Publications by authors named "Deven Patel"

71 Publications

Obesity prevalence among active component service members prior to and during the COVID-19 pandemic, January 2018-July 2021.

MSMR 2022 Mar 1;29(3):8-16. Epub 2022 Mar 1.

This study examined monthly prevalence of obesity and exercise in active component U.S. military members prior to and during the COVID-19 pandemic. Information about obesity (BMI≥30) and self-reported vigorous exercise (≥150 minutes per week) were collected from Periodic Health Assessment (PHA) data. From 1 January 2018 through 31 July 2021, there was a gradual increase in obesity and an overall decrease in vigorous exercise. Comparing the mean monthly percentage of obesity during the 12-month period prior to the pandemic to the 12 months after its start showed an overall increase in obesity (0.43%); however, no obvious spike in the obesity trend was apparent following the onset of the pandemic. The prevalence of vigorous exercise showed an abrupt decrease following the onset of the COVID-19 pandemic, but this change did not coincide with an abrupt change in the obesity trend. These results suggest that the COVID-19 pandemic had a small effect on the trend of obesity in the active component U.S. military and that obesity prevalence continues to increase.
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March 2022

COVID-19 and depressive symptoms among active component U.S. service members, January 2019-July 2021.

MSMR 2022 01;29(1):7-13

This study examined the rates of depressive symptoms in active component U.S. service members prior to and during the COVID-19 pandemic and evaluated whether SARS-CoV-2 test results (positive or negative) were associated with self-reported depressive symptoms. Depressive symptoms were measured by the Patient Health Questionnaire-2 (PHQ-2) screening instrument and were defined as positive if the total score was 3 or greater. From 1 January 2019 through 31 July 2021, 2,313,825 PHQ-2s were completed with an increase in the positive rate from 4.0% to 6.5% (absolute % difference, +2.5%; relative % change, +67.1%) from the beginning to the end of the period. While there was a gradual increase of 19.8% in the months prior to the pandemic (1.4%/month average), this increase grew to 40.4% during the pandemic (2.5%/month average). However, no association was found between a positive or negative SARS-CoV-2 test result and the PHQ-2 screening instrument result. These findings suggest that the accelerated increase in depressive symptoms is likely a function of the environment of the COVID-19 pandemic instead of the SARS-CoV-2 infection itself. Further research to better understand specific factors of the pandemic leading to depressive symptoms will improve efficient allocation of military medical resources and safeguard military medical readiness.
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January 2022

A national analysis of open versus minimally invasive thymectomy for stage I-III thymic carcinoma.

Eur J Cardiothorac Surg 2022 Mar 8. Epub 2022 Mar 8.

Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.

Objectives: The oncological efficacy of minimally invasive thymectomy for thymic carcinoma is not well characterized. We compared overall survival and short-term outcomes between open and minimally invasive surgical (video-assisted thoracoscopic and robotic) approaches using the National Cancer Database.

Methods: Perioperative outcomes and overall survival of patients who underwent open versus minimally invasive thymectomy for Masaoka stage I-III thymic carcinoma from 2010 to 2015 in the National Cancer Database were evaluated using propensity score-matched analysis and multivariable Cox proportional hazards modelling. Outcomes by surgical approach were assessed using an intent-to-treat analysis.

Results: Of the 216 thymectomies that were evaluated, 43 (20%) were performed with minimally invasive techniques (22 video-assisted thoracoscopic and 21 robotic). The minimally invasive approach was associated with a shorter median length of stay when compared to the open approach (3 vs 5 days, P < 0.001). In the propensity score-matched analysis of 30 open and 30 minimally invasive thymectomies, the minimally invasive group did not differ significantly in median length of stay (3 vs 4.5 days, P = 0.27), 30-day readmission (P = 0.13), 30-day mortality (P = 0.60), 90-day mortality (P = 0.60), margin positivity (P = 0.39) and 5-year survival (78.6% vs 54.6%, P = 0.15) when compared to the open group.

Conclusions: In this national analysis, minimally invasive thymectomy for stage I-III thymic carcinoma was found to have no significant differences in short-term outcomes and overall survival when compared to open thymectomy.
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http://dx.doi.org/10.1093/ejcts/ezac159DOI Listing
March 2022

Sepsis hospitalizations among active component service members, U.S. Armed Forces, 2011-2020.

MSMR 2021 Nov 1;28(11):2-8. Epub 2021 Nov 1.

The objective of this study was to assess the incidence and trends of sepsis hospitalizations in the active component U.S. military over the past decade. Between 1 January 2011 and 31 December 2020, there were 5,278 sepsis hospitalizations of any severity recorded among the active component. The overall incidence was 39.8 hospitalizations per 100,000 person-years (p-yrs). Annual incidence increased 64% from 2011 through 2019, then dropped considerably in 2020. Compared to their respective counterparts, rates were highest among female service members, the oldest and youngest age groups, and recruits. The gap in sepsis hospitalization rates between female and male service members increased over the surveillance period. Pneumonia was the most commonly co-occurring infection, followed by genitourinary infections. Among female service members, genitourinary infections were more commonly diagnosed compared to pneumonia. The most common non-infection co-occurring diagnoses were acute kidney failure and acute respiratory failure. This study demonstrates an apparent sex disparity in sepsis rates and further study is recommended to understand its cause.
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November 2021

Perioperative Outcomes After Combined Esophagectomy and Lung Resection.

J Surg Res 2022 02 11;270:413-420. Epub 2021 Nov 11.

Department of Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University Medical Center, Stanford, California. Electronic address:

Introduction: The impact of concomitant lung resection during esophagectomy on short-term outcomes is not well characterized. This study tests the hypothesis that lung resection at the time of esophagectomy is not associated with increased perioperative morbidity or mortality.

Methods: Perioperative outcomes for esophageal cancer patients who underwent esophagectomy alone (EA) were compared to patients who had concurrent esophagectomy and lung resection (EL) using the NSQIP database between 2006-2017. Predictors of morbidity and mortality, including combined surgery, were evaluated using multivariable logistic regression.

