Background Gastrointestinal (GI) luminal cancers can be detected at early stages by endoscopic procedures. Place -based factors, such as social deprivation and distance to specialist care, are under-investigated with regard to the stage of diagnosis. Methods This was a retrospective cohort study among persons >= 18 years of age in the Florida Cancer Data System, a population -based cancer incidence registry. We included persons diagnosed with esophageal cancer, gastric canceror colorectal cancer, with at least 1 measure of geographic location during the period January 1, 1981, to December 31, 2016. Multivariate multinomial logistic regression was used to identify factors associated with the stage of diagnosis, including social deprivation and proximity to GI care. Results Among 379,054 persons, the median age was 71 years, and 54% were male. Distant stage disease was significantly less likely than local stage in those of non-Hispanic/Latino ethnicity (odds ratio [OR] 0.92, 95% confidence interval [CI] 0.89-0.94, P<0.001). Distant disease was more likely in African Americans (OR 1.30, 95%CI 1.26-1.34) and Asians (OR 1.41, 95%CI 1.27-1.56, P<0.001), with each 5 -min increase in travel time to specialists, (OR 1.02, 95%CI 1.01-1.02, P<0.001), and with each 10 -point increase in Social Deprivation Index (OR 1.01, 95%CI 1.01-1.02, P<0.001). Conclusions A greater distance from care and living in areas with increased deprivation are associated with an advanced stage of diagnosis and should be recipients of policy -driven efforts to improve access to care. That the strongest risk factors include minority race and ethnicity underlines the complexity of healthcare disparities.

Gaddipati, Neelima; Chyou, Darius; Blandon, Catherine; Goldberg, David S. Author Information

1Department of Internal Medicine, University of Miami, Miami, Florida, USA 2University of Miami, Division of Digestive Health and Liver Diseases, Miami, Florida, USA Abbreviations: AC, acuity circles; DDLT, Deceased donor liver Transplant; MELD, Model for End-Stage Liver Disease; MMaT, Median MELD at Transplant; OPTN, organ procurement and transplantation network; UNOS, United Network for Organ Sharing. Correspondence David S. Goldberg, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Room 807, Miami, Florida 33136, USA. Email: [email protected]

Organ procurement organizations (OPOs) are the federal contractors who manage all aspects of deceased organ donation, such as procurement of organs from deceased donors for research purposes. On November 20, 2020, the Centers for Medicare and Medicaid Services (CMS) updated the "Final Rule" for OPO Conditions for Coverage, which included redefining an organ donor for regulatory purposes as an individual with: (1) ≥1 organ transplanted or (2) pancreas procured for research or islet cell transplantation (only performed under research protocol).

Since its inception in 2002, Model for End-Stage Liver Disease (MELD)-based allocation has undergone a series of revisions, especially with respect to exception points. Hepatocellular carcinoma (HCC) is the most common indication for MELD exceptions, and as a result of higher transplant proportions and lower waitlist mortality, a series of policy changes have been implemented to deprioritize HCC transplants. We examined the impact of HCC exception policy changes on transplant and waitlist mortality rates. We evaluated Organ Procurement and Transplantation Network/United Network for Organ Sharing data on adult patients from January 1, 2005, to June 4, 2021, focusing on waitlist mortality and deceased donor liver transplantation (DDLT) proportions. The data were divided into four policy eras: (1) MELD 22 points at waitlisting with an increase in points every 3 months (i.e., elevator) (January 2005-October 2015), (2) delay and cap at MELD 34 points (October 2015-May 2019), (3) delay and fixed exceptions based on donor service area (DSA) median MELD at transplantation minus three (MMaT-3; May 2019-February 2020), and (4) delay and fixed exceptions based on the MMaT-3 of centers within 250 nautical miles (i.e., acuity circles; February 2020-June 2021). We evaluated (a) changes in the proportions of DDLTs for patients with HCC exceptions within each era nationally and by DSA and (b) waitlist mortality in the three recent policy eras, focusing on mortality in the 6 months after the 6-month delay period. The percentage of adult DDLT with HCC exceptions decreased through the four eras: 22.9% (n = 14,049), 17.9% (n = 4598), 14.3% (n = 851), and 12.4% (n = 1425), respectively. Of the 51 DSAs analyzed, the annual percent change in DDLTs for patients with HCC exceptions was negative (i.e., decreased) in 47 (92.2%). Waitlist mortality remained stable. All HCC policy implementations led to a decrease in the percentage of transplants for HCC without an increase in waitlist mortality. The impact is not uniform across geographic areas.

