Association of social determinants of health-related diagnosis codes with postoperative outcomes

BACKGROUND

The association of an individual's social determinants of health-related problems with surgical outcomes has not been well-characterized. The objective of this study was to determine whether documentation of social determinants of a health-related diagnosis code (Z code) is associated with postoperative outcomes.

METHODS

This retrospective cohort study included surgical cases from a single institution's national surgical quality improvement program (NSQIP) clinical registry from October 2015 to December 2021. The primary predictor of interest was documentation of a Z code for social determinants of health-related problems. The primary outcome was 30-day postoperative morbidity. Secondary outcomes included postoperative length of stay, disposition, and 30-day postoperative mortality, reoperation, and readmission. Multivariable regression models were fit to evaluate the association between the documentation of a Z code and outcomes.

RESULTS

Of 10,739 surgical cases, 348 patients (3.2%) had a documented social determinants of health-related Z code. In multivariable analysis, documentation of a Z code was associated with increased odds of morbidity (20.7% vs. 9.9%; adjusted odds ratio [aOR], 1.88; 95% confidence interval [CI], 1.39-2.53), length of stay (median, 3 vs. 1 day; incidence rate ratio, 1.49; 95% CI, 1.33-1.67), odds of disposition to a location other than home (11.3% vs. 3.9%; aOR, 2.86; 95% CI, 1.89-4.33), and odds of readmission (15.3% vs. 6.1%; aOR, 1.99; 95% CI, 1.45-2.73).

CONCLUSIONS

Social determinants of health-related problems evaluated using Z codes were associated with worse postoperative outcomes. Improved documentation of social determinants of health-related problems among surgical patients may facilitate improved risk stratification, perioperative planning, and clinical outcomes.

A-11 The Contribution of Psychological Stress to Adolescent Post-Concussive Symptoms Across Recovery

Objective

The aim of this study was to explore whether less commonly explored injury factors account for variance in post-concussive symptoms across recovery.

Method

Participants aged 12–18 (n = 440) who reported to clinic within 14 days of concussion sustained in either sport injury, MVA, fall, or hit were selected from the ConTex registry. A PCS log, PHQ-8, and GAD-7 were completed at initial visit and 3-month follow-up. Separate hierarchical linear regressions determined predictors of PCS scores at both time points. Demographic, premorbid, injury, and psychological factors were entered in Step 1–4, respectively. A sample subset completed the PTSD Checklist (PCL-5) at initial (n = 58) and 3-month visits (n = 27). Exploratory analyses added the PCL-5 to determine whether post-traumatic stress symptoms contributed to the model.

Results

At initial visit, sex, post-traumatic amnesia (PTA), PHQ-8, and GAD-7 significantly predicted PCS total scores (p < .001), accounting for 43% of the variance. At 3-month follow-up, PTA dropped out of the model, and psychiatric history and mechanism of injury became significant, explaining an additional 15% of the variance in PCS scores (R2 = .58, p < .001). In exploratory analyses, when PCL-5 scores were added to the final models, demographic, premorbid, and injury factors did not remain significant, and the PCL-5 significantly contributed to the variance in PCS scores at both initial (p = .01) and 3-month follow-up (p < .001).

Conclusions

Psychological stress and context of injury may be strong predictors of PCS in addition to demographic and premorbid factors. These findings warrant continued investigation of less explored injury factors contribution to initial mTBI presentation and recovery.

The role of radioactive iodine in the management of patients with differentiated thyroid cancer - An oncologic surgical perspective

With improved understanding of the biology of differentiated thyroid carcinoma its management is evolving. The approach to surgery for the primary tumour and elective nodal surgery is moving from a "one-size-fits-all" recommendation to a more personalised approach based on risk group stratification. With this selective approach to initial surgery, the indications for adjuvant radioactive iodine (RAI) therapy are also changing. This selective approach to adjuvant therapy requires understanding by the entire treatment team of the rationale for RAI, the potential for benefit, the limitations of the evidence, and the potential for side-effects. This review considers the evidence base for the benefits of using RAI in the primary and recurrent setting as well as the side-effects and risks from RAI treatment. By considering the pros and cons of adjuvant therapy we present an oncologic surgical perspective on selection of treatment for patients, both following pre-operative diagnostic biopsy and in the setting of a post-operative diagnosis of malignancy.

