Publications by authors named "Dan G Blazer"

262 Publications

Quality of Life Associated with Open vs Minimally Invasive Pancreaticoduodenectomy: A Prospective Pilot Study.

J Am Coll Surg 2022 04;234(4):632-644

From the Department of Surgery (Moris, Shah, Zani, Allen, Blazer), Duke University Medical Center, Durham, NC.

Background: This prospective study was designed to compare quality of life (QoL) among patients who underwent open (O-PD) vs minimally invasive pancreaticoduodenectomy (MI-PD), using a combination of validated qualitative and quantitative methodologies.

Study Design: From 2017 to 2019, patients scheduled for pancreaticoduodenectomy (PD) were enrolled and presented with Functional Assessment of Cancer Therapy-Hepatobiliary surveys preoperatively, before discharge, at first postoperative visit and approximately 3 to 4 months after operation ("3 months"). Longitudinal plots of median QoL scores were used to illustrate change in each score over time. In a subset of patients, content analysis of semistructured interviews at postoperative time points (1.5 to 6 months after operation) was conducted.

Results: Among 56 patients who underwent PD, 33 had an O-PD (58.9%). Physical and functional scores decreased in the postoperative period but returned to baseline by 3 months. No significant differences were found in any domains of QoL at baseline and in the postoperative period between patients who underwent O-PD and MI-PD. Qualitative findings were concordant with quantitative data (n = 14). Patients with O-PD and MI-PD reported similar experiences with complications, pain, and wound healing in the postoperative period. Approximately half the patients in both groups reported "returning to normal" in the 6-month postoperative period. A total of 4 patients reported significant long-term issues with physical and functional well-being.

Conclusions: Using a novel combination of qualitative and quantitative analyses in patients undergoing PD, we found no association between operative approach and QoL in patients who underwent O-PD vs MI-PD. Given the increasing use of minimally invasive techniques for PD and the steep learning curve associated with these techniques, continued assessment of patient benefit is critical.
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http://dx.doi.org/10.1097/XCS.0000000000000102DOI Listing
April 2022

A Multidimensional Bioinformatic Platform for the Study of Human Response to Surgery.

Ann Surg 2022 Mar 3. Epub 2022 Mar 3.

Department of Surgery, Duke University; Durham, North Carolina, USA Department of Head and Neck Surgery & Communication Sciences, Duke University; Durham, North Carolina, USA Department of Obstetrics and Gynecology, Duke University; Durham, North Carolina, USA Department of Medicine, Duke University; Durham, North Carolina, USA Duke Molecular Physiology Institute, Duke University; Durham, North Carolina, USA Duke Center for Genomic and Computational Biology, Duke University; Durham, North Carolina, USA Department of Molecular Genetics and Microbiology, Duke University; Durham, North Carolina, USA Department of Electrical and Computer Engineering, Duke University; Durham, North Carolina, USA Department of Biostatistics and Bioinformatics, Duke University; Durham, North Carolina, USA.

Objective: To design and establish a prospective biospecimen repository that integrates multi-omics assays with clinical data to study mechanisms of controlled injury and healing.

Summary Background Data: Elective surgery is an opportunity to understand both the systemic and focal responses accompanying controlled and well-characterized injury to the human body. The overarching goal of this ongoing project is to define stereotypical responses to surgical injury, with the translational purpose of identifying targetable pathways involved in healing and resilience, and variations indicative of aberrant peri-operative outcomes.

Methods: Clinical data from the electronic medical record combined with large-scale biological data sets derived from blood, urine, fecal matter, and tissue samples are collected prospectively through the peri-operative period on patients undergoing fourteen surgeries chosen to represent a range of injury locations and intensities. Specimens are subjected to genomic, transcriptomic, proteomic, and metabolomic assays to describe their genetic, metabolic, immunologic, and microbiome profiles, providing a multidimensional landscape of the human response to injury.

Results: The highly multiplexed data generated includes changes in over 28,000 mRNA transcripts, 100 plasma metabolites, 200 urine metabolites, and 400 proteins over the longitudinal course of surgery and recovery. In our initial pilot dataset, we demonstrate the feasibility of collecting high quality multi-omic data at pre- and post-operative time points and are already seeing evidence of physiologic perturbation between timepoints.

Conclusions: This repository allows for longitudinal, state-of-the-art genomic, transcriptomic, proteomic, metabolomic, immunologic, and clinical data collection and provides a rich and stable infrastructure on which to fuel further biomedical discovery.
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http://dx.doi.org/10.1097/SLA.0000000000005429DOI Listing
March 2022

The Great Health Paradox: A Call for Increasing Investment in Public Health.

Acad Med 2022 Apr;97(4):484-486

B.V. Reifler is professor and chair emeritus, Wake Forest School of Medicine, Winston-Salem, North Carolina.

