No prior studies have compared Tc-99m tilmanocept (TcTM) one-day and two-day injection protocols for sentinel lymph node (SLN) biopsy in breast cancer (BC). We retrospectively identified patients with clinically node-negative BC undergoing SLN biopsy at our institution. Patients received a single, intradermal peritumoral injection of TcTM on day of surgery or day prior to surgery in addition to an intraoperative injection of isosulfan blue dye. Univariable and multivariable Poisson regression count models were constructed to assess the effects of injection timing, radiologist, patient and surgeon characteristics on the number of removed SLNs. A total of 617 patients underwent SLN biopsy with TcTM and blue dye. Sixty-seven (10.9%) patients were injected with the two-day protocol. Patients in the one-day protocol had a mean of 3.0 (standard deviation (SD) 1.9) SLNs removed compared with 2.7 (SD 1.4) SLNs in the two-day protocol, P-value = .13. On multivariable analysis, patient age and operating surgeon significantly affected the number of removed SLNs; however, the injection timing and the nuclear radiologist did not influence the number of removed SLNs. The performance of Tc-99m tilmanocept did not differ significantly between one-day and two-day injection protocols. These results are similar to other radiotracers used for SLN biopsy in BC.

OBJECTIVES: The addition of a perioperative continuous paravertebral nerve block (cPVB) to a single-injection thoracic paravertebral nerve block (tPVB) has demonstrated improved analgesia in breast surgery. However, its use following isolated post-mastectomy reconstruction using a latissimus dorsi flap (LDF) has not previously been examined. METHODS: We performed a retrospective review of patients who underwent salvage breast reconstruction with a unilateral LDF by a single surgeon. Preoperatively, all patients received a single-injection tPVB with 0.5% ropivacaine. Additionally, patients had the option for catheter placement to receive a continuous 0.2% ropivacaine infusion with intermittent boluses. Infusions commenced in the recovery room and the catheters were removed on the morning of discharge. The primary endpoint was the mean pain numeric rating scale (NRS) scores for the 24-hour period beginning at 7:00 on post-operative day 1. RESULTS: A total of 22 patients were included in this study (11-cPVB and 11-tPVB). The mean NRS pain score of cPVB patients (3.5 (standard deviation (SD) 1.8) was lower than that of the single-injection tPVB patients (4.4 (SD 2.1), however this difference was not statistically significant (P = 0.31). The length of hospital stay and opioid use was not statistically different between groups. CONCLUSIONS: Patients receiving a cPVB in addition to tPVB after LDF reconstruction experienced similar pain to those receiving tPVB alone. A larger, randomized clinical trial is warranted to fully determine the benefits of using cPVB in addition to tPVB for this procedure.

Limited research exists examining self-perceived vision and driving ability among individuals with glaucoma, and this study assessed the relationship between glaucoma, visual field, and visual acuity with driving capability. 137 individuals with glaucoma and 75 healthy controls were asked to evaluate self-rated vision, self-perceived driving ability, and self-perceived distracted driving. Visual acuity and visual field measurements were also obtained. Multivariable linear regressions were run to test each visual measure with driving outcomes. The average age was 72.2 years, 57.3% were male, and 72.5% were White. There were significant associations for a one-point increase in visual field and quality of corrected vision (RR = 1.06; 95% CI = 1.03-1.10), day vision (RR = 1.05; 95% CI = 1.03-1.08), night vision (RR = 1.08; 95% CI = 1.05-1.13), visual acuity score and higher quality of corrected of vision (RR = .41; 95% CI = .22-.77), day vision (RR = .39; 95% CI=.22-.71), and night vision (RR = .41; 95% CI = .18-.94); visual acuity score and ability to drive safely compared to other drivers your age (RR = .53; 95% CI = .29-.96). Individuals with poorer visual acuity and visual fields rate their vision and ability to drive lower than those with better vision, and this information will allow clinicians to understand where to target interventions to enhance safe driving practices.

Background

Given more emphasis on training primary care physicians for underserved areas, we hypothesized that students self-identifying as "disadvantaged" would be less likely to pursue surgical training.

Methods

We retrospectively reviewed medical school data on students graduating 2005-2014. Students were stratified into "disadvantaged" and "nondisadvantaged". Data were recorded on age, grade point average, Medical College Admission Test (MCAT), gender, surgery grade, United States Medical Licensing Examination step 1 score, and residency match into a surgical field. A comparison of the proportion of students matching into a surgical field was assessed with chi-square test. Multivariate logistic regression was performed to assess the factors that predict the choice of general surgery versus another surgical field.

Results

Of the 1140 students who graduated during the study period, 219 (19.2%) students self-identified as "disadvantaged". Of all students, 158 (13.9%) chose a surgical field. The disadvantaged group was older at entry and had lower grade point average and total MCAT scores. Twenty-seven (12.3%) disadvantaged students chose a surgical residency versus 130 (14.1%) nondisadvantaged students (P = 0.56). On multivariate logistic regression, female gender (odds ratio [OR] = 3.9; 95% confidence interval = [1.9-8.3], P < 0.01), disadvantaged status (OR = 2.8 [1.1-7.1], P = 0.03), and United States Medical Licensing Examination step 1 score ≥ 227 (OR = 0.43 [0.21-0.88], P = 0.02) were significantly associated with matching into general surgery versus another surgical specialty.