Results: Among the 6,225 study patients, 6,068 (97.5%) underwent EA and 157 (2.5%) underwent EL. There were no differences in baseline characteristics between the two groups. Operating time for EL was longer than EA (median 416 versus 371 minutes, P < 0.01). Median length of stay was 10 d for both groups. Perioperative mortality was not significantly different between EL and EA patients (5.1% versus 2.8%, P = 0.08). EL patients had higher rates of postoperative pneumonia (22.3% versus 16.2%, P = 0.04) and sepsis (11.5% versus 7.1%, P = 0.03), however major complication rates overall were similar (40.8% versus 35.3%, P = 0.16). Combining lung resection with esophagectomy was not independently associated with increased postoperative morbidity (AOR 1.21 [95% CI 0.87-1.69]) or mortality (AOR 1.63 [95% CI 0.74-3.58]).

Conclusions: Concurrent lung resection during esophagectomy is not associated with increased mortality or overall morbidity, but is associated with higher rates of pneumonia beyond esophagectomy alone. Surgeons considering combined lung resection with esophagectomy should carefully evaluate the patient's risk for pulmonary complications and pursue interventions preoperatively to optimize respiratory function.
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http://dx.doi.org/10.1016/j.jss.2021.09.037DOI Listing
February 2022

Percutaneous Cholecystostomy Tube for Acute Cholecystitis: Quantifying Outcomes and Prognosis.

J Surg Res 2022 02 5;270:405-412. Epub 2021 Nov 5.

Department of Surgery, Division of Acute Care Surgery and Surgical Critical Care, Cedars-Sinai Medical Center, Los Angeles, California. Electronic address:

Background: Percutaneous cholecystostomy tubes (PCT) are utilized in the management of acute cholecystitis in patients deemed unsuitable for surgery. However, the drive for these decisions and the outcomes remain understudied. We sought to characterize the practices and utilization of PCT and evaluate associated outcomes at an urban medical center.

Methods: Patients undergoing PCT placement over a 12-y study period ending May 2019 were reviewed. Demographics, clinical presentation, labs, imaging studies, and outcomes were abstracted. The primary and secondary outcomes were 30-d mortality and interval cholecystectomy, respectively.

Results: Two hundred and four patients met inclusion criteria: 59.3% were male with a median age of 67.5 y and a National Surgical Quality Improvement Program (NSQIP) risk of serious complication of 8.0%. Overall, 57.8% of patients were located in an intensive care unit setting. The majority (80.9%) had an ultrasound and 48.5% had a hepatobiliary iminodiacetic acid scan. The overall 30-d mortality was 31.9%: 41.5% for intensive care unit and 18.6% for ward patients (P < 0.01). Of patients surviving beyond 30 d (n = 139), the PCT was removed from 106 (76.3%), and a cholecystectomy was performed in 55 (39.6%) at a median interval of 58.0 d. A forward logistic regression identified total bilirubin (Adjusted Odds Ratio: 1.12, adjusted P < 0.01) and NSQIP risk of serious complication (Adjusted Odds Ratio: 1.16, adjusted P < 0.01) as the only predictors for 30-d mortality.

Conclusions: Patients selected for PCT placement have a high mortality risk. Despite subsequent removal of the PCT, the majority of surviving patients did not undergo an interval cholecystectomy. Total bilirubin and NSQIP risk of serious complication are useful adjuncts in predicting 30-d mortality in these patients.
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http://dx.doi.org/10.1016/j.jss.2021.09.018DOI Listing
February 2022

The Academic Impact of Advanced Clinical Fellowship Training among General Thoracic Surgeons.

J Surg Educ 2022 Mar-Apr;79(2):417-425. Epub 2021 Oct 19.

Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California; VA Palo Alto Health Care System, Palo Alto, California. Electronic address:

Objective: Advanced clinical fellowship training has become a popular option for surgical trainees seeking to bolster their clinical training and expertise. However, the long-term academic impact of this additional training following a traditional thoracic surgery fellowship is unknown. This study aimed to delineate the impact of an advanced clinical fellowship on subsequent research productivity and advancement in academic career among general thoracic surgeons.

Methods: Using an internally constructed database of active, academic general thoracic surgeons who are current faculty at accredited cardiothoracic surgery training programs within the United States, surgeons were dichotomized according to whether an advanced clinical fellowship was completed or not. Academic career metrics measured by research productivity, scholarly impact (H-index), funding by the National Institutes of Health, and academic rank were compared.

Results: Among 285 general thoracic surgeons, 89 (31.2%) underwent an advanced fellowship, whereas 196 (68.8%) did not complete an advanced fellowship. The most commonly pursued advanced fellowship was minimally invasive thoracic surgery (32.0%). There were no differences between the two groups in terms of gender, international medical training, or postgraduate education. Those who completed an advanced clinical fellowship were less likely to have completed a dedicated research fellowship compared to those who had not completed any additional clinical training (58.4% vs. 74.0%, p = 0.0124). Surgeons completing an advanced clinical fellowship demonstrated similar cumulative first-author publications (p = 0.4572), last-author publications (p = 0.7855), H-index (p = 0.9651), National Institutes of Health funding (p = 0.7540), and years needed to advance to associate professor (p = 0.3410) or full rank professor (p = 0.1545) compared to surgeons who did not complete an advanced fellowship. These findings persisted in sub-analyses controlling for surgeons completing a dedicated research fellowship.

Conclusions: Academic general thoracic surgeons completing an advanced clinical fellowship demonstrate similar research output and ascend the academic ladder at a similar pace as those not pursuing additional training.
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http://dx.doi.org/10.1016/j.jsurg.2021.09.003DOI Listing
March 2022

Long-acting reversible contraceptive use, active component service women, U.S. Armed Forces, 2016-2020.

MSMR 2021 Jul 1;28(7):2-10. Epub 2021 Jul 1.

Long-acting reversible contraceptives (LARCs) are highly effective means of birth control that can improve service women's overall health and readiness. This report expands upon prior data and summarizes the annual prevalence (overall and by demographics) of LARC use from 2016 through 2020 among active component U.S. service women, compares LARC prevalence to the prevalence of short-acting reversible contraceptives (SARCs), and evaluates the probability of continued use of LARCs by type. LARC use increased from 21.9% to 23.9% from 2016 through 2019 while SARC use decreased from 28.3% to 24.9%. Both SARC and LARC use decreased in 2020 which may have been related to the coronavirus disease 2019 (COVID-19) pandemic. The prevalence of intrauterine devices (IUDs) was greater than implants, and IUDs also had a higher probability of continuation than implants. At 12 months, the continuation for IUDs was 81% compared to 73% for implants. At 24 months, the probabilities of continuation were 70% for IUDs and 54% for implants. Probabilities of continuation were similar across outsourced care and direct care settings. The increased use of LARCs along with their high frequency of continuation in U.S. service women may have a positive impact on overall health and readiness.
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July 2021

Surgical resection for patients with pulmonary aspergillosis in the national inpatient sample.