The great health paradox is that the least expensive and most effective public health measures available for addressing the COVID-19 pandemic-and other society-wide health challenges-have long been ignored and rejected in the United States in favor of more expensive and personalized care. The U.S. medical system is being overwhelmed in part because of this paradox. The authors argue that the country has invested excessively in acute care medical technology while investing insufficiently in its public health infrastructure. In this Invited Commentary, the authors recommend 5 steps that academic medicine should take to increase emphasis on and understanding of public health interventions to address society's health problems: (1) incorporate problem-based learning experiences in the medical school curriculum and community-based clinical rotations in public health departments, (2) better integrate schools of public health and schools of medicine, (3) encourage physicians to pursue public health careers, (4) educate the public about strategies for decreasing chronic illnesses, and (5) increase collaboration with colleagues around the world to identify and track outbreaks.
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http://dx.doi.org/10.1097/ACM.0000000000004591DOI Listing
April 2022

Surgical resection is associated with improved long-term survival of patients with resectable pancreatic head cancer compared to multiagent chemotherapy.

HPB (Oxford) 2021 Dec 17. Epub 2021 Dec 17.

Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.

Background: Standard of care for resectable pancreatic cancer is a combination of surgical resection (SR) and multiagent chemotherapy (MCT). We aim to determine whether SR or MCT is associated with superior survival for patients receiving only single-modality therapy.

Methods: Patients with stage I-IIb pancreatic head adenocarcinoma who received either MCT or SR were identified in the NCDB (2013-2015). Following a piecewise approach to estimating hazards over the course of follow-up, conditional overall survival (OS) at 30, 60, and 90 days after treatment initiation was estimated using landmark analyses.

Results: 3103 patients received MCT alone (60.3%) and 2043 underwent SR alone (39.7%). SR had an OS disadvantage at 30 (HR 3.99, 95% CI 3.12-5.11) and 60 days (HR 1.85, 95% CI 1.4-2.45), but an OS advantage after 90 days (HR 0.59, 95% CI 0.55-0.64). In a landmark analysis conditioned on 90 days survival post treatment initiation, median OS was improved for SR (17.0 vs. 12.2 months, p < 0.0001); SR improved 3-year OS by 21.3% (p < 0.05), despite patients being older (median 72 vs. 67 years, p < 0.0001) with higher Charlson-Deyo comorbidity scores (≥2: 11.2 vs. 8.6%, p = 0.006).

Conclusion: For patients with resectable pancreatic cancer, SR is associated with superior long-term survival compared to MCT.
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http://dx.doi.org/10.1016/j.hpb.2021.12.007DOI Listing
December 2021

Review of Religious Variables in Advance Care Planning for End-of-Life Care: Consideration of Faith as a New Construct.

Am J Geriatr Psychiatry 2021 Dec 3. Epub 2021 Dec 3.

JP Gibbons Professor Emeritus of Psychiatry and Behavioral Sciences, Dean Emeritus of Medical Education (DGB), Duke University School of Medicine, Durham, NC.

Religion and spirituality have long been considered important social determinants of human health, and there exists an extensive body of research to support such. End-of-life (EOL) may raise complex questions for individuals about religious and spiritual (R/S) values guiding advance care planning (ACP) and EOL care decisions, including the provision of spiritual care. This commentary will review the history and current national trends of ACP activities for EOL, principally within the United States. It will describe the relationship of religious variables and the attributes of selected research instruments used to study religious variables on ACP and EOL preferences. The review also summarizes unique ACP challenges for patients with neurocognitive disorders and severe mental illness. Findings disclose that higher levels of religiosity, reliance on religious coping, conservative faith traditions, and "belief in God's control over life's length and divine intervention have lower levels of ACP and more intensive EOL care preferences, although the provision of spiritual spiritual care at EOL mitigates intensive EOL care. Based upon the curated evidence, we propose an epistemological justification to consider "faith" as a separately defined religious variable in future ACP and EOL research. This review is relevant to geriatric psychiatrists and gerontological health care professionals, as they may be part of multidisciplinary palliative care teams; provide longitudinal care to patients with neurocognitive disorders and severe mental illness; and may provide diagnostic, emotional, and therapeutic services for patients and families who may struggle with EOL care decisions.
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http://dx.doi.org/10.1016/j.jagp.2021.11.014DOI Listing
December 2021

Domains of delirium severity in Alzheimer's disease and related dementias.

J Am Geriatr Soc 2022 May 24;70(5):1495-1503. Epub 2021 Dec 24.

Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.

Background: The ability to rate delirium severity is key to providing optimal care for persons with Alzheimer's Disease and Related Dementias (ADRD). Such ratings would allow clinicians to assess response to treatment, recovery time and prognosis, nursing burden and staffing needs, and to provide nuanced, appropriate patient-centered care. Given the lack of existing tools, we defined content domains for a new delirium severity instrument for use in individuals with mild to moderate ADRD, the DEL-S-AD.

Methods: We built upon our previous study in which we created a content domain framework to inform development of a general delirium severity instrument, the DEL-S. We engaged a new expert panel to discuss issues of measurement in delirium and dementia and to determine which content domains from the prior framework were useful in characterizing delirium severity in ADRD. We also asked panelists to identify new domains. Our panel included eight interdisciplinary members with expertise in delirium and dementia. Panelists participated in two rounds of review followed by two surveys over 2 months.

Results: Panelists endorsed the same content domains as for general delirium severity, including Cognitive, Level of Consciousness, Inattention, Psychiatric-Behavioral, Emotional Dysregulation, Psychomotor Features, and Functional; however, they excluded six of the original subdomains which they considered unhelpful in the context of ADRD: cognitive impairment; anxiety; fear/sense of unease; depression; gait/walking; and incontinence. Debated measurement challenges included assessment at one point in time versus over time, accounting for differences in clinical settings, and accurate assessment of symptoms related to delirium versus dementia.