Discussion

Although the disadvantaged cohort was older and had lower undergraduate GPAs and MCAT scores, the proportion of disadvantaged students matching into a surgical residency was not statistically different. To address the future shortage of general surgeons in underserved areas, increasing enrollment of "disadvantaged" students may alleviate the "surgical desert".

Background

Loss of muscle mass with age may be a key player in metabolic dysregulation. We examined the associations between abdominal muscle area and density with lipids and lipoproteins.

Methods

One thousand eight hundred and sixty eight adults completed health history and physical activity questionnaires, provided venous blood samples for lipids and inflammatory biomarkers, and underwent computed tomography to quantify body composition. Associations between muscle area and density with multiple lipid measures were assessed with multivariable linear and logistic regression.

Results

The mean age and body mass index of participants was 65 years and 28 kg/m², respectively, and 50% were female. After adjustment for demographics, cardiovascular disease risk factors, lipid-lowering medications, physical activity, sedentary behavior, inflammatory biomarkers, and central obesity, a 1-standard deviation increase in total abdominal, stability, and locomotor muscle areas was associated with a 13%, 11%, and 8% lower high-density lipoprotein cholesterol level, respectively (P < .05). With similar adjustment, a 1-standard deviation increase in total abdominal and stability muscle area was associated with a 13% and 12% lower total cholesterol level, respectively (P < .01). Compared to the lowest quartiles of total, stability, and locomotor muscle area, those in the higher quartiles of muscle area had over a 40% reduction in the odds of triglyceride levels greater than 150 mg/dL (P < .05). Total abdominal muscle density was positively associated with total cholesterol (P < .05) but was not associated with the other lipid outcomes.

Conclusion

Maintaining adequate skeletal muscle mass with age may decrease specific lipid levels related to hyperlipidemia and development of cardiometabolic disease.

Aims

To investigate associations of health insurance with measures of glucose metabolism, and whether associations vary by diabetes status or insurance type.

Methods

Cross-sectional analysis of baseline data from the Multi-Ethnic Study of Atherosclerosis. Cohort a priori stratified by age <65 (N = 3,665) and ≥65 years (N = 2,924). Multivariable linear and logistic regression assessed associations between insurance and fasting glucose, HOMA-IR, and prevalent diabetes, controlling for relevant confounders, including age, sex, race/ethnicity, income, and education.

Results

In participants <65, compared to uninsured, having any insurance was associated with lower fasting glucose in participants with diabetes (Mean Difference = -20.4 mg/dL, P = 0.01), but not in participants without diabetes. Compared to Private insurance, uninsured participants had higher fasting glucose (Mean Difference = 3.8 mg/dL, P = 0.03), while participants with Medicaid had higher HOMA-IR (Mean Difference = 3.5 mg/dL, P < 0.01). In participants ≥65, compared to Private insurance, uninsured participants (Mean Difference = 7.5 mg/dL, P = 0.02), and participants with Medicaid only (Mean Difference = 19.9 mg/dL, P < 0.01) or Medicare + Medicaid (Mean Difference = 5.2 mg/dL, P = 0.03) had higher fasting glucose.

Conclusions

In this large multiethnic cohort, having any insurance was associated with significantly lower fasting glucose for individuals with diabetes. Levels of fasting glucose and insulin resistance varied across different insurance types.

Background Previous data suggest that using renin-angiotensin-aldosterone system inhibitors (RAASIs) improves survival in patients with cardiovascular diseases. We sought to investigate the association of different patterns of use of RAASIs on perioperative and 1-year outcomes following carotid revascularization. Methods and Results We investigated patients undergoing carotid revascularization, either with carotid endarterectomy or transfemoral carotid artery stenting, in the VQI (Vascular Quality Initiative) VISION (Vascular Implant Surveillance and Interventional Outcomes Network) data set between 2003 and 2018. We divided our cohort into 3 groups: (1) no history of RAASI intake, (2) preoperative intake only, and (3) continuous pre- and postoperative intake. The final cohort included 73 174 patients; 44.4% had no intake, 50% had continuous intake, and 5.6% had only preoperative intake. Compared with continuous intake, preoperative and no intake were associated with higher odds of postoperative stroke (odds ratio [OR], 1.7 [95% CI, 1.5-1.9]; P<0.001; OR, 1.1 [95% CI, 1.03-1.2]; P=0.010); death (OR, 4.8 [95% CI, 3.8-6.1]; P<0.001; OR, 1.9 [95% CI, 1.6-2.2]; P<0.001); and stroke/death (OR, 2.05 [95% CI, 1.8-2.3]; P<0.001; OR, 1.2 [95% CI, 1.1-1.3]; P<0.001), respectively. At 1 year, preoperative and no intake were associated with higher odds of stroke (hazard ratio [HR], 1.4 [95% CI, 1.3-1.6]; P<0.001; HR, 1.15, [95% CI, 1.08-1.2]; P<0.001); death (HR, 1.7 [95% CI, 1.5-1.9]; P<0.001; HR, 1.3 [95% CI, 1.2-1.4]; P<0.001); and stroke/death (HR, 1.5 [95% CI, 1.4-1.7]; P<0.001; HR, 1.2 [95% CI, 1.17-1.3]; P<0.001), respectively. Conclusions Compared with subjects discontinuing or never starting RAASIs, use of RAASIs before and after carotid revascularization was associated with a short-term stroke and mortality benefit. Future clinical trials examining prescribing patterns of RAASIs should aim to clarify the timing and potential to maximize the protective effects of RAASIs in high-risk vascular patients.

