Race-based disparities in loss of functional independence after hysterectomy for uterine cancer.
ABSTRACT: Racial disparities in uterine cancer-related outcomes have been reported. The goal of this study was to determine if race, pre-operative body mass index (BMI), and medical comorbidities are predictors of loss of functional independence after hysterectomy for uterine cancer.Loss of independence was defined as a change from pre-operative functional independence, to a post-operative requirement of discharge to a post-care facility, or death within the first 30 days following uterine cancer surgery. Demographic factors, comorbidities, BMI, intra-operative and post-operative outcomes, and discharge status were abstracted from the 2011 and 2012 American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Statistical analyses included multivariable logistic regression and Wald tests for interaction.A total of 4005 patients had uterine cancer and were functionally independent pre-operatively. After adjusting for clinical features and comorbidities, Black women were not significantly more likely to lose functional independence than non-Black women. However, a significant interaction (OR = 1.17, p < 0.001) was found between race and BMI for loss of functional independence. Interaction plots revealed worsening functional outcomes for Black women with BMI >40 but not in non-Blacks.The interaction suggests a 17 % increased odds of losing independence for each unit of BMI difference for Black uterine cancer patients, or 170 % increased odds of losing independence for a 10-point increase in BMI, given a linear association. To reduce the likelihood of losing post-operative functional independence, Black, high-BMI patients with or at risk for uterine cancer may especially benefit from weight loss or interventions to optimize physical function.
Project description:Objective:To study temporal trends of hysterectomy routes performed for uterine cancer and their associations with body mass index (BMI) and perioperative morbidity. Methods:A retrospective review of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) 2005-2013 databases was conducted. All patients who were 18 years old and older with a diagnosis of uterine cancer and underwent hysterectomy were identified using ICD-9-CM and CPT codes. Surgical route was classified into four groups: total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH), laparoscopic assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH) including both conventional and robotically assisted. Patients were then stratified according to BMI. Results:7199 records were included in the study. TLH was the most commonly performed route of hysterectomy regardless of BMI, with proportions of 50.9%, 48.9%, 50.4%, and 51.2% in ideal, overweight, obese, and morbidly obese patients, respectively. The median operative time for TAH was 2.2 hours compared to 2.7 hours for TLH (p < 0.01). The median length of stay for TAH was 3 days compared to 1 day for TLH (p < 0.01). The percentage of patients with an adverse outcome (composite indicator including transfusion, deep venous thrombosis, and infection) was 17.1 versus 3.7 for TAH and TLH, respectively (p < 0.01). Conclusion:During the last decade, TLH has been increasingly performed in women with uterine cancer. The increased adoption of TLH was seen in all BMI subgroups.
Project description:UNLABELLED:We present a case series of 19 patients requiring complex abdominal hernia repairs. Patients presented with challenging clinical histories with 95% having multiple significant comorbidities including overweight or obesity (84%), hypertension (53%), diabetes (42%), cancer (26%), and pulmonary disease (16%). The majority of patients (68%) had prior abdominal infections and 53% had at least one failed prior hernia repair. Upon examination, fascial defects averaged 282 cm(2). Anterior and posterior component separation was performed with placement of a human acellular dermal mesh. Midline abdominal closure under minimal tension was achieved primarily in all cases. Post-operative complications included 2 adverse events (11%) - one pulmonary embolism and one post-operative hemorrhage requiring transfusion; 6 wound-related complications (32%), 1 seroma (5%) and 1 patient with post-operative ileus (5%). Operative intervention was not required in any of the cases and most patients made an uneventful recovery. Increased patient age and longer OR time were independently predictive of early post-operative complications. At a median 2-year follow-up, three patients had a documented hernia recurrence (16%) and one patient was deceased due to unrelated causes. CONCLUSION:Patients at high risk for post-operative events due to comorbidities, prior abdominal infection and failed mesh repairs do well following component separation reinforced with a human bioprosthetic mesh. Anticipated post-operative complications were managed conservatively and at a median 2-year follow-up, a low rate of hernia recurrence was observed with this approach.
Project description:The purpose of this study was to examine post-diagnosis BMI, very low physical activity, and comorbidities, as predictors of breast cancer-specific and all-cause mortality. Data from three female US breast cancer survivor cohorts were harmonized in the After Breast Cancer Pooling Project (n = 9513). Delayed entry Cox proportional hazards models were used to examine the impact of three post-diagnosis lifestyle factors: body mass index (BMI), select comorbidities (diabetes only, hypertension only, or both), and very low physical activity (defined as physical activity <1.5 MET h/week) in individual models and together in multivariate models for breast cancer and all-cause mortality. For breast cancer mortality, the individual lifestyle models demonstrated a significant association with very low physical activity but not with the selected comorbidities or BMI. In the model that included all three lifestyle variables, very low physical activity was associated with a 22 % increased risk of breast cancer mortality (HR 1.22, 95 % CI 1.05, 1.42). For all-cause mortality, the three individual models demonstrated significant associations for all three lifestyle predictors. In the combined model, the strength and significance of the association of comorbidities (both hypertension and diabetes versus neither: HR 2.16, 95 % CI 1.79, 2.60) and very low physical activity (HR 1.35, 95 % CI 1.22, 1.51) remained unchanged, but the association with obesity was completely attenuated. These data indicate that after active treatment, very low physical activity, consistent with a sedentary lifestyle (and comorbidities for all-cause mortality), may account for the increased risk of mortality, with higher BMI, that is seen in other studies.
Project description:OBJECTIVES:To describe whether body mass index (BMI) is a clinically meaningful predictor of patient reported outcomes following primary total hip replacement (THR) surgery. DESIGN:Combined data from prospective cohort studies. We obtained information from four cohorts of patients receiving primary THR for osteoarthritis: Exeter Primary Outcomes Study (EPOS) (n = 1431); EUROHIP (n = 1327); Elective Orthopaedic Centre (n = 2832); and St. Helier (n = 787). The exposure of interest was pre-operative BMI. Confounding variables included: age, sex, SF-36 mental health, comorbidities, fixed flexion, analgesic use, college education, OA in other joints, expectation of less pain, radiographic K&L grade, ASA grade, years of hip pain. The primary outcome was the Oxford Hip Score (OHS). Regression models describe the association of BMI on outcome adjusting for all confounders. RESULTS:For a 5-unit increase in BMI, the attained 12-month OHS decreases by 0.78 points 95%CI (0.27-1.28), P-value 0.001. Compared to people of normal BMI (20-25), those in the obese class II (BMI 35-40) would have a 12-month OHS that is 2.34 points lower. Although statistically significant this effect is small and not clinically meaningful in contrast to the substantial change in OHS seen across all BMI groupings. In obese class II patients achieved a 22.2 point change in OHS following surgery. CONCLUSIONS:Patients achieved substantial change in OHS after THR across all BMI categories, which greatly outweighs the small difference in attained post-operative score. The findings suggest BMI should not present a barrier to access THR in terms of PROMs.
