during the 12 months after diagnosis was assessed. RESULTS The proportion of patients receiving any psychotherapy increased across the three study time points (FY 2004, 21%; FY 2007, 22%; and FY 2010, 27%). Amount of psychotherapy also increased such that with time a growing proportion of patients received eight or more psychotherapy sessions. The median time between diagnosis and start of psychotherapy decreased from 56 to 47 days from FY 2004 to FY 2010. Consistent with VHA expansion efforts, more substantial increases in psychotherapy reach, amount, and timeliness occurred between FY 2007 and 2010 than between FY 2004 and FY 2007. CONCLUSIONS These findings highlight recent increases in the use of VHA psychotherapy and correspond to substantial efforts to improve access to mental health services. Despite these advances, most newly diagnosed patients received no psychotherapy or a low-intensity amount of psychotherapy. Additional efforts to promote veteran engagement in needed mental health services appear warranted.

Disparities in the use of minimally invasive surgery for colorectal disease.

BackgroundMorbidity and mortality rates for major surgical procedures are decreased in high-volume hospitals (HVH). Additionally, HVH are often leaders in the utilization of novel surgical technology such as minimally invasive surgery (MIS). Although HVH often serve diverse patient populations, it is unknown if there are disparities in the application of new surgical technologies within these hospitals. We sought to determine if ethnic and socioeconomic disparities in the use of MIS for colorectal disease exist at HVH.MethodsLaparoscopic and open colectomies performed at HVH were identified using the 2008 Nationwide Inpatient Sample database. ICD-9 codes were used to identify MIS colorectal resections. Multiple logistic regression including ethnic and socioeconomic variables were used to identify independent predictive factors for undergoing MIS.ResultsA total of 211,862 colorectal resections were performed at HVH in 2008. Only 16,637 (7.3%) colorectal resections were performed using MIS. When evaluating racial and socioeconomic factors, patients within the highest income quartile were more likely to undergo MIS than those in the lowest income groups. In addition, patients with Medicaid and uninsured patients were significantly less likely to undergo MIS compared to patients with private insurance. Lastly, race was not a significant predictive factor for undergoing MIS for colorectal disease at HVH.ConclusionThere are significant socioeconomic disparities in the use of MIS for colorectal disease at HVH. Future studies should be aimed at identifying access barriers to MIS in the treatment of colorectal disease.

Centralization of HIV services in HIV-positive African-American and Hispanic youth improves retention in care

Abstract African-American and Hispanic HIV-infected youth are a high risk group for not remaining in HIV care. We examined differences in retention in care among 174 HIV-infected African-American and Hispanic youth between 13 and 23 years old who presented for HIV primary care between 1 January 2002 and 31 August 2008. Patients were included in three service eras, based on when they entered the clinic: when no youth-specific services were available (the decentralized era), after formation of a youth clinic staffed by adolescent providers and a case-manager (the centralized era), and after educational activities and support groups were added and the social services staff were trained in the use of motivational interviewing (the centralized with supportive services era). Patient and attendance data for the 12-months following entry into care were captured. Retention in HIV care was examined using two different measures: adequate visit constancy (at least three quarters with at least one visit in each quarter) and having a gap in care (two consecutive medical visits ≥180 days apart). Adequate visit constancy improved by service era from 31% in the decentralized era to 57% in the centralized era and 65% in the centralized with supportive services era (p=0.01). The percent of patients with no gap in care remained stable at about 80% in the decentralized and centralized eras, but then increased to 96% in the centralized with supportive services era (p=0.04). Results suggest that centralizing youth-specific care and expanding youth services can improve retention in HIV care. These system changes should be considered when resources allow.

Outcomes of damage-control celiotomy in elderly nontrauma patients with intra-abdominal catastrophes.

