Annals of surgery最新文献

Objective: To understand how breast cancer patients experience the surgical decision process and identify strategies surgeons can employ to empower patients to engage in decision-making.

Background: Patient engagement in decision-making is associated with improved patient outcomes. Although, some patients prefer that their healthcare provider drive the decision, the benefits of engaging in decision-making hold true even for patients who prefer to defer to their provider.

Methods: We performed semi-structured interviews with patients that experienced low engagement in clinical trial A231701CD (n=30). We used qualitative content analysis to analyze data and organize it into overarching themes that represent experiences with decision-making.

Results: Patients could be grouped based on their experiences with the decision process into those that wanted to defer, share, or drive the decision. Three domains differentiated patients between groups: (1) overall disposition toward the surgeon, (2) tendency to exchange information and ask questions, and (3) attitudes toward how their preferences should shape the treatment decision. We identified surgeon behaviors that could optimize patient engagement. These opportunities were observed across all patients, regardless of their experience with the decision process.

Conclusion: Surgeons can empower patients to engage in decision-making by getting to know patients as individuals, ensuring all treatment options are presented, and integrating patient preferences into the decision process. Through these actions, surgeons can help patients with varied preferences for decision-making engage in making high quality decisions that reflect patients' priorities. These suggestions may have the greatest impact on socially disadvantaged patients and help to reduce disparities in care.

Aim: To validate the prognostic value of the PAncreatic NeoAdjuvant MAssachusetts (PANAMA)-score and to determine its predictive ability for survival benefit derived from adjuvant treatment in patients after resection of pancreatic ductal adenocarcinoma (PDAC) following neoadjuvant FOLFIRINOX.

Background: The PANAMA-score was developed to guide prognostication in patients after neoadjuvant therapy and resection for PDAC. As this score focuses on the risk for residual disease after resection, it might also be able to select patients who benefit from adjuvant after neoadjuvant therapy.

Methods: This retrospective international multicenter study is endorsed by the European-African Hepato-Pancreato-Biliary Association (E-AHPBA). Patients with PDAC who underwent resection after neoadjuvant FOLFIRINOX were included. Mantel-Cox regression with interaction analysis was performed to assess the impact of adjuvant chemotherapy.

Results: Overall, 383 patients after resection of PDAC following neoadjuvant FOLFIRINOX were included of whom 187 (49%), 137 (36%), and 59 (15%) had a low-risk, intermediate-risk, and high-risk PANAMA-score, respectively. A discrimination in median OS was observed stratified by risk groups (48.5, 27.6, and 22.3 months, Log-Rank-Plow-intermediate=0.004, Log-Rank-Pintermediate-high=0.027). Adjuvant therapy was not associated with an OS difference in the low-risk group (HR 1.50, 95%CI:0.92-2.50), whereas improved OS was observed in the intermediate (HR 0.58, 95%CI:0.34-0.97) and high-risk groups (HR 0.47, 95%CI:0.24-0.94) (p-interaction=0.008).

Conclusions: The PANAMA 3-tier risk groups (low-risk, intermediate-risk, and high-risk, available via pancreascalculator.com) correspond with differential survival in patients with resected PDAC following neoadjuvant FOLFIRINOX. The risk groups also differentiate between survival benefit associated with adjuvant treatment, with only the intermediate- and high-risk groups associated with improved OS.

Objective: To assess the research productivity, career advancement, grant funding, and scholarly impact of international medical graduates (IMGs) in academic cardiothoracic surgery.

Summary background data: Physician shortages undermine patient care and risk exacerbating inequities, especially in cardiothoracic surgery, which may lose a quarter of its workforce by 2050-the most substantial reduction in surgery. IMGs could help alleviate these shortages, but there is limited data about their academic experiences.

Methods: All cardiothoracic surgeons (n=1065) at accredited United States cardiothoracic surgery training centers in 2020 were included. IMGs were defined as surgeons who completed medical school outside the US and Canada, per the Association of American Medical Colleges. Educational and professional backgrounds were recorded from publicly available sources.

Results: 24.0% of academic cardiothoracic surgeons were IMGs. These surgeons started as attendings in later years (2012 vs. 2005, P<0.001) than non-IMGs. In unadjusted analyses, IMGs had lower publication counts and H-index, as well as reduced likelihood of R01 funding and full professor attainment. To match for attending start year, propensity score analysis created two groups of 254 surgeons: both IMGs and non-IMGs had similar publication counts (45.0 vs. 45.0, P=0.98), H-index (10.5 vs. 11.0, P=0.61), R01 funding rates (4.3% vs. 5.1%, P=0.83), and full professor attainment (24.8% vs. 20.5%, P=0.45).

Conclusions: IMGs represent a more junior cohort of surgeons but contribute significantly to the cardiothoracic surgery workforce, with comparable academic success. Policy efforts to streamline IMGs' path toward US practice could help alleviate surgical shortages, while enhancing diversity and strengthening academia.

Objective: The aim of this study is to explore the risk profiles associated with Abdominal aortic aneurysm (AAA) incidence in both the general population and diverse subpopulations.

Summary background data: AAA is a life-threatening arterial disease, and there is limited understanding of its etiological spectrum across the age, sex, and genetic risk subgroups, making early prevention efforts more complicated.