Conclusions: By capturing a range of characteristics of delirium severity potentially present in patients with ADRD, a population that may already have attention, functional, and emotional changes at baseline, the DEL-S-AD provides a novel rating tool that will be useful for clinical and research purposes to improve patient care.
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http://dx.doi.org/10.1111/jgs.17624DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9106827PMC
May 2022

Extent of tumor fibrosis/hyalinization and infarction following neoadjuvant radiation therapy is associated with improved survival in patients with soft-tissue sarcoma.

Cancer Med 2022 01 27;11(1):194-206. Epub 2021 Nov 27.

Department of Orthopaedics, Duke University, Durham, North Carolina, USA.

Introduction: Current standard of care for most intermediate and high-grade soft-tissue sarcomas (STS) includes limb-preserving surgical resection with either neoadjuvant radiation therapy (NRT) or adjuvant radiation therapy. To date, there have been a few studies that attempt to correlate histopathologic response to NRT with oncologic outcomes in patients with STS.

Methods: Using our institutional database, we identified 58 patients who received NRT followed by surgical resection for primary intermediate or high-grade STS and 34 patients who received surgical resection without NRT but did receive adjuvant radiation therapy or did not receive any radiation therapy. We analyzed four histologic parameters of response to therapy: residual viable tumor, fibrosis/hyalinization, necrosis, and infarction (each ratiometrically determined). Data were stratified into two binary groups. Unadjusted, 5- and 10-year overall survival, and relapsed-free survival (RFS) were calculated using the Kaplan-Meier method.

Results: Analysis of pathologic characteristics showed that patients treated with NRT demonstrate significantly higher tumor infarction, higher tumor fibrosis/hyalinization, and a lower percent viable tumor compared with patients not treated with NRT (p < 0.0001). Based on Kaplan-Meier curve analysis and multivariate cox proportional hazard model for OS and RFS, patients treated with NRT and showing >12.5% tumor fibrosis/hyalinization have significantly higher overall survival and recurrence-free survival at 5 and 10 years.

Discussion And Conclusion: We have identified three histopathologic characteristics-fibrosis, hyalinization, and infarction-that may serve as predictive biomarkers of response to NRT for STS patients. Future prospective studies will be needed to confirm this association.
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http://dx.doi.org/10.1002/cam4.4428DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8704179PMC
January 2022

Identifying Modifiable and Non-modifiable Risk Factors of Readmission and Short-Term Mortality in Chondrosarcoma: A National Cancer Database Study.

Ann Surg Oncol 2022 Feb 27;29(2):1392-1408. Epub 2021 Sep 27.

Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA.

Background: Limited data are available to inform the risk of readmission and short-term mortality in musculoskeletal oncology. The goal of this study was to identify factors independently associated with 30-day readmission and 90-day mortality following surgical resection of chondrosarcoma.

Methods: We retrospectively reviewed 6653 patients following surgical resection of primary chondrosarcoma in the National Cancer Database (2004-2017). Both demographic and clinicopathologic variables were assessed for correlation with readmission and short-term mortality utilizing univariate and multivariate logistic regression modeling.

Results: Of 220 readmissions (3.26%), risk factors independently associated with an increased risk of unplanned 30-day readmission included Charlson-Deyo Comorbidity Index (CDCC) (odds ratio [OR] 1.31; p = 0.027), increasing American Joint Committee on Cancer (AJCC) stage (OR 1.31; p = 0.004), undergoing major amputation (OR 2.38; p = 0.001), and axial skeletal location (OR 1.51; p = 0.028). A total of 137 patients died within 90 days of surgery (2.25%). Risk factors associated with increased mortality included the CDCC (OR 1.60; p = 0.001), increasing age (OR 1.06; p < 0.001), having Medicaid insurance status (OR 3.453; p = 0.005), living in a zip code with a higher educational attainment (OR 1.59; p = 0.003), increasing AJCC stage (OR 2.32; p < 0.001), longer postoperative length of stay (OR 1.015; p = 0.033), and positive surgical margins (OR 2.75; p = 0.001). Although a majority of the cohort did not receive radiation therapy (88.8%), receiving radiotherapy (OR 0.132; p = 0.010) was associated with a decreased risk of short-term mortality.

Conclusions: Several tumor, treatment, and patient factors can help inform the risk of readmission and short-term mortality in patients with surgically treated chondrosarcoma.
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http://dx.doi.org/10.1245/s10434-021-10802-8DOI Listing
February 2022

Empiric nasogastric decompression after pancreaticoduodenectomy is not necessary.

HPB (Oxford) 2021 12 7;23(12):1906-1913. Epub 2021 Jun 7.

Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA.

Background: The aim of the present study was to evaluate the impact of routine NGT decompression after PD on postoperative outcomes in the era of an enhanced recovery after surgery (ERAS) protocol.

Materials And Methods: A retrospective review of all patients undergoing PD between January 2015 and October 2017 at our institution was performed comparing routine post-operative NGT decompression versus omission. The incidence of delayed gastric emptying, post-operative pancreatic fistula, hospital length of stay, operative time, 30-day readmission rate as well the time to first oral intake were evaluated.

