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Fitzgerald TN, Zambeli-Ljepović A, Olatunji BT, Saleh A, Ameh EA. Gaps and priorities in innovation for children's surgery. Semin Pediatr Surg 2023; 32:151352. [PMID: 37976896 DOI: 10.1016/j.sempedsurg.2023.151352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Lack of access to pediatric medical devices and innovative technology contributes to global disparities in children's surgical care. There are currently many barriers that prevent access to these technologies in low- and middle-income countries (LMICs). Technologies that were designed for the needs of high-income countries (HICs) may not fit the resources available in LMICs. Likewise, obtaining these devices are costly and require supply chain infrastructure. Once these technologies have reached the LMIC, there are many issues with sustainability and maintenance of the devices. Ideally, devices would be created for the needs and resources of LMICs, but there are many obstacles to innovation that are imposed by institutions in both HICs and LMICs. Fortunately, there is a growing interest for development of this space, and there are many examples of current technologies that are paving the way for future innovations. Innovations in simulation-based training with incorporated learner self-assessment are needed to fast-track skills acquisition for both specialist trainees and non-specialist children's surgery providers, to scale up access for the larger population of children. Pediatric laparoscopy and imaging are some of the innovations that could make a major impact in children's surgery worldwide.
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Affiliation(s)
- Tamara N Fitzgerald
- Department of Surgery, Duke University, Durham, NC, USA; Duke Global Health Institute, Durham, NC, USA
| | - Alan Zambeli-Ljepović
- Philip R. Lee Institute for Health Policy Studies, University of California San Fransisco, USA
| | | | | | - Emmanuel A Ameh
- Division of Paediatric Surgery, Department of Surgery, National Hospital, Abuja, Nigeria.
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Zambeli-Ljepović A, Hoffman D, Barnes KE, Romero-Hernandez F, Ashraf Ganjouei A, Adam MA, Sarin A. Inadequate Lymph Node Yield: An Inadequate Indication for Adjuvant Chemotherapy in Stage II Colon Cancer. Ann Surg Open 2023; 4:e338. [PMID: 38144492 PMCID: PMC10735076 DOI: 10.1097/as9.0000000000000338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 08/11/2023] [Indexed: 12/26/2023] Open
Abstract
Background Optimal therapy for stage II colon cancer remains unclear, and national guidelines recommend "consideration" of adjuvant chemotherapy (ACT) in the presence of high-risk features, including inadequate lymph node yield (LNY, <12 nodes). This study aims to determine whether the survival benefit of ACT in stage II disease varies based on the adequacy of LNY. Methods We used the National Cancer Database (NCDB) to identify adults who underwent resection for a single primary T3 or T4 colon cancer between 2006 and 2018. Multivariable logistic regression tested for associations between ACT and prespecified demographic and clinical characteristics, including the adequacy of LNY. We used Cox proportional hazards models to assess overall survival and restricted cubic splines to estimate the optimal LNY threshold to dichotomize patients based on overall survival. Results Unadjusted 5- and 10-year survival rates were 84% and 75%, respectively, among patients who received ACT and 70% and 50% among patients who did not (log-rank P < 0.01). Inadequate LNY was independently associated with both receipt of ACT (odds ratios, 1.50; P < 0.01) and decreased overall survival [hazard ratio (HR), 1.56; P < 0.01]. ACT was independently associated with improved survival (HR, 0.67; P < 0.01); this effect size did not change based on the adequacy of LNY (interaction P = 0.41). Results were robust to re-analysis with our cohort-optimized threshold of 18 lymph nodes. Conclusions Consistent with contemporary guidelines, patients with inadequate LNY are more likely to receive ACT. LNY adequacy is an independent prognostic factor but, in isolation, should not dictate whether patients receive ACT.