Methods: This study encompassed a sample size of 364399 participants from the UK. Utilizing the Cox proportional hazards model, we estimated the hazard ratios (HRs) and population attributable fraction (PAF) for 24 risk factors and 5 weighted risk scores associated with AAA incidence. Subsequently, this study investigated the relationships between AAA onset and various risk factors based on age, sex, and genetic susceptibility subgroups, and assessed the two- and three-way interactions.

Results: After a median follow-up of 12.62 years, 1684 participants developed AAA. Among the 24 risk factors from 5 different aspects, 12 exhibited significant associations with AAA development. Socio-demographic factors (age and sex) and genetic factors accounted for the majority of AAA cases in both the general population and diverse subpopulations. For lifestyle factors, AAA cases attributable to smoking are larger in the older group (PAF: 15.45% vs. 11.25%) and women (PAF: 23.79% vs. 16.75%). Similarly, physical inactivity had a greater effect on AAA risk in women (4.84% vs. 1.95%), but no age and genetic risk differences were observed. PAF of high C-reactive protein was the most prominent of all cardiometabolic factors across different age, sex, and genetic risk strata, with 18.92% (< 60 years) and 13.71% (≥ 60 years) in age groups, 18.18% (women) and 13.31% (men) in sex groups, and 17.64% (intermediate genetic risk) and 13.01% (high genetic risk) in genetic risk groups. Clinical comorbidities, such as cardiovascular diseases, dyslipidemia, and hypertension significantly associated with the risk of incident AAA, and these factors exerted a greater influence on AAA risk in younger group, women, and those with low genetic risk (P for interaction < 0.05).

Conclusions: This study depicted specific risk profiles that influence AAA incidence among general population and diverse subpopulations, thereby aiding in the formulation of precise and effective strategies for AAA prevention.

Objective: To investigate whether tangential versus segmental portomesenteric venous resection (PVR) impacts surgical and oncological outcome in patients undergoing pancreatoduodenectomy for pancreatic cancer with portomesenteric vein (PMV) involvement.

Summary background data: Current comparative studies on tangential versus segmental PVR as part of pancreatoduodenectomy for pancreatic cancer include all degrees of PMV involvement, including cases where tangential PVR may not be a feasible approach, limiting the clinical applicability.

Methods: International retrospective study in 10 centers from 5 countries, including all consecutive patients after pancreatoduodenectomy with PVR for pancreatic cancer with ≤180° PMV involvement on cross-sectional imaging at diagnosis (2014-2020). Cox and logistic regression analyses were performed to investigate the association of tangential versus segmental PVR with overall survival (OS) from surgery, recurrence-free survival (RFS), locoregional recurrence, and in-hospital/30-day major morbidity, adjusting for potential confounders.

Results: Overall, 357 patients who underwent pancreatoduodenectomy with PVR were included (42% tangential PVR, 58% segmental PVR). The adjusted risk for in-hospital/30-day major morbidity was 23% (95%CI, 17-32) after tangential and 23% (95%CI, 17-30) after segmental PVR (P=0.98). After adjusting for confounders, PVR type was not associated with OS (HR=0.94 [95%CI, 0.69-1.30]), RFS (HR=0.94 [95% CI, 0.69 to 1.28), and locoregional recurrence (OR=0.76 [95%CI, 0.40-1.46]).

Conclusions: In patients undergoing pancreatoduodenectomy for pancreatic cancer with ≤180° PMV involvement, the type of PVR (i.e., tangential vs. segmental) was not associated with differences in surgical and oncological outcome. This suggest that if both procedures are technically feasible, surgeons can choose the type of PVR based on their preference.

Objective: To determine the feasibility, efficacy, and safety of cold stored compared to room temperature platelet transfusion in patients with traumatic brain injury.

Summary background data: Data demonstrating the safety and efficacy of cold stored platelet transfusion are lacking following traumatic brain injury.

Methods: A phase 2, randomized, open label, clinical trial was performed at a single U.S. trauma center. Traumatic brain injured patients with positive brain imaging and a need for platelet transfusion received up to two apheresis units of cold stored platelets stored out to 14 days versus standard care room temperature platelet transfusion. The primary outcome was feasibility and the principal clinical outcome for efficacy and safety was the 6-month Glasgow Coma Scale-Extended score.

Results: The 6-month Glasgow Outcome Scale-Extended score distributions were not different across cold stored and room temperature platelet arms (OR-1.58, 95%CI 0.71 to 3.54, P=0.27). A lower rate of neurosurgical craniotomy/craniectomy was found for those receiving cold stored platelets (difference -14.4%, 95%CI -26.5% to -2.3%, P=0.03). Adverse event rates did not differ across groups. The storage age of the cold stored product was not associated with outcome differences.

Conclusions and relevance: In brain injured patients requiring platelet transfusion, early cold stored platelet transfusion is feasible, and did not result in improved 6-month Glasgow Coma Scale-Extended scores. Early cold stored platelet transfusion was associated with a lower rate of neurosurgical operative intervention without an increase in adverse events. The storage age of the cold stored platelet product was not associated with outcome differences. Future phase 3 clinical trials are required to determine clinical outcome differences and safety attributable to cold stored platelet transfusion following traumatic brain injury.