Liver transplantation (LT) is considered the optimal treatment for hepatocellular carcinoma (HCC) because it removes tumor as well as the underlying cirrhotic liver. Because of a global organ ...shortage, LT for patients with HCC is limited to patients with expected survival comparable to that of nonmalignant indications. Therefore, identifying patients with lower rates of HCC recurrence and higher rates of survival is critical. International guidelines have considered the Milan Criteria (MC) the standard for selecting patients with HCC for deceased‐donor LT (DDLT). However, several alternative criteria have been reported in the Western world. Interestingly, the two most recent models combining α‐fetoprotein level, number of nodules, and size of the largest nodule have been shown to outperform MC in identifying patients with low risk of HCC recurrence or those who will survive for 5 years after liver transplantation. In addition, new models overcome limitations of MC in improving classification of high‐ versus low‐risk patients with HCC for DDLT. These recent scoring systems also provide clinicians with user‐friendly tools to better identify patients at lower risk of recurrence. Conclusion: Although most Western countries still select patients based on MC, there is a mounting change in recent practice patterns regarding the selection of patients with HCC for DDLT. Herein, we describe how alternative criteria should lead to reconsideration of MC as it applies to selecting patients with HCC for DDLT in international guidelines.
This study assesses the age distribution of breast cancer diagnosis across race/ethnicity in US female patients using the Surveillance, Epidemiology, and End Results Program database.
Most Americans consult the Internet to address their health concerns. Limited health literacy among the public highlights the need for patient education Web sites to deliver understandable health ...information. We assessed the understandability and actionability of online neurosurgical patient education materials (PEMs) provided by the American Association of Neurological Surgeons (AANS) and MedlinePlus.
Articles on neurosurgical conditions and treatments listed on both the AANS site and MedlinePlus were analyzed. Two reviewers scored articles using 2 validated health literacy tools, the Centers for Disease Control and Prevention Clear Communication Index (CCI) and the Agency for Healthcare Research and Quality (AHRQ) Patient Education Materials Assessment Tool (PEMAT). These tools evaluate the quality of written health information and assess for content, organization, and actionability of PEMs.
One hundred and thirty-eight articles were evaluated from the AANS (n = 61) and MedlinePlus (n = 77). The median CCI score for MedlinePlus and AANS articles was 68.9 (interquartile range IQR, 62.5-81.3) and 56.3 IQR, 46.7-73.7, respectively (P < 0.001). Only 1 article scored ≥90%, which is the CCI threshold for PEMs to be considered easy to read. Although the AANS and Medline performed similarly on the understandability component of the PEMAT (66.7 IQR, 53.8-69.2 vs. 69.2 IQR, 66.7-83.3, respectively; P < 0.001), significant differences were observed for the actionability section of the PEMAT (Medline 60 IQR, 60-60 vs. AANS 0 IQR, 0-60; P < 0.001). Less than 13% of articles provided summaries, visual aids, and tangible tools to aid patient action.
Neurosurgical online PEMs may be difficult to understand and potentially act as barriers for patients' engagement with health systems. There is a need to deliver patient-centered health information that effectively informs patients, aiding in meaningful health decision making.
In uncomplicated type B aortic dissection (UTBAD), the “gold standard” has been nonoperative treatment with medical therapy, although this has been questioned by studies demonstrating improved ...outcomes in those treated with thoracic endovascular aortic repair (TEVAR). This study assessed long-term survival after acute UTBAD comparing medical therapy, open repair, and TEVAR.
The California Office of Statewide Hospital Planning Development database was analyzed from 2000 to 2010 for adult patients with acute UTBAD. Patients with nonemergent admission for aortic dissection, type A dissection, trauma, bowel ischemia, lower extremity ischemia, acidosis, or shock were excluded. The cohort was stratified by treatment type at index admission into medical therapy, open surgical repair, and TEVAR. Multivariable regression and survival analyses were used to evaluate the association of treatment type with long-term overall survival.
