Disparities in the surgical treatment of colorectal liver metastases.

BACKGROUND: Hepatectomy is an accepted standard of care for patients with resectable colorectal liver metastases (CLM). Given that it is unclear whether disparities exist between different patient populations, a population-based analysis was performed to analyze this issue with regards to resection rates and surgical mortality in patients with CLM. METHODS: Using the Nationwide Inpatient Sample, characteristics and outcomes of adult patients with a diagnosis of colorectal cancer and colorectal metastases that subsequently underwent a liver resection during the years 1993-2007 were identified. Multivariate analysis was used to determine the effects of demographic and clinical covariables on resection rates and in-hospital mortality. RESULTS: Incident colorectal and liver metastases were identified in 138,565 patients; 3,528 patients (2.6%) underwent subsequent resection. African American and Hispanic race were associated with lower resection rates compared to Caucasian patients (adjusted OR 0.61 (0.52 - 0.71) and 0.81 (0.68 - 0.96) respectively). Medicaid insurance was associated with decreased resection rates compared to private insurance (AOR 0.47 (0.40 - 0.56)). The overall inpatient mortality rate was 3.1%. Multivariate analysis determined that mortality rate was correlated to both insurance status and geographic region. CONCLUSIONS: The national resection rate is significantly lower than has been reported by most case series. Race and insurance status appear to be correlated to the likelihood of surgical resection. In-hospital mortality is equivalent to the rates reported elsewhere, but is correlated to insurance status and region.

Sequential preoperative hepatic vein embolization after portal vein embolization for extended left hepatectomy in colorectal liver metastases.

BACKGROUND: The role of portal vein embolization to increase future liver remnant (FLR) is well-established in the treatment of colorectal liver metastases. However, the role of hepatic vein embolization is unclear. CASE REPORT: A patient with colorectal liver metastases received neoadjuvant chemotherapy prior to attempted resection. At the time of resection his tumor appeared to invade the left and middle hepatic vein, requiring an extended left hepatectomy including segments five and eight. Post-operatively, he underwent sequential left portal vein embolization followed by left hepatic vein embolization and finally, middle hepatic vein embolization. Hepatic vein embolization was performed to increase the FLR as well as to allow collateral drainage of the FLR to develop. A left trisectionectomy was then performed and no evidence of postoperative liver congestion or morbidity was found. CONCLUSION: Sequential portal vein embolization and hepatic vein embolization for extended left hepatectomy may be considered to increase FLR and may prevent right hepatic congestion after sacrificing the middle vein.

Functional outcomes for 2 years comparing hip resurfacing and total hip arthroplasty.

This prospective observational study of 499 patients with hip resurfacing and 255 patients with total hip arthroplasty compared outcomes for 2 years. We used propensity scores to identify matched cohorts of 118 patients with hip resurfacing and 118 patients with total hip arthroplasty. We used these cohorts to compare improvements in the Western Ontario and McMaster University (WOMAC) osteoarthritis index and Medical Outcomes Short-Form 36 physical function component (SF-36 PF) scores at 3 months and at 1 and 2 years postsurgery. Both groups demonstrated significant improvements from baseline in WOMAC and SF-36 PF. Improvements in SF-36 PF were greater for patients with hip resurfacing than for patients with total hip arthroplasty 1 and 2 years postsurgery; improvements in WOMAC were similar for both groups. The clinical significance of this observation needs further investigation.

Measuring the value of total hip and knee arthroplasty: considering costs over the continuum of care.

BACKGROUND: Controlling escalating costs of hip (THA) and knee arthroplasty (TKA) without compromising quality of care has created the need for innovative system reorganization to inform sustainable solutions. QUESTIONS/PURPOSES: The purpose of this study was to inform estimates of the value of THA and TKA by determining: (1) the data sources data required to obtain costs across the care continuum; (2) the data required for different analytical perspectives; and (3) the relative costs across the continuum of care. METHODS: Within the context of a pragmatic randomized controlled trial comparing alternative care pathways, we captured healthcare resource use: (1) 12 months before surgery; (2) inpatient; (3) acute recovery; and (4) long-term recovery 3 and 12 months postsurgery. We established a standardized costing model to reflect both the healthcare payer and patient perspectives. RESULTS: Multiple data sources from regional health authorities, administrative databases, and patient questionnaire were required to estimate costs across the care continuum. Inpatient and acute care costs were approximately 60% of the total with the remaining 40% incurred 12 months presurgery and 12 months postsurgery. Regional health authorities bear close to 60%, and patient costs are approximately 30% of the mean total costs, most of which were incurred after the acute inpatient stay. CONCLUSIONS: To fully understand the value of an orthopaedic intervention such as THA and TKA, a broader perspective than one limited to the payer should be considered using a standardized measurement framework over a relevant time horizon and from multiple viewpoints to reflect the substantial patient burden and support sustainable improvement over the care continuum. LEVEL OF EVIDENCE: Level III, economic and decision analyses study. See Guidelines for Authors for a complete description of levels of evidence.