Results: Out of 149 patients who underwent PD, 65 maintained post-operative NGT decompression while post-operative NGT decompression was omitted in 84 patients. No differences were noted in delayed gastric emptying rates (both p>0.05). The median length of stay (9 days for NGT group versus 8.5 days for no NGT group) and 30-day readmission rates (13.8% versus 15.5%, respectively) were similar (p=0.781). Compared with patients who had routine post-operative NGT placed, those who had omission of a post-operative NGT had a lower need for reinsertion, shorter time to PO intake, and a lower likelihood of extended length of stay.

Conclusions: In the era of ERAS protocols, we observed no association between routine post-operative NGT decompression after PD and improved postoperative outcomes.
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http://dx.doi.org/10.1016/j.hpb.2021.05.004DOI Listing
December 2021

Identifying Modifiable and Non-modifiable Risk Factors of Readmission and Short-Term Mortality in Osteosarcoma: A National Cancer Database Study.

Ann Surg Oncol 2021 Nov 20;28(12):7961-7972. Epub 2021 May 20.

Department of Orthopaedic Surgery, Duke University Hospital, Durham, NC, USA.

Background: There are limited data to inform risk of readmission and short-term mortality in musculoskeletal oncology. The goal of this study was to identify factors independently associated with 30-day readmission and 90-day mortality following surgical resection of osteosarcoma.

Methods: We retrospectively reviewed patients (n = 5293) following surgical resection of primary osteosarcoma in the National Cancer Database (2004-2015). Univariate and multivariate methods were used to correlate variables with readmission and short-term mortality.

Results: Of 210 readmissions (3.97%), risk factors independently associated with unplanned 30-day readmission included comorbidity burden (odds ratio [OR] 2.4, p = 0.042), Medicare insurance (OR 1.9, p = 0.021), and axial skeleton location (OR 1.5, p = 0.029). A total of 91 patients died within 90 days of their surgery (1.84%). Risk factors independently associated with mortality included age (hazard ratio 1.1, p < 0.001), increasing comorbidity burden (OR 6.6, p = 0.001), higher grade (OR 1.7, p = 0.007), increasing tumor size (OR 2.2, p = 0.03), metastatic disease at presentation (OR 8.5, p < 0.001), and amputation (OR 2.0, p = 0.04). Chemotherapy was associated with a decreased risk of short-term mortality (p < 0.001).

Conclusions: Several trends were clear: insurance status, tumor location and comorbidity burden were independently associated with readmission rates, while age, amputation, grade, tumor size, metastatic disease, and comorbidity burden were independently associated with short-term mortality.
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http://dx.doi.org/10.1245/s10434-021-10099-7DOI Listing
November 2021

Hospital-level compliance with the commission on cancer's quality of care measures and the association with patient survival.

Cancer Med 2021 06 4;10(11):3533-3544. Epub 2021 May 4.

Department of Surgery, Duke University, Duke Cancer Institute, Durham, NC, USA.

Background: Quality measurement has become a priority for national healthcare reform, and valid measures are necessary to discriminate hospital performance and support value-based healthcare delivery. The Commission on Cancer (CoC) is the largest cancer-specific accreditor of hospital quality in the United States and has implemented Quality of Care Measures to evaluate cancer care delivery. However, none has been formally tested as a valid metric for assessing hospital performance based on actual patient outcomes.

Methods: Eligibility and compliance with the Quality of Care Measures are reported within the National Cancer Database, which also captures data for robust patient-level risk adjustment. Hospital-level compliance was calculated for the core measures, and the association with patient survival was tested using Cox regression.

Results: Seven hundred sixty-eight thousand nine hundred sixty-nine unique cancer cases were included from 1323 facilities. Increasing hospital-level compliance was associated with improved survival for only two measures, including a 35% reduced risk of mortality for the gastric cancer measure G15RLN (HR 0.65, 95% CI 0.58-0.72) and a 19% reduced risk of mortality for the colon cancer measure 12RLN (HR 0.81, 95% CI 0.77-0.85). For the lung cancer measure LNoSurg, increasing compliance was paradoxically associated with an increased risk of mortality (HR 1.14, 95% CI 1.08-1.20). For the remaining measures, hospital-level compliance demonstrated no consistent association with patient survival.

Conclusion: Hospital-level compliance with the CoC's Quality of Care Measures is not uniformly aligned with patient survival. In their current form, these measures do not reliably discriminate hospital performance and are limited as a tool for value-based healthcare delivery.
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http://dx.doi.org/10.1002/cam4.3875DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8178497PMC
June 2021

Validation of the 8th Edition American Joint Commission on Cancer (AJCC) Gallbladder Cancer Staging System: Prognostic Discrimination and Identification of Key Predictive Factors.

Cancers (Basel) 2021 Feb 1;13(3). Epub 2021 Feb 1.

Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.