J Thorac Dis 2021 Aug;13(8):4977-4987

Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, CA, USA.

Background: The role of lung resection in patients with pulmonary aspergillosis is generally reserved for those with localized disease who fail medical management. We used a national database to investigate the influence of preoperative patient comorbidities on inpatient mortality and need for surgery.

Methods: Patients admitted with pulmonary aspergillosis between 2007 to 2015 were identified in the National Inpatient Sample dataset. Inpatient mortality rates were compared between patients treated medically and surgically. Predictors of mortality, surgical intervention, and non-elective admission were evaluated using multivariable logistic regression.

Results: Among a population estimate of 112,998 patients with pulmonary aspergillosis, 107,606 (95.2%) underwent medical management alone and 5,392 (4.8%) underwent surgical resection. Positive predictors for surgery included hemoptysis, and history of lung cancer or chronic pulmonary diseases. Surgically treated patients had a lower inpatient mortality when compared to those treated medically (11.5% . 15.1%, P<0.001) in univariate analysis, but this finding did not persist in multivariable analysis (AOR 0.97, P=0.509). The odds of mortality were lower in patients undergoing video assisted thoracoscopic surgery compared to an open approach (AOR 0.77, P=0.001). Among patients treated surgically, mortality was higher in those with a history of lung cancer, solid organ transplantation, liver disease, human immunodeficiency virus infection, hematologic diseases, chronic pulmonary diseases, and those admitted non-electively requiring surgery.

Conclusions: In this generalizable study, medical and surgical management of pulmonary aspergillosis were comparable in terms of inpatient mortality. However, non-elective admission and patients with select comorbidities have significantly worse outcomes after surgical intervention.
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http://dx.doi.org/10.21037/jtd-21-151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8411153PMC
August 2021

Short-term and intermediate-term readmission after esophagectomy.

J Thorac Dis 2021 Aug;13(8):4678-4689

Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University Medical Center, Falk Building, Stanford, CA, USA.

Background: The objective of this study was to characterize short- and intermediate-term readmissions following esophagectomy and to identify predictors of readmission in these two groups.

Methods: Patients who underwent esophagectomy in the National Readmissions Database (2013-2014) were grouped according to whether first readmission was "short-term" (readmitted <30 days) or "intermediate-term" (readmitted 31-90 days) following index admission for esophagectomy. Predictors of readmission were evaluated using multivariable logistic regression modeling.

Results: Of the 3,005 patients who underwent esophagectomy, 544 (18.1%) had a short-term readmission and 305 (10.1%) had an intermediate-term readmission. The most frequent reasons for short-term readmission were post-operative infection (7.5%), dysphagia (6.3%) and pneumonia (5.1%). The most common intermediate-term complications were pneumonia (7.2%), gastrointestinal stricture/stenosis (6.9%) and dysphagia (5.9%). In multivariable analysis, being located in a micropolitan area, increasing number of comorbidities and higher severity of illness score were associated with an increased likelihood of having a short-term readmission while being discharged to a facility (as opposed to directly home) was associated with increased likelihood of both short- and intermediate-term readmission (all P<0.05).

Conclusions: In this analysis, postoperative infection was the most common reason for short-term readmission. Dysphagia and pneumonia were common reasons for both short- and intermediate-term readmission of patients following esophagectomy. Interventions focused on reducing the risk of postoperative infection and pneumonia may reduce hospital readmissions. Gastrointestinal stricture and dysphagia were associated with increased risk of intermediate readmission and should be examined in the context of morbidity associated with pyloric procedures (e.g., pyloromyotomy) at the time of esophagectomy.
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http://dx.doi.org/10.21037/jtd-21-637DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8411130PMC
August 2021

Influence of facility volume on long-term survival of patients undergoing esophagectomy for esophageal cancer.

J Thorac Cardiovasc Surg 2022 04 10;163(4):1536-1546.e3. Epub 2021 Jun 10.

Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif; VA Palo Alto Health Care System, Palo Alto, Calif. Electronic address:

Objective: This study investigated the influence of facility volume on long-term survival in patients with esophageal cancer treated with esophagectomy.

Methods: Patients treated with esophagectomy for cT1 3N0 3M0 adenocarcinoma or squamous cell carcinoma of the mid-distal esophagus in the National Cancer Database between 2006 and 2013 were stratified by annual facility esophagectomy volume dichotomized as more/less than both 6 and 20. Patient characteristics associated with facility volume were evaluated using logistic regression, and the influence of facility volume on survival was evaluated with Kaplan-Meier curves, Cox proportional hazards methods, and propensity matched analysis.

Results: Of 11,739 patients who had esophagectomy at 1018 facilities where annual volume ranged from 1 to 47.6 cases, 4262 (36.3%) were treated at 44 facilities with annual esophagectomy volume > 6 and 1515 (12.9%) were treated at 7 facilities with annual volume > 20. Higher volume was associated with significantly better 5-year survival for both annual volume > 6 (47.6% vs 40.2%; P < .001) and annual volume > 20 (47.2% vs 42.3%; P < .001), which persisted in propensity matched analyses as well as Cox multivariable analysis (hazard ratio, 0.81; 95% confidence interval, 0.74-0.89; P < .001 for facility volume > 6 and hazard ratio, 0.78; 95% confidence interval, 0.65-0.95; P = .01 for facility volume > 20). In Cox multivariable analysis that considered facility volume as a continuous variable, higher volume continued to be associated with better survival (hazard ratio, 0.93 per 5 cases; 95% CI, 0.91-0.96; P < .001).

Conclusions: Esophageal cancer patients treated with esophagectomy at higher volume facilities have significantly better long-term survival than patients treated at lower volume facilities.
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http://dx.doi.org/10.1016/j.jtcvs.2021.05.048DOI Listing
April 2022

Ingestion of Nitrate and Nitrite and Risk of Stomach and Other Digestive System Cancers in the Iowa Women's Health Study.

