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Background: With an increasing number of potential recipients and a comparatively static number of donors, lung transplantation (LT) in the elderly has come under significant scrutiny. Previous studies have been limited by single-center experiences with small population sizes and often mixed results. Using a national registry, we sought to evaluate the following: (1) differences in survival outcomes in septuagenarians compared with sexagenarians; and (2) the effect of temporal trends on the development of other comorbidities in this population., Methods: We analyzed the Scientific Registry of Transplant Recipients (SRTR) data files from the United Network for Organ Sharing (UNOS) database to identify recipients who underwent LT between the years 2000 and 2013. The study period was divided into two equal eras. Using Kaplan-Meier analysis, we compared the 30-day, 3-month, 1-year, 3-year and 5-year patient survival between septuagenarians and sexagenarians in both eras. Separate multivariate analyses were performed to estimate the risk of renal failure, risk of rejection and length of hospital stay (LOS) post-LT in each of these time periods., Results: A total of 6,596 patients were identified comprising 1,726 (26.2%) during 2000 to 2005 and 4,870 (73.8%) during 2006 to 2012. In the "early era," 32 (1.9%) septuagenarians and 1,694 (98.1%) sexagenarians underwent LT, whereas 543 (11.1%) septuagenarians and 4,327 (88.9%) sexagenarians underwent transplantation in the "latter era." A comparison of patient survival between the two groups in the early era revealed no difference at 30 days (95.7% vs 93.8%, p = 0.65). However, 3-month (91.2% vs 75%, p = 0.04) and 1-year patient survival (79.5% vs 62.5%, p = 0.048) were both lower in the septuagenarian group. In the later era, however, there were no differences in 30-day (96.2% vs 96.8, p = 0.5), 3-month (92.7% vs 91.9%, p = 0.56) or 1-year (81.7% vs 78.6%, p = 0.12) patient survival between the two age groups. Survival rates at 3 years (63.7% vs 49.3%, p < 0.001) and 5 years (47.5% vs 28.2%, p < 0.001) were each significantly lower in the septuagenarian group., Conclusion: Overall, LT outcomes for the elderly have improved significantly over time and early outcomes in the modern era rival those found in younger recipients., (Copyright © 2015 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objective: Improvements in technology have led to a resurgence in the use of extracorporeal membrane oxygenation as a bridge to lung transplantation. By using a national registry, we sought to evaluate how short-term survival has evolved using this strategy., Methods: With the use of the United Network for Organ Sharing database, we analyzed data from 12,458 adults who underwent lung transplantation between 2000 and 2011. Patients were categorized into 2 cohorts: 119 patients who were bridged to transplantation using extracorporeal membrane oxygenation and 12,339 patients who were not. The study period was divided into four 3-year intervals: 2000 to 2002, 2003 to 2005, 2006 to 2008, and 2009 to 2011. With Kaplan-Meier analysis, 1-year survival was compared for the 2 cohorts of patients in each of the time periods. A propensity score-adjusted Cox regression model was used to estimate the risk of 1-year mortality., Results: Of the total number of recipients, 4 (3.4%) were bridged between 2000 and 2002, 17 (14.3%) were bridged between 2003 and 2005, 31 (26.1%) were bridged between 2006 and 2008, and 67 were bridged (56.3%) between 2009 and 2011. Recipients bridged using extracorporeal membrane oxygenation were more likely to be younger and diabetic and to have higher serum creatinine and bilirubin levels. The 1-year survival for those bridged with extracorporeal membrane oxygenation was significantly lower in subsequent periods: 25.0% versus 81.0% (2000-2002), 47.1% versus 84.2% (2006-2008), and 74.4% versus 85.7% (2009-2011). However, this survival progressively increased with each period, as did the number of patients bridged using extracorporeal membrane oxygenation., Conclusions: Short-term survival with the use of extracorporeal membrane oxygenation as a bridge to lung transplantation has significantly improved over the past few years., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Lung cancer mortality rates may vary with access to specialty providers and local resources. We sought to examine the effect of access to care, using density of lung cancer care providers, on lung cancer mortality among blacks and whites in the United States., Methods: We examined U.S. county-level data for age-adjusted lung cancer mortality rates from 2003 to 2007. Our primary independent variable was per capita number of thoracic oncologic providers, adjusting for county-level smoking rates, socioeconomic status, and other geographic factors. Data were obtained from 2009 Area Resource File, National Center for Health Statistics, and the County Health Rankings Project., Results: Providers of lung cancer care were unevenly distributed among the U.S. counties. For example, 41.4% of the U.S. population reside in counties with less than four thoracic surgeons per 100,000 people, 23.4% in counties with 4 to 15 surgeons per 100,000 people, and 35.3% in counties with more than 15 surgeons per 100,000 people. Geographically, 4.3% of whites compared with 11.2% of blacks lived in high lung cancer mortality zones. Lung cancer mortality did not vary by density of thoracic surgeons or oncology services; however, higher primary care provider density was associated with lung cancer mortality reduction of 4.1 per 100,000 for whites., Conclusion: Variation in provider density for thoracic oncology in the United States was not associated with a difference in lung cancer mortality. Lower mortality associated with higher primary care provider density suggests that equitable access to primary care may lead to reduced cancer disparities.

