Recent Publications by CFE Educators

Having a pregnancy complicated by hypertensive disorders of pregnancy (HDP) and/or having a small or preterm baby put a woman at risk for later cardiovascular disease (CVD). It is uncertain if higher maternal CVD risk factors (reflected by increased peripartum CVD biomarker levels) account for this risk, or if experiencing a complicated pregnancy itself increases a woman's CVD risk (reflected by an increase in biomarker trajectories from early pregnancy to postpartum). We conducted a secondary analysis of an 8-week mindful eating and stress reduction intervention in 110 pregnant women. We used mixed linear regression analysis to compare CVD biomarker levels and trajectories, between women with and without a CVD-related pregnancy complication (including HDP [gestational hypertension or preeclampsia] or having a small for gestational age [10th percentile] or preterm [37 weeks] baby), at three times: (1) 12-20 weeks of gestation, (2) 3 months postpartum, and (3) 9 months postpartum. CVD biomarkers studied included serum glucose, insulin, homeostasis model assessment of insulin resistance (HOMA-IR), body mass index (BMI), blood pressure (BP), interleukin-6 (IL-6), tumor necrosis factor, and lipids. We adjusted for age, maternal smoking, prepregnancy BMI, BP, age × time, and BMI × time. Women had a mean age of 28 years (standard deviation [SD] 6), mean prior pregnancies of 0.8 (SD 1.0), and 22 women had one or more CVD-related pregnancy complications. HOMA-IR, diastolic BP, triglyceride, high-density lipoprotein cholesterol, and IL-6 average levels, but not trajectories, differed among women with complicated versus normal pregnancy (all values were ≤0.04). Peripartum glucose and systolic BP trajectories were statistically greater in complicated versus normal pregnancies ( values were 0.008 and 0.01, respectively). We conclude that the experience of a complicated pregnancy in addition to elevated CVD risk factor levels may both increase a woman's risk of future CVD. ClinicalTrials.gov Identifier: NCT01307683.

BACKGROUND

Optimal treatment of pancreatic ductal adenocarcinoma of the neck, body and tail (PDAC-NBT) necessitates R0 surgical resection. Preoperative radiographic identification of patients likely to achieve successful oncologic resection remains difficult. This study seeks to identify preoperative imaging characteristics predictive of non-R0 resections or impaired survival for PDAC-NBT.

METHODS

Patients at five high-volume centers who underwent resection for PDAC-NBT were retrospectively analyzed. The most immediate preoperative cross-sectional scan was assessed along with outcome measures of overall survival and margin status.

RESULTS

330 patients were treated between 2001 and 2016. Margin status included 247 R0 (78.2%), 67 R1 (21.2%), and 2 R2 (0.6%). A non-R0 resection predicted worse survival (p = 0.0002). On preoperative imaging, patients with tumors greater than 20 mm, tumor attenuation greater than 70 Hounsfield units, or who demonstrated pancreatic atrophy and/or calcifications also had worse survival (p = 0.010, p = 0.036, p = 0.025 respectively). Patients with tumors interfacing with the splenic artery or vein or extending posteriorly achieved fewer R0 resections (p = 0.0006, p = 0.0004, p = 0.001, respectively).

CONCLUSION

Preoperative cross-sectional imaging can identify tumor characteristics associated with poor survival and non-R0 resection. Further investigation is needed to identify the appropriate surgical and treatment modifications necessary to clinically benefit this subset of patients.

BACKGROUND & AIMS

Colorectal cancer (CRC) incidence and mortality are increasing among persons younger than 50 years old in the United States, but risk factors associated with early-onset CRC (EOCRC) have not been widely studied.

METHODS

We conducted a case-control study of US veterans 18 to 49 years old who underwent colonoscopy examinations from 1999 through 2014. EOCRC cases were identified from a national cancer registry; veterans who were free of CRC at their baseline colonoscopy through 3 years of follow-up were identified as controls. We collected data on age, sex, race/ethnicity, body weight, body mass index (BMI), diabetes, smoking status, and aspirin use. Multivariate-adjusted EOCRC odds were estimated for each factor, with corresponding 95% confidence interval (CI) values.

RESULTS

Our final analysis included 651 EOCRC cases and 67,416 controls. Median age was 45.3 years, and 82.3% were male. Higher proportions of cases were older, male, current smokers, nonaspirin users, and had lower BMIs, compared with controls (P .05). In adjusted analyses, increasing age and male sex were significantly associated with increased risk of EOCRC, whereas aspirin use and being overweight or obese (relative to normal BMI) were significantly associated with decreased odds of EOCRC. In post hoc analyses, weight loss of 5 kg or more within the 5-year period preceding colonoscopy was associated with higher odds of EOCRC (odds ratio 2.23; 95% CI 1.76-2.83).

CONCLUSIONS

In a case-control study of veterans, we found increasing age and male sex to be significantly associated with increased risk of EOCRC, and aspirin use to be significantly associated with decreased risk; these factors also affect risk for CRC onset after age 50. Weight loss may be an early clinical sign of EOCRC. More intense efforts are required to identify the factors that cause EOCRC and signs that can be used to identify individuals at highest risk.

Impaired lung function is often caused by cigarette smoking, making it challenging to disentangle its role in lung cancer susceptibility. Investigation of the shared genetic basis of these phenotypes in the UK Biobank and International Lung Cancer Consortium (29,266 cases, 56,450 controls) shows that lung cancer is genetically correlated with reduced forced expiratory volume in one second (FEV: r = 0.098, p = 2.3 × 10) and the ratio of FEV to forced vital capacity (FEV/FVC: r = 0.137, p = 2.0 × 10). Mendelian randomization analyses demonstrate that reduced FEV increases squamous cell carcinoma risk (odds ratio (OR) = 1.51, 95% confidence intervals: 1.21-1.88), while reduced FEV/FVC increases the risk of adenocarcinoma (OR = 1.17, 1.01-1.35) and lung cancer in never smokers (OR = 1.56, 1.05-2.30). These findings support a causal role of pulmonary impairment in lung cancer etiology. Integrative analyses reveal that pulmonary function instruments, including 73 novel variants, influence lung tissue gene expression and implicate immune-related pathways in mediating the observed effects on lung carcinogenesis.

OBJECTIVE

To better understand promotion timelines across gender and race/ethnicity and how academic output impacts promotion in urology.

METHODS

We examined the 2017 census. An academic subset was asked questions regarding their promotion timeline. We obtained demographic, academic output, and family responsibility data.

RESULTS

Of 2926 academic urologists who identified a position of Assistant, Associate, or Full professor, 11.2% were women, 75% were White, and 94% were non-Hispanic. Men authored more papers and achieved principal investigator status more often than women. Non-Hispanics authored more papers than Hispanics. On average, women took 1.2 years longer than men to advance from Assistant to Associate Professor (7.3 years [95% CI: 6.8-7.8] vs 6.1 years, [95% CI: 5.8-6.6, P .001]). Advancement from Associate to Full Professor was similar between women and men (6.0 years [95% CI: 5.1-6.9] vs 6.6 [95% CI: 6.1-7.1, P = .25]). Compared to women, men were more likely to experience rapid promotion (≤4 years) to Associate Professor (odds ratio 3 [95% CI: 1.8-5.1]). There was no statistical difference across race/ethnicity for promotion from Assistant to Associate, Associate to Full Professor, or rapid promotion.

CONCLUSION

We identified disparities in promotion times based on gender but not race and ethnicity. The number of under-represented minority faculty in urology is low. Understanding the causes of disparities should be a priority in order to support fair promotion practices and retention of diverse faculty.

Opioids are routinely prescribed to manage acute postoperative pain, but changes in postoperative opioid prescribing associated with the marketing of long-acting opioids such as OxyContin have not been described in the surgical cohort.

Methods

Using a large commercial claims data set, we studied postoperative opioid prescribing after selected common surgical procedures between 1994 and 2014. For each procedure and year, we calculated the mean postoperative morphine milligram equivalents (MME) filled on the index prescription and assessed the proportion of patients who filled a high-dose prescription (≥350 MME). We reported changes in postoperative opioid prescribing over time and identified predictors of filling a high-dose postoperative opioid prescription.

Results

We identified 1,321,264 adult patients undergoing selected common surgical procedures between 1994 and 2014, of whom 80.3% filled a postoperative opioid prescription. One in five surgery patients filled a high-dose postoperative opioid prescription. Between 1994 and 2014, the mean MME filled increased by 145%, 84%, and 85% for lumbar laminectomy/laminotomy, total knee arthroplasty, and total hip arthroplasty, respectively. The procedures most likely to be associated with a high-dose opioid fill were all orthopaedic procedures (AOR 5.20 to 7.55, 0.001 for all). Patients whose postoperative opioid prescription included a long-acting formulation had the highest odds of filling a prescription that exceeded 350 MME (AOR 32.01, 95% CI, 30.23-33.90).

Discussion

After the US introduction of long-acting opioids such as OxyContin, postoperative opioid prescribing in commercially insured patients increased in parallel with broader US opioid-prescribing trends, most notably among patients undergoing orthopaedic surgical procedures. The increase in the mean annual MME filled starting in the late 1990s was driven in part by the higher proportion of long-acting opioid formulations on the index postoperative opioid prescription filled by orthopaedic surgery patients.