Int J Environ Res Public Health 2021 06 25;18(13). Epub 2021 Jun 25.

Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD 20850, USA.

Nitrate and nitrite are precursors in the endogenous formation of N-nitroso compounds (NOC) which are potent animal carcinogens for the organs of the digestive system. We evaluated dietary intakes of nitrate and nitrite, as well as nitrate ingestion from drinking water (public drinking water supplies (PWS)), in relation to the incidence (1986-2014) of cancers of the esophagus (n = 36), stomach (n = 84), small intestine (n = 32), liver (n = 31), gallbladder (n = 66), and bile duct (n = 58) in the Iowa Women's Health Study (42,000 women aged from 50 to 75 in 1986). Dietary nitrate and nitrite were estimated using a food frequency questionnaire and a database of nitrate and nitrite levels in foods. Historical nitrate measurements from PWS were linked to the enrollment address by duration. We used Cox regression to compute hazard ratios (HR) and 95% confidence intervals (CI) for exposure quartiles (Q), tertiles (T), or medians, depending on the number of cancer cases. In adjusted models, nitrite intake from processed meats was associated with an increased risk of stomach cancer (HR = 2.2, CI: 1.2-4.3). A high intake of total dietary nitrite was inversely associated with gallbladder cancer (HR = 0.3, CI: 0.1-0.96), driven by an inverse association with plant sources of nitrite (HR = 0.3, CI: 0.1-0.9). Additionally, small intestine cancer was inversely associated with a high intake of animal nitrite (HR = 0.2, CI: 0.1-0.7). There were no other dietary associations. Nitrate concentrations in PWS (average, years ≥ 1/2 the maximum contaminant level) were not associated with cancer incidence. Our findings for stomach cancer are consistent with prior dietary studies, and we are the first to evaluate nitrate and nitrite ingestion for certain gastrointestinal cancers.
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http://dx.doi.org/10.3390/ijerph18136822DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8297261PMC
June 2021

Early Discharge After Lobectomy for Lung Cancer Does Not Equate to Early Readmission.

Ann Thorac Surg 2022 May 11;113(5):1634-1640. Epub 2021 Jun 11.

Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California; Department of Cardiothoracic Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California. Electronic address:

Background: Enhanced recovery after surgery pathways in several specialties reduce length of stay, but accelerated discharge after thoracic surgery is not well characterized. This study tested the hypothesis that patients discharged on postoperative day 1 (POD1) after lobectomy for lung cancer have an increased risk of readmission.

Methods: Patients who underwent a lobectomy for lung cancer between 2011 and 2019 in the American College of Surgeons National Surgical Quality Improvement Program database were identified. Readmission rates were compared between patients discharged on postoperative day 1 (POD 1) and patients discharged on POD 2 to 6. Early discharge and readmission predictors were evaluated using multivariable logistic regression analysis.

Results: Only 854 (3.8%) of 22,585 patients who met inclusion criteria were discharged on POD 1, although POD 1 discharge rates increased from 2.3% to 8.1% (P < .001) from 2011 to 2019, respectively. Median hospitalization for patients discharged on POD 2 to 6 was 4 days (interquartile range, 3 to 5 days). Patients' characteristics associated with a lower likelihood of POD 1 discharge were increasing age, smoking, or a history of dyspnea, whereas a minimally invasive approach was the strongest predictor of early discharge (adjusted odds ratio, 5.42; P < .001). Readmission rates were not significantly different for the POD 1 and POD 2 to 6 groups in univariate analysis (6.0% vs 7.0%; P = .269). Further, POD 1 discharge was not a risk factor for readmission in multivariable analysis (adjusted odds ratio, 1.10; P = .537).

Conclusions: Select patients can be discharged on POD 1 after lobectomy for lung cancer without an increased readmission risk, a finding supporting this accelerated discharge target inclusion in lobectomy enhanced recovery after surgery protocols.
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http://dx.doi.org/10.1016/j.athoracsur.2021.05.053DOI Listing
May 2022

Applying a Human Factors Approach to Improve Patient Experience with Sacral Neuromodulation.

Urology 2021 10 17;156:78-84. Epub 2021 May 17.

Department of Surgery, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA; Department of Urology, University of California, Los Angeles, CA.

Objectives: To apply a human factors approach, the study of interactions between humans and complex systems, to investigate patient preparedness, satisfaction, and perceived usability with sacral neuromodulation (SNM) and develop interventions aimed at improving patient experience.

Materials And Methods: Ten patients with overactive bladder undergoing staged SNM were observed, and data including pre-operative preparedness, satisfaction, perceived usability and barriers impacting patient experience were collected. Interventions were developed and an additional ten patients were observed. All patients were English-speaking and at least 18 years of age.

Results: Pre-intervention patients had difficulty understanding the risks of the procedure, did not know what to expect post-operatively and were unsatisfied with pre-operative materials. Interventions included: A pre-procedure educational video and informational sheet, detailed discharge instructions; and a nursing inservice. Pre-operative preparedness (Stage I: U = 100, z = 3.785, P = .000; Stage II: U = 80, z = 2.864, P = .003), post-operative satisfaction (Stage I: U = 100, z = 3.788, P = .000; Stage II: U = 77.5, z = 2.665, P = .006.) and perceptions of usability (Stage I: U = 77.00, z = 2.056, P = .043.; Stage II: U = 80.50, z = 2.308, P = .019) increased significantly after the intervention.

Conclusion: Our observations highlight the value of implementing a human factors approach to identify and mitigate barriers impacting patient experiences with SNM. Through the implementation of systems-level interventions (ie, interventions that impact the non-clinical aspects of surgery such as patient and/or staff education), significant improvements can be made.
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http://dx.doi.org/10.1016/j.urology.2021.05.007DOI Listing
October 2021

A novel Ca indicator for long-term tracking of intracellular calcium flux.

Biotechniques 2021 05 18;70(5):271-277. Epub 2021 May 18.

AAT Bioquest, Inc., Sunnyvale, CA, USA.

