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BACKGROUND Non-small cell lung cancer patients with multiple high-risk socioeconomic factors experience treatment and survival disparities. We aim to assess whether disparities in treatment and survival vary by region for patients with 3 or more high-risk socioeconomic factors. METHODS The National Cancer Database was queried for patients with clinical stage I-IIA non-small cell lung cancer diagnosed between 2010 and 2015. Patients were categorized into 3 groups: standard treatment, nonstandard treatment, and no curative treatment. Multivariable logistic regression was used to evaluate regional differences in treatment. Cox proportional hazards regression and the Kaplan-Meier method were used for survival analysis. All statistical tests were 2-sided. RESULTS A total of 93,211 patients met inclusion criteria. For patients with 3 or more high-risk socioeconomic factors, the odds of nonstandard treatment were significantly greater in 6 regions compared with New England, greatest in West North Central (odds ratio 2.09, P < .001). The odds of no curative treatment were significantly greater in 7 regions compared with New England, greatest in West South Central (odds ratio 3.56, P < .001). West North Central was associated with the highest risk of all-cause mortality compared with New England (hazard ratio 1.10, P < .001), and Middle Atlantic was associated with the lowest (hazard ratio 0.86, P < .001). The 5-year overall survival was longest in Middle Atlantic (60.8%) and shortest in Mountain (36.8%). CONCLUSIONS Patients with 3 or more high-risk socioeconomic factors experience treatment and survival disparities across the United States, though disparities are more pronounced in certain regions. Regional interventions may help mitigate disparities among highest risk non-small cell lung cancer patients.

Background Living donor liver transplantation (LDLT) has expanded the availability of liver transplant but has been associated with early technical complications including the devastating complication of hepatic artery thrombosis (HAT), which has been reported to occur in 14% to 25% of LDLT using standard anastomotic techniques. Microvascular hepatic artery reconstruction (MHAR) has been implemented in an attempt to decrease rates of HAT. The purpose of this study was to review the available literature in LDLT, specifically related to MHAR to determine its impact on rates of posttransplant complications including HAT. Methods A systematic review was conducted using PubMed/Medline and Web of Science. Case series and reviews describing reports of microscope-assisted hepatic artery anastomosis in adult patients were considered for meta-analysis of factors contributing to HAT. Results In all, 462 abstracts were screened, resulting in 20 studies that were included in the meta-analysis. This analysis included 2,457 patients from eight countries. The pooled rate of HAT was 2.20% with an overall effect size of 0.00906. Conclusion Systematic literature review suggests that MHAR during LDLT reduces vascular complications and improves outcomes posttransplant. Microvascular surgeons and transplant surgeons should collaborate when technical challenges such as small vessel size, short donor pedicle, or dissection of the recipient vessel wall are present.

The revenue generated by plastic surgeons assisting other surgical services is poorly captured by hospital accounting systems, which categorize solely by attending physician of record. The financial impact of reconstructive surgery is thus systematically underestimated. The authors sought to quantify the overlooked value of plastic surgeons as consultants who facilitate complex and profitable operations.Hospital billing data were reviewed for inpatient operations over a 3-year fiscal period (2015 to 2017). Cases in which a plastic surgeon assisted were identified. Case mix index, a measure of complexity that correlates with profit, and contribution margin, defined as revenue minus cost, were obtained for each case.Five hundred fifty-four cases required a reconstructive surgeon; 18,904 nonconsultation cases were identified for comparison. Average net revenue per case involving a consultation was 1.79 times greater than for control cases (p0.0001). Average contribution margin was 1.73 times greater (p0.005). The highest contribution margins stemmed from joint cases with cardiothoracic surgery and neurosurgery. Case mix index was significantly higher for consultation cases than for controls (4.5 versus 3.9; p0.0001). In 434 cases (78 percent), plastic surgery assisted with an integral aspect of the operation, meaning the surgery could not have been technically performed without reconstructive assistance.The authors' findings demonstrate that cases involving plastic surgeons have a higher profit margin than those performed by any department alone. However, this revenue is not appropriately attributed because of oversimplified financial metrics. The skill set of reconstructive surgeons is an undervalued resource for both patient care and hospital economics.

Thin flaps, a modification of traditional flaps that minimize the need for debulking and revision, offer unique advantages in the field of lower limb reconstruction. Advances in the field of microsurgery have made this streamlined method of reconstruction a viable solution for soft tissue coverage in patients with both trauma and nonhealing wounds. Better understanding of anatomy has allowed for flap harvest above the fascia level and the Scarpal plane. These modifications allow for flap transfer with thicknesses more comparable to the native anatomy of the lower leg, ankle, and foot. Flap survival is comparable to traditional techniques with greater potential for improved patient-centered outcomes.

