Coordinated Strategy for a Model-Based Decision Support Tool for Coronavirus Disease,Utah, USA

The coronavirus disease pandemic has highlighted the key role epidemiologic models play in supporting public health decision-making. In particular, these models provide estimates of outbreak potential when data are scarce and decision-making is critical and urgent. We document the integrated modeling response used in the US state of Utah early in the coronavirus disease pandemic, which brought together a diverse set of technical experts and public health and healthcare officials and led to an evidence-based response to the pandemic. We describe how we adapted a standard epidemiologic model; harmonized the outputs across modeling groups; and maintained a constant dialogue with policymakers at multiple levels of government to produce timely, evidence-based, and coordinated public health recommendations and interventions during the first wave of the pandemic. This framework continues to support the state’s response to ongoing outbreaks and can be applied in other settings to address unique public health challenges.     

Comparing the Approach to Radical Prostatectomy Using the Multiport da Vinci Xi and da Vinci SP Robots: A Propensity Score Analysis of Perioperative Outcomes

BackgroundUse of the single-port da Vinci SP robotic platform for various urological procedures has been described by several groups. However, the comparative performance of the SP robot in relation to earlier models such as the da Vinci Xi is still unclear.ObjectiveTo compare intraoperative and short-term postoperative outcomes between the da Vinci Xi and SP robots for patients undergoing radical prostatectomy (RP) in a referral center.Design, setting, and participantsData were prospectively collected for patients undergoing RP from June 2019 to April 2020 in a single center. The da Vinci SP was used for 71 patients and the da Vinci Xi for 875 patients. After propensity score (PS) matching, two groups of 71 patients were selected for the comparative study.InterventionRP via a transperitoneal approach using the same technique steps and anatomy access with both robot consoles.Outcome measurements and statistical analysisA PS analysis was performed using the covariates age, body mass index, Charlson comorbidity index, Sexual Health Inventory for Men score, American Urological Association symptom score, prostate size, prostate-specific antigen levels, Gleason score, D’Amico risk group, and degree of nerve-sparing. Intraoperative performance and short-term functional (continence and potency) and oncological outcomes were compared between the groups.Results and limitationsMedian follow-up was 4.4 mo (interquartile range [IQR] 1.6–7.2) for the SP group and 3.2 mo (IQR 1.6–4.8) for the Xi group (p = 0.2). The median total operative time and median console time were both significantly higher in the SP group, with median differences of 14 min (95% confidence interval [CI] 9–19) and 5 min (95% CI 0–5), respectively. The proportion of patients with blood loss of >100 ml was significantly lower in the SP group (difference of 27%, 95% CI 12–42%). No intra- or postoperative complications were reported in either group. There were no significant differences in pain scores at 6, 12, and 18 h or in positive surgical margin rates between the groups. The SP group had a significantly higher percentage of extraprostatic extension than the Xi group (difference of 16%, 95% CI 4.6–27%). None of the patients experienced biochemical recurrence during follow-up. The difference in continence rates at 45 d between the SP and Xi groups was 11% (95% CI ?5.6% to 28%) and the difference in potency rates at 45 d was ?7.3% (95% CI ?21% to 6.2%). The short-term follow-up for comparison of functional and oncological outcomes is a limitation.ConclusionsDespite differences in trocar placement and technology between the two da Vinci consoles, the SP has satisfactory intraoperative performance compared to the Xi. SP surgery can be performed safely and effectively during the initial learning phase. However, longer-term follow-up is needed to provide further evidence on the impact of SP implementation on functional and oncological outcomes.Patient summaryWe compared intraoperative and short-term postoperative outcomes for patients who underwent radical prostatectomy using two different robots, the da Vinci Xi and the single-port da Vinci SP. We found that operative time was longer for the Single Port console. Studies with long-term follow-up are needed to compare the functional and oncological outcomes.     