OBJECTIVE Damage-control laparotomy, initially developed for trauma patients, has expanded into the general surgery arena. Little evidence exists regarding the utility of damage-control celiotomy (DCCT) in elderly nontrauma patients. Our objective was to review the management and outcomes of DCCT in elderly patients with intra-abdominal catastrophes. METHODS Retrospective chart review from 1998 to 2008 identified cases of DCCT. Demographics, comorbidities, surgical techniques, morbidity, long-term disposition, and mortality were analyzed. RESULTS From 210 patients with emergency surgeries, 88 (42%) patients with DCCT were identified, 33 (38%) were greater than 65 years old and 55 (63%) were ≤ 65 years old. The average APACHE IV score for the elderly was 84 ± 2 versus 68 ± 2 for the younger group (p < .001). Elderly patients had significantly higher comorbidites with respect to cardiovascular, pulmonary, and renal disease. When comparing the 2 groups, there were no significant differences in-hospital or intensive care unit lengths of stay or ventilator days. There were also no significant differences in complications and disposition. Using Cox proportional hazards analysis, age was not an independent predictor of 30-day mortality. CONCLUSIONS Age is not an independent predictor of worse outcomes in patients managed by the DCCT technique after intra-abdominal catastrophes. This management technique should be considered for elderly patients who require DCCT.

Obesity Does Not Increase Complications Following Pancreatic Surgery

BACKGROUND Recent evidence suggests that the quantity of intra-abdominal fat may be a more important predictor of postoperative complications than body mass index (BMI). We hypothesized that increased intra-abdominal fat would be associated with longer operations, increased blood loss, more complications, and prolonged length of stay after pancreatic resection. METHODS Retrospective cohort study. Intra-abdominal fat was quantified using CT imaging, and patients were divided into three groups (low, moderate, high). Unconditional multiple logistic regression was used to evaluate the relationship between obesity measures and complications. RESULTS Between 2002 and 2010, 255 patients underwent pancreaticoduodenectomy or distal pancreatectomy, and 201 had preoperative CT imaging available for review. Operative time was significantly prolonged in patients with high quantities of intra-abdominal fat compared with those with low fat quantity (median 438 versus 354 min, P < 0.05), while BMI was not associated with changes in duration of surgery. Neither obesity defined by BMI (OR 0.90, 95% CI 0.36-2.21) nor visceral fat (OR 1.20, 95% CI 0.46-3.16) significantly predicted risk of complications. Median length of stay was similar in patients who were obese by BMI (7 versus 7.5 d) or amount of intra-abdominal fat (7 d). CONCLUSIONS Intra-abdominal fat was a better predictor than BMI for determining length of procedure. However, in contrast to previous studies evaluating abdominal surgery, neither BMI nor intra-abdominal fat significantly predicted risk of complication or length of hospital stay. Further research is needed to determine the best measure to assist in risk prediction of obese patients undergoing pancreatic surgery.

Postoperative transitional care needs in the elderly: an outcome of recovery associated with worse long-term survival.

OBJECTIVE To characterize transitional care needs (TCNs) after colorectal cancer (CRC) surgery and examine their association with age and impact on overall survival (OS). BACKGROUND TCNs after cancer surgery represent additional burden for patients and are associated with higher short-term mortality. They are not well-characterized in CRC patients, particularly in the context of a growing elderly population, and their effect on long-term survival is unknown. METHODS A retrospective cohort study of CRC patients (N = 486) having curative surgery at a tertiary referral center (2002-2011) was conducted. Outcomes included TCNs (home health or nonhome destination at discharge) and OS. Patients were compared on the basis of age: young (<65 years), old (65-74 years), and oldest (≥75 years). Multivariate logistic regression models were used to examine the association of age with TCNs, and OS was compared on the basis of TCNs and stage, using the Kaplan-Meier method. RESULTS TCNs were required by 130 patients (27%). The oldest patients had highest TCNs (49%) compared with the other age groups (P < 0.01), with rehabilitation services as their primary TCNs (80%). After multivariate analysis, patients 75 years or older had significantly increased TCN risk (odds ratio, 4.7; 95% confidence interval, 2.6-8.5). TCN was associated with worse OS for patients with early- and advanced stage CRC (P < 0.001). CONCLUSIONS TCNs after CRC surgery are common and significantly increased in patients 75 years or older, represent an outcome of postoperative recovery, and are associated with worse long-term survival. Preoperative identification of higher risk populations should be used for patient counseling, advanced preoperative planning, and to implement strategies targeted at minimizing TCNs.