The objective of this study was to identify the most effective treatment for survival in patients with solitary fibrous tumors of the pleura (SFTP).The National Cancer Database was queried for patients with malignant SFTPs. Patients were divided into two groups, those who had surgical treatment and those who did not. The primary outcome was 5-year overall survival, which was assessed by the Kaplan-Meier method and compared using the log rank test.There were 204 patients with SFTPs identified between 2004 and 2014. Of those, 65% of patients (133) had surgical intervention, whereas 18% (37) had no surgical intervention, and 17% (34) had unknown treatment information. Among patients who underwent resection, 42% (56) had sublobar resections, 45% (60) had lobectomies, and 13% (17) had pneumonectomies. The overall 5-year survival for SFTP patients was 56%. Patients who had surgical intervention had a relative survival of 64%, and patients with no surgical intervention had 22% (p0.001). There was no difference in 5-year survival among patients who had sublobar resections compared with patients who had greater anatomic resections (65% versus 64%, p = 0.823).Patients with SFTP who were managed with surgical intervention have better overall survival than patients who are not managed with surgery. Furthermore, similar 5-year survival for sublobar resections compared with greater anatomic resections suggested that the former, when possible, is sufficient.

Background Mobile health provides promising opportunities to perform population surveillance in rural, impoverished, or unstable communities. The objective of this study was to test the efficacy and accuracy of data collected by community informants in extreme low-resource environments using electronic surveys and mobile phones. Methods We carried out a population-based, cross-sectional survey between October and November 2017 measuring access to health care and prenatal services for pregnant women in the Northern Region of Malawi. The survey was conducted by members of the community who received one day of training and volunteered to conduct a survey for each live birth that occurred within their predetermined catchment area. A study member audited less than 2% of survey responses, where community informant responses were compared to community member self-reports. Results A total of 915 survey responses were recorded by 21 community informants. These surveys recorded 621 live births and 4 cases of maternal mortality. This represents a maternal mortality rate of 0.64% (95% confidence interval (CI) = 0.2% to 1.6%), roughly equal to the United Nations Children's Fund (UNICEF) estimate from 2015 of 634 per 100 000 live births, or 0.63%. This survey captured 120 births by adolescent mothers aged 15-19 out of 673 responses about maternal age. This represents 17.8% (95% CI = 15.1% to 20.9%) of all births, slightly higher than the UNICEF estimate of 143 per 1000 live births (14.3%). Finally, 51.7% of women were recorded as attending 4 antenatal care visits (95% CI = 47.8% to 55.7%), consistent with the 2015-2016 Demographic and Health Survey (DHS) value of 51%. Conclusions The use of cellular phones and electronic surveys by community informants allowed for the real-time capture of data in an area where access is limited by seasonally impassable roads and unreliable cell reception. The data recorded by the surveys is comparable to accepted statistics in several measures. Community reporting of health care data can provide an efficient method of monitoring extremely rural or hard to reach communities.

Introduction Outpatient follow-up is a critical component of burn recovery. Sociodemographic variables that prevent patients from pursuing follow-up can lead vulnerable groups to have a lower quality of life after burn injury. Social media provides a platform for improvement of patient outreach and support. The purpose of this study is to investigate accessibility and interest in social media interventions among socioeconomically disadvantaged and minority burn patients. Methods Patients receiving treatment at a burn clinic in a large public hospital were asked to complete a survey about social media usage, difficulty attending follow-up appointments, and interest in engaging with the hospital through social media. Patient demographics and clinical data were obtained via chart review. The relationship between clinical or demographic factors, and interest in social media engagement, was assessed via exact logistic regression. Results Data were collected from 65 eligible patients. Social media use among participants (76.9%) was similar to the proportion in the U.S. general population (72%). 61.5% of participants used Facebook, 40% used Instagram, and 4.6% used Twitter. 81% of participants had consistent internet access. 58.3% of respondents expected to encounter challenges when planning follow-up appointments. Challenges included difficulty with transportation (26.2%), trouble taking time off work (9.8%), and forgetting to schedule (9.8%). Participants were asked if they were interested in receiving post-discharge education, care team outreach, and follow-up reminders via social media. 36.5% of patients were very or moderately interested, 27% were slightly interested, and 36.5% were unsure or not at all interested. 20% of patients both expected follow-up challenges and were moderately or very interested in social media engagement. While controlling for social media use, the odds of having moderate or greater interest in the post-discharge engagement program were estimated to be 2.6 times higher for patients older than 39 (OR 3.64; 95% CI 1.03-14.24; P=.044). There was a pattern of lower interest in social media engagement with higher %TBSA, while controlling for age or social media use, though P values were higher than .05. Conclusions Over half of the burn patients surveyed expected to face challenges when planning follow-up appointments, a third of whom were moderately or very interested in social media engagement. Social media may be an alternative form of outreach with older patients in particular. Observed overlap between follow-up difficulty and outreach program interest may suggest such a program could ameliorate follow-up challenges.

On January 30, 2020, the World Health Organization (WHO) declared SARS-CoV-2 a global pandemic, based on a high infection rate and a high case fatality rate (CFR). The combination of these two points led WHO to forecast a high expected mortality rate of approximately 2% of the population. The phenomenon of Simpson's paradox teaches us that we should be careful when we combine two variables together. Indeed, despite the high mortality rate in several places, this forecast seems to have collapsed. We believe one of the reasons for the erroneous forecasts is that combining the above points ignored a confounding variable - many of the virus carriers are asymptomatic and therefore not diagnosed.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a T-cell neoplasm that arises in the capsule around breast implants. While an association with implants has been proposed, no causal link has been identified and the pathophysiology and natural history of BIA-ALCL remain unknown. A literature review of 391 articles was performed to assess the current understanding of BIA-ALCL and to provide a balanced and unbiased view of the current controversy surrounding the disease.

