The effect of insurance status on outcomes after laparoscopic cholecystectomy.

BACKGROUND: Part of the ongoing healthcare debate is the care of uninsured patients. A common theory is that without regular outpatient care, these patients present to the hospital in the late stages of disease and therefore have worse outcomes. The purpose of this study was to evaluate any differences in outcomes after laparoscopic cholecystectomies between insured and uninsured patients. METHODS: We reviewed all laparoscopic cholecystectomies (LC) done in our institution between 2006 and 2009. Patients were divided into two groups: insured patients (IP) and uninsured patients (UIP). Outcomes, including conversion and complication rates and postoperative length of stay (LOS), were collected and statistically analyzed using χ(2) and ANOVA tests. RESULTS: There were 1,090 LCs done during the study period: 944 patients (86.6 %) were insured (IP) and 146 (13.4 %) were uninsured (UIP). In the IP group there were 63/944 (6.7 %) conversions and 59/944 (6.3 %) complications, while in the UIP group there were 15/146 (10.3 %) conversions and 12/146 (8.2 %) complications. There was no statistically significant difference in either of these categories. Mean (±SD) LOS was 1.73 ± 4.34 days for the IP group and 2.72 ± 4.35 days for the UIP group (p = 0.010, ANOVA). Uninsured patients were much more likely to have emergency surgery (99.3 % vs. 47.9 %, p < 0.001, χ(2)). CONCLUSIONS: In our study group, being uninsured did not correlate with having a higher rate of conversion or complications. However, more uninsured patients had their surgery done emergently, and this led to significantly longer lengths of stay. Further research is necessary to study the cost impact of these findings and to see whether insuring these patients can lead to changes in their outcomes.

Ten years later: a single hospital experience with malignancy in HIV/AIDS.

BACKGROUND AND OBJECTIVE: We present our experience in the era of HAART with 5,112 patients having HIV infection or AIDS, treated between 2002 and 2006 in our hospital, 182 of whom had malignancies (3.56%). We compared our findings to those from a similar cohort of patients studied 10 years earlier. METHODS: The charts were reviewed and data was electronically collected as in our 1993-1998 study. Similar statistical analyses were performed in both studies and the results were compared. RESULTS: For the current study the average patient age increased by 9 years. A decrease in AIDS-defining cancers (ADC), from 63.6% to 37.3% and a higher incidence of non-AIDS-defining cancers (NADC), 62.7 as opposed to 37.9% was found. No decrease in the incidence of non-Hodgkin's B cell lymphoma (NHL) was noted. There was an increase in the number of opportunistic infections notably hepatitis C virus (HCV) and hepatitis B virus (HBV). CONCLUSIONS: HIV/AIDS patients on HAART are older, have lower rates of AIDS related Kaposi's sarcoma and a higher incidence of NADCs than did patients in the early HAART era. No decrease in the proportion of NHL was observed.

Mantle cell lymphoma of the gastrointestinal tract presenting with multiple intussusceptions--case report and review of literature.

BACKGROUND: Mantle cell lymphoma (MCL) is an aggressive type of B-cell non-Hodgkin's lymphoma that originates from small to medium sized lymphocytes located in the mantle zone of the lymph node. Extra nodal involvement is present in the majority of cases, with a peculiar tendency to invade the gastro-intestinal tract in the form of multiple lymphomatous polyposis. MCL can be accurately diagnosed with the use of the highly specific marker Cyclin D1. Few cases of mantle cell lymphoma presenting with intussuception have been reported. Here we present a rare case of multiple intussusceptions caused by mantle cell lymphoma and review the literature of this disease. CASE PRESENTATION: A 68-year-old male presented with pain, tenderness in the right lower abdomen, associated with nausea and non-bilious vomiting. CT scan of abdomen revealed ileo-colic intussusception. Laparoscopy confirmed multiple intussusceptions involving ileo-colic and ileo-ileal segments of gastrointestinal tract. A laparoscopically assisted right hemicolectomy and extended ileal resection was performed. Postoperative recovery was uneventful. The histology and immuno-histochemistry of the excised small and large bowel revealed mantle cell lymphoma with multiple lymphomatous polyposis and positivity to Cyclin D1 marker. The patient was successfully treated with Rituximab-CHOP chemotherapy and remains in complete remission at one-year follow-up. CONCLUSION: This is a rare case of intestinal lymphomatous polyposis due to mantle cell lymphoma presenting with multiple small bowel intussusceptions. Our case highlights laparoscopic-assisted bowel resection as a potential and feasible option in the multi-disciplinary treatment of mantle cell lymphoma.

Medical student perception of night call in a night float system.