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Affiliation(s)
- Alan Zambeli-Ljepović
- From the Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Daniel Hoffman
- From the Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Katherine E. Barnes
- From the Department of Surgery, University of California, San Francisco, San Francisco, CA
| | | | - Amir Ashraf Ganjouei
- From the Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Mohamed A. Adam
- From the Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Ankit Sarin
- Department of Surgery, University of California Davis, Sacramento, CA
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Greenberg AL, Brand NR, Zambeli-Ljepović A, Barnes KE, Chiou SH, Rhoads KF, Adam MA, Sarin A. Exploring the complexity and spectrum of racial/ethnic disparities in colon cancer management. Int J Equity Health 2023; 22:68. [PMID: 37060065 PMCID: PMC10105474 DOI: 10.1186/s12939-023-01883-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 04/04/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND Colorectal cancer is a leading cause of morbidity and mortality across U.S. racial/ethnic groups. Existing studies often focus on a particular race/ethnicity or single domain within the care continuum. Granular exploration of disparities among different racial/ethnic groups across the entire colon cancer care continuum is needed. We aimed to characterize differences in colon cancer outcomes by race/ethnicity across each stage of the care continuum. METHODS We used the 2010-2017 National Cancer Database to examine differences in outcomes by race/ethnicity across six domains: clinical stage at presentation; timing of surgery; access to minimally invasive surgery; post-operative outcomes; utilization of chemotherapy; and cumulative incidence of death. Analysis was via multivariable logistic or median regression, with select demographics, hospital factors, and treatment details as covariates. RESULTS 326,003 patients (49.6% female, 24.0% non-White, including 12.7% Black, 6.1% Hispanic/Spanish, 1.3% East Asian, 0.9% Southeast Asian, 0.4% South Asian, 0.3% AIAE, and 0.2% NHOPI) met inclusion criteria. Relative to non-Hispanic White patients: Southeast Asian (OR 1.39, p < 0.01), Hispanic/Spanish (OR 1.11 p < 0.01), and Black (OR 1.09, p < 0.01) patients had increased odds of presenting with advanced clinical stage. Southeast Asian (OR 1.37, p < 0.01), East Asian (OR 1.27, p = 0.05), Hispanic/Spanish (OR 1.05 p = 0.02), and Black (OR 1.05, p < 0.01) patients had increased odds of advanced pathologic stage. Black patients had increased odds of experiencing a surgical delay (OR 1.33, p < 0.01); receiving non-robotic surgery (OR 1.12, p < 0.01); having post-surgical complications (OR 1.29, p < 0.01); initiating chemotherapy more than 90 days post-surgery (OR 1.24, p < 0.01); and omitting chemotherapy altogether (OR 1.12, p = 0.05). Black patients had significantly higher cumulative incidence of death at every pathologic stage relative to non-Hispanic White patients when adjusting for non-modifiable patient factors (p < 0.05, all stages), but these differences were no longer statistically significant when also adjusting for modifiable factors such as insurance status and income. CONCLUSIONS Non-White patients disproportionately experience advanced stage at presentation. Disparities for Black patients are seen across the entire colon cancer care continuum. Targeted interventions may be appropriate for some groups; however, major system-level transformation is needed to address disparities experienced by Black patients.
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Affiliation(s)
- Anya L Greenberg
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Nathan R Brand
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Alan Zambeli-Ljepović
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Katherine E Barnes
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Sy Han Chiou
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Kim F Rhoads
- Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Mohamed A Adam
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA
| | - Ankit Sarin
- Department of Surgery, University of California San Francisco, 550 16Th Street, 6Th Floor, San Francisco, CA, 94158, USA.
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Fergus KB, Zambeli-Ljepović A, Hampson LA, Copp HL, Nagata JM. Health care utilization in young adults with childhood physical disabilities: a nationally representative prospective cohort study. BMC Pediatr 2022; 22:505. [PMID: 36008822 PMCID: PMC9413894 DOI: 10.1186/s12887-022-03563-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/19/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Young people with physical disabilities face barriers to accessing health care; however, few studies have followed adolescents with physical disabilities longitudinally through the transition of care into adulthood. The objective of this study was to investigate differences in health care utilization between adolescents with physical disabilities and those without during the transition period from adolescent to adult care. METHODS We utilized the National Longitudinal Study of Adolescent to Adult Health, a prospective cohort study following adolescents ages 11-18 at baseline (1994-1995) through adulthood. Baseline physical disability status was defined as difficulty using limbs, using assistive devices or braces, or having an artificial limb; controls met none of these criteria. Health care utilization outcomes were measured seven years after baseline (ages 18-26). These included yearly physical check-ups, unmet health care needs, and utilization of last-resort medical care, such as emergency departments, inpatient hospital wards, and inpatient mental health facilities. Multiple logistic regression models were used to predict health care utilization, controlling for age, sex, race/ethnicity, insurance status, and history of depression. RESULTS Thirteen thousand four hundred thirty-six participants met inclusion criteria, including 4.2% with a physical disability and 95.8% without. Half (50%) of the sample were women, and the average age at baseline was 15.9 years (SE = 0.12). In logistic regression models, those with a disability had higher odds of unmet health care needs in the past year (Odds Ratio (OR) 1.41 95% CI 1.07-1.87), two or more emergency department visits in the past five years (OR 1.34 95% CI 1.06-1.70), and any hospitalizations in the past five years (OR 1.36 95% CI 1.07-1.72). No statistically significant differences in preventive yearly check-ups or admission to mental health facilities were noted. CONCLUSIONS Young adults with physical disabilities are at higher risk of having unmet health care needs and using last-resort health care services compared to their non-disabled peers.
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Affiliation(s)
- Kirkpatrick B Fergus
- Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Alan Zambeli-Ljepović
- Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Lindsay A Hampson
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Hillary L Copp
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Jason M Nagata
- Department of Pediatrics, University of California-San Francisco, 550 16th Street, 4th Floor, Box 0530, San Francisco, CA, 94143, USA.