Socioeconomic status (SES) disparities in the surgical management of patients with non-small cell lung cancer (NSCLC) are well described. Disparities in the receipt of adjuvant chemotherapy are poorly understood. We assessed the influence of SES on adjuvant chemotherapy after resection in patients with pN1 NSCLC.The National Cancer Database was queried for cN0/N1 NSCLC patients who underwent surgical resection and had demonstrated pN1 disease. This cohort was further divided into those who received multiagent adjuvant chemotherapy (MAAC) vs surgery-only treatment. Factors associated with treatment assignment were examined, and long-term survival was compared.Of the 14,892 patients who underwent resection for pN1 disease, 8061 (54.1%) received MAAC. Patients were less likely to receive MAAC if they resided in rural areas (odds ratio, 1.23; 95% confidence interval [CI], 1.11-1.37; P.001), or were uninsured or on Medicaid (odds ratio, 1.23; 95% CI, 1.07-1.41; P = .004). The propensity score-weighted 5-year survival was significantly higher for those receiving MAAC compared with surgery only (53.6% vs 39.5%, log-rank P.001). Lower income (hazard ratio, 1.06; 95% CI, 1.00-1.12; P = .044) and uninsured or Medicaid insurance status (hazard ratio, 1.22; 95% CI, 1.13-1.31; P.001) were independently associated with increased mortality by Cox regression in the propensity score-weighted cohort.pN1 NSCLC patients living in rural areas or who are uninsured or on Medicaid insurance are at increased risk of not receiving MAAC. Treatment with MAAC significantly improves long-term survival of pN1 patients. Efforts should be made to ensure these at-risk groups receive guideline-concordant care.

Background Treatment decisions for patients with non-small cell lung cancer (NSCLC) are based on patient and tumor characteristics, including socioeconomic status (SES) factors. The objective was to assess the contribution of SES factors to treatment and outcomes among patients with stage I NSCLC. Methods The National Cancer Database was queried for operable patients with stage I NSCLC. Patients were divided into three treatment groups: primary resection (ie, surgery only); nonstandard treatments consisting of chemotherapy with or without radiation; and no therapy. The SES of patients who made up the treatment groups was assessed, and the 5-year survival of all groups was analyzed. Results The cohort included 69,168 patients with stage I NSCLC. Each of these patients had between zero and five SES risk factors. The factors associated with no surgery were low income, nonwhite race, low high school graduation rate, Medicaid or no insurance, rural residence, and distance less than 12.5 miles from treatment facility. Patients with several SES risk factors have linearly increasing odds of undergoing nonstandard treatments and quadratically increasing odds of having no therapy (for patients with five factors, to odds ratio 4.7; 95% confidence interval, 3.44 to 6.30). Surgery alone was associated with significantly longer 5-year survival (71.8%) compared with nonstandard treatments (22.7%) and no therapy (21.8%; P Conclusions Socioeconomic status factors increase the risk of undergoing guideline discordant therapy for stage I NSCLC. As the number of SES factors increases, the odds of no therapy rises quadratically whereas the odds of nonstandard treatments rises constantly. The surgery only group had significantly longer survival than the nonstandard treatment and no therapy groups.

Effective immunotherapy options for patients with non-small cell lung cancer (NSCLC) are becoming increasingly available. The immunotherapy focus has been on tumor infiltrating T cells (TILs); however, tumor infiltrating B cells (TIL-Bs) have also been reported to correlate with NSCLC patient survival. The function of TIL-Bs in human cancer has been understudied, with little focus on their role as antigen-presenting cells and their influence on CD4+ TILs. Compared to other immune subsets detected in freshly isolated primary tumors from NSCLC patients, we observed increased numbers of intratumoral B cells relative to B cells from tumor-adjacent tissues. Furthermore, we demonstrated that TIL-Bs can efficiently present antigen to CD4+ TILs and alter the CD4+ TIL phenotype using an in vitro antigen-presentation assay. Specifically, we identified three CD4+ TIL responses to TIL-Bs, which we categorized as: activated, antigen-associated, and non-responsive. Within the activated and antigen-associated CD4+ TIL population, activated TIL-Bs (CD19+CD20+CD69+CD27+CD21+) were associated with an effector T-cell response (IFNγ+ CD4+ TILs). Alternatively, exhausted TIL-Bs (CD19+CD20+CD69+CD27–CD21–) were associated with a regulatory T-cell phenotype (FoxP3+ CD4+ TILs). Our results demonstrate a new role for TIL-Bs in NSCLC tumors in their interplay with CD4+ TILs in the tumor microenvironment, establishing them as a potential therapeutic target in NSCLC immunotherapy.