Does Trauma Influence Post-concussive Symptom Recovery in Youth?

Objective

Minimal research has focused on youth concussions acquired in traumatic events versus non-traumatic events, despite overlap between post-concussive and post-traumatic stress symptoms. Youth sustaining a concussion during a motor vehicle accident (MVA) may endorse greater emotional and cognitive symptoms than those with sports-related concussion (SRC). This study’s aim was to compare recovery from concussion due to MVA versus SRC to determine if recovery profiles differ.

Data Selection

Participants aged 7-25 who reported to clinic within 30 days of SRC (n = 329) or MVA-related concussion (n = 67) and endorsed persistent post-concussive symptomatology (>1 month) were selected from the North Texas Concussion Registry (ConTex). Data collected at initial visit and 3-month follow-up included a four-factor symptom checklist (physical, emotional, cognitive, sleep), GAD-7 for anxiety, and PHQ-8 for depression.

Data Synthesis

Repeated measures ANOVA compared longitudinal score differences. MVA and SRC groups significantly improved on all measures at follow up; however, the MVA group reported higher symptomatology on all measures at both visits (ps < .01). For all cognitive and emotional scores, a significant interaction was found (ps < .01), with the MVA group demonstrating greater improvement over 3 months (See Image Attachment).

Conclusions

Mechanism of injury influences post-concussion symptom recovery. Despite greater improvement in cognitive and emotional symptoms between visits, the MVA group endorsed significantly higher post-concussive symptomatology across the recovery period. Perhaps because of trauma related to mechanism of injury, specific differences in cognitive and emotional symptom presentation/recovery profiles were observed. Posttraumatic stress symptom assessment may be useful in examining the influence of potential trauma/reactions on post-concussive symptom recovery.

Co-occurrence and hybridization of anther-smut pathogens specialized on Dianthus hosts

Host specialization has important consequences for the diversification and ecological interactions of obligate pathogens. The anther-smut disease of natural plant populations, caused by Microbotryum fungi, has been characterized by specialized host-pathogen interactions, which contribute in part to the isolation among these numerous fungal species. This study investigated the molecular variation of Microbotryum pathogens within the geographic and host-specific distributions on wild Dianthus species in southern European Alps. In contrast to prior studies on this pathogen genus, a range of overlapping host specificities was observed for four delineated Microbotryum lineages on Dianthus hosts, and their frequent co-occurrence within single-host populations was quantified at local and regional scales. In addition to potential consequences for direct pathogen competition, the sympatry of Microbotryum lineages led to hybridization between them in many populations, and these admixed genotypes suffered significant meiotic sterility. Therefore, this investigation of the anther-smut fungi reveals how variation in the degrees of host specificity can have major implications for ecological interactions and genetic integrity of differentiated pathogen lineages.

Altered regulatory T cell phenotype in latent autoimmune diabetes of the adults (LADA)

Latent autoimmune diabetes of the adults (LADA) accounts for up to 12% of all patients with diabetes. Initially the disease resembles type 2 diabetes (T2D); however, the typical presence of β cell autoantibodies indicates an autoimmune basis of LADA. While dysfunctional regulatory T cells (Tregs ) have been implicated in autoimmune diabetes, these cells have been scarcely studied in LADA. The aim of this study was to investigate the frequency and phenotype of circulating Tregs in LADA patients early during disease progression. Flow cytometric analysis was performed on whole blood and peripheral mononuclear cells (PBMC) from patients diagnosed with LADA prior to insulin deficiency (n = 39) and from healthy volunteers (n = 20). Overall, we found the frequency and activation status of peripheral putative Tregs to be altered in LADA patients compared to healthy controls. While total T cells and CD4(+) T cells expressing high levels of CD25 (CD4(+) CD25(hi) ) were unchanged, the frequency and total numbers of CD4(+) T cells expressing an intermediate level of CD25 (CD4(+) CD25(int) ) were decreased in LADA patients. Interestingly, the expression of the Treg -specific marker forkhead box protein 3 (FoxP3), as well as the activation and memory makers CD69, cytotoxic T lymphocyte associated antigen 4 (CTLA-4), CCR4 and CD45RO were increased in CD4(+) CD25(+) T cells of the patients. Our data depict phenotypical changes in T cells of LADA patients that may reflect a derangement in peripheral immune regulation contributing to the slow process leading to insulin-dependent diabetes in these patients.