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Zambeli-Ljepović A, Wang F, Dinan MA, Hyslop T, Stang MT, Roman SA, Sosa JA, Scheri RP. Extent of surgery for low-risk thyroid cancer in the elderly: Equipoise in survival but not in short-term outcomes. Surgery 2019; 166:895-900. [PMID: 31288935 DOI: 10.1016/j.surg.2019.05.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/29/2019] [Accepted: 05/31/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Total thyroidectomy is more common than lobectomy for low-risk papillary thyroid cancer, despite equipoise in survival. Because postoperative morbidity increases with age, we aimed to investigate how the extent of thyroidectomy affects short-term outcomes among older patients. METHODS Using the Surveillance, Epidemiology, and End Results-Medicare database, we identified patients aged ≥66 years who were treated between 1996 and 2011 for papillary thyroid cancer with tumors ≤2 cm in diameter. We used multivariable logistic regression to evaluate the effect of extent of surgery on complications, emergency-department visits, and unplanned readmissions. RESULTS Among 3,341 selected patients, 77.3% were female, mean age was 72.9 years, and tumors averaged 0.8 cm in diameter. A total of 67.6% of patients underwent total thyroidectomy, and 32.4% underwent lobectomy. Total thyroidectomy was associated with complications (odds ratio = 1.99) and readmissions (odds ratio = 1.59; both P < 0.01). Complications were higher in female patients (odds ratio = 1.34), black patients (versus white patients, odds ratio = 1.65), and those with ≥2 comorbidities (vs 0, odds ratio = 1.43; all P < 0.01). Black patients and those with ≥2 comorbidities had more emergency-department visits (odds ratio = 1.50 and 1.92, respectively) and readmissions (odds ratio = 2.19 and 2.29, respectively; all P < 0.01). CONCLUSION Total thyroidectomy for older adults with low-risk papillary thyroid cancer may lead to potentially avoidable complications and readmissions, particularly for black and female patients. In many cases, lobectomy may be a safer and less costly alternative.
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Affiliation(s)
| | - Frances Wang
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Michaela A Dinan
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Terry Hyslop
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Michael T Stang
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Sanziana A Roman
- Department of Surgery, University of California at San Fransisco, San Francisco, CA
| | - Julie A Sosa
- Department of Surgery, University of California at San Fransisco, San Francisco, CA
| | - Randall P Scheri
- Department of Surgery, Duke University Medical Center, Durham, NC.
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Chereau N, Oyekunle TO, Zambeli-Ljepović A, Kazaure HS, Roman SA, Menegaux F, Sosa JA. Predicting recurrence of papillary thyroid cancer using the eighth edition of the AJCC/UICC staging system. Br J Surg 2019; 106:889-897. [PMID: 31012500 DOI: 10.1002/bjs.11145] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 11/09/2018] [Accepted: 01/29/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND The AJCC/UICC classification is widely used for predicting survival in papillary thyroid cancer (PTC), but has not been evaluated as a predictor of recurrence. The hypothesis of this study was that the eighth edition of the AJCC system can be used in this novel way. METHODS All patients in the study underwent surgery for PTC at a high-volume endocrine surgery centre in France between 1985 and 2015. The seventh and eighth editions of the AJCC/UICC staging system for PTC were employed to predict recurrence and disease-specific survival using the Kaplan-Meier and log rank tests. RESULTS Among 4124 patients (79·7 per cent female), median age was 50 (i.q.r. 38-60) years; 3906 patients (94·7 per cent) underwent total thyroidectomy, with lymph node dissection in 2495 (60·5 per cent). The eighth edition of the AJCC/UICC staging system placed 91·8, 7·1, 0·4 and 0·7 per cent of patients in stages I-IV respectively. After reclassifying patients from the seventh to the eighth AJCC/UICC edition, the disease was downstaged in 23·8 per cent. Over a median follow-up of 7 years, 260 patients (6·4 per cent) developed recurrent disease, including 5·2 per cent of patients with stage I, 19·6 per cent with stage II, 59 per cent with stage III and 50 per cent with stage IV disease, according to the eighth edition. The eighth edition was a better predictor of recurrence than the seventh edition. CONCLUSION The eighth edition of the AJCC/UICC staging system appears to be a novel tool for predicting PTC recurrence, which is a meaningful outcome for this indolent disease. The eighth edition can be used to risk-stratify patients, keeping in mind that other molecular and pathological predictive factors must be integrated into the assessment of recurrence risk.
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Affiliation(s)
- N Chereau
- Department of Endocrine and Digestive Surgery, Sorbonne Université, Hospital Pitié Salpêtrière, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - T O Oyekunle
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - H S Kazaure
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - S A Roman
- Department of Surgery, University of California at San Francisco, San Francisco, California, USA
| | - F Menegaux
- Department of Endocrine and Digestive Surgery, Sorbonne Université, Hospital Pitié Salpêtrière, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - J A Sosa
- Department of Surgery, University of California at San Francisco, San Francisco, California, USA
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