BACKGROUND & AIMS:Significant geographic variability in gastrointestinal (GI) cancer-related death has been reported in the United States. We aimed to evaluate both modifiable and nonmodifiable factors associated with intercounty differences in mortality due to GI cancer.METHODS:Data from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research platform were used to calculate county-level mortality from esophageal, gastric, pancreatic, and colorectal cancers. Multivariable linear regression models were fit to adjust for county-level covariables, considering both patient (eg, sex, race, obesity, diabetes, alcohol, and smoking) and structural factors (eg, specialist density, poverty, insurance prevalence, and colon cancer screening prevalence). Intercounty variability in GI cancer-related mortality explained by these covariables was expressed as the multivariable model R2.RESULTS:There were significant geographic disparities in GI cancer-related county-level mortality across the US from 2010-2019 with the ratio of mortality between 90th and 10th percentile counties ranging from 1.5 (pancreatic) to 2.1 (gastric cancer). Counties with the highest 5% mortality rates for gastric, pancreatic, and colorectal cancer were primarily in the Southeastern United States. Multivariable models explained 43%, 61%, 14%, and 39% of the intercounty variability in mortality rates for esophageal, gastric, pancreatic, and colorectal cancer, respectively. Cigarette smoking and rural residence (independent of specialist density) were most strongly associated with GI cancer-related mortality.CONCLUSIONS:Both patient and structural factors contribute to significant geographic differences in mortality from GI cancers. Our findings support continued public health efforts to reduce smoking use and improve care for rural patients, which may contribute to a reduction in disparities in GI cancer-related death.

Kumar, Smriti Rajita M.D., E.D.M.; Chyou, Darius BS; Goldberg, David M.D., M.S.C.E. Author Information

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Introduction: Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality in patients with cirrhosis, and HCC survival is directly correlated with stage at diagnosis. Current guidelines recommend HCC surveillance with an abdominal ultrasound every 6 months, but unfortunately many patients do not meet this threshold.1 Our aim was to determine whether distance to a radiology center, measured in travel time, was associated with HCC surveillance rates. Methods: We included data on adult patients with cirrhosis within the OneFlorida Clinical Research Consortium from October 1, 2015- December 31, 2019. The primary outcome was a continuous measure of the percentage of time up to date with HCC surveillance (PTUDS) based on abdominal ultrasound (US), triple phase CT, and/or MRI with contrast. Travel time was calculated using ArcGIS geomodelling software as the estimated minimum travel time between the geographic centroid of patient’s zip code and the nearest American College of Radiology-accredited center for US, CT, and/or MRI. Linear regression models were fit with PTUDS as the outcome; all covariates with a p< 0.05 were included in the final multivariable model. (Figure) Results: Among 25,299 patients with cirrhosis (median follow-up=4.1 years), the median PTUDS was 10.0% (interquartile range 0-29.9%). Variables found to have a statistically significant association with PTUDS are displayed in Table. Travel time, hepatic encephalopathy at baseline, and ascites at baseline were associated with increased PTUDS. Patients with alcohol-related liver disease, nonalcoholic steatohepatitis, and cryptogenic cirrhosis had lower PTUDS compared with patients with HCV. Conclusion: Travel time to the nearest radiology center is not associated with lower HCC surveillance rates while race, etiology of liver disease, and disease severity do appear to variably influence surveillance. By establishing factors associated with currently suboptimal surveillance rates, we can create targeted interventions to improve surveillance and, ultimately, patient outcomes.Figure 1.: Median PTUDS by County Table 1. - Multivariable Linear Regression Model of Factors Associated with HCC Surveillance Variable Beta Coefficient, 95% CI P-Value Travel Time 0.0016 (0.0012-0.0020) <0.001 Liver Disease Etiology Hepatitis C Virus Reference - Hepatitis B Virus 0.0246 (0.0019-0.0473) 0.034 Wilson's Disease 0.0137 (-0.571-0.0845) 0.704 Hemochromatosis 0.0067 (-0.0220-0.0354) 0.647 a1-Antitrypsin Deficiency 0.0673 (0.0200-0.1145) 0.005 Alcohol-Related Liver Disease -0.0720 (-0.0801- -0.0639) <0.001 Primary Biliary Cholangitis -0.0037 (-0.0261- 0.0186) 0.745 Autoimmune Hepatitis -0.0193 (-0.0406- 0.0019) 0.075 Primary Sclerosing Cholangitis 0.0123 (-0.0462- 0.0708) 0.680 Nonalcoholic Steatohepatitis -0.0835 (-0.0917- -0.0752) <0.001 Unknown/Cryptogenic -0.01566 (-0.1664- -0.1467) <0.001 Race White/Caucasian Reference - American Indian/Alaskan -0.0207 (-0.0871- 0.0457) 0.541 Asian 0.0531 (0.0258- 0.0805) <0.001 Black 0.0171 (0.0082- 0.0260) <0.001 Native Hawaiian/Pacific Islander -0.0075 (-0.1109- 0.0959) 0.887 Multiple Race -0.0474 (-0.0781- -0.0168) 0.002 Refuse to answer 0.0904 (0.0212- 0.1596) 0.010 No information 0.0575 (0.0283- 0.0866) <0.001 Other 0.0050 (-0.0048- 0.0148) 0.318 Unknown -0.0591 (-0.0837- -0.0346) <0.001 Disease Severity Hepatic Encephalopathy at Baseline 0.0431 (0.0328- 0.0534) <0.001 Ascites at Baseline 0.0638 (0.0551- 0.0724) <0.001