The scope of our study was to compare the predictive ability of American Joint Committee on Cancer (AJCC) 7th and 8th edition in gallbladder carcinoma (GBC) patients, investigate the effect of AJCC 8th nodal status on the survival, and identify risk factors associated with the survival after N reclassification using the National Cancer Database (NCDB) in the period 2005-2015. The cohort consisted of 7743 patients diagnosed with GBC; 202 patients met the criteria for reclassification and were denoted as stage ≥III by AJCC 7th and 8th edition criteria. Overall survival concordance indices were similar for patients when classified by AJCC 8th (OS c-index: 0.665) versus AJCC 7th edition (OS c-index: 0.663). Relative mortality was higher within strata of T1, T2, and T3 patients with N2 compared with N1 stage (T1 HR: 2.258, < 0.001; T2 HR: 1.607, < 0.001; Τ3 HR: 1.306, < 0.001). The risk of death was higher in T1-T3 patients with Nx compared with N1 stage (T1 HR: 1.281, = 0.043, T2 HR: 2.221, < 0.001, T3 HR: 2.194, < 0.001). In patients with AJCC 8th edition stage ≥IIIB GBC and an available grade, univariate analysis showed that higher stage, Charlson-Deyo score ≥ 2, higher tumor grade, and unknown nodal status were associated with an increased risk of death, while year of diagnosis after 2013, academic center, chemotherapy. and radiation therapy were associated with decreased risk of death. Chemotherapy and radiation therapy were associated with decreased risk of death in patients with T3-T4 and T2-T4 GBC, respectively. In conclusion, the updated AJCC 8th GBC staging system was comparable to the 7th edition, with the recently implemented changes in N classification assessment failing to improve the prognostic performance of the staging system. Further prospective studies are needed to validate the T2 stage subclassification as well as to clarify the association, if any is actually present, between advanced N staging and increased risk of death in patients of the same T stage.
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http://dx.doi.org/10.3390/cancers13030547DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7867111PMC
February 2021

Association Between Depressive Symptoms and Incident Cardiovascular Diseases.

JAMA 2020 12;324(23):2396-2405

Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.

Importance: It is uncertain whether depressive symptoms are independently associated with subsequent risk of cardiovascular diseases (CVDs).

Objective: To characterize the association between depressive symptoms and CVD incidence across the spectrum of lower mood.

Design, Setting, And Participants: A pooled analysis of individual-participant data from the Emerging Risk Factors Collaboration (ERFC; 162 036 participants; 21 cohorts; baseline surveys, 1960-2008; latest follow-up, March 2020) and the UK Biobank (401 219 participants; baseline surveys, 2006-2010; latest follow-up, March 2020). Eligible participants had information about self-reported depressive symptoms and no CVD history at baseline.

Exposures: Depressive symptoms were recorded using validated instruments. ERFC scores were harmonized across studies to a scale representative of the Center for Epidemiological Studies Depression (CES-D) scale (range, 0-60; ≥16 indicates possible depressive disorder). The UK Biobank recorded the 2-item Patient Health Questionnaire 2 (PHQ-2; range, 0-6; ≥3 indicates possible depressive disorder).

Main Outcomes And Measures: Primary outcomes were incident fatal or nonfatal coronary heart disease (CHD), stroke, and CVD (composite of the 2). Hazard ratios (HRs) per 1-SD higher log CES-D or PHQ-2 adjusted for age, sex, smoking, and diabetes were reported.

Results: Among 162 036 participants from the ERFC (73%, women; mean age at baseline, 63 years [SD, 9 years]), 5078 CHD and 3932 stroke events were recorded (median follow-up, 9.5 years). Associations with CHD, stroke, and CVD were log linear. The HR per 1-SD higher depression score for CHD was 1.07 (95% CI, 1.03-1.11); stroke, 1.05 (95% CI, 1.01-1.10); and CVD, 1.06 (95% CI, 1.04-1.08). The corresponding incidence rates per 10 000 person-years of follow-up in the highest vs the lowest quintile of CES-D score (geometric mean CES-D score, 19 vs 1) were 36.3 vs 29.0 for CHD events, 28.0 vs 24.7 for stroke events, and 62.8 vs 53.5 for CVD events. Among 401 219 participants from the UK Biobank (55% were women, mean age at baseline, 56 years [SD, 8 years]), 4607 CHD and 3253 stroke events were recorded (median follow-up, 8.1 years). The HR per 1-SD higher depression score for CHD was 1.11 (95% CI, 1.08-1.14); stroke, 1.10 (95% CI, 1.06-1.14); and CVD, 1.10 (95% CI, 1.08-1.13). The corresponding incidence rates per 10 000 person-years of follow-up among individuals with PHQ-2 scores of 4 or higher vs 0 were 20.9 vs 14.2 for CHD events, 15.3 vs 10.2 for stroke events, and 36.2 vs 24.5 for CVD events. The magnitude and statistical significance of the HRs were not materially changed after adjustment for additional risk factors.

Conclusions And Relevance: In a pooled analysis of 563 255 participants in 22 cohorts, baseline depressive symptoms were associated with CVD incidence, including at symptom levels lower than the threshold indicative of a depressive disorder. However, the magnitude of associations was modest.
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http://dx.doi.org/10.1001/jama.2020.23068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7739139PMC
December 2020

Response to Central Boost Radiation Therapy in an Unresectable Retroperitoneal Sarcoma: A Case Report.

Adv Radiat Oncol 2020 Nov-Dec;5(6):1375-1379. Epub 2020 Jun 6.

Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.

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http://dx.doi.org/10.1016/j.adro.2020.05.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7718497PMC
June 2020

Percutaneous Gastrojejunostomy Tube Insertion in Patients with Surgical Gastrojejunal Anastomoses: Analysis of Success Rates and Durability.