BACKGROUND: Because of work hour regulations, many surgical residency programs have moved to a night float system. Previously, our medical students took call for 24 hours, whereas currently they also follow a night float system. This study looked at their evaluations of these 2 systems. METHODS: Students were anonymously surveyed to evaluate the rotation (on a 5-point scale) as well as various components including night call. Responses from each group were compared. RESULTS: There were 104 students included: 46 in the traditional 24-hour call group and 58 in the night float group. Students rated night call significantly higher in the night float system (4.62 ± .64 vs 3.52 ± 1.00, P < .001). There was no difference in the other components or the overall evaluation. CONCLUSIONS: After switching to a night float system, students had a much more positive perception of their night call experience. We believe more clerkships should switch to a night float system.

Effect of insurance status on the stage of breast and colorectal cancers in a safety-net hospital.

OBJECTIVES: Screening can increase early detection and reduce rates of advanced-stage cancer. Uninsured patients have been shown to have lower rates of screening. Previous studies have shown that uninsured patients and patients with Medicaid present with more advanced stages of cancer. The aim of this study was to measure the effect of insurance status in the setting of a safety-net hospital. METHODS: Patients in our tumor registry with a diagnosis of breast or colorectal cancer between 2001 and 2010 were included. On the basis of their insurance status, they were divided into the following groups: Medicaid, Medicare, Medicare age <65 years, commercial, uninsured, and unknown. Cancer stage was recorded for each patient, with stages III and IV considered advanced disease. The primary end point was the rate of advanced disease in each patient group. RESULTS: A total of 910 patients were included in the study: 836 (91.9%) insured, 54 (5.9%) uninsured, and 20 (2.2%) unknown. Of the insured patients, 301 (36.0%) had Medicaid; 237 (30.7%) of 836 insured patients had advanced disease, compared with 27 (50.0%) of 54 uninsured patients (odds ratio, 1.63; P = .003). Of patients with Medicaid, 83 (27.6%) of 301 had advanced disease, which was not statistically different from patients with other insurance. CONCLUSIONS: In a safety-net hospital, patients with Medicaid had rates of advanced-stage cancer similar to those in patients with other types of insurance. However, patients with no insurance had significantly higher rates of advanced disease. This has significant ramifications in view of the new healthcare law, which will convert many patients from being uninsured to having Medicaid.

Effect of insurance status on the stage of breast and colorectal cancers in a safety-net hospital.

PURPOSE: Screening can increase early detection and reduce rates of advanced-stage cancer. Uninsured patients have been shown to have lower rates of screening. Previous studies have shown that uninsured patients and patients with Medicaid present with more advanced stages of cancer. The aim of this study was to measure the effect of insurance status in the setting of a safety-net hospital. METHODS: Patients in our tumor registry with a diagnosis of breast or colorectal cancer between 2001 and 2010 were included. On the basis of their insurance status, they were divided into the following groups: Medicaid, Medicare, Medicare age < 65 years, commercial, uninsured, and unknown. Cancer stage was recorded for each patient, with stages III and IV considered advanced disease. The primary end point was the rate of advanced disease in each patient group. RESULTS: A total of 910 patients were included in the study: 836 (91.9%) insured, 54 (5.9%) uninsured, and 20 (2.2%) unknown. Of the insured patients, 301 (36.0%) had Medicaid. Two hundred thirty-seven (30.7%) of 836 insured patients had advanced disease, compared with 27 (50.0%) of 54 uninsured patients (odds ratio, 1.63; P = .003). Of patients with Medicaid, 83 (27.6%) of 301 had advanced disease, which was not statistically different from patients with other insurance. CONCLUSION: In a safety-net hospital, patients with Medicaid had rates of advanced-stage cancer similar to those in patients with other types of insurance. However, patients with no insurance had significantly higher rates of advanced disease. This has significant ramifications in view of the new health care law, which will convert many patients from being uninsured to having Medicaid.

Osteogenic sarcoma of the breast arising in a cystosarcoma phyllodes: a case report and review of the literature.

INTRODUCTION: Primary tumors of the breast containing bone and cartilage are extremely rare, and an osteogenic sarcoma arising from a cystosarcoma phyllodes is exceptional. CASE PRESENTATION: A 40-year-old Indian woman presented with a breast mass which was diagnosed as osteosarcoma of the breast on biopsy. Our patient was treated with a simple mastectomy after excluding the presence of skeletal primary and extra-mammary metastases. Final pathology showed a cystosarcoma phyllodes with signs of osteogenic sarcoma. CONCLUSION: Although osteogenic sarcomas of the breast are rare, they need to be distinguished from carcinosarcomas and metaplastic carcinomas as the management of the two differ.

Emergency subtotal colectomy in a Jehovah's Witness with massive lower gastrointestinal bleeding: challenges encountered and lessons learned.

A 66-year-old woman who was a Jehovah's Witness had massive lower gastrointestinal bleeding and subsequent hypovolemic shock, necessitating a subtotal colectomy. During the postoperative period, her hemoglobin level decreased to a low of 2.6 g/dL, prolonging her dependence on mechanical ventilation. Prudent perioperative care resulted in a successful outcome. Blood-conserