Race as a factor in adverse outcomes following unruptured aneurysm surgery

INTRODUCTION

Strong evidence demonstrates that race is associated with health outcomes. Previous neurosurgical research has focused predominantly on subjective data, such as patient satisfaction. Our objective was to assess whether racial disparities are present in primary objective outcomes for treatment of intracranial, unruptured aneurysms in the United States.

METHODS

Data from the 2012-2015 National Inpatient Sample (NIS) database was analyzed. Patients who underwent either open or endovascular treatment of unruptured intracranial aneurysms were included (n = 11663). Patients were stratified by race, and those of unknown race or whose race sample size was too underpowered for analysis were excluded (n = 1202), along with those who experienced head trauma (n = 110) or concurrent AVM (n = 71). Poor outcome was defined as in-hospital mortality, discharge to a nursing facility or hospice, placement of a tracheostomy tube, or placement of a gastrostomy tube. The associations between race and adverse outcomes were determined through multivariate logistic regression, corrected for potentially confounding variables such as age, sex, procedural type, elective procedure, obesity, diabetes, tobacco, severity of illness, and hospital type.

RESULTS

7478 White, 1460 Black, 1086 Hispanic, and 279 Asian patients were included in the final analysis. Complication rates were not significantly different between races, however Black patients experienced the highest proportion of complications (24 %). After adjusting for confounders, the odds of poor outcomes were significantly higher for Black patients (OR = 1.32 95 % CI: 1.07-1.62; p = 0.008) when compared to White patients. Black and Hispanic patients demonstrated a longer length of stay (Black, B: 0.04; 95 % CI: 0.03, 0.06; p < 0.001; Hispanic, B: 0.04; 95 % CI: 0.02, 0.05; p < 0.001) when compared to White patients.

CONCLUSION

Our nationwide analysis using the NIS suggests that Black patients treated for unruptured intracranial aneurysms experience worse outcomes and longer lengths of stay when compared to White patients. Recognizing the differences in objective outcomes and the presence of neurosurgical healthcare disparities is an important first step in providing equitable care to all patients. Future studies that carefully follow the social determinants of health and consider more confounding factors in the association between outcomes and determinants are needed.

The Role of Race and Gender in the Career Experiences of Black/African American Academic Surgeons: A Survey of the Society of Black Academic Surgeons and a Call to Action

OBJECTIVE

To determine the role of race and gender in the career experience of Black/AA academic surgeons and to quantify the prevalence of experience with racial and gender bias stratified by gender.

SUMMARY OF BACKGROUND DATA

Compared to their male counterparts, Black/African American women remain significantly underrepresented among senior surgical faculty and department leadership. The impact of racial and gender bias on the academic and professional trajectory of Black/AA women surgeons has not been well-studied.

METHODS

A cross-sectional survey regarding demographics, employment, and perceived barriers to career advancement was distributed via email to faculty surgeon members of the Society of Black American Surgeons (SBAS) in September 2019.

RESULTS

Of 181 faculty members, 53 responded (29%), including 31 women (58%) and 22 men (42%). Academic positions as a first job were common (men 95% vs women 77%, P = 0.06). Men were more likely to attain the rank of full professor (men 41% vs women 7%, P = 0.01). Reports of racial bias in the workplace were similar (women 84% vs men 86%, not significant); however, reports of gender bias (women 97% vs men 27%, P < 0.001) and perception of salary inequities (women 89% vs 63%, P = 0.02) were more common among women.

CONCLUSIONS AND RELEVANCE

Despite efforts to increase diversity, high rates of racial bias persist in the workplace. Black/AA women also report experiencing a high rate of gender bias and challenges in academic promotion.

Erratum: Multidisciplinary Management of Breast Cancer During Pregnancy

[This corrects the article DOI: 10.1634/theoncologist.2016-0208.].

Wound complications in preoperatively irradiated soft-tissue sarcomas of the extremities

PURPOSE

To determine whether the involvement of plastic surgery and the use of vascularized tissue flaps reduces the frequency of major wound complications after radiation therapy for soft-tissue sarcomas (STS) of the extremities.

METHODS AND MATERIALS

This retrospective study evaluated patients with STS of the extremities who underwent radiation therapy before surgery. Major complications were defined as secondary operations with anesthesia, seroma/hematoma aspirations, readmission for wound complications, or persistent deep packing.

RESULTS

Between 1996 and 2010, 73 patients with extremity STS were preoperatively irradiated. Major wound complications occurred in 32% and secondary operations in 16% of patients. Plastic surgery closed 63% of the wounds, and vascularized tissue flaps were used in 22% of closures. When plastic surgery performed closure the frequency of secondary operations trended lower (11% vs 26%; P=.093), but the frequency of major wound complications was not different (28% vs 38%; P=.43). The use of a vascularized tissue flap seemed to have no effect on the frequency of complications. The occurrence of a major wound complication did not affect disease recurrence or survival. For all patients, 3-year local control was 94%, and overall survival was 72%.

CONCLUSIONS

The rates of wound complications and secondary operations in this study were very similar to previously published results. We were not able to demonstrate a significant relationship between the involvement of plastic surgery and the rate of wound complications, although there was a trend toward reduced secondary operations when plastic surgery was involved in the initial operation. Wound complications were manageable and did not compromise outcomes.

Long-term survival after 67 hours of anhepatic state due to primary liver allograft nonfunction

Primary liver allograft nonfunction immediately after transplantation poses a life-threatening situation for the recipient. Emergency retransplantation may not be immediately possible due to organ unavailability. Total hepatectomy with temporary portacaval shunt has been described as a bridge to retransplantation when the presence of the graft appears to be harming the recipient. Case reports of retransplantation after total hepatectomy with anhepatic times greater than 48 hours routinely describe poor outcomes. We present a case with excellent patient outcome after 95 hours of clinical anhepatic state, including 67 hours of anatomical anhepatic time, because of primary liver allograft nonfunction. This case report documents the longest anhepatic time with subsequent successful transplant to date.