J Vasc Interv Radiol 2021 02 5;32(2):277-281. Epub 2020 Nov 5.

Division of Interventional Radiology, Department of Radiology, Duke University Medical Center, Box 3808, 2301 Erwin Road, Durham, NC 27710. Electronic address:

Patients with a gastrojejunal anastomosis pose challenging anatomy for percutaneous gastrojejunostomy (GJ)-tube placement. A retrospective review of 24 patients (mean age 67.8 years, 13 males) with GJ anastomoses who underwent attempted GJ tube placement revealed infeasible placement in 6 patients (25%) due to an inadequate window for puncture. When a gastric puncture was achieved, GJ tube insertion was technically successful in 83% (15/18) of attempts, resulting in an overall technical success rate of 63% (15/24). The most common tube-related complication was the migration of the jejunal limb into the stomach, which occurred in 40% (6/15) of successful cases. No major procedure related complications were encountered.
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http://dx.doi.org/10.1016/j.jvir.2020.10.001DOI Listing
February 2021

Limb salvage versus amputation in patients with osteosarcoma of the extremities: an update in the modern era using the National Cancer Database.

BMC Cancer 2020 Oct 14;20(1):995. Epub 2020 Oct 14.

Department of Orthopaedic Surgery, Duke University Hospital, 311 Trent Drive, Durham, NC, 27710, USA.

Background: Historically, amputation was the primary surgical treatment for osteosarcoma of the extremities; however, with advancements in surgical techniques and chemotherapies limb salvage has replaced amputation as the dominant treatment paradigm. This study assessed the type of surgical resection chosen for osteosarcoma patients in the twenty-first century.

Methods: Utilizing the largest registry of primary osteosarcoma, the National Cancer Database (NCDB), we retrospectively analyzed patients with high grade osteosarcoma of the extremities from 2004 through 2015. Differences between patients undergoing amputation and patients undergoing limb salvage are described. Unadjusted five-year overall survival between patients who received limb salvage and amputation was assessed utilizing Kaplan Meier curves. A multivariate Cox proportional hazard model and propensity matched analysis was used to determine the variables independently correlated with survival.

Results: From a total of 2442 patients, 1855 underwent limb salvage and 587 underwent amputation. Patients undergoing amputation were more likely to be older, male, uninsured, and live in zip codes associated with lower income. Patients undergoing amputation were also more likely to have larger tumors, more comorbid conditions, and metastatic disease at presentation. After controlling for confounders, limb salvage was associated with a significant survival benefit over amputation (HR: 0.70; p < 0.001). Although this may well reflect underlying biases impacting choice of treatment, this survival benefit remained significant after propensity matched analysis of all significantly different independent variables (HR: 0.71; p < 0.01).

Conclusion: Among patients in the NCDB, amputation for osteosarcoma is associated with advanced age, advanced stage, larger tumors, greater comorbidities, and lower income. Limb salvage is associated with a significant survival benefit, even when controlling for significant confounding variables and differences between cohorts.
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http://dx.doi.org/10.1186/s12885-020-07502-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7557006PMC
October 2020

Age differences in trajectories of depressive, anxiety, and burnout symptoms in a population with a high likelihood of persistent occupational distress.

Int Psychogeriatr 2022 01 28;34(1):21-32. Epub 2020 Sep 28.

Duke Global Health Institute, Center for Health Policy and Inequalities Research, Duke University, Durham, NC, USA.

Objectives: Work in occupations with higher levels of occupational stress can bring mental health costs. Many older adults worldwide are continuing to work past traditional retirement age, raising the question whether older adults experience depression, anxiety, or burnout at the same or greater levels as younger workers, and whether there are differences by age in these levels over time.

Design/setting/participants: Longitudinal survey of 1161 currently employed US clergy followed every 6-12 months for up to 66 months.

Measurements: Depression was measured with the 8-item Patient Health Questionnaire (PHQ-8). Anxiety was measured using the anxiety component of the Hospital Anxiety and Depression Scale (HADS). Burnout symptoms were assessed using the three components of the Maslach Burnout Inventory: emotional exhaustion (EE), depersonalization (DP), and sense of personal accomplishment (PA).

Results: Older participants had lower scores of depression, anxiety, EE, and DP and higher levels of PA over time compared to younger adults. Levels of EE decreased for older working adults, while not significantly changing over time for those younger. DP symptoms decreased over time among those 55 years or older but increased among those 25-54 years.

Conclusions: Older working adults may have higher levels of resilience and be able to balance personal life with their occupation as well as may engage in certain behaviors that increase social support and, for clergy, spiritual well-being that may decrease stress in a way that allows these older adults to appear to tolerate working longer without poorer mental health outcomes.
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http://dx.doi.org/10.1017/S1041610220001751DOI Listing
January 2022

Feeding the Beast.

J Am Geriatr Soc 2020 10 11;68(10):2205-2206. Epub 2020 Aug 11.

Professor and Chair Emeritus, Department of Psychiatry, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.

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http://dx.doi.org/10.1111/jgs.16753DOI Listing
October 2020

Defining a textbook surgical outcome for patients undergoing surgical resection of intermediate and high-grade soft tissue sarcomas of the extremities.

J Surg Oncol 2020 Oct 21;122(5):884-896. Epub 2020 Jul 21.