Abstract Objective The study aimed to (1) quantify readmission rates and common causes of readmission following endoscopic transsphenoidal pituitary surgery (ETPS); (2) identify risk factors that may predict readmission within 30 days; (3) assess postoperative care coordination with endocrinology follow-up; and (4) identify patients for whom targeted interventions may reduce 30-day readmissions. Methods Retrospective quality improvement review of patients with pituitary adenoma who underwent ETPS from December 2010 to 2018 at a single tertiary care center. Results A total of 409 patients were included in the study, of which 57 (13.9%) were readmitted within 30 days. Hyponatremia was the most common cause of readmission (4.2%) followed by pain/headache (3.9%), cerebrospinal fluid leak (3.4%), epistaxis (2.7%), hypernatremia (1.2%), and adrenal insufficiency (1.2%). Patients with hyponatremia were readmitted significantly earlier than other causes (4.3 ± 2.2 vs. 10.6 ± 10.9 days from discharge, p = 0.032). Readmitted patients had significantly less frequent outpatient follow-up with an endocrinologist than the nonreadmitted cohort (56.1 vs. 70.5%, p = 0.031). Patients who had outpatient follow-up with an endocrinologist were at lower risk of readmission compared with those without (odds ratio: 0.46; 95% confidence interval: 0.24–0.88). Conclusion Delayed hyponatremia is one of the most common causes of 30-day readmission following ETPS. Postoperative follow-up with an endocrinologist may reduce risk of 30-day readmission following ETPS. Implications for Clinical Practice A multidisciplinary team incorporating otolaryngologist, neurosurgeons, and endocrinologist may identify patients at risk of 30-day readmissions. Protocols checking serum sodium within 1 week of surgery in conjunction with endocrinologist to tailor fluid restriction may reduce readmissions from delayed hyponatremia.

Despite increases in the number of deceased donors in the US, the donor supply fails to meet the ever-increasing demand. Centers have had to increase utilization of 'marginal' liver grafts to increase the number of deceased donor liver transplants (DDLT).

OBJECTIVES In this review, we discuss current knowledge about the genetics and epigenetics of vestibular schwannoma (VS) in relation to hearing loss. A multistep and sequential genetic algorithm suitable for the identification of Neurofibromatosis Type 2 (NF2) constitutional and somatic mutations is discussed. DATA SOURCES, STUDY SELECTION A review was performed of the English literature from 1990 to 2019 using PubMed regarding genetics and epigenetics of vestibular schwannoma and NF2. CONCLUSION NF2 is a genetic disorder characterized by NF2 mutations that affect the function of a tumor suppressor called merlin. In particular, individuals with NF2 develop bilateral VS that can lead to hearing loss and even deafness. Recent advances in genetic and epigenetic studies have improved our understanding of the genotype-phenotype relationships that affect hearing in NF2 patients. Specific constitutional NF2 mutations including particular truncating, deletion, and missense mutations have been associated with poorer hearing outcomes and more severe clinical manifestations. Epigenetic events, such as DNA methylation and histone modifications, also contribute to the development and progression of hearing loss in NF2 patients. Furthermore, the accumulation of multiple NF2 and non-NF2 genetic and epigenetic abnormalities at the level of the tumor may contribute to worse hearing outcomes. Understanding genetic and epigenetic signatures in individual NF2 patients and particularly in each VS will allow us to develop novel gene therapies and precision medicine algorithms to preserve hearing in NF2 individuals.

