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Banks KC, Wei J, Morales LM, Islas ZA, Alcasid NJ, Susai CJ, Sun A, Burapachaisri K, Patel AR, Ashiku SK, Velotta JB. Differences in outcomes by race/ethnicity after thoracic surgery in a large integrated health system. Surg Open Sci 2024; 19:118-124. [PMID: 38655068 PMCID: PMC11035076 DOI: 10.1016/j.sopen.2024.04.002] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 04/05/2024] [Indexed: 04/26/2024] Open
Abstract
Background Disparities exist throughout surgery. We aimed to assess for racial/ethnic disparities among outcomes in a large thoracic surgery patient population. Methods We reviewed all thoracic surgery patients treated at our integrated health system from January 1, 2016-December 31, 2020. Post-operative outcomes including length of stay (LOS), 30-day return to the emergency department (30d-ED), 30-day readmission, 30- and 90-day outpatient appointments, and 30- and 90-day mortality were compared by race/ethnicity. Bivariate analyses and multivariable logistic regression were performed. Our multivariable models adjusted for age, sex, body mass index, Charlson Comorbidity Index, surgery type, neighborhood deprivation index, insurance, and home region. Results Of 2730 included patients, 59.4 % were non-Hispanic White, 15.0 % were Asian, 11.9 % were Hispanic, 9.6 % were Black, and 4.1 % were Other. Median (Q1-Q3) LOS (in hours) was shortest among non-Hispanic White (37.3 (29.2-76.1)) and Other (36.5 (29.3-75.4)) patients followed by Hispanic (46.8 (29.9-78.1)) patients with Asian (51.3 (30.7-81.9)) and Black (53.7 (30.6-101.6)) patients experiencing the longest LOS (p < 0.01). 30d-ED rates were highest among Hispanic patients (21.3 %), followed by Black (19.2 %), non-Hispanic White (18.1 %), Asian (13.4 %), and Other (8.0 %) patients (p < 0.01). On multivariable analysis, Hispanic ethnicity (Odds Ratio (OR) 1.43 (95 % CI 1.03-1.97)) and Medicaid insurance (OR 2.37 (95 % CI 1.48-3.81)) were associated with higher 30d-ED rates. No racial/ethnic disparities were found among other outcomes. Conclusions Despite parity across multiple surgical outcomes, disparities remain related to patient encounters within our system. Health systems must track such disparities in addition to standard clinical outcomes. Key message While our large integrated health system has been able to demonstrate parity across many major surgical outcomes among our thoracic surgery patients, race/ethnicity disparities persist including in the number of post-operative return trips to the emergency department. Tracking outcome disparities to a granular level such as return visits to the emergency department and number of follow up appointments is critical as health systems strive to achieve equitable care.
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Affiliation(s)
- Kian C. Banks
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
| | - Julia Wei
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Leyda Marrero Morales
- University of California, San Francisco, School of Medicine, 533 Parnassus Ave, San Francisco, CA 94143, USA
| | - Zeuz A. Islas
- Kaiser Permanente Bernard J. Tyson School of Medicine, 98 S Los Robles Ave, Pasadena, CA 91101, USA
| | - Nathan J. Alcasid
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
| | - Cynthia J. Susai
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
| | - Angela Sun
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Katemanee Burapachaisri
- University of California, San Francisco, School of Medicine, 533 Parnassus Ave, San Francisco, CA 94143, USA
| | - Ashish R. Patel
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
| | - Simon K. Ashiku
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
| | - Jeffrey B. Velotta
- Division of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, 3600 Broadway, Oakland, CA 94611, USA
- Department of Surgery, University of California, San Francisco- East Bay, 1411 E 31st St, Oakland, CA 94602, USA
- University of California, San Francisco, School of Medicine, 533 Parnassus Ave, San Francisco, CA 94143, USA
- Kaiser Permanente Bernard J. Tyson School of Medicine, 98 S Los Robles Ave, Pasadena, CA 91101, USA