The effects of 3,4,3'-triiodo-l-thyronine on didehydroretinol synthesis by isolated coho salmon retinal pigment epithelial cells

The effects of thyroid hormone on the production of vitamin A(2) retinoids from vitamin A(1) precursor were investigated in retinal pigmented epithelial (RPE) cells obtained from juvenile coho salmon. Specifically, changes in the production of both the storage and the free forms of radiolabeled 3,4-didehydroretinoids were measured after 24 and 48 h incubation with [11,12-(3)H]all-trans-retinol with (or in the absence of) exogenous 3,4,3'-triiodo-l-thyronine (T(3)). RPE cells incubated with radiolabeled all-trans-retinol showed double the production of radiolabeled 3,4-didehydroretinoids (both storage and free forms) after 48 h compared to 24 h incubation. The addition of T(3) had no significant effect on the production of didehydroretinyl esters (storage form) after 24 h incubation, but did have a significant effect after 48 h, with a ca. 50% reduction in the amount of labeled didehydroretinyl produced compared to the amount produced by the controls after 48 h. Essentially the same observation was made for the production of radiolabeled didehydroretinol (free form) where, after 48 h of incubation with T(3), there was a ca. 50% reduction in the amount of labeled didehydroretinol produced compared to the amount produced by the controls after 48 h. The reduction in both the storage and the free forms of didehydroretinoids indicates that T(3) probably had the effect of altering the activity of the "terminal ring dehydrogenase" enzyme which acts on the outer ring of retinoids. The scope of this experiment, however, does not indicate whether the production of didehydroretinoids is specific to the free or to the storage forms as retinoids within the RPE can shuttle between both forms. The results of this experiment do indicate that the in vitro observations of this experiment may be extended to in vivo and field observations. In vitro, T(3) by itself altered the production of didehydro-derivatives of retinoids. The changes in visual pigment complement seen in salmonids, which are due to changes in relative proportions of 11-cis-retinal and 11-cis-3,4-didehydroretinal in the photoreceptors, may also be the result of T(3) acting by itself on the RPE cells.

Release of atrial natriuretic factor prohormone peptides 1-30, 31-67 and 99-126 from freshwater- and seawater-acclimated perfused trout (Oncorhynchus mykiss) hearts

Atrial natriuretic factor (ANF), a 28-amino-acid peptide hormone produced in the heart, circulates in both freshwater and seawater rainbow trout. In mammals, two other peptide hormones, proANF 1-30 and proANF 31-67, derived from the same 126-amino-acid prohormone as ANF (amino acids 99&shyp;126), circulate and have natriuretic and diuretic properties. It has never been determined whether these peptides circulate in fish. The present investigation was designed to determine (1) whether proANF 1-30 and/or proANF 31-67 circulate in perfused hearts from freshwater- and seawater-acclimated rainbow trout (Oncorhynchus mykiss) in situ, and (2) if they do, to determine whether increasing the filling pressure of the heart causes their release in trout as it does in mammals. High-performance gel-permeation chromatography of fish plasma revealed that both proANF 1-30 and 31-67 circulate in freshwater- and seawater-acclimated trout plasma at threefold higher concentrations than does ANF. The basal rates of release of ANF and proANF 1-30 and 31-67 were similar in both freshwater and seawater trout, with the rate of release of proANF 1-30 being 10 times higher and that of proANF 31-67 20 times higher than that of ANF. When the filling pressure was increased to the peak of the Starling curve (max), the rate of release of ANF and proANFs 1-30 and 31-67 increased fivefold for each peptide in the freshwater trout, while in seawater trout the rates of release increased six- to ninefold. We conclude that proANF 1-30 and 31-67, as well as ANF, circulate in both freshwater-and seawater-acclimated trout and do so at concentrations higher than that of ANF. Increasing the filling pressure to the trout heart was found to cause a similar increase in the release rates for each of these peptides, but the maximal increase was higher in the seawater-acclimated trout, apparently because they showed a larger increase in cardiac output.

THE SHIFT IN VISUAL PIGMENT DOMINANCE IN THE RETINAE OF JUVENILE COHO SALMON (ONCORHYNCHUS KISUTCH): AN INDICATOR OF SMOLT STATUS

Smolting juvenile coho salmon were sampled to determine (1) whether a correlation between hypo-osmoregulatory ability and visual pigment composition existed and (2) whether the hormone 3,5,3'-tri-iodothyronine (T3) was playing a role in the visual pigment conversion process. Plasma sodium levels of seawater-challenged fish (30 ) indicated that there was a 5 week period of optimal ability to excrete excess plasma sodium ions (hypo-osmoregulation) in the late spring/early summer that represented the 'window of opportunity' for the entry or introduction to sea water of the salmon. Early in the smoltification process, the vitamin-A2-based visual pigment porphyropsin increased its dominance in the retinae, and radioimmunoassay of plasma indicated that T3 levels were at a maximum prior to this increase in porphyropsin. As the parr&shy;smolt transformation continued, there was a steady decrease in the relative amounts of porphyropsin, indicating that the retinae were favouring the acquisition of rhodopsin. Rhodopsin dominance virtually coincided with the period of best hypo-osmoregulatory ability. Subsequently, the salmon showed a loss of hypo-osmoregulatory ability and concomitant increases in the amount of porphyropsin in the retina were observed. The relationship between the visual pigment shift and the smoltification process is discussed in terms of preparation for migration and thyroid hormone involvement, and the use of retinal visual pigment composition as an index of smolt status is proposed.