The molecular basis of drug resistance against hepatitis C virus NS3/4A protease inhibitors

Hepatitis C virus (HCV) infects over 170 million people worldwide and is the leading cause of chronic liver diseases, including cirrhosis, liver failure, and liver cancer. Available antiviral therapies cause severe side effects and are effective only for a subset of patients, though treatment outcomes have recently been improved by the combination therapy now including boceprevir and telaprevir, which inhibit the viral NS3/4A protease. Despite extensive efforts to develop more potent next-generation protease inhibitors, however, the long-term efficacy of this drug class is challenged by the rapid emergence of resistance. Single-site mutations at protease residues R155, A156 and D168 confer resistance to nearly all inhibitors in clinical development. Thus, developing the next-generation of drugs that retain activity against a broader spectrum of resistant viral variants requires a comprehensive understanding of the molecular basis of drug resistance. In this study, 16 high-resolution crystal structures of four representative protease inhibitors – telaprevir, danoprevir, vaniprevir and MK-5172 – in complex with the wild-type protease and three major drug-resistant variants R155K, A156T and D168A, reveal unique molecular underpinnings of resistance to each drug. The drugs exhibit differential susceptibilities to these protease variants in both enzymatic and antiviral assays. Telaprevir, danoprevir and vaniprevir interact directly with sites that confer resistance upon mutation, while MK-5172 interacts in a unique conformation with the catalytic triad. This novel mode of MK-5172 binding explains its retained potency against two multi-drug-resistant variants, R155K and D168A. These findings define the molecular basis of HCV N3/4A protease inhibitor resistance and provide potential strategies for designing robust therapies against this rapidly evolving virus.

Hepatitis C virus (HCV) infects over 170 million people worldwide and is the leading cause of chronic liver diseases, including cirrhosis, liver failure, and liver cancer. New classes of directly-acting antiviral agents that target various HCV enzymes are being developed. Two such drugs that target the essential HCV NS3/4A protease are approved by the FDA and several others are at various stages of clinical development. These drugs, when used in combination with pegylated interferon and ribavirin, significantly improve treatment outcomes. However HCV evolves very quickly and drug resistance develops against directly-acting antiviral agents. Thus, despite the therapeutic success of NS3/4A protease inhibitors, their long-term effectiveness is challenged by drug resistance. Our study explains in atomic detail how and why drug resistance occurs for four chemically representative protease inhibitors –telaprevir, danoprevir, vaniprevir and MK-5172. Potentially with this knowledge, new drugs could be developed that are less susceptible to drug resistance. More generally, understanding the underlying mechanisms by which drug resistance occurs can be incorporated in drug development to many quickly evolving diseases.

Laryngeal and sinonasal paragangliomas

Laryngeal paragangliomas are classified as supraglottic and infraglottic. This article defines each type of paraganglioma, discusses the clinical features and diagnoses, and covers the surgical management. This article also addresses sinonasal paragangliomas, including their clinical features, diagnosis, and treatment.

Just what the patient ordered: the case for result-based compensation arrangements

For more than twenty years, Opinion 6.01 of the American Medical Association's (AMA) Code of Medical Ethics has specified that “a physician's fee for medical services should be based on the value of the service provided by the physician to the patient.” In 1994, the AMA amended Opinion 6.01, adding a new statement that “a physician's fee should not be made contingent on the successful outcome of medical treatment.”

We believe that the amendment is wholly indefensible. Therefore, in this essay, we argue that the AMA should lift this prohibition and encourage the use of result-based compensation for medical services in appropriate circumstances.