Department of Orthopaedic Surgery, Duke University, Durham, North Carolina.

Background: Quality measures for the surgical management soft tissue sarcoma of the extremity are limited. The purpose of this study was to define a textbook surgical outcome (TO) for soft tissue sarcoma of the extremities (STS-E) and to examine its associations with hospital volume and overall survival.

Methods: All patients in the National Cancer Database undergoing resection of primary STS-E between 2004 and 2015 were identified. The primary outcome was a TO, defined as: hospital length of stay (LOS) <75th percentile, survival >90 days from the date of surgery, no readmission within 30 days of discharge, and negative surgical margins (R0 resection).

Results: Overall, 7658 patients met criteria for inclusion; a TO was achieved in 4291 (56%) patients. Of patients who did not achieve TOs, 51.9% (n = 1748) had an extended LOS, and 47.3% (n = 1591) did not have negative margins. Older age, more medical comorbidities, and non-white or black race were independently associated with not receiving a TO (P = .034). With respect to tumor and treatment characteristics, larger tumor size, lower extremity location and higher grade were independently associated with not receiving a TO (P < .001). Hospital volume was not associated with a TO. TOs conferred a significant survival benefit (hazrds ratio = 0.71 [0.65-0.78], P < .001). A TO was associated with a 27.5% longer survival time (P < .001).

Conclusions: This study defined a TO in intermediate and high-grade STS-E and demonstrated that this outcome measure is associated with overall survival. Facility volume was not associated with a TO.
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http://dx.doi.org/10.1002/jso.26087DOI Listing
October 2020

Hands On.

Authors:
Dan G Blazer

Am J Geriatr Psychiatry 2020 10 12;28(10):1126-1127. Epub 2020 Jun 12.

Duke University Medical Center (DGB), Durham, NC. Electronic address:

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http://dx.doi.org/10.1016/j.jagp.2020.06.001DOI Listing
October 2020

ASO Author Reflection: Postoperative Chemotherapy for Nonmetastatic, Poorly Differentiated Gastroenteropancreatic Neuroendocrine Carcinomas.

Ann Surg Oncol 2020 Dec 1;27(Suppl 3):804-805. Epub 2020 Jul 1.

Department of Surgery, Duke University Medical Center, Durham, USA.

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http://dx.doi.org/10.1245/s10434-020-08802-1DOI Listing
December 2020

Impact of Postoperative Chemotherapy on the Survival of Patients with High-Grade Gastroenteropancreatic Neuroendocrine Carcinoma.

Ann Surg Oncol 2021 Jan 18;28(1):114-120. Epub 2020 Jun 18.

Department of Surgery, Duke University Medical Center, Durham, NC, USA.

Background: This study aimed to determine whether postoperative chemotherapy is associated with a survival benefit for patients with poorly differentiated neuroendocrine carcinoma (NEC) of the stomach, small bowel, or pancreas.

Methods: Patients were identified in the National Cancer Database (NCDB) between 2004 and 2014. Inverse probability of treatment weighting (IPTW) was used to reduce selection bias. To compare the overall survival (OS) of patients in different treatment groups, IPTW-adjusted Kaplan-Meier curves and Cox proportional hazards models were used.

Results: The inclusion criteria were met by 759 patients. The diagnosis was NEC of the stomach for 195 patients (25.7%), NEC of the small intestine for 278 patients (36.6%), and NEC of the pancreas for 286 patients (37.7%). Overall, 213 patients (28.1%) received postoperative chemotherapy after curative resection. For the patients who received chemotherapy, IPTW-adjusted survival showed no OS benefit. However, subgroup analysis demonstrated improved OS with observation (OB) for patients with NEC of the small intestine (hazard ratio [HR], 1.436; 95% confidence interval [CI] 1.13-1.823; P = 0.003), T3 or T4 primary tumor (HR, 1.258; 95% CI 1.08-1.465; P = 0.003), node-positive disease (HR, 1.238; 95% CI 1.040-1.475; P = 0.0165), or positive resection margin (HR, 1.4283; 95% CI 1.02-2.00; P = 0.038).

Conclusions: In this national database analysis, postoperative chemotherapy was not associated with improved survival for patients with poorly differentiated gastroenteropancreatic (GEP) NECs. These findings highlight the need for continued efforts to understand better which patients in this high-risk population will benefit from additional systemic therapy and the need for continued development of more effective therapies for these patients.
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http://dx.doi.org/10.1245/s10434-020-08730-0DOI Listing
January 2021

Toward a Multidimensional Perspective on Wisdom and Health-An Analogy With Depression Intervention and Neurobiological Research.

JAMA Psychiatry 2020 09;77(9):895-896

Duke University Medical Center, Durham, North Carolina.

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http://dx.doi.org/10.1001/jamapsychiatry.2020.0642DOI Listing
September 2020

Improved overall survival is still observed in patients receiving delayed adjuvant chemotherapy after pancreaticoduodenectomy for pancreatic adenocarcinoma.

HPB (Oxford) 2020 11 13;22(11):1542-1548. Epub 2020 Apr 13.

Department of Surgery, Duke University Medical Center, Durham, NC, USA.