There were 9165 cases, 95% medical therapy, 2% open repair, and 2.9% TEVAR. The mean age was 66 ± 15 years, with 39% female, 2.4% cocaine users, 18% with congestive heart failure, and 17% with Charlson Comorbidity Index >3. Mean inpatient costs were $57,000 for medical therapy, $200,000 for open repair, and $130,000 for TEVAR (P < .01). Inpatient mortality was 6.5% overall, 6.3% for medical therapy, 14% for open repair, and 7.1% for TEVAR (P < .01). One-year and 5-year survivals were 84% and 60% in medical therapy, 76% and 67% in open repair, and 85% and 76% in TEVAR (log-rank, P < .01). On risk-adjusted multivariable analysis, TEVAR had improved survival compared with medical therapy (hazard ratio, 0.68; 95% confidence interval, 0.6-0.8; P < .01), with no difference between open repair and medical therapy (hazard ratio, 1.0; 95% confidence interval, 0.8-1.3; P < .01).
This statewide study on survival after acute UTBADs shows an independent survival advantage for TEVAR over medical therapy. These data add further evidence for a paradigm shift in acute management of type B dissection in favor of early TEVAR.
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Previous associations between surgeon volume with adrenalectomy outcomes examined only a sample of procedures. We performed an analysis of all adrenalectomies performed in New York state to assess ...the effect of surgeon volume and specialty on clinical outcomes.
Adrenalectomies performed in adults were identified from the New York Statewide Planning and Research Cooperative System from 2000–2014. Surgeon specialty, volume, and patient demographics were assessed. High volume was defined using a significance threshold at ≥4 adrenalectomies per year. Outcome variables included in-hospital mortality, duration of stay, and in-hospital complications.
A total of 6,054 adrenalectomies were included. Median patient age was 56 years; 41.9% were men and 68.3% were white. Urologists (n = 462) performed 46.8% of adrenalectomies, general surgeons (n = 599) performed 35.0%, and endocrine surgeons (n = 23) performed 18.1%. Significantly more endocrine surgeons were high-volume compared with urologists and general surgeons (65.2% vs 10.2% and 6.7%, respectively, P < .001). High-volume surgeons had significantly lower mortality compared with low-volume surgeons (0.56% vs 1.25%, P = .004) and a lower rate of complications (10.2% vs 16.4%, P = < .001). Endocrine surgeons were more likely to perform laparoscopic procedures (34.8% vs 22.4% general surgeons and 27.7% US, P < .001) and had the lowest median hospital duration of stay (2 days vs 4 days general surgeons and 3 days urologists, P < .001). After risk adjustment, low surgeon volume was an independent predictor of inpatient complications (odds ratio = 0.96, P = .002).
Patients with adrenal disease should be referred to surgeons based on adrenalectomy volume regardless of specialty, but most endocrine surgeons that perform adrenalectomy are high-volume for the procedure.
Background A minimum-volume policy restricting hospitals not meeting the threshold from performing complex operation may increase travel burden and decrease spatial access to operation. We aim to ...identify vulnerable populations that would be sensitive to an added travel burden. Methods We performed a retrospective analysis of the database of the California Office of Statewide Health Planning and Development for patients undergoing pancreatectomy from 2005 to 2014. Number of hospitals bypassed was used as a metric for travel. Patients bypassing fewer hospitals were deemed to be more sensitive to an added travel burden. Results There were 13,374 patients who underwent a pancreatectomy, of whom 2,368 (17.7%) were nonbypassers. On unadjusted analysis, patients >80 year old travelled less than their younger counterparts, bypassing a mean of 10.9 ± 9.5 hospitals compared with 14.2 ± 21.3 hospitals bypassed by the 35–49 year old age group ( P < .001). Racial minorities travelled less when compared with non-Hispanic whites ( P < .001). Patients identifying their payer status as self-pay (8.9 ± 15.6 hospitals bypassed) and Medicaid (10.1 ± 17.2 hospitals bypassed) also travelled less when compared with patients with private insurance (13.8 ± 20.4 hospitals bypassed, P < .001). On multivariate analysis, advanced age, racial minority, and patients with self-pay or Medicaid payer status were associated independently with increased sensitivity to an added travel burden. Conclusion In patients undergoing pancreatectomy, the elderly, racial minorities, and patients with self-pay or Medicaid payer status were associated with an increased sensitivity to an added travel burden. This vulnerable cohort may be affected disproportionately by a minimum-volume policy.