The major drawback of using Fluo-4 AM is that it requires an organic anion transporter inhibitor, such as probenecid, to prevent leakage. This can hinder the studies that require extended monitoring time and longer cellular retention. To address the issue, a novel Ca indicator, Calbryte 520 AM, was developed. We compared the performance of Fluo-4 AM and Calbryte 520 AM following prolonged incubation periods after cell loading. Cells loaded with Calbryte 520 AM retained the dye for up to 24 h while exhibiting significant fluorescence brightness and superior F/F ratios (F: fluorescence intensity upon stimulation; F: intensity before stimulation). It demonstrated that the longer retention of Calbryte 520 AM can be exploited to accommodate for the extended time required when monitoring calcium dynamics.
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http://dx.doi.org/10.2144/btn-2020-0161DOI Listing
May 2021

Disparities in COVID-19 Vaccine Initiation and Completion Among Active Component Service Members and Health Care Personnel, 11 December 2020-12 March 2021.

MSMR 2021 Apr;28(4):2-9

The objective of this study was to assess overall vaccine initiation and completion in the active component U.S. military, with a focus on racial/ethnic disparities. From 11 December 2020 through 12 March 2021, a total of 361,538 service members (27.2%) initiated a COVID-19 mRNA vaccine. Non-Hispanic Blacks were 28% less likely to initiate vaccination (95% confidence interval: 25%-29%) in comparison to non-Hispanic Whites, after adjusting for potential confounders. Increasing age, higher education levels, higher rank, and Asian/Pacific Islander race/ethnicity were also associated with increasing incidence of initiation after adjustment. When the analysis was restricted to active component health care personnel, similar patterns were seen. Overall, 93.8% of those who initiated the vaccine series completed it during the study period, and only minor differences in completion rates were noted among the demographic subgroups. This study suggests additional factors, such as vaccine hesitancy, influence COVID-19 vaccination choices in the U.S. military. Military leadership and vaccine planners should be knowledgeable about and aware of the disparities in vaccine series initiation.
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April 2021

Cancer diagnoses and survival rise as 65-year-olds become Medicare-eligible.

Cancer 2021 07 29;127(13):2302-2310. Epub 2021 Mar 29.

Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California.

Background: A Medicare effect has been described to account for increased health care utilization occurring at the age of 65 years. The existence of such an effect in cancer care, where it would be most likely to reduce mortality, has been unclear.

Methods: Patients aged 61 to 69 years who were diagnosed with lung, breast, colon, or prostate cancer from 2004 to 2016 were identified with the Surveillance, Epidemiology, and End Results database and were dichotomized on the basis of eligibility for Medicare (61-64 vs 65-69 years). With age-over-age (AoA) percent change calculations, trends in cancer diagnoses and staging were characterized. After matching, uninsured patients who were 61 to 64 years old (pre-Medicare group) were compared with insured patients who were 65 to 69 years old (post-Medicare group) with respect to cancer-specific mortality.

Results: In all, 134,991 patients were identified with lung cancer, 175,558 were identified with breast cancer, 62,721 were identified with colon cancer, and 238,823 were identified with prostate cancer. The AoA growth in the number of cancer diagnoses was highest at the age of 65 years in comparison with all other ages within the decade for all 4 cancers (P < .01, P < .001, P < .01, and P < .001, respectively). In a comparison of diagnoses at the age of 65 years with those in the 61- to 64-year-old cohort, the greatest difference for all 4 cancers was seen in stage I. In matched analyses, the 5-year cancer-specific mortality was worse for lung (86.3% vs 78.5%; P < .001), breast (32.7% vs 11.0%; P < .001), colon (57.1% vs 35.6%; P < .001), and prostate cancer (16.9% vs 4.8%; P < .001) in the uninsured pre-Medicare group than the insured post-Medicare group.

Conclusions: The age threshold of 65 years for Medicare eligibility is associated with more cancer diagnoses (particularly stage I), and this results in lower long-term cancer-specific mortality for all cancers studied.

Lay Summary: Contributing to the current debate regarding Medicare for all, this study shows that the expansion of Medicare would improve cancer outcomes for the near elderly.
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http://dx.doi.org/10.1002/cncr.33498DOI Listing
July 2021

Strong for Surgery: Association Between Bundled Risk Factors and Outcomes After Major Elective Surgery in the VA Population.

World J Surg 2021 06 17;45(6):1706-1714. Epub 2021 Feb 17.

Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, CA, USA.

Background: Strong for Surgery (S4S) is a public health campaign focused on optimizing patient health prior to surgery by identifying evidence-based modifiable risk factors. The potential impact of S4S bundled risk factors on outcomes after major surgery has not been previously studied. This study tested the hypothesis that a higher number of S4S risk factors is associated with an escalating risk of complications and mortality after major elective surgery in the VA population.

Methods: The Veterans Affairs Surgical Quality Improvement Program (VASQIP) database was queried for patients who underwent major non-emergent general, thoracic, vascular, urologic, and orthopedic surgeries between the years 2008 and 2015. Patients with complete data pertaining to S4S risk factors, specifically preoperative smoking status, HbA1c level, and serum albumin level, were stratified by number of positive risk factors, and perioperative outcomes were compared.

Results: A total of 31,285 patients comprised the study group, with 16,630 (53.2%) patients having no S4S risk factors (S4S0), 12,323 (39.4%) having one (S4S1), 2,186 (7.0%) having two (S4S2), and 146 (0.5%) having three (S4S3). In the S4S1 group, 60.3% were actively smoking, 35.2% had HbA1c > 7, and 4.4% had serum albumin < 3. In the S4S2 group, 87.8% were smokers, 84.8% had HbA1c > 7, and 27.4% had albumin < 3. Major complications, reoperations, length of stay, and 30-day mortality increased progressively from S4S0 to S4S3 groups. S4S3 had the greatest adjusted mortality risk (adjusted odds radio [AOR] 2.56, p = 0.04) followed by S4S2 (AOR 1.58, p = 0.02) and S4S1 (AOR 1.34, p = 0.02).

Conclusion: In the VA population, patients who had all three S4S risk factors, namely active smoking, suboptimal nutritional status, and poor glycemic control, had the greatest risk of postoperative mortality compared to patients with fewer S4S risk factors.
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http://dx.doi.org/10.1007/s00268-021-05979-8DOI Listing
June 2021

The role of induction therapy for thymic malignancies: a narrative review.