The 1994 amendment dramatically changed the significance and scope of Opinion 6.01. Result-based compensation arrangements clearly satisfy the original version of Opinion 6.01 because they base compensation on the “value of the services provided … to the patient.” Yet, it is equally clear that result-based compensation arrangements violate the amended version of Opinion 6.01 because they necessarily make compensation “contingent on the successful outcome of medical treatment.”

A re-evaluation of hypopharyngeal reconstruction: pedicled flaps versus microvascular free flaps

Reconstruction of hypopharyngeal defects can be accomplished with the use of pedicled myocutaneous flaps or with microvascular free flaps. The authors contrast their results using the trapezoidal paddle pectoralis major myocutaneous flap with the reported results of two published series of free jejunal flaps. The severity of the defects, preprocedure irradiation, and mix of primary and secondary reconstruction were comparable between series. The benefits, complications, and functional results of either technique also seem to be comparable. However, the authors recommend the trapezoidal paddle pectoralis major myocutaneous flap for its ease of performance, rapidity of surgery, and absence of intraperitoneal approach. With the current effort to achieve comparable results with shorter procedures, and with greater conservation of patient and public resources, the pedicled flap should be reconsidered.

Establishing a home care protocol for early discharge of patients with hip and knee arthroplasties

Joint arthroplasty procedures are significant in number and cost. Discharging hip and knee arthroplasty patients early from the hospital to a transitional home care program has the potential to reduce costs, while maintaining quality. A retrospective review of hospital records of hip and knee arthroplasty patients quantified patient problems during postoperative days 3 through 12 and analyzed them by age, gender, and joint type. The pilot study also allowed the development of a protocol for transitional home care after hip and knee arthroplasty.

Embolization of the ophthalmic artery for control of epistaxis: report of two cases

Embolization of the internal maxillary artery, an accepted method for control of severe or recurrent posterior epistaxis, usually involves the ipsilateral artery, but occasionally the contralateral vessel and the facial arteries as well. Such endovascular treatment may fail if the vascular supply to the bleeding vessels originates in derivative branches of the ophthalmic artery. We report two unusual cases in which embolization of the ophthalmic artery was performed to control epistaxis. The first patient had a prosthetic eye. In the second, sight in one eye was sacrificed after careful consideration in order to prolong life.

Radiation therapy as a treatment for benign lymphoepithelial parotid cysts in patients infected with human immunodeficiency virus-1

Patients who are infected with the human immunodeficiency virus (HIV) may develop benign lymphoepithelial cysts within the parotid gland that cause severe facial deformity. Standard treatment for this disorder has been superficial parotidectomy, repeated fine-needle aspirations or observation alone. These approaches are unsatisfactory because elective surgery in immunocompromised patients should be avoided, the cysts recur soon after aspiration, and observation alone for a treatable deforming facial process is unacceptable. Radiotherapy's proven effectiveness in treating other benign disorders of the parotid gland led us to evaluate its usefulness as a treatment for this disorder. Eight patients with parotid enlargement, who were seropositive for HIV, received 8-10 Gy to the parotids in 1 week. Five patients had complete response and three patients had partial response. All were very satisfied with the cosmetic result. Treatment-related toxicity was well tolerated and consisted of mild xerostomia and transient taste loss. In all cases, these side effects resolved within 1 month. Radiation therapy thus appears to be an effective and well-tolerated treatment for AIDS-related parotid enlargement.

Management of necrotic neck wounds with a "sandwich" pectoralis myocutaneous flap

A modified pectoralis major myocutaneous flap was used to stabilize necrotic neck wounds rapidly in irradiated patients. The flap was a "sandwich" flap that included an overlying "parasternal" pectoral skin paddle for pharyngeal reconstruction, the pectoralis muscle for carotid protection, and a meshed skin graft applied to the undersurface of the muscle to replace cervical skin. This flap has been used to reconstruct seven patients with severe wound necrosis from pharyngeal fistula and infection. All patients had carotid exposure in the infected wound. Reconstruction in all patients accomplished restoration of pharyngeal continuity, carotid protection, and cervical skin replacement. Some patients required more than one procedure for closure. There were no carotid "blowouts" in any of the patients. This technique enables the head and neck surgeon to stabilize these contaminated wounds rapidly and to reconstruct complex defects of the pharynx and cervical skin.