Objectives

The addition of a perioperative continuous paravertebral nerve block (cPVB) to a single-injection thoracic paravertebral nerve block (tPVB) has demonstrated improved analgesia in breast surgery. However, its use following isolated post-mastectomy reconstruction using a latissimus dorsi flap (LDF) has not previously been examined.

Methods

We performed a retrospective review of patients who underwent salvage breast reconstruction with a unilateral LDF by a single surgeon. Preoperatively, all patients received a single-injection tPVB with 0.5% ropivacaine. Additionally, patients had the option for catheter placement to receive a continuous 0.2% ropivacaine infusion with intermittent boluses. Infusions commenced in the recovery room and the catheters were removed on the morning of discharge. The primary endpoint was the mean pain numeric rating scale (NRS) scores for the 24-hour period beginning at 7:00 on post-operative day 1.

Results

A total of 22 patients were included in this study (11-cPVB and 11-tPVB). The mean NRS pain score of cPVB patients (3.5 (standard deviation (SD) 1.8) was lower than that of the single-injection tPVB patients (4.4 (SD 2.1), however this difference was not statistically significant (P = 0.31). The length of hospital stay and opioid use was not statistically different between groups.

Conclusions

Patients receiving a cPVB in addition to tPVB after LDF reconstruction experienced similar pain to those receiving tPVB alone. A larger, randomized clinical trial is warranted to fully determine the benefits of using cPVB in addition to tPVB for this procedure.

Background

Due to the opposing cardiovascular risk profiles of CAC volume and density, we tested the hypothesis that increased abdominal muscle area (AMA) and density (AMD) were significantly associated with lower coronary arterial calcium (CAC) volume and higher CAC density.

Methods

Using data from 787 participants from the Multi-Ethnic Study of Atherosclerosis, Ancillary Body Composition Study, we analyzed abdominal and chest computed tomography (CT) scans. Abdominal scans were scored for muscle area, muscle density (attenuation) and visceral and subcutaneous fat. Chest scans were scored for CAC volume and Agatston values, which were used to derive CAC density scores.

Results

The mean (SD) age and BMI of the participants was 67.8 (9.0) years and 27.9 (4.8) kg/m², respectively. Forty-one percent were female, 46% were Caucasian, 60% had hypertension, 17% had diabetes, and 46% had dyslipidemia. AMA was positively associated with CAC volume (p < .001) and inversely associated with CAC density (p < .001). Conversely, AMD was inversely associated with CAC volume and positively associated with CAC density in minimally adjusted models (p < .001), but not significant in confounder adjusted models.

Conclusion

AMA and AMD had differing associations with CAC volume and density, with AMA significantly associated with a higher risk CAC profile (high volume, low density) and AMD not significantly associated with CAC volume or density. Future research needs to account for the unique components of both muscle composition and CAC.

Background

No prior studies have examined injection pain associated with Technetium-99m Tilmanocept (TcTM).

Methods

This was a randomized, double-blinded study comparing postinjection site pain between filtered Technetium Sulfur Colloid (fTcSC) and TcTM in breast cancer lymphoscintigraphy. Pain was evaluated with a visual analogue scale (VAS) (0-100 mm) and the short-form McGill Pain Questionnaire (SF-MPQ). The primary endpoint was mean difference in VAS scores at 1-min postinjection between fTcSC and TcTM. Secondary endpoints included a comparison of SF-MPQ scores between the groups at 5 min postinjection and construction of a linear mixed effects model to evaluate the changes in pain during the 5-min postinjection period.

Results

Fifty-two patients underwent injection (27-fTcSC, 25-TcTM). At 1-min postinjection, patients who received fTcSC experienced a mean change in pain of 16.8 mm (standard deviation (SD) 19.5) compared with 0.2 mm (SD 7.3) in TcTM (p = 0.0002). At 5 min postinjection, the mean total score on the SF-MPQ was 2.8 (SD 3.0) for fTcSC versus 2.1 (SD 2.5) for TcTM (p = 0.36). In the mixed effects model, injection agent (p < 0.001), time (p < 0.001) and their interaction (p < 0.001) were associated with change in pain during the 5-min postinjection period. The model found fTcSC resulted in significantly more pain of 15.2 mm (p < 0.001), 11.3 mm (p = 0.001), and 7.5 mm (p = 0.013) at 1, 2, and 3 min postinjection, respectively.

Conclusions

Injection with fTcSC causes significantly more pain during the first 3 min postinjection compared with TcTM in women undergoing lymphoscintigraphy for breast cancer.