Perioperative atrial arrhythmias in noncardiothoracic patients: a review of risk factors and treatment strategies in the veteran population

BACKGROUND Perioperative atrial arrhythmias (PAAs) in noncardiothoracic patients have poorly defined risk factors and management. METHODS The surgical intensive care unit database was queried for patients who developed PAAs from 2008 to 2009. Demographics, comorbidities, preoperative data (electrocardiography, chest x-rays, laboratory results), medications, intraoperative variables, management, and outcomes of atrial arrhythmias were collected. Controls were randomly chosen in a 3:1 ratio. Comparisons were performed using χ² tests, Students t tests, or nonparametric comparisons as appropriate. Multivariate logistic regression was performed. RESULTS Five hundred sixty-one patients were admitted to the surgical intensive care unit. Three hundred fifty-four (63%) had noncardiothoracic surgery, and 30 (8.5%) developed PAAs. The mean age of patients with PAAs was 66 ± 7.3 years, compared with 64 ± 11 years for controls (P = NS), with most patients undergoing general (60%) and vascular (33%) surgery. PAA patients were more likely to have coronary artery disease (P = .029), cardiomegaly (P = .011), and premature atrial contractions (P = .016) and to take aspirin (P = .010). On multivariate logistic regression, predictors of atrial arrhythmias were premature atrial contractions, preoperative hypokalemia, intraoperative adverse events, and cardiomegaly. Most PAA patients received amiodarone (63%). Ten percent required electrical cardioversion, and 26% received anticoagulation. PAA patients had significantly longer intensive care unit lengths of stay (P = .032). CONCLUSION Coronary artery disease, cardiomegaly, hypokalemia, and premature atrial contractions were significantly associated with PAAs in noncardiothoracic patients. Prospective studies are needed to define treatment guidelines.

Predictors of relaparotomy after nontrauma emergency general surgery with initial fascial closure.

BACKGROUND Relaparotomy after emergency surgery for nontrauma intraabdominal catastrophes (NTIAC) is morbid. Our objective was to identify patients who likely will need on-demand relaparotomy after surgery for NTIAC. METHODS A retrospective chart review of patients from 1998 to 2008 identified cases of NTIAC surgery with fascial closure. Demographics, comorbidities, intraoperative findings, morbidity, and mortality were analyzed. Relaparotomy was defined as any return to the operating room with surgical re-entry of the abdominal cavity. RESULTS A total of 129 patients underwent NTIAC surgery with fascial closure. Twenty-nine patients (22%) required relaparotomy and 100 patients (78%) did not. Multivariate analysis identified the following predictors of relaparotomy: peripheral vascular disease (P = .04), alcohol abuse (P = .02), body mass index of 29 kg/m(2) or greater (P = .04), the finding of any ischemic bowel (P = .02), and operating room latency of 60 hours or longer (P = .01). Patients with 2 or more of these predictors had a 55% risk of relaparotomy whereas patients with fewer than 2 of these predictors had a 9% risk (P < .001). CONCLUSIONS Patients whose fascia is closed during NTIAC surgery do worse when they require relaparotomy. We have identified preoperative and intraoperative predictors that may help identify patients at high risk of on-demand relaparotomy.

The Effect of Conspiracy Beliefs and Trust on HIV Diagnosis, Linkage, and Retention in Young MSM with HIV

Conspiracy beliefs about HIV may result in delayed diagnosis, medication non-adherence, and low retention in care. The impact of such beliefs is not well described for minority youth. We assessed conspiracy beliefs, trust in physicians, and trust in the health care system in 47 HIV-infected, minority, adolescent men who have sex with men (MSM). We identified correlations of these factors with two intermediate outcomes (general self-efficacy and medication attitudes) and with three clinical outcomes (CD4 cell count at diagnosis, linkage to care, and retention in care). Greater conspiracy beliefs were associated with negative medication attitudes (r=-0.37, p=.01), while trust in physicians was correlated with positive medication attitudes (r=0.42, p=.003). Neither conspiracy beliefs nor trust was correlated with self-efficacy, nor were they correlated with any of the three clinical outcomes. Conspiracy beliefs and lack of trust did not predict delayed diagnosis or poor linkage and retention in this population of young, minority MSM.