Mediastinum 2020 30;4:36. Epub 2020 Dec 30.

Division of Medical Oncology, Department of Medicine, Stanford University School of Medicine/Stanford Cancer Institute, Stanford, CA, USA.

Advanced thymic epithelial tumors pose a clinical dilemma for surgeons and medical oncologists. Given the prognostic importance of obtaining a complete resection, interventions that improve resectability may have profound implications. The documented chemosensitivity and radiosensitivity of thymic tumors present an opportunity to use these therapies in the neoadjuvant setting to reduce tumor burden and improve the likelihood of achieving a complete resection. The current evidence available is limited to institutional case-series, large retrospective multi-institutional databases, and phase II clinical trials. The primary objective of considering induction therapy should be facilitating a complete resection; other endpoints such as down-staging or pathologic response have not been shown to result in meaningful improvements in long-term outcomes. There are certain high-risk tumor characteristics that may aid clinicians in appropriately selecting patients for induction therapy. The selection of candidates for induction therapy should take place in a multidisciplinary tumor board including medical oncologist, surgeon, and radiation oncologist with experience in managing advanced thymic malignancies. Without randomized controlled trials, it is unlikely the thymic medical community will arrive at a consensus on the utility of induction therapy. This review will summarize the existing literature and provide insight into the role of induction therapy for advanced thymic malignancies.
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http://dx.doi.org/10.21037/med-20-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8794335PMC
December 2020

Impact of residential mobility on estimated environmental exposures in a prospective cohort of older women.

Environ Epidemiol 2020 Oct 24;4(5):e110. Epub 2020 Aug 24.

Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland.

Longitudinal studies of environmental hazards often rely on exposure estimated at the participant's enrollment residence. This could lead to exposure misclassification if participants move over time.

Methods: We evaluated residential mobility in the Iowa Women's Health Study (age 55-69 years) over 19 years of follow-up (1986-2004). We assessed several environmental exposures of varying spatial scales at enrollment and follow-up addresses. Exposures included average nitrate concentrations in public water supplies, percent of agricultural land (row crops and pasture/hay) within 750 m, and the presence of concentrated animal feeding operations within 5 km. In comparison to gold standard duration-based exposures averaged across all residences, we evaluated the sensitivity and specificity of exposure metrics and attenuation bias for a hypothetical nested case-control study of cancer, which assumed participants did not move from their enrollment residence.

Results: Among 41,650 participants, 32% moved at least once during follow-up. Mobility was predicted by working outside the home, being a former/current smoker, having a higher education level, using a public drinking water supply, and town size of previous residence. Compared with duration-based exposures, the sensitivity and specificity of exposures at enrollment ranged from 94% to 99% and 97% to 99%, respectively. A hypothetical true odds ratio of 2.0 was attenuated 8% for nitrate, 9%-10% for agricultural land, and 6% for concentrated animal feeding operation exposures.

Conclusions: Overall, we found low rates of mobility and mobility-related exposure misclassification in the Iowa Women's Health Study. Misclassification and attenuation of hypothetical risk estimates differed by spatial variability and exposure prevalence.
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http://dx.doi.org/10.1097/EE9.0000000000000110DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7595244PMC
October 2020

Stereotactic Body Radiotherapy Versus Delayed Surgery for Early-stage Non-small-cell Lung Cancer.

Ann Surg 2020 12;272(6):925-929

Department of Surgery, Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Objective: To evaluate the overall survival of patients with operable stage IA non-small-cell lung cancer (NSCLC) who undergo "early" SBRT (within 0-30 days after diagnosis) versus "delayed" surgery (90-120 days after diagnosis).

Summary Of Background Data: During the COVID-19 pandemic, national guidelines have recommended patients with operable stage IA NSCLC to consider delaying surgery by at least 3 months or, alternatively, to undergo SBRT without delay. It is unknown which strategy is associated with better short- and long-term outcomes.

Methods: Multivariable Cox proportional hazards modeling and propensity score-matched analysis was used to compare the overall survival of patients with stage IA NSCLC in the National Cancer Data Base from 2004 to 2015 who underwent "early" SBRT (0-30 days after diagnosis) versus that of patients who underwent "delayed" wedge resection (90-120 days after diagnosis).

Results: During the study period, 570 (55%) patients underwent early SBRT and 475 (45%) underwent delayed wedge resection. In multivariable analysis, delayed resection was associated with improved survival [adjusted hazard ratio 0.61; (95% confidence interval (CI): 0.50-0.76)]. Propensity-score matching was used to create 2 groups of 279 patients each who received early SBRT or delayed resection that were well-matched with regard to baseline characteristics. The 5-year survival associated with delayed resection was 53% (95% CI: 45%-61%) which was better than the 5-year survival associated with early SBRT (31% [95% CI: 24%-37%]).

Conclusion: In this national analysis, for patients with stage IA NSCLC, extended delay of surgery was associated with improved survival when compared to early treatment with SBRT.
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http://dx.doi.org/10.1097/SLA.0000000000004363DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7668323PMC
December 2020

Paradoxical Motion on Sniff Test Predicts Greater Improvement Following Diaphragm Plication.

Ann Thorac Surg 2021 06 5;111(6):1820-1826. Epub 2020 Oct 5.

Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California; Veterans Affairs Palo Alto Health System, Palo Alto, California. Electronic address:

Background: Diaphragm plication (DP) improves pulmonary function and quality of life for those with diaphragm paralysis or dysfunction. It is unknown whether differing degrees of diaphragm dysfunction as measured by sniff testing affect results after plication.

Methods: Patients who underwent minimally invasive DP from 2008 to 2019 were dichotomized based on sniff test results: paradoxical motion (PM) versus no paradoxical motion (NPM); the latter included normal, decreased, and no motion. Preoperative and postoperative pulmonary function testing (PFT) after DP was compared between groups. The impact of the diaphragm height index, a measure of diaphragm elevation, was also assessed.