The existence of disparities within our healthcare system is receiving considerable national attention, as we seek to understand the magnitude of these disparities with the goal of eliminating them altogether. Herein, we review recent important work that captures the current progress in this important area that has direct implications for the thoracic surgeon's daily practice management., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To examine the relationship between race and lung cancer mortality and the effect of residential segregation in the United States., Design: A retrospective, population-based study using data obtained from the 2009 Area Resource File and Surveillance, Epidemiology and End Results program., Setting: Each county in the United States., Patients: Black and white populations per US county., Main Outcome Measures: A generalized linear model with a Poisson distribution and log link was used to examine the association between residential segregation and lung cancer mortality from 2003 to 2007 for black and white populations. Our primary independent variable was the racial index of dissimilarity. The index is a demographic measure that assesses the evenness with which whites and blacks are distributed across census tracts within each county. The score ranges from 0 to 100 in increasing degrees of residential segregation. RESULTS The overall lung cancer mortality rate was higher for blacks than whites (58.9% vs 52.4% per 100 000 population). Each additional level of segregation was associated with a 0.5% increase in lung cancer mortality for blacks (P < .001) and an associated decrease in mortality for whites (P = .002). Adjusted lung cancer mortality rates among blacks were 52.4% and 62.9% per 100 000 population in counties with the least (<40% segregation) and the highest levels of segregation (≥60% segregation), respectively. In contrast, the adjusted lung cancer mortality rates for whites decreased with increasing levels of segregation., Conclusion: Lung cancer mortality is higher in blacks and highest in blacks living in the most segregated counties, regardless of socioeconomic status.

Objective: To compare risk- and volume-adjusted outcomes of colon resections performed at teaching hospitals (THs) vs non-THs to assess whether benign disease may influence the volume-outcome effect., Design: Retrospective data analysis examining colon resections determined by International Classification of Diseases, Ninth Revision, Clinical Modification classification performed in the United States from 2001 through 2005 using the Nationwide Inpatient Sample (NIS) and the Area Resource File (2004). Patient covariates used in adjustment included age, sex, race, Charlson Index comorbidity score, and insurance status. Hospital covariates included TH status, presence of a colorectal surgery fellowship approved by the Accreditation Council for Graduate Medical Education, geographical region, institutional volume, and urban vs rural location. County-specific surgeon characteristics used in adjustment included average age of surgeons and proportion of colorectal board-certified surgeons within each county. Environmental or county covariates included median income and percentage of county residents living below the federal poverty level., Setting: A total of 1045 hospitals located in 38 states in the United States that were included in the NIS., Patients: All patients older than 18 years who had colon resection and were discharged from a hospital included in the NIS., Main Outcome Measures: Operative mortality, length of stay (LOS), and total charges., Results: A total of 115 250 patients were identified, of whom 4371 died (3.8%). The mean LOS was 10 days. Fewer patients underwent surgical resection in THs than in non-THs (46 656 vs 68 589). Teaching hospitals were associated with increased odds of death (odds ratio, 1.14) (P = .03), increased LOS (P = .003), and a nonsignificant trend toward an increase in total charges (P = .36)., Conclusions: With the inclusion of benign disease, colon surgery displays a volume-outcome relationship in favor of non-THs. Inclusion of benign disease may represent a tipping point.

Background: Effective communication and teamwork are critical in many health care settings, particularly the operating room (OR). Several studies have implicated failures of communication and teamwork as the root cause in a high proportion of sentinel events in the OR., Methods: In a prospective cohort study at a high-volume teaching, research, and tertiary care referral hospital, a standardized one-page briefing and debriefing tool was developed and implemented in October 2006 to improve interdisciplinary communication and teamwork in the OR. The briefing portion of the tool was completed by the surgical team after the patient's final positioning and before incision; the debriefing portion was initiated and completed by the circulating nurse after the first counts were conducted. Compliance was calculated as the number of cases where the briefing and debriefing tool was completed divided by the total number of eligible cases. Surveys (n=40) were conducted to elicit caregiver perceptions of interdisciplinary communication and teamwork in the OR and the burden and average time taken to complete the briefing and debriefing tool., Results: Between October 2006 and March 2008, 37,133 briefings and debriefings were conducted. Average compliance varied over time since implementation, with overall compliance ranging from 76% to 95%. The majority of caregivers perceived that the briefing and debriefing tool improved interdisciplinary communication and teamwork. On average, it took 2.9 minutes (range, 1-5 minutes) to complete the briefing portion of the tool and 2.5 minutes (range, 1-5 minutes) to complete the debriefing portion., Discussion: Implementation of a standardized briefing and debriefing tool in a large regional medical center was a, practical and feasible strategy to improve perceptions of interdisciplinary communication and teamwork in the OR.