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Alcasid NJ, Banks KC, Susai CJ, Victorino GP. Early Abnormal Vital Signs Predict Poor Outcomes in Normotensive Patients Following Penetrating Trauma. J Surg Res 2024; 295:393-398. [PMID: 38070252 DOI: 10.1016/j.jss.2023.11.018] [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] [Received: 03/01/2023] [Revised: 10/17/2023] [Accepted: 11/12/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Because trauma patients in class II shock (blood loss of 15%-30% of total blood volume) arrive normotensive, this makes the identification of shock and subsequent prognostication of outcomes challenging. Our aim was to identify early predictive factors associated with worse outcomes in normotensive patients following penetrating trauma. We hypothesize that abnormalities in initial vital signs portend worse outcomes in normotensive patients following penetrating trauma. METHODS A retrospective review was performed from 2006 to 2021 using our trauma database and included trauma patients presenting with penetrating trauma with initial normotensive blood pressures (systolic blood pressure ≥90 mmHg). We compared those with a narrow pulse pressure (NPP ≤25% of systolic blood pressure), tachycardia (heart rate ≥100 beats per minute), and elevated shock index (SI ≥ 0.8) to those without. Outcomes included mortality, intensive care unit admission, and ventilator use. Chi-squared, Mann-Whitney tests, and regression analyses were performed as appropriate. RESULTS We identified 7618 patients with penetrating injuries and normotension on initial trauma bay assessment. On univariate analysis, NPP, tachycardia, and elevated SI were associated with increases in mortality compared to those without. On multivariable logistic regression, only NPP and tachycardia were independently associated with mortality. Tachycardia and an elevated SI were both independently associated with intensive care unit admission. Only an elevated SI had an independent association with ventilator requirements, while an NPP and tachycardia did not. CONCLUSIONS Immediate trauma bay NPP and tachycardia are independently associated with mortality and adverse outcomes and may provide an opportunity for improved prognostication in normotensive patients following penetrating trauma.
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Affiliation(s)
- Nathan J Alcasid
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California.
| | - Kian C Banks
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Cynthia J Susai
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Gregory P Victorino
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
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Susai CJ, Alcasid NJ, Banks KC, Victorino GP. Multiple Casualty Incidents at a Level I Trauma Center: A 15-year Analysis. J Surg Res 2024; 295:487-492. [PMID: 38071778 DOI: 10.1016/j.jss.2023.11.022] [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] [Received: 03/01/2023] [Revised: 09/28/2023] [Accepted: 11/12/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Limited evidence regarding multiple casualty outcomes exists. Given resource strain with increasing patient load, we hypothesized that patients involved in a multiple casualty incident have worse outcomes compared to standard trauma patients. METHODS Multiple casualty victims from 2006 to 2021 at our institution were identified; admission data and trauma outcomes were then compared to standard trauma patients. Chi-square tests and Mann-Whitney U-tests were performed for categorical and non-normal continuous data, respectively. Logistic regression was performed to evaluate associations with mortality and intensive care unit (ICU) admission. RESULTS We identified 39,924 patients, of which 612 were multiple casualty patients (1.5%). Multiple casualty involvement was associated with younger age (29 y versus 44 y, P < 0.001) and higher rates of penetrating trauma (26.1% versus 21.4%; P < 0.001). Multiple casualty involvement was associated with higher injury severity score (ISS) (11.6 versus 7.9, P < 0.001), mortality (2.4% versus 1.5% P < 0.005), and ICU admission (17% versus 13%, P < 0.005). On logistic regression analysis, age, ISS, shock index, presence of the COVID-19 pandemic, and mechanism all independently predicted mortality (P ≤ 0.003), while multiple casualty involvement did not (P = 0.302). CONCLUSIONS Although multiple casualty incidents are associated with patient factors that increase hospital resource strain, when controlling for age, ISS, shock index, presence of the COVID-19 pandemic, and trauma mechanism, involvement in multiple casualty incident was not independently associated with ICU admission or mortality. Improved understanding of the impact of high-volume trauma may allow us to improve our care of this at-risk population.
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Affiliation(s)
- Cynthia J Susai
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, California.
| | - Nathan J Alcasid
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, California
| | - Kian C Banks
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, California
| | - Gregory P Victorino
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, California
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Banks KC, Mooney CM, Alcasid NJ, Susai CJ, Mazzolini K, Browder TD, Victorino GP. Colon Injuries and Infectious Complications in Concurrent Gunshot-Related Fractures. J Surg Res 2024; 293:152-157. [PMID: 37774592 DOI: 10.1016/j.jss.2023.09.042] [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] [Received: 03/01/2023] [Revised: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 10/01/2023]
Abstract
INTRODUCTION Concurrent colonic injury among patients with gunshot-related fractures presents a potential risk for infectious complications. We hypothesized that colon injuries are associated with more infectious orthopedic complications among gunshot victims with concurrent fractures. MATERIALS AND METHODS We reviewed trauma patients arriving at our level 1 trauma center from January 1, 2019 to May 31, 2022 who suffered any gunshot-related fracture and also underwent an exploratory laparotomy. Of these patients, those with colon injuries were compared to those without colon injuries. Baseline characteristics, including antibiotic regimens, were collected in addition to outcomes of length of stay, intensive care unit admission, ventilator requirement, and development of infectious orthopedic complications. RESULTS Overall, 56 of the 107 included patients had colon injuries. Age, sex, race/ethnicity, and Injury Severity Score were similar between groups. Of patients with colonic injuries, 16.1% received early, repeat dosing of broad-spectrum antibiotics, while only 3.9% of patients without colonic injuries received this antibiotic dosing (P = 0.04). Interestingly, only patients with colon injuries developed infectious orthopedic complications and none of the patients without colon injuries developed such complications (10.7% versus 0.0%, P = 0.03). All patients with orthopedic infections had infected pelvic fractures. Length of stay was 3 d longer in the colon injury group (P = 0.04). There was no difference in intensive care unit admission, ventilator requirement, or death. CONCLUSIONS Concurrent colon injuries among patients with gunshot-related fractures are associated with higher risk of infectious orthopedic complications, likely from direct spread of fecal contaminant. Early, broad-spectrum antibiotics may be associated with reduced infectious orthopedic complications.
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Affiliation(s)
- Kian C Banks
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California.
| | - Colin M Mooney
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Nathan J Alcasid
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Cynthia J Susai
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Kirea Mazzolini
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Timothy D Browder
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
| | - Gregory P Victorino
- Department of Surgery, University of California, San Francisco- East Bay, Oakland, California
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Kwak HV, Banks KC, Hung YY, Alcasid NJ, Susai CJ, Patel A, Ashiku S, Velotta JB. Adjuvant Immunotherapy in Curative Intent Esophageal Cancer Resection Patients: Real-World Experience within an Integrated Health System. Cancers (Basel) 2023; 15:5317. [PMID: 38001577 PMCID: PMC10669669 DOI: 10.3390/cancers15225317] [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: 10/05/2023] [Revised: 10/30/2023] [Accepted: 11/03/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Adjuvant immunotherapy has been shown in clinical trials to prolong the survival of patients with esophageal cancer. We report our initial experience with immunotherapy within an integrated health system. METHODS A retrospective cohort study was performed reviewing patients undergoing minimally invasive esophagectomy at our institution between 2017 and 2021. The immunotherapy cohort was assessed for completion of treatment, adverse effects, and disease progression, with emphasis on patients who received surgery in 2021 and their eligibility to receive nivolumab. RESULTS There were 39 patients who received immunotherapy and 137 patients who did not. In logistic regression, immunotherapy was not found to have a statistically significant impact on 1-year overall survival after adjusting for age and receipt of adjuvant chemoradiation. Only seven patients out of 39 who received immunotherapy successfully completed treatment (18%), with the majority failing therapy due to disease progression or side effects. Of the 17 patients eligible for nivolumab, 13 patients received it (76.4%), and three patients completed a full course of treatment. CONCLUSIONS Despite promising findings of adjuvant immunotherapy improving the survival of patients with esophageal cancer, real-life practice varies greatly from clinical trials. We found that the majority of patients were unable to complete immunotherapy regimens with no improvement in overall 1-year survival.
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Affiliation(s)
- Hyunjee V. Kwak
- Department of Surgery, University of California, San Francisco-East Bay, 1411 E 31st Street, QIC 22134, Oakland, CA 94602, USA; (K.C.B.); (N.J.A.); (C.J.S.)
| | - Kian C. Banks
- Department of Surgery, University of California, San Francisco-East Bay, 1411 E 31st Street, QIC 22134, Oakland, CA 94602, USA; (K.C.B.); (N.J.A.); (C.J.S.)
| | - Yun-Yi Hung
- Biostatistical Consulting Unit, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA;
| | - Nathan J. Alcasid
- Department of Surgery, University of California, San Francisco-East Bay, 1411 E 31st Street, QIC 22134, Oakland, CA 94602, USA; (K.C.B.); (N.J.A.); (C.J.S.)
| | - Cynthia J. Susai
- Department of Surgery, University of California, San Francisco-East Bay, 1411 E 31st Street, QIC 22134, Oakland, CA 94602, USA; (K.C.B.); (N.J.A.); (C.J.S.)
| | - Ashish Patel
- Division of Thoracic Surgery, Department of Surgery, Kaiser Permanente Northern California, 3600 Broadway, Oakland, CA 94612, USA; (A.P.); (S.A.); (J.B.V.)
| | - Simon Ashiku
- Division of Thoracic Surgery, Department of Surgery, Kaiser Permanente Northern California, 3600 Broadway, Oakland, CA 94612, USA; (A.P.); (S.A.); (J.B.V.)
| | - Jeffrey B. Velotta
- Division of Thoracic Surgery, Department of Surgery, Kaiser Permanente Northern California, 3600 Broadway, Oakland, CA 94612, USA; (A.P.); (S.A.); (J.B.V.)
- Department of Surgery, University of California, San Francisco School of Medicine, 533 Parnassus Ave, San Francisco, CA 94143, USA
- Department of Clinical Medicine, Kaiser Permanente Bernard J. Tyson School of Medicine, 98 S Los Robles Ave, Pasadena, CA 91101, USA
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Susai CJ, Velotta JB, Sakoda LC. Clinical Adjuncts to Lung Cancer Screening: A Narrative Review. Thorac Surg Clin 2023; 33:421-432. [PMID: 37806744 PMCID: PMC10926946 DOI: 10.1016/j.thorsurg.2023.03.002] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
The updated US Preventive Services Task Force guidelines on lung cancer screening have significantly expanded the population of screening eligible adults, among whom the balance of benefits and harms associated with lung cancer screening vary considerably. Clinical adjuncts are additional information and tools that can guide decision-making to optimally screen individuals who are most likely to benefit. Proposed adjuncts include integration of clinical history, risk prediction models, shared-decision-making tools, and biomarker tests at key steps in the screening process. Although evidence regarding their clinical utility and implementation is still evolving, they carry significant promise in optimizing screening effectiveness and efficiency for lung cancer.
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Affiliation(s)
- Cynthia J Susai
- UCSF East Bay General Surgery, 1411 East 31st Street QIC 22134, Oakland, CA 94612, USA
| | - Jeffrey B Velotta
- Department of Thoracic Surgery, Kaiser Permanente Northern California, 3600 Broadway, Oakland, CA 94611, USA
| | - Lori C Sakoda
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA.
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Susai CJ, Banks KC, Alcasid NJ, Velotta JB. A clinical review of spontaneous pneumomediastinum. Mediastinum 2023; 8:4. [PMID: 38322193 PMCID: PMC10839511 DOI: 10.21037/med-23-25] [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] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 10/12/2023] [Indexed: 02/08/2024]
Abstract
Primary spontaneous pneumomediastinum is a rare, often benign and self-limited condition defined by air within the mediastinum. However, correctly distinguishing primary spontaneous pneumomediastinum from secondary causes, especially esophageal perforation, remains a diagnostic challenge. There is significant debate regarding the balance of completing a thorough but not overly invasive and costly diagnostic workup. This clinical review aims to gather the limited data regarding spontaneous pneumomediastinum management from case series and retrospective cohort studies, and presents an evaluation algorithm and treatment plan stratified by clinical history. Understanding specifically if the patient presents with coughing versus forceful vomiting is critical to help elucidate the etiology and guide management of pneumomediastinum. Patients who present with forceful vomiting or retching should be considered with higher degree of suspicion for secondary causes of pneumomediastinum, specifically esophageal perforation. However, especially in children, aggressive diagnostic workup is not warranted in every case. After ruling out other etiologies of pneumomediastinum, spontaneous pneumomediastinum can be commonly treated with symptomatic management without the aggressive use of antibiotics or diet restriction. Hospital length of stay may also be minimized on a case-by-case basis. Overall, recurrence of spontaneous pneumomediastinum is rare and outpatient follow up may be safely limited to those at highest risk of recurrence.
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Affiliation(s)
- Cynthia J. Susai
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA, USA
| | - Kian C. Banks
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA, USA
| | - Nathan J. Alcasid
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA, USA
| | - Jeffrey B. Velotta
- Department of Thoracic Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
- Department of Clinical Science at Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
- Department of Surgery, UCSF School of Medicine, San Francisco, CA, USA
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Abstract
Mesenchymal stromal cells (MSCs) have been a promising area of study for regenerative medicine. These cells can be harvested from bone marrow, adipose tissue, and other areas allowing for autologous transplantation of these cells into the area of degeneration or injury. With the proper signals, these cells may be able to regenerate healthy tissue. Recent studies have yielded promising evidence supporting translational mesenchymal stromal cell applications particularly in spinal fusion surgery.
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Affiliation(s)
- Adam E M Eltorai
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Cynthia J Susai
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alan H Daniels
- Division of Spine Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
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