Perioperative dysfunction of the fibrinolytic system may play a role in adverse outcomes for liver transplant recipients. There is a paucity of data describing the potential impact of the ...postoperative fibrinolytic system on these outcomes. Our objective was to determine whether fibrinolysis resistance (FR), on postoperative day one (POD-1), was associated with early allograft dysfunction (EAD). We hypothesized that FR, quantified by tissue plasminogen activator thrombelastography, is associated with EAD. Tissue plasminogen activator thrombelastography was performed on POD-1 for 184 liver transplant recipients at a single institution. A tissue plasminogen activator thrombelastography clot lysis at 30 minutes of 0.0% was identified as the cutoff for FR on POD-1. EAD occurred in 32% of the total population. Fifty-nine percent (n=108) of patients were categorized with FR. The rate of EAD was 42% versus 17%, p <0.001 in patients with FR compared with those without, respectively. The association between FR and EAD risk was assessed using multivariable logistic regression after controlling for known risk factors. The odds of having EAD were 2.43 times (95% CI, 1.07-5.50, p =0.03) higher in recipients with FR model C statistic: 0.76 (95% CI, 0.64-0.83, p <0.001. An additive effect of receiving a donation after circulatory determination of death graft and having FR in the rate of EAD was observed. Finally, compared with those without FR, recipients with FR had significantly shorter graft survival time ( p =0.03). In conclusion, FR on POD-1 is associated with EAD and decreased graft survival time. Postoperative viscoelastic testing may provide clinical utility in identifying patients at risk for developing EAD, especially for recipients receiving donation after circulatory determination of death grafts.
The number of simultaneous liver-kidney (SLK) transplants has significantly increased in the United States. There has also been an increase in kidney-after-liver transplants associated with 2017 ...policy revisions aimed to fairly allocate kidneys after livers. SLK and kidney-after-liver candidates are prioritized in allocation policy for kidney offers ahead of kidney-alone candidates.
We compared kidney graft outcomes of kidney-alone transplant recipients with SLK and kidney-after-liver transplants using paired kidney models to mitigate differences among donor risk factors. We evaluated recipient characteristics between transplant types and calculated differential graft years using restricted mean survival estimates.
We evaluated 3053 paired donors to kidney-alone and SLK recipients and 516 paired donors to kidney-alone and kidney-after-liver recipients from August 2017 to August 2022. Kidney-alone recipients were younger, more likely on dialysis, and Black race. One-year and 3-year post-transplant kidney graft survival for kidney-alone recipients was 94% and 86% versus SLK recipients 89% and 80%, respectively, P < 0.001. One-year and 3-year kidney graft survival for kidney-alone recipients was 94% and 84% versus kidney-after-liver recipients 93% and 87%, respectively, P = 0.53. The additional kidney graft years for kidney-alone versus SLK transplants was 21 graft years/100 transplants (SEM=5.0) within 4 years post-transplantation, with no significant difference between kidney-after-liver and kidney-alone transplants.
Over a 5-year period in the United States, SLK transplantation was associated with significantly lower kidney graft survival compared with paired kidney-alone transplants. Most differences in graft survival between SLK and kidney-alone transplants occurred within the first year post-transplantation. By contrast, kidney-after-liver transplants had comparable graft survival with paired kidney-alone transplants.
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