Disparities in the Surgical Treatment of Cerebrovascular Pathologies: A Contemporary Systematic Review

Racial and Socioeconomic Status among a Patient Population Presenting with Aneurysmal Subarachnoid Hemorrhage versus Unruptured Intracranial Aneurysm: A Single-Center Study

Racial and socioeconomic health disparities are well documented in the literature. This study examined patient demographics, including socioeconomic status (SES), among individuals presenting with aneurysmal subarachnoid hemorrhage (aSAH) and unruptured intracranial aneurysm (UIA) to identify factors associated with aSAH presentation. A retrospective assessment was conducted of all patients with aSAH and UIA who presented to a large-volume cerebrovascular center and underwent microsurgical treatment from January 2014 through July 2019. Race and ethnicity, insurance type, and SES data were collected for each patient. Comparative analysis of the aSAH and UIA groups was conducted. Logistic regression models were also employed to predict the likelihood of aSAH presentation based on demographic and socioeconomic factors. A total of 640 patients were included (aSAH group, 251; UIA group, 389). Significant associations were observed between race and ethnicity, SES, insurance type, and aneurysm rupture. Non-White race or ethnicity, lower SES, and having public or no insurance were associated with increased odds of aSAH presentation. The aSAH group had poorer functional outcomes and higher mortality rates than the UIA group. Patients who are non-White, have low SES, and have public or no insurance were disproportionately affected by aSAH, which is historically associated with poorer functional outcomes.

Provider care segregation and hospital-region racial disparities for carotid interventions in the USA

BACKGROUND

Reasons for racial disparities in the utilization and outcomes of carotid interventions (carotid endarterectomy (CEA) and carotid artery stenting (CAS)) are not well understood, especially segregation of care associated with carotid intervention. We examined patterns of geographic and provider care segregation in carotid interventions and outcomes.

METHOD

We used de-identified Medicare datasets to identify CEA and CAS interventions between January 1, 2016 and December 31, 2019 using validated ICD-10 codes. For patients who underwent carotid intervention, we calculated (1) the proportion of White patients at the hospital, (2) the proportional difference in the proportion of White patients between hospital patients and the county, and (3) provider care segregation by the dissimilarity index for carotid intervention cases. We examined associations between measures of segregation and outcomes.

RESULTS

Despite higher proportions of Black patients in counties with hospitals that provide carotid intervention, lower proportions of Black patients received intervention. The difference in the proportion of White patients comparing CEA patients to the county race distribution was 0.143 (SD 0.297) at the hospital level (for CAS, 0.174 (0.315)). The dissimilarity index for CEA providers was high, with mean (SD) 0.387 (0.274) averaged across all hospitals and higher among CAS providers at 0.472 (0.288). Black patients receiving CEA and CAS (compared with Whites) had reduced odds of discharge home. Better outcomes (inpatient mortality and 30-day mortality) were independently associated with higher proportion of White CAS patients.

CONCLUSION

In this national study with contemporary data on carotid intervention, we found evidence for segregation of care of both CEA and CAS.

Pancreatic Cancer Biopsy Modalities: Comparing Insurance Status, Length of Stay, and Hospital Complications Based on Percutaneous, Endoscopic, and Surgical Biopsy Methods

BACKGROUND

Pancreatic cancer is diagnosed histologically through percutaneous biopsy (PB), endoscopic biopsy (EB), or surgical biopsy (SB). Factors and outcomes associated with method type are not clearly understood. We aimed to evaluate the relationship between insurance status, length of hospital stay (LOS), complications, and different pancreatic biopsy modalities.

STUDY

The 2001-2013 database from the National (Nationwide) Inpatient Sample (NIS) was queried for those with pancreatic cancer who underwent biopsies using International Classification of Diseases, Ninth Revision (ICD-9) codes. Data regarding insurance status, hospital stay, demographics, and complications were analyzed using chi-square and multivariate analysis with α < 0.001.

RESULTS

A total of 824,162 patients with pancreatic cancer were identified. Uninsured and Medicaid patients were more likely to get PB compared to SB. Patients were more likely to have acute renal failure (ARF) with an EB compared to SB. Patients were more likely to have a urinary tract infection (UTI) with EB or PB compared to SB. All biopsy types were less likely to have pneumonia; pancreatitis was more prevalent in EB compared to PB and SB.