Two-stage Study of Familial Prostate Cancer by Whole-exome Sequencing and Custom Capture Identifies 10 Novel Genes Associated with the Risk of Prostate Cancer

BackgroundFamily history of prostate cancer (PCa) is a well-known risk factor, and both common and rare genetic variants are associated with the disease.ObjectiveTo detect new genetic variants associated with PCa, capitalizing on the role of family history and more aggressive PCa.Design, setting, and participantsA two-stage design was used. In stage one, whole-exome sequencing was used to identify potential risk alleles among affected men with a strong family history of disease or with more aggressive disease (491 cases and 429 controls). Aggressive disease was based on a sum of scores for Gleason score, node status, metastasis, tumor stage, prostate-specific antigen at diagnosis, systemic recurrence, and time to PCa death. Genes identified in stage one were screened in stage two using a custom-capture design in an independent set of 2917 cases and 1899 controls.Outcome measurements and statistical analysisFrequencies of genetic variants (singly or jointly in a gene) were compared between cases and controls.Results and limitationsEleven genes previously reported to be associated with PCa were detected (ATM, BRCA2, HOXB13, FAM111A, EMSY, HNF1B, KLK3, MSMB, PCAT1, PRSS3, and TERT), as well as an additional 10 novel genes (PABPC1, QK1, FAM114A1, MUC6, MYCBP2, RAPGEF4, RNASEH2B, ULK4, XPO7, and THAP3). Of these 10 novel genes, all but PABPC1 and ULK4 were primarily associated with the risk of aggressive PCa.ConclusionsOur approach demonstrates the advantage of gene sequencing in the search for genetic variants associated with PCa and the benefits of sampling patients with a strong family history of disease or an aggressive form of disease.Patient summaryMultiple genes are associated with prostate cancer (PCa) among men with a strong family history of this disease or among men with an aggressive form of PCa.     

Perioperative Mortality and Periprosthetic Fracture: A Single-Center Experience of 857 Uncemented Hemiarthroplasties for Displaced Femoral Neck Fractures

BackgroundUncemented hemiarthroplasty (UHA) for displaced femoral neck fracture (FNF) is favored by some surgeons because of the reduced rate of perioperative mortality and operative time. However higher rates of intraoperative and postoperative periprosthetic fractures (PPFs) have been reported. The aim of the study was to review day-0, day-1, day-2, day-30, and one-year mortality as well as intraoperative and postoperative PPF after UHA for displaced FNF and compare this with cemented hemiarthroplasties (CHAs) performed. Secondary objectives were to assess whether femoral stem geometry and alignment were associated with PPF in UHA.MethodsA retrospective observational study was conducted of patients treated with a hemiarthroplasty for a displaced FNF over an eleven-year period. Radiographic analysis was conducted of femoral geometry and stem alignment.ResultsOver the 11-year study period, 857 UHAs and 247 CHAs were performed. There were no on-table, day-0, day-1, or day-2 deaths in UHA. Intraoperative PPF occurred in 3.6% UHA and 2% CHA and postoperative PPF in 2.4% UHA and 4.8% CHA. Intraoperative PPF was not associated with increased mortality (P = .15), postoperative PPF, or all-cause revision in UHA. Valgus stem alignment was a risk factor for a postoperative PPF and additional surgery in UHA (P = .004).ConclusionUHA was associated with no perioperative deaths and a 30-day mortality rate of 5% in this series. It can be considered in patients with multiple medical comorbidities. Careful surgical planning and technique is important to optimize stem alignment particularly in Dorr C type femurs.     

Bolus versus continuous feeding regimens post gastrostomy tube placement in children

Background/purposeOwing to the frequency of gastrostomy tube placement in children and the numerous regimens used to start feeds after placement we attempted to see if it matters if the initial feeds after a gastrostomy tube placement are provided in a bolus or continuous manner.MethodsUsing a prospective randomized trial, children were randomized to initial bolus or continuous chimney feeding after gastrostomy tube placement. Feeding tolerance and complications related to the gastrostomy tube were collected for 4 weeks after placement.ResultsDemographics were similar in the two groups. Times to goal feeds were similar in both groups, but in the first two weeks more feeding modifications were required in the bolus group. Other than the rate of leakage during the second week after placement which occurred more in the bolus group, all other clinical outcomes were similar in the two groups.ConclusionsOther than minor, clinically insignificant differences noted above, the method of initial feeding after a gastrostomy tube placement does not affect feeding tolerance or gastrostomy tube complication in the first month after placement.Level of evidenceTherapeutic, level II.     

Do microscopic surgical margins matter for primary gastric gastrointestinal stromal tumor?