Background: Adjuvant chemotherapy (AC) is associated with improved survival following resection of pancreatic adenocarcinoma but is frequently delayed or deferred due to perioperative complications or patient deconditioning. The aim of this study was to assess impact of delayed AC on overall survival after pancreaticoduodenectomy for pancreatic head adenocarcinoma.

Methods: Patients with stage I-III pancreatic head adenocarcinoma in the 2006-2015 National Cancer Database were grouped by timing of AC (<6-weeks, 6-12-weeks, and 12-24-weeks). Overall survival was compared using Cox proportional hazard models adjusting for patient, tumor, and hospital factors. Subgroup analyses were conducted to assess the impact of comorbidities, readmission or extended hospital stay, and receipt of single- versus multi-agent chemotherapy.

Results: Of 13438 patients, 4552 (33.9%) received no AC, 2112 (15.7%) received AC <6-weeks following resection, 5580 (41.5%) within 6-12 weeks, and 1194 (8.9%) within 12-24 weeks. AC was associated with improved overall survival (adjusted hazard ratio [HR] <6-weeks: 0.765, 6-12-weeks: 0.744, and 12-24-weeks: 0.736 (p < 0.001)). This survival advantage persisted for patients with comorbidities, those with postoperative complications, and in those receiving single- or multi-agent regimens.

Conclusions: For patients with stage I-III pancreatic adenocarcinoma, receipt of AC is associated with improved overall survival, even if delayed up to 24-weeks.
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http://dx.doi.org/10.1016/j.hpb.2020.03.006DOI Listing
November 2020

COVID-19: Financial Stress Test for Academic Medical Centers.

Acad Med 2020 08;95(8):1143-1145

D.G. Blazer II is professor emeritus, Department of Psychiatry, and former dean of medical education, Duke University School of Medicine, Durham, North Carolina.

The coronavirus (COVID-19) pandemic is having profound effects on the lives and well-being of the world's population. All levels of the nation's public health and health care delivery systems are rapidly adjusting to secure the health infrastructure to manage the pandemic in the United States. As the nation's safety net health care systems, academic medical centers (AMCs) are vital clinical and academic resources in managing the pandemic. COVID-19 may also risk the financial underpinnings of AMCs because their cost structures are high, and they may have incurred large amounts of debt over the last decade as they expanded their clinical operations and facilities. This Invited Commentary reviews existing data on AMC debt levels; summarizes relief provided in the Coronavirus Aid, Relief, and Economic Security Act; and suggests policy options to help mitigate risk.
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http://dx.doi.org/10.1097/ACM.0000000000003418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7179061PMC
August 2020

Textbook Outcomes Among Patients Undergoing Retroperitoneal Sarcoma Resection.

Anticancer Res 2020 Apr;40(4):2107-2115

Department of Surgery, Duke University Medical Center, Durham, NC, U.S.A.

Background/aim: Recently, the concept of textbook outcome (TO) has emerged as a novel effort to develop a benchmark that reflects multiple domains of quality. The aims of the current study were to define TO for retroperitoneal sarcoma (RPS), evaluate the relationship of TO with hospital volume and assess the association of TO with overall survival.

Patients And Methods: Patients who underwent resection for RPS diagnosed between 2004 and 2015 were identified in the National Cancer Database. The primary outcome was TO that was defined as: hospital length of stay<75 percentile, survival>90 days from surgery, no readmission within 30 days and grossly negative margins.

Results: Of the 11,032 patients analyzed, 54.0% had a TO. Among patients who had a TO, 57.8% were treated in high-volume hospitals. Undergoing surgery at high-volume centers was associated with a higher probability of a TO (p=0.009). TO were associated with significantly longer overall survival (p<0.001). In a subgroup analysis with grossly negative margins and no 90-day mortality, the association of TO with improved survival persisted (p<0.001).

Conclusion: The concept of TO is a promising tool for measuring patient-level hospital performance and may be useful for identifying important variations in care for patients with RPS.
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http://dx.doi.org/10.21873/anticanres.14169DOI Listing
April 2020

Geriatric Psychiatry.

Clin Geriatr Med 2020 05 15;36(2):xiii-xv. Epub 2019 Nov 15.

Geriatric Psychiatry, James A. Haley Veterans Hospital, University of South Florida, Morsani College of Medicine, 13000 Bruce B. Downs Boulevard (116A), Tampa, FL 33612-4745, USA. Electronic address:

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http://dx.doi.org/10.1016/j.cger.2019.11.014DOI Listing
May 2020

Hearing Loss: The Silent Risk for Psychiatric Disorders in Late Life.

Authors:
Dan G Blazer

Clin Geriatr Med 2020 05;36(2):201-209

JP Gibbons Professor Emeritus of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3003, 3521 Hosp South, Durham, NC 27710, USA. Electronic address:

Hearing loss is among the most frequent problems experienced by older adults, yet psychiatrists and other clinicians often ignore the problem as an aggravation rather than recognizing that the problem might benefit from appropriate hearing health care. Many psychiatric disorders have been associated with hearing loss, including depression, schizophrenia and other psychoses, anxiety, and neurocognitive disorders. In this article, hearing loss among older adults is reviewed, with special attention directed toward the recognition and proper referral to a hearing health care provider. Finally, major advances in hearing health care are discussed.
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http://dx.doi.org/10.1016/j.cger.2019.11.002DOI Listing
May 2020
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