Liver TransplantationVolume 27, Issue 5 p. 756-759 Brief Report A 6-Month Report on the Impact of the Organ Procurement and Transplantation Network/United Network for Organ Sharing Acuity Circles Policy Change Darius Chyou, Darius Chyou University of Miami Miller School of Medicine, Miami, FLSearch for more papers by this authorSeth Karp M.D., Seth Karp M.D. Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TNSearch for more papers by this authorMalay B. Shah M.D., Malay B. Shah M.D. Division of Transplantation, Department of Surgery, University of Kentucky Medical Center, Lexington, KYSearch for more papers by this authorRaymond Lynch M.D., Raymond Lynch M.D. Division of Transplantation, Department of Surgery, Emory University, Atlanta, GASearch for more papers by this authorDavid S. Goldberg M.D., Corresponding Author David S. Goldberg M.D. dsgoldberg@miami.edu Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL Address reprint requests to David S. Goldberg, M.D., M.S.C.E., Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Room 807, Miami, FL 33136. Telephone: 305-243-7956; FAX: 305-689-1820; E-mail: dsgoldberg@miami.eduSearch for more papers by this author Darius Chyou, Darius Chyou University of Miami Miller School of Medicine, Miami, FLSearch for more papers by this authorSeth Karp M.D., Seth Karp M.D. Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TNSearch for more papers by this authorMalay B. Shah M.D., Malay B. Shah M.D. Division of Transplantation, Department of Surgery, University of Kentucky Medical Center, Lexington, KYSearch for more papers by this authorRaymond Lynch M.D., Raymond Lynch M.D. Division of Transplantation, Department of Surgery, Emory University, Atlanta, GASearch for more papers by this authorDavid S. Goldberg M.D., Corresponding Author David S. Goldberg M.D. dsgoldberg@miami.edu Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL Address reprint requests to David S. Goldberg, M.D., M.S.C.E., Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, 1120 NW 14th Street, Room 807, Miami, FL 33136. Telephone: 305-243-7956; FAX: 305-689-1820; E-mail: dsgoldberg@miami.eduSearch for more papers by this author First published: 12 December 2020 https://doi.org/10.1002/lt.25972Citations: 12 Potential conflict of interest: Nothing to report. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume27, Issue5May 2021Pages 756-759 RelatedInformation

Background Patients present to rhinology clinics with various complaints. Symptoms may be attributable to objective findings, some remain unexplained. The objective is to investigate the incidence of psychological disorders in a rhinologic practice and evaluate a correlation of these psychiatric diseases with rhinologic symptoms. Methods Patients presenting to a rhinology clinic were administered the Generalized Anxiety Disorder 7 (GAD 7), Patient Health Questionnaire 9 (PHQ 9), and PHQ 15, psychometric instruments that can screen for generalized anxiety, major depression, and somatization disorder, respectively. Patients’ symptoms, endoscopic findings, medication, and psychiatric history were recorded. Multivariable analysis was performed for patients showed moderate-to-severe anxiety, depression, and somatic symptoms via 3 logistic regressions where the outcome was a GAD 7, PHQ 9, or PHQ 15 above 10. Results One hundred ninety-six patients were included for this study. There were 109 females and 87 males with a mean age of 49 years. Overall, 9%, 14%, and 21% exhibited moderate-to-severe anxiety, depressive, and somatization symptoms, respectively. Nasal obstruction was the only statistically significant variable that increased the odds of having moderate-to-severe anxiety symptoms. Similarly, headache, nasal obstruction, and anosmia/hyposmia were associated with increased odds of having depressive symptoms, and female gender, headache, and nasal discharge increased the odds of somatic symptom disorder. Edema was the only objective endoscopic finding, which was associated with depression only. Conclusions Patients should be counseled about the pathophysiology and psychiatric comorbidities affecting their primary rhinologic complaints. The provider needs to set realistic treatment expectations in order to achieve the desired clinical outcomes.

Objective Disparities in health and health care access are widely prevalent. However, disparities among patients with chronic rhinosinusitis (CRS) are poorly understood. We investigated if CRS severity at presentation according to socioeconomic factors. Study Design Cross-sectional study. Setting Tertiary rhinology center. Subjects and Methods Three hundred prospectively recruited patients presenting with CRS were included. Outcome variables included CRS symptomatology, as reflected by the 22-item Sinonasal Outcome Test (SNOT-22); general health status, as reflected by the EuroQol 5-dimensional visual analog scale (EQ-5D VAS); and CRS-related antibiotic and systemic corticosteroid use. Race/ethnicity, zip code income bracket, education level, and insurance status were used as predictor variables. Regression, controlling for clinical and demographic characteristics, was used to determine associations between predictor and outcome variables. Results Mean SNOT-22 score was 33.8 (SD, 23.2), and mean EQ-5D VAS score was 74.2 (SD, 18.9). On multivariable analysis, presenting SNOT-22 and EQ-5D VAS scores were not associated with nonwhite patient race/ethnicity ( P = .634 and P = .866), education ( P = .106 and P = .586), or the percentage of households in zip code with incomes <$50,000 per year ( P = .917 and P = .979, respectively). SNOT-22 scores did not differ by insurance type, but patients receiving Medicare reported worse general health status. Use of oral antibiotics or oral steroids for CRS was not associated with predictor variables. Conclusion Patients with CRS presented to a tertiary rhinology center with similar metrics for CRS severity and pre-presentation medical management regardless of race/ethnicity, education status, or zip code income level. Patients with Medicare had worse general health status. Further research should investigate potential disparities in diagnosis of CRS, specialist referral, and treatment outcomes.