Project description:Quality of life (QoL) for women with gynecologic malignancies is predictive of chemotherapy related toxicity and overall survival but has not been studied in relation to surgical outcomes and hospital readmissions. Our goal was to evaluate the association between baseline, pre-operative QoL measures and 30-day post-operative morbidity and health resource utilization by gynecologic oncology patients.We analyzed prospectively collected survey data from an institution-wide cohort study. Patients were enrolled from 8/2012 to 6/2013 and medical record data was abstracted (demographics, comorbid conditions, and operative outcomes). Responses from several validated health-related QoL instruments were collected. Bivariate tests and multivariable linear and logistic regression models were used to evaluate factors associated with QoL scores.Of 182 women with suspected gynecologic malignancies, 152 (84%) were surveyed pre-operatively and 148 (81%) underwent surgery. Uterine (94; 63.5%), ovarian (26; 17.5%), cervical (15; 10%), vulvar/vaginal (8; 5.4%), and other (5; 3.4%) cancers were represented. There were 37 (25%) cases of postoperative morbidity (PM), 18 (12%) unplanned ER visits, 9(6%) unplanned clinic visits, and 17 (11.5%) hospital readmissions (HR) within 30days of surgery. On adjusted analysis, lower functional well-being scores resulted in increased odds of PM (OR 1.07, 95%CI 1.01-.1.21) and HR (OR 1.11, 95%CI 1.03-1.19). A subjective global assessment score was also strongly associated with HR (OR 1.89, 95%CI 1.14, 3.16).Lower pre-operative QoL scores are significantly associated with post-operative morbidity and hospital readmission in gynecologic cancer patients. This relationship may be a novel indicator of operative risk.
Project description:PurposeTo determine the accuracy of MRI in detecting craniocaudal tumour extension, compared to histopathology, of the hysterectomy specimen in patients with early-stage uterine cervical cancer. Three complementary methods were investigated.Materials and methodsThirty-four patients with early-stage cervical cancer had pre-operative MRI, followed by radical hysterectomy or trachelectomy. 1) craniocaudal tumour extension was measured on MRI by two radiologists and compared to microscopy by a pathologist, 2) to compensate for changes in uterine shape between pre-operative MRI and the surgical specimen, craniocaudal tumour extensions were directly compared and appreciated as being a part of a 3-dimensional tumour by a radiation oncologist and resident, and 3) tumour size on MRI was compared macroscopically after digital non-rigid registration of the uterus, uterine cavity and tumour of both modalities.ResultsThe craniocaudal tumour extension measured on histopathology minus MRI gives: 1) on average +3 mm difference when measured by a radiologist compared to the microscopic extension (range −13 to +15 mm), 2) −0.2 mm (range −11 to +6.0 mm) when evaluated on MRI by a radiation oncologist compared to the macroscopic tumour; 3) after non-rigid organ registration, a margin of 10 mm around the tumour on MRI would be needed to cover 95% of the tumour in 90% of the patients.ConclusionsResults indicate that microscopic tumour extension towards the uterine fundus is within a margin of 10 mm around the visible tumour on MRI. The major source of measurement uncertainty is post-surgical change of organ shape and form.
Project description:Uterine leiomyoma is a major reproductive health disease among women and in particular Black women. The present study sought to determine whether a single nucleotide polymorphism (SNP) of CYP17 (rs743572) was associated with the risk of developing uterine leiomyoma (UL) in affected women in Barbados; a majority Black population. It also sought to determine if BMI, waist circumference and oestradiol levels were associated with UL in this group. A total of 96 random persons were assessed in a case-control study using a PCR-RFLP assay, and measurements of body mass index, waist circumference, and oestradiol levels were also assessed. Our results showed no genetic association with the risk of UL and this gene. The genetic distribution of CYP 17α- alleles resembled a normal Hardy-Weinberg distribution, and a relatively low risk of 0.25 at a confidence interval at 95%, of UL disease development. However, a significant association was found between oestradiol levels and fibroids, as well as oestradiol levels and BMI, at P < 0.05 among cases. Therefore our study indicates that significant associations between physiochemical factors comprising BMI, waist circumference, and oestrogen levels are disease indicators in this population. In conclusion, our findings suggest that obesity and its associated risk factors are important in a majority Black Caribbean population, although the sample size needs to be increased.