BackgroundAlthough tumor size and mitotic rate are established prognostic factors for worse survival in patients undergoing surgical resection for gastric gastrointestinal stromal tumors, the impact of microscopic margins, or R1 resection, is not completely established.MethodsPatients who received no neoadjuvant therapy and underwent surgical resection for stage I to III gastric gastrointestinal stromal tumors were identified from the 2010 to 2013 National Cancer Database and divided into 2 cohorts, R0 and R1 resections. Cox proportional hazards ratio and Kaplan Meier survival estimates were utilized to analyze 5-y overall survival.ResultsOf 2,084 patients, those with R1 resection (57, 2.7%) were more likely to have tumors >10 cm (28.1% vs 11.9%, odds ratio 3.51, P = .017) and stage III disease (26.3% vs 11.2%, odds ratio 2.26, P = .047). Although margin status was associated with higher risk tumors, it was not associated with receipt of adjuvant therapy. After multivariate Cox regression, R1 and R0 patients did not have a difference in 5-y overall survival (82.5% vs 88.6%, hazards ratio 1.26, P = .49). When stratified by stage of disease, there remained no difference in survival across all stages when comparing R1 and R0 patients.ConclusionPositive microscopic margins are uncommon but do not appear to impact survival outcomes in patients with resected localized gastric gastrointestinal stromal tumors.     

Total Talus Replacement: Case Series and Literature Review

Custom 3D printed total talus implants have been used successfully as a functional alternative to arthrodesis or amputation in cases of severe talar destruction or loss. However, the ideal material and construct still remains to be elucidated. Current models have been made from aluminum ceramic, cobalt chrome, stainless steel, titanium, or metal combinations. The implants may be constrained (subtalar arthrodesis) or unconstrained (press fit within mortise). They may also be combined with a tibial prosthesis or used in isolation. The majority of currently published case studies examine unconstrained and isolated implants. This case study presents satisfactory 1-y outcomes in 3 cobalt chrome constrained total talar implants used in combination with a tibial prosthesis, and a literature review of total talus replacements.     

Five-Year Breast Surgeon Experience in LYMPHA at Time of ALND for Treatment of Clinical T1–4N1–3M0 Breast Cancer

Annals of Surgical Oncology - Breast cancer-related lymphedema (BCRL) is a source of postoperative morbidity for breast cancer survivors. Lymphatic microsurgical preventive healing approach...     

PROMISE: Working with the CF community to understand emerging clinical and research needs for those treated with highly effective CFTR modulator therapy

Highly effective CFTR modulator drug therapy is increasingly available to those with cystic fibrosis. Multiple observational research studies are now being conducted to better understand the impacts of this important therapeutic milestone on long-term outcomes, patient care needs, and future research priorities. PROMISE is a large, multi-disciplinary academic study focused on the broad impacts of starting elexacaftor/tezacaftor/ivacaftor in the US population age 6 years and older. The many areas of investigation and rationale for each are discussed by organ systems, along with recognition of remaining important questions that will not be addressed by this study alone. Knowledge gained through this and multiple complementary studies around the world will help to understand important health outcomes, clinical care priorities, and research needs for a large majority of people treated with these or similarly effective medications targeting the primary cellular impairment in cystic fibrosis.     

An Investigation of Sexual and Relationship Adjustment During COVID-19

The COVID-19 pandemic and the mitigation measures put in place have resulted in universal disruption in the usual ways of life for individuals. The current study sought to investigate how aspects of sexual health (well-being and functioning) and relationship satisfaction changed or remained stable during the pandemic. During two separate time points (Time 1 including Time 1 and a retrospective baseline, Time 2), participants completed online measures of sexual well-being (sexual pleasure, partnered and solitary orgasm frequency, sexual distress), sexual functioning, and relationship satisfaction. Participants reported slight declines in sexual pleasure, frequency of orgasms with a partner, and frequency of solitary orgasms from pre-COVID-19 (retrospective baseline) to Time 1, with no significant differences in sexual distress and relationship satisfaction. For individuals with vulvas, sexual functioning improved from Time 1 to Time 2, whereas no significant differences in sexual functioning were observed for individuals with penises. Aspects of sexual health and relational satisfaction did not sufficiently change across time points to be considered meaningful health outcome changes. Given that minimal disruptions were noted in pre-COVID-19 to COVID-19 sexuality, these results highlight the potential resiliency of individuals’ sexuality when facing sudden changes in their daily lives. Implications of COVID-19’s effects on sexual well-being and relationship satisfaction research are broadly discussed.