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Become a member and receive career-enhancing benefits
Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
Available data have confirmed that delays in the care of cancer patients and screening for malignancy occur because of public health crises such as the COVID-19 pandemic. In this report, the authors used information from the National Cancer Database to determine the risks for tumor upgrading and decreased overall survival for patients with estrogen receptor (ER)-negative ductal carcinoma in situ resulting from delays in surgical treatment following diagnostic biopsy.
The study cohort included approximately 220,000 patients cared for before the COVID-19 pandemic; tumors were upstaged in 11.1% of patients compared with 10.1% of patients with ER-positive tumors. Younger age and Black race were documented as risk factors for tumor upstaging. The risk of tumor upstaging was significantly higher in patients who had a delay of longer than 30 days between biopsy and surgical care. Of interest was the observation that patients with delays of more than 30 days had equivalent overall survival rates compared with patients who had an interval between biopsy and surgical care of less than 30 days. The authors suggested that the fact that tumor upstaging did not influence overall survival was more likely a result of more sophisticated pathological evaluation methods, leading to increases in upstaging rather than upstaging being a marker for tumor lethality.
These findings apply only to the tumor type that was the focus of this study. As a rule, surgeons should attempt to perform therapeutic operations for patients with breast cancer as soon as possible after biopsy diagnosis. The Commission on Cancer has recently established a benchmark for quality surgical care of patients with breast cancer that recommends therapeutic surgery within 60 days of biopsy diagnosis.
Direct Oral Anticoagulants Appear to Reduce Length of Stay after Lower Extremity Bypass
Postoperative therapeutic anticoagulation using a vitamin K antagonist or a direct anticoagulant is routine practice following lower extremity vascular bypass. Available data support the conclusion that this practice improves rates of graft patency when risk factors for early graft thrombosis are present. Because venous thromboembolism is a common postoperative complication in patients undergoing lower extremity bypass, anticoagulation treatment for this condition is common. Patients with significant atherosclerotic disease also have an elevated risk for atrial fibrillation. Anticoagulant therapy for this condition is recommended.
The authors noted that use of direct anticoagulants is increasing because of the perceived ease of achieving therapeutic anticoagulation without the need for blood sampling to monitor drug effects. This study sought to determine risks for extended length of stay, thrombotic complications, and bleeding events in patients treated with anticoagulants following lower extremity vascular bypass procedures.
The authors used data from the Vascular Quality Initiative database; the total cohort included nearly 25,000 patients. Within the total cohort were 2,656 patients who were newly anticoagulated following lower extremity bypass; direct anticoagulant therapy was used in 22% of patients. Risks for thrombotic complications and bleeding events were equivalent in patients receiving vitamin K antagonists compared with patients receiving direct anticoagulants.
The data confirmed that hospital length of stay was significantly less in patients receiving direct anticoagulants, likely because of the reduced need for blood sampling to confirm anticoagulant effectiveness. The authors concluded that direct anticoagulants may be associated with reduced healthcare costs in this patient group.
Study Examines Association between Time to Source Control in Sepsis and 90-Day Mortality
Katherine Reitz, MD, MSc, and coauthors conducted a retrospective analysis of data from a single healthcare system over a 4-year interval to determine the effect of time from diagnosis of sepsis to source control on patient outcomes. A recognized national definition of sepsis (Sepsis-3) was used to confirm the accuracy of the sepsis diagnosis. A panel of experts chose Current Procedural Terminology codes for source control procedures, and the timing of these interventions was identified within electronic health records.
The total patient cohort included 4,962 patients. The median interval between diagnosis and source control was 15.4 hours. Source control within 6 hours of diagnosis occurred in 27% of patients; this intervention was associated with a significant reduction in 90-day mortality rates. This effect was particularly evident in patients with gastrointestinal, abdominal, and soft tissue sources of sepsis. Elderly patients, especially those diagnosed with frailty, did not have improved mortality associated with early source control. The data also showed that female patients had early source control significantly less often than their male counterparts.
The authors concluded that rapid identification of the source of sepsis followed by source control interventions resulted in a survival benefit for patients diagnosed with sepsis from abdominal, gastrointestinal, and soft tissue sources. Additional efforts to improve rates of early diagnosis and interventional therapy, especially for female patients, were recommended.
In the editorial that accompanied this article, Pamela Lipsett, MD, MHPE, MCCM, emphasized that early recognition of sepsis and septic shock, early administration of effective antibiotic therapy, and source control are essential elements for successful treatment of patients with sepsis. The editorial stressed that although it is unlikely that a randomized trial will be performed to confirm the value of the practice, the available data support the conclusion that clinicians should seek to achieve source control within six hours of a sepsis diagnosis.