Project description:Pre-operative weight loss has been consistently associated with increased post-operative morbidity. The study aims to determine if pre-operative oral nutritional supplements (ONSs) with dietary advice reduce post-operative complications.Single-blinded randomized controlled trial. People with colorectal cancer scheduled for surgery with pre-operative weight loss >1?kg/3-6?months were randomized by using stratified blocks (1:1 ratio) in six hospitals (1 November 2013-28 February 2015). Intervention group was given 250?mL/day ONS (10.1?KJ and 0.096?g protein per mL) and dietary advice. Control group received dietary advice alone. Oral nutritional supplements were administered from diagnosis to the day preceding surgery. Research team was masked to group allocation. Primary outcome was patients with one or more surgical site infection (SSI) or chest infection; secondary outcomes included percentage weight loss, total complications, and body composition measurements. Intention-to-treat analysis was performed with both unadjusted and adjusted analyses. A sample size of 88 was required.Of 101 participants, (55 ONS, 46 controls) 97 had surgery. In intention-to-treat analysis, there were 21/45 (47%) patients with an infection-either an SSI or chest infection in the control group vs. 17/55 (30%) in the ONS group. The odds ratio of a patient incurring either an SSI or chest infection was 0.532 (P?=?0.135 confidence interval 0.232 to 1.218) in the unadjusted analysis and when adjusted for random differences at baseline (age, gender, percentage weight loss, and cancer staging) was 0.341 (P?=?0.031, confidence interval 0.128 to 0.909). Pre-operative percentage weight loss at the first time point after randomization was 4.1% [interquartile range (IQR) 1.7-7.0] in ONS group vs. 6.7% (IQR 2.6-10.8) in controls (Mann-Whitney U P?=?0.021) and post-operatively was 7.4% (IQR 4.3-10.0) in ONS group vs. 10.2% (IQR 5.1-18.5) in controls (P?=?0.016).Compared with dietary advice alone, ONS resulted in patients having fewer infections and less weight loss following surgery for colorectal cancer. We have demonstrated that pre-operative oral nutritional supplementation can improve clinical outcome in weight losing patients with colorectal cancer.
Project description:Despite world-wide emphasis on falls prevention, falls and their consequences remain a major health issue for older people, and their health care providers. Many systematic reviews have been undertaken to evaluate the impact of intervention programmes on falls reduction, however, relatively little research provides a voice for older people's own perceptions of such programmes. To readdress this imbalance the current research utilized a purposive sampling method to recruit a hard to reach group of older people who had received a post-fall health and social-care programme to investigate their experiences of the programme. Semi-structured interviews with eight housebound people aged over 65 who had fallen were undertaken, and data analysed using interpretative phenomenological analysis. Four themes were identified: losing independence; losing confidence; losing social identity; managing a changed self. Despite a tailored intervention programme minimal improvement in participants' psychological adjustment to falls was noted. Outcomes from this study are of interest to health and social-care staff who deliver falls prevention programmes. Staff need to enhance constructive adjustment to the older person's altered circumstances and ensure behaviours do not exacerbate their clients' loss of independence. This should assist older people's ability to positively manage their sense of self, allowing them to find continuing meaning in their daily lives.
Project description:Two pivotal randomized controlled trials (RCTs), the Intergroup (INT-0116) and Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC) trials, demonstrated a survival benefit of multimodality therapy in patients with resectable gastric cancer. The purpose of this study was to determine utilization rates of these treatment regimens in the United States and to identify factors associated with receipt of evidence-based care.We performed a retrospective cohort study of patients with Stage IB-IV (M0) gastric adenocarcinoma who underwent resection from 1991 to 2009 using the linked SEER-Medicare database.Only 19.1% of patients received post-operative chemoradiation therapy (CRT), and 1.9% received peri-operative chemotherapy; most patients underwent surgery alone (60.9%). Patients with more advanced stage, younger age, and fewer comorbidities were more likely to receive evidence-based care. We found no association between National Cancer Institute (NCI) designation and delivery of multimodality therapy. However, patients who underwent medical oncology consultation were much more likely to receive evidence-based treatment (OR 3.10, 95% CI 2.35-4.09).Rates of peri-operative chemotherapy and post-operative CRT in patients with resected gastric cancer remain remarkably low, despite high-quality RCT evidence demonstrating their benefit. Furthermore, NCI designation does not appear to be associated with administration of evidence-based treatment.