Predicting in-hospital mortality in patients undergoing complex gastrointestinal surgery: determining the optimal risk adjustment method.

OBJECTIVE: To compare the performance of Charlson/Deyo, Elixhauser, Disease Staging, and All Patient Refined Diagnosis-Related Groups (APR-DRGs) algorithms for predicting in-hospital mortality after 3 types of major abdominal surgeries: gastric, hepatic, and pancreatic resections. DESIGN: Cross-sectional nationwide sample. SETTING: Nationwide Inpatient Sample from 2002 to 2007. PATIENTS: Adult patients (≥18 years) hospitalized with a primary or secondary procedure of gastric, hepatic, or pancreatic resection between 2002 and 2007. MAIN OUTCOME MEASURES: Predicting in-hospital mortality using the 4 comorbidity algorithms. Logistic regression analyses were used and C statistics were calculated to assess the performance of the indexes. Risk adjustment methods were then compared. RESULTS: In our study, we identified 46,395 gastric resections, 18,234 hepatic resections, and 15,443 pancreatic resections. Predicted in-hospital mortality rates according to the adjustment methods agreed for 43.8% to 74.6% of patients. In all types of resections, the APR-DRGs and Disease Staging algorithms predicted in-hospital mortality better than the Charlson/Deyo and Elixhauser indexes (P < .001). Compared with the Charlson/Deyo algorithm, the Elixhauser index was of higher accuracy in gastric resections (0.847 vs 0.792), hepatic resections (0.810 vs 0.757), and pancreatic resections (0.811 vs 0.741) (P < .001 for all comparisons). Higher accuracy of the Elixhauser algorithm compared with the Charlson/Deyo algorithm was not affected by diagnosis rank, multiple surgeries, or exclusion of transplant patients. CONCLUSIONS: Different comorbidity algorithms were validated in the surgical setting. The Disease Staging and APR-DRGs algorithms were highly accurate. For commonly used algorithms such as Charlson/Deyo and Elixhauser, the latter showed higher accuracy.

Health status and health-related behaviors in epilepsy compared to other chronic conditions--a national population-based study.

PURPOSE: The negative impact of epilepsy is disproportionate to its prevalence. Our objectives were to determine if health-related behaviors (HRBs) and health status differ between patients with epilepsy, migraine, or diabetes. METHODS: The 2001-2005 Canadian Community Health Survey (N = 400,055) was used to explore health status and HRBs in patients with epilepsy, migraine, and diabetes and in the general population. Weighted estimates of association were produced as proportions with 95% confidence intervals (CIs). Logistic regression was used to explore the association between demographic variables and HRBs in epilepsy. RESULTS: The prevalence of active epilepsy, migraine, and diabetes was 0.6%, 8.4%, and 3.8%, respectively. Those with epilepsy and diabetes were more likely than migraineurs to perceive their health as poor and to be physically inactive. Obesity and comorbidities were more likely in all chronic conditions studied compared to the general population. Those with epilepsy or migraine were significantly more likely to smoke compared to the general population or to those with diabetes. Those with epilepsy were more likely to ever have consumed more than 12 alcoholic drinks per week. Health monitoring did not differ between groups. In the logistic regression analysis, epilepsy was associated with physical inactivity and lower alcohol consumption in the past 12 months compared to the general population. DISCUSSION: Our study demonstrated that those with epilepsy have a poorer pattern of HRBs and poorer health status compared to the general population. Screening for and managing comorbidities, and promoting exemplary HRBs, should improve overall health and quality-of-life in those with epilepsy.