Malignant paraganglioma of the thyroid gland

Paragangliomas of the thyroid gland are rare lesions, only four previous cases having been reported in the literature, to our knowledge. We report herein a fifth case, which, to our knowledge, is the first to exhibit malignant behavior manifested by invasion into perithyroidal soft tissue through the wall of the trachea into the tracheal mucosa.

Primary reconstruction of palatal defects

Removal of the soft palate can cause marked functional deficit in deglutition and phonation. Most commonly, treatment of this deformity with prosthetic obturation has been less than ideal. Numerous reconstructive techniques have met with only partial success, while deforming distant structures. We will present a technique of reconstruction of the soft palate by use of a superiorly based pharyngeal flap. It has been used successfully in five patients who underwent soft palatectomy for malignant disease. The flaps have been the full width of the pharynx and extended down to the esophageal inlet. Viability of the flap is excellent, and the donor site is allowed to heal by secondary intention. Excellent function has been achieved in all cases with no compromise of oncological principles.

Osteoradionecrosis of the maxilla and skull base

Osteoradionecrosis of the maxilla and base of skull are rare phenomena, usually seen after combined therapy for malignancies of the maxillary sinus. While the mandible is most commonly affected by osteoradionecrosis, the maxilla and skull base may also be affected when preoperative or postoperative radiotherapy is combined with surgery. Contributing factors may be: high radiation dosage delivered to the treatment volume (greater than 6000 rads), loss of tissue protective effects due to surgery, decreased vascularity caused by surgery and radiation, and proximity of a contaminated field. Onset of symptoms may vary. One patient presented 25 years after postoperative radiotherapy. Major symptoms were pain, trismus, and purulent discharge. The best diagnostic modality remains the history and physical exam, as the area is readily accessible. CT scans may be helpful in diagnosis and treatment planning. Therapy should follow time honored principles of local wound care. Home irrigations and hyperbaric therapy have been helpful in encouraging early sequestration and rapid healing.

Cellular immunity in patients with epidermoid cancer of the head and neck

Forty-three patients with squamous cell carcinoma of the head and neck were evaluated immunologically at various times before and after treatment. Impaired DNCB skin reactivity was found in patients with more advanced disease (Stages II-IV). In the 24 patients evaluated prior to therapy, only the mean percentages of two subpopulation T-cell tests, T-RFC29 and "active" T-RFC and mean absolute T-RFC29 per mm3 and PHA responses were significantly depressed. These depressed values could not, however, be correlated with the stage of the disease. In patients with poorly to moderatley differentiated tumors there was a significant decrease in mean percentage of active T-RFC and PHA stimulation. A marked difference in mean percentages of T-RFC29 between pretreated patients without nodal involvement (40.5 +/- 2.1) and those with this complicity (58.1 +/- 4.9) suggests that this assay may be used to detect occult nodal involvement. A comparison of the effects of surgery, irradiation and the combination of the two no patients indicated that only radiation affected any of their immune parameters. Irradiated patients demonstrated a marked decline in the mean absolute level of lymphocytes, total T-RFC and mean PHA responsiveness within one month of the termination of therapy: however, these values returned to the pretreatment level within seven months. None of the treatments was effective in "curing" the immune deficits observed in pretreatment patients.

Treatment of carcinoma of the oral tongue by radium needle implantation

Forty-nine patients had a radium implant for carcinoma of the oral tongue. In thirty-four of the forty-nine (70 per cent), local three year control of the cancer was achieved. Three patients in whom the radiation failed were rescued by subsequent surgery. The five year absolute survival in this series was 63.8 per cent. In conclusion, we believe that improved survival rates without functional and cosmetic defect can be obtained by closer cooperation between surgeons and radiotherapists.