CONCLUSIONS

Uninsured and Medicaid patients were most likely to have a PB compared to EB despite unclear indications which may represent an underlying discrepancy in healthcare utilization. EB patients had the shortest LOS while SB patients stayed three more days; those who underwent a combination of biopsies had the greatest LOS. Patients with EB were more likely to develop ARF, UTI, and pancreatitis than SB, possibly attributed to the advanced nature of endoscopic ultrasound. It is important to establish appropriate algorithm contributors to guide decision-making.

Review on the Therapeutic Potential of Curcumin and its Derivatives on Glioma Biology

Gliomas are common and aggressive brain tumors that carry a poor prognosis. The current multimodal therapeutic option for glioma includes surgery subsequently temozolomide chemotherapy and/or radiation; but gliomas are often associated with multidrug resistance, intensive adverse events, and tumor relapse. Thus, novel interventions that can enhance successful chemo-prevention and overcome therapeutic resistance are urgently needed. Phytochemicals have several biological properties with multi-target sites and relatively limited degrees of toxicity. Curcumin is a natural polyphenolic compound with several anti-tumor effects which potentially inhibit tumor growth, development, proliferation, invasion, dissemination, and angiogenesis in different human malignancies. Experimental model studies have demonstrated that curcumin attenuates glioma cell viability by G2/M cell cycle arrest, apoptosis, induction of autophagy, gene expression alteration, and disruption of multi-molecular pathways. Moreover, curcumin has been reported to re-sensitize cancer to chemotherapeutics as well as augment the effect of radiotherapy on glioma cells. In this review, we have provided an update on the in vitro and in vivo effects of curcumin-based therapy on gliomas. We have also discussed the use of curcumin in combination therapies, its effectiveness on drug-resistant cells, and new formulations of curcumin in the treatment of gliomas.

Expert surgeons and deep learning models can predict the outcome of surgical hemorrhage from 1 min of video

Major vascular injury resulting in uncontrolled bleeding is a catastrophic and often fatal complication of minimally invasive surgery. At the outset of these events, surgeons do not know how much blood will be lost or whether they will successfully control the hemorrhage (achieve hemostasis). We evaluate the ability of a deep learning neural network (DNN) to predict hemostasis control ability using the first minute of surgical video and compare model performance with human experts viewing the same video. The publicly available SOCAL dataset contains 147 videos of attending and resident surgeons managing hemorrhage in a validated, high-fidelity cadaveric simulator. Videos are labeled with outcome and blood loss (mL). The first minute of 20 videos was shown to four, blinded, fellowship trained skull-base neurosurgery instructors, and to SOCALNet (a DNN trained on SOCAL videos). SOCALNet architecture included a convolutional network (ResNet) identifying spatial features and a recurrent network identifying temporal features (LSTM). Experts independently assessed surgeon skill, predicted outcome and blood loss (mL). Outcome and blood loss predictions were compared with SOCALNet. Expert inter-rater reliability was 0.95. Experts correctly predicted 14/20 trials (Sensitivity: 82%, Specificity: 55%, Positive Predictive Value (PPV): 69%, Negative Predictive Value (NPV): 71%). SOCALNet correctly predicted 17/20 trials (Sensitivity 100%, Specificity 66%, PPV 79%, NPV 100%) and correctly identified all successful attempts. Expert predictions of the highest and lowest skill surgeons and expert predictions reported with maximum confidence were more accurate. Experts systematically underestimated blood loss (mean error - 131 mL, RMSE 350 mL, R² 0.70) and fewer than half of expert predictions identified blood loss > 500 mL (47.5%, 19/40). SOCALNet had superior performance (mean error - 57 mL, RMSE 295 mL, R² 0.74) and detected most episodes of blood loss > 500 mL (80%, 8/10). In validation experiments, SOCALNet evaluation of a critical on-screen surgical maneuver and high/low-skill composite videos were concordant with expert evaluation. Using only the first minute of video, experts and SOCALNet can predict outcome and blood loss during surgical hemorrhage. Experts systematically underestimated blood loss, and SOCALNet had no false negatives. DNNs can provide accurate, meaningful assessments of surgical video. We call for the creation of datasets of surgical adverse events for quality improvement research.