The Alberta Hip and Knee Replacement Project: a model for health technology assessment based on comparative effectiveness of clinical pathways.

BACKGROUND: The Alberta Hip and Knee Replacement Project developed a new evidence-based clinical pathway (NCP) for total hip (THR) and knee (TKR) replacement. The aim was to facilitate the delivery of services in a timely and cost-effective manner while achieving the highest quality of care for the patient across the full continuum of care from patient referral to an orthopedic surgeon through surgery, recovery, and rehabilitation. The purpose of this article is to provide an overview of the study design, rationale, and execution of this project as a model for health technology assessment based on comparative effectiveness of alternative clinical pathways. METHODS: A pragmatic randomized controlled trial study design was used to evaluate the NCP compared with the standard of care (SOC) for these procedures. The pragmatic study design was selected as a rigorous approach to produce high quality evidence suitable for informing decisions between relevant interventions in real clinical practice. The NCP was evaluated in three of the nine regional health authorities (RHAs) in Alberta with dedicated central intake clinics offering multidisciplinary care teams, constituting 80 percent of THR and TKR surgeries performed annually in Alberta. Patients were identified in the offices of twenty orthopedic surgeons who routinely performed THR or TKR surgeries. Evaluation outcome measures were based on the six dimensions of the Alberta Quality Matrix for Health (AQMH): acceptability, accessibility, appropriateness, effectiveness, efficiency and safety. Data were collected prospectively through patient self-completed questionnaires at baseline and 3 and 12 months after surgery, ambulatory and inpatient chart reviews, and electronic administrative data. RESULTS: The trial design was successful in establishing similar groups for rigorous evaluation. Of the 4,985 patients invited to participate, 69 percent of patients consented. A total of 3,434 patients were randomized: 1,712 to SOC and 1,722 to the NCP. The baseline characteristics of patients in the two study arms, including demographics, comorbidity as measured by CDS and exposure to pain medications, and health-related quality of life, as measured by Western Ontario and McMaster Universities Osteoarthritis Index and Short Form-36, were similar. CONCLUSIONS: The Alberta Hip and Knee Replacement Project demonstrates the feasibility and advantages of applying a pragmatic randomized controlled trial to ascertain comparative effectiveness. This is a model for health technology assessment that incorporates how clinical pathways can be effectively evaluated.

Oxidative stress and pathogenesis of inflammatory bowel disease: an epiphenomenon or the cause?

Crohn's disease (CD) and ulcerative colitis (UC), known as inflammatory bowel disease (IBD), are fairly common chronic inflammatory conditions of the gastrointestinal tract. Although the exact etiology of IBD remains uncertain, dysfunctional immunoregulation of the gut is believed to be the main culprit. Amongst the immunoregulatory factors, reactive oxygen species are produced in abnormally high levels in IBD. Their destructive effects may contribute to the initiation and/or propagation of the disease. We provided an extensive overview on the evidences from animal and human literature linking oxidative stress to IBD and its activity. Moreover, the effects of antioxidant therapy on IBD patients in randomized, controlled trials were reviewed and the need for further studies elaborated. We also summarized the evidence in support for causality of oxidative stress in IBD.

How long does stridor at rest persist in croup after the administration of oral prednisolone?

OBJECTIVES: To determine the duration of stridor at rest (SAR) after the administration of oral prednisolone (1 mg/kg) to children admitted to hospital with croup from the ED. The secondary objective was to determine whether children with mild croup had a more rapid resolution of SAR. METHODS: This was a retrospective explicit chart review of all children admitted to the paediatric ward of a community, paediatric teaching hospital with a diagnosis of croup over one year. Data collected included patient demographics, Westley and Geelhoed croup scores on presentation to the ED and the duration of SAR after administration of steroids. RESULTS: For the 188 cases analyzed, median duration of SAR was 6.5 h (95% CI 6-7 h, range 0.5-82 h). Children with a Westley score of < or = 2 or a Geelhoed score of < or = 3 had a shorter duration of SAR than those with higher scores (6 h vs. 7 h, P < 0.05), which although statistically significant is unlikely to be of clinical significance. CONCLUSIONS: Stridor at rest resolves promptly after the administration of oral steroids in the vast majority of cases. This suggests that a subset of patients previously admitted to hospital with croup may be able to be treated and discharged from the ED.