Background: Minority groups have poor access to quality health care services. This is true of colorectal cancer care and may be related to both geographical proximity and use of surgical, gastroenterology, and radiation oncology services. Without suitable access, many minority patients may present with advanced colorectal cancer and be less likely to receive appropriate adjuvant therapies. We sought to examine the variations in geographical access among minorities at a county level., Design: A retrospective analysis was performed using data from the Area Resource File. Multivariate linear regression analysis was performed to identify the variations in access to colorectal surgeons, gastroenterologists, and radiation oncologists., Setting: All counties in the United States., Participants: Prevalence rate of African Americans and Asian Americans within a county., Main Outcome Measure: Rate of colorectal surgeons, gastroenterologists, and radiation oncologists., Results: Unadjusted analysis revealed that each percentage point increase in the African American population within a county was associated with a decrease in the number of specialists within that county. Multivariate analysis also revealed a statistically significant decrease in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with each percentage point increase in the African American population and a trend toward a decrease in colorectal surgeons within that county (P = .28). Each percentage point increase in the Asian American population was associated with a significant increase in the number of gastroenterologists (P < .001) and radiation oncologists (P < .001) with a similar trend toward an increase in the number of colorectal surgeons within that county (P = .13)., Conclusion: Increasing numbers of minority patients in counties is accompanied by a differential access to specialists. This may affect the likelihood of a patient to receive appropriate care.

Background: Black patients with rectal cancer are considerably less likely than white patients to receive adjuvant therapy. We examined the hypothesis that the lower treatment rate for blacks is due to underreferral to medical and radiation oncologists., Methods: We used 1992-1999 Surveillance, Epidemiology, and End Results-Medicare data to identify elderly (> or = 66 years of age) patients who had been hospitalized for resection of stage II or III rectal cancer (n = 2716). We used chi(2) tests to examine associations between race and 1) consultation with an oncologist and 2) receipt of adjuvant therapy. We then used logistic regression to analyze the influence of sociodemographic and clinical characteristics (age at diagnosis, sex, marital status, median income and education in area of residence, comorbidity, and cancer stage) on black-white differences in the receipt of adjuvant therapy. All statistical tests were two-sided., Results: There was no statistically significant difference between the 134 black patients and the 2582 white patients in the frequency of consultation with a medical oncologist (73.1% for blacks vs 74.9% for whites, difference = 1.8%, 95% confidence interval [CI] = > 5.9% to 9.5%, P = .64) or radiation oncologist (56.7% vs 64.8%, difference = 8.1%, 95% CI = > 0.5% to 16.7%, P = .06), but blacks were less likely than whites to consult with both a medical oncologist and a radiation oncologist (49.2% vs 58.8%, difference = 9.6%, 95% CI = 0.9% to 18.2%, P = .03). Among patients who saw an oncologist, black patients were less likely than white patients to receive chemotherapy (54.1% vs 70.2%, difference = 16.1%, 95% CI = 6.0% to 26.2%, P = .006), radiation therapy (73.7% vs 83.4%, difference = 9.7%, 95% CI = 0.4% to 19.8%, P = .06), or both (60.6% vs 76.9%, difference = 16.3%, 95% CI = 4.3% to 28.3%, P = .008). Patient and provider characteristics had minimal influence on the racial disparity in the use of adjuvant therapy., Conclusion: Racial differences in oncologist consultation rates do not explain disparities in the use of adjuvant treatment for rectal cancer. A better understanding of patient preferences, patient-provider interactions, and potential influences on provider decision making is necessary to develop strategies to increase the use of adjuvant treatment for rectal cancer among black patients.

Disparities in incidence, mortality, and age of onset of breast cancer between women of African ancestry and women of other racial/ethnic backgrounds are poorly understood. A more comprehensive elaboration of genetic variants that occur in African women may facilitate a better understanding of the disease in African American women and explain the role of genetic admixture on the variation in the expression of the disease. Large-scale, population-based databases that document the cancer burden of Africa are lacking because of financial and infrastructural limitations. The development of such programs would represent an important cancer control and research strategy.