Results: A total of 26 patients underwent preoperative sniff testing, DP, and postoperative PFT. Including all patients, DP resulted in a 17.8% ± 5.5% improvement in forced expiratory volume in 1 second (P < .001), a 14.4% ± 5.3% improvement in forced vital capacity (P < .001), and a 4.7% ± 4.6% improvement in the diffusing capacity of carbon monoxide (P = .539). There were greater improvements in the PM group (n = 16) compared with the NPM group (n = 10) for forced expiratory volume in 1 second (27.2% ± 6.0% versus 3.9% ± 6.2%; P = .017) and forced vital capacity (28.1% ± 5.3% versus -0.5% ± 3.3%; P = .001). There was no difference in the change in the diffusing capacity of carbon monoxide between groups. There were no differences between patients with PM and NPM in the postoperative course or complications. No value for diaphragm height index predicted improvement in PFT after DP.

Conclusions: Patients with PM on sniff test have dramatically greater objective improvements in pulmonary function after plication compared with those without PM. Most patients without PM do not demonstrate improvement in standard PFT. Improvements in dyspnea require additional study.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.049DOI Listing
June 2021

A National Analysis of Treatment Patterns and Outcomes for Patients 80 Years or Older With Esophageal Cancer.

Semin Thorac Cardiovasc Surg 2021 22;33(3):884-892. Epub 2020 Sep 22.

Department of Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University Medical Center, Stanford, California.

The purpose of this study was to evaluate practice patterns and outcomes for patients 80 years or older with esophageal cancer using a nationwide cancer data base. Practice patterns for patients 80 years or older with stage I-IV esophageal cancer in the National Cancer Data Base from 2004 to 2014 were analyzed. Overall survival associated with different treatment strategies were evaluated using the Kaplan-Meier method and multivariable Cox proportional hazard models. In the study period, 40.5% and 46.2% of patients with stage I adenocarcinoma and squamous cell carcinoma, respectively, did not receive any treatment at all. Less than 11% (196/1,865) of patients with stage I-II disease underwent esophagectomy, even though surgery was associated with a better 5-year survival compared to no treatment (stage I: 47.3% [95% confidence interval [CI] 36.2-57.6%] vs 14.9% [95% CI: 11.2-19.1%]; stage II: 29.3% [95% CI 20.1-39.1%] vs 1.2% [95% CI: 0.1-5.5%]). Of the 1,596 (37.7%) patients with stage III disease who received curative-intent treatment (surgery or chemoradiation), the 5-year survival was significantly better than that of patients who received no treatment (11.9% [95% CI: 9.7-14.4% vs 4.3% [95% CI: 1.9-8.3%]). In this national analysis of patients 80 years and older with esophageal cancer, over 40% of patients with stage I disease did not receive treatment. Patients with stage I-III disease had better survival and risks and benefits of treatment for elderly patients should be discussed in a multidisciplinary setting.
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http://dx.doi.org/10.1053/j.semtcvs.2020.09.004DOI Listing
October 2021

Comparing clinical outcomes of image-guided percutaneous transperitoneal and transhepatic cholecystostomy for acute cholecystitis.

Acta Radiol 2021 Sep 22;62(9):1142-1147. Epub 2020 Sep 22.

Department of Imaging, Section of Interventional Radiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

Background: Percutaneous cholecystostomy is performed by interventional radiologists for patients with calculous/acalculous cholecystitis who are poor candidates for cholecystectomy. Two anatomical approaches are widely utilized: transperitoneal and transhepatic.

Purpose: To compare the clinical outcomes of transperitoneal and transhepatic approaches to cholecystostomy catheter placement.

Material And Methods: From December 2007 to August 2015, 165 consecutive patients (97 men, 68 women) underwent either transperitoneal (n = 89) or transhepatic (n = 76) cholecystostomy at a single center. Indications were calculous cholecystitis (n = 21), acalculous cholecystitis (n = 35), hydrops (n = 1), gangrenous cholecystitis (n = 1), and other cholecystitis (n = 107). The most common high-risk co-morbidities were sepsis (n = 53) and cardiac (n = 11). Outcomes were compared using univariate and multivariable analysis.

Results: Post-procedure outcomes included tube dislodgement (transperitoneal [n = 6] and transhepatic [n = 3],  = 0.44), bile leak (transperitoneal [n = 5], transhepatic [n = 1],  = 0.14), gallbladder hemorrhage (transperitoneal [n = 2]; transhepatic [n = 3],  = 0.52), duodenal fistula (transperitoneal [n = 0], transhepatic [n = 1],  = 0.27), repeat cholecystostomy (transperitoneal [n = 1], transhepatic [n = 3],  = 0.27), and repeat cholecystitis requiring separate admission (transperitoneal [n = 6], transhepatic [n = 10],  = 0.15). All complications were Common Terminology Criteria for Adverse Events grade <3. Twenty transperitoneal patients underwent post-procedure cholecystectomy: 13 laparoscopic, three open, and four unclear/outside records. The mean time from cholecystostomy to operation was 38 days (range 3-211 days). Twenty-three transhepatic patients underwent cholecystectomy: 14 laparoscopic, eight open, and one unclear/outside records, with the mean time from cholecystostomy being 98 days (range 0-1053 days). One transhepatic and three transperitoneal patients died during admission.

Conclusion: There were no significant differences in short-term complications after transperitoneal and transhepatic approaches to percutaneous cholecystostomy catheter placement.
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http://dx.doi.org/10.1177/0284185120959829DOI Listing
September 2021

A highly selective fluorescent probe for the intracellular measurement of magnesium ion.

Anal Biochem 2020 11 18;609:113910. Epub 2020 Aug 18.

AAT Bioquest, Inc. 520 Mercury Drive, Sunnyvale, CA, 94085, USA.

Magnesium ion (Mg) plays an important role in various biological processes. All the commercial indicators available share a common drawback, i.e., they have a higher affinity towards calcium ions (Ca) than Mg. In this study, we reported a new robust green fluorescent indicator, Mag-520, for detection of Mg in live cells. Our results showed that Mag-520 has 10 fold higher affinity towards Mg than Ca, while mag-fluo-4 has less than 0.5 fold affinity to Mg than Ca under the same conditions using flow cytometry and fluorescence microscopy. The results demonstrated that Mag-520 provides a better tool to measure Mg with less interference from Ca.
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http://dx.doi.org/10.1016/j.ab.2020.113910DOI Listing
November 2020

Residential proximity to agriculture and risk of childhood leukemia and central nervous system tumors in the Danish national birth cohort.

Environ Int 2020 10 22;143:105955. Epub 2020 Jul 22.

Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, 9609 Medical Center Dr., Rockville, MD 20850, USA. Electronic address:

Background: Living in an agricultural area or on farms has been associated with increased risk of childhood cancer but few studies have evaluated specific agricultural exposures. We prospectively examined residential proximity to crops and animals during pregnancy and risk of childhood leukemia and central nervous system (CNS) tumors in Denmark.

Methods: The Danish National Birth Cohort (DNBC) consists of 91,769 pregnant women (96,841 live-born children) enrolled in 1996-2003. For 61 childhood leukemias and 59 CNS tumors <15 years of age that were diagnosed through 2014 and a ~10% random sample of the live births (N = 9394) with geocoded addresses, we linked pregnancy addresses to crop fields and animal farm locations and estimated the crop area (hectares [ha]) and number of animals (standardized by their nitrogen emissions) by type within 250 meters (m), 500 m, 1000 m, and 2000 m of the home. We also estimated pesticide applications (grams, active ingredient) based on annual sales data for nine herbicides and one fungicide that were estimated to have been applied to >30% of the area of one or more crop. We used Cox proportional hazard models (weighted to the full cohort) to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association of childhood leukemia and CNS tumors with crop area, animals, and pesticide applications adjusted for gender and maternal age.

Results: Sixty-three percent of mothers had crops within 500 m of their homes during pregnancy; winter and spring cereals were the major crop types. Compared to mothers with no crops <500 m, we found increasing risk of childhood leukemia among offspring of mothers with increasing crop area near their home (highest tertile >24 ha HR: 2.0, CI:1.02-3.8), which was stronger after adjustment for animals (within 1000 m) (HR: 2.6, CI:1.02-6.8). We also observed increased risk for grass/clover (highest tertile >1.1 ha HR: 3.1, CI:1.2-7.7), peas (>0 HR: 2.4, CI: 1.02-5.4), and maize (>0 HR: 2.8, CI: 1.1-6.9) in animal-adjusted models. We found no association between number of animals near homes and leukemia risk. Crops, total number of animals, and hogs within 500 m of the home were not associated with CNS tumors but we observed an increased risk with >median cattle compared with no animals in crop-adjusted models (HR = 2.2, CI: 1.02-4.9). In models adjusted for total animals, the highest tertiles of use of three herbicides and one fungicide were associated with elevated risk of leukemia but no associations were statistically significant; there were no associations with CNS tumors.

Conclusions: Risk of childhood leukemia was associated with higher crop area near mothers' homes during pregnancy; CNS tumors were associated with higher cattle density. Quantitative estimates of crop pesticides and other agricultural exposures are needed to clarify possible reasons for these increased risks.
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http://dx.doi.org/10.1016/j.envint.2020.105955DOI Listing
October 2020

Patient Expectations After Collis Gastroplasty.

JAMA Surg 2020 09;155(9):888-889

Division of General Surgery, Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California.

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http://dx.doi.org/10.1001/jamasurg.2020.1762DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7315389PMC
September 2020

EMP2 Is a Novel Regulator of Stemness in Breast Cancer Cells.

Mol Cancer Ther 2020 08 25;19(8):1682-1695. Epub 2020 May 25.

Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.

Little is known about the role of epithelial membrane protein-2 (EMP2) in breast cancer development or progression. In this study, we tested the hypothesis that EMP2 may regulate the formation or self-renewal of breast cancer stem cells (BCSC) in the tumor microenvironment. analysis of gene expression data demonstrated a correlation of EMP2 expression with known metastasis-related genes and markers of cancer stem cells (CSC) including aldehyde dehydrogenase (ALDH). In breast cancer cell lines, EMP2 overexpression increased and EMP2 knockdown decreased the proportion of stem-like cells as assessed by the expression of the CSC markers CD44/CD24, ALDH activity, or by tumor sphere formation. , upregulation of EMP2 promoted tumor growth, whereas knockdown reduced the ALDH CSC population as well as retarded tumor growth. Mechanistically, EMP2 functionally regulated the response to hypoxia through the upregulation of HIF-1α, a transcription factor previously shown to regulate the self-renewal of ALDH CSCs. Furthermore, in syngeneic mouse models and primary human tumor xenografts, mAbs directed against EMP2 effectively targeted CSCs, reducing the ALDH population and blocking their tumor-initiating capacity when implanted into secondary untreated mice. Collectively, our results show that EMP2 increases the proportion of tumor-initiating cells, providing a rationale for the continued development of EMP2-targeting agents.
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http://dx.doi.org/10.1158/1535-7163.MCT-19-0850DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415657PMC
August 2020

Identifying Opportunities to Improve Patient Experience With Sacral Neuromodulation: A Human Factors Approach.

Urology 2021 04 8;150:207-212. Epub 2020 May 8.

Cedars-Sinai Health System, Department of Surgery, Division of Urology, Los Angeles, CA.

Objectives: To use a human factors approach to conduct a needs assessment of patient preparedness, education, device usability, and satisfaction regarding all stages of sacral neuromodulation therapy and identify opportunities for improvement. Sacral neuromodulation, though minimally invasive, involves an initial testing phase that requires active patient participation. This process is relatively complex and, if a patient does not receive adequate preprocedure education, can be difficult to conceptualize.

Materials And Methods: Candidates were recruited to participate before undergoing staged sacral neuromodulation. Ten patients were observed, and their experiences were evaluated at 4 phases: (1) date of test implant (Stage I), (2) 5 days following Stage I, (3) date of permanent implant (Stage II), and (4) 3 months following Stage II. Administered questionnaires focused on preoperative preparedness, postoperative satisfaction, and usability.

Results: While every patient reported that their symptoms were at least "a little better" postoperatively, they generally had difficulty understanding the risks of the planned procedure, did not know what to expect postoperatively and were unsatisfied with the preoperative materials. Patients struggled with adjusting the settings for their implant devices and usability was considered "below average." Despite overall objective success, 30% of patients indicated that they would not recommend this treatment to friends/family.

Conclusion: This pilot needs analysis demonstrates several opportunities for improvement in the experience of patients undergoing sacral neuromodulation. These findings highlight the opportunities for a multifaceted intervention to improve patient understanding through the testing phase.
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http://dx.doi.org/10.1016/j.urology.2020.04.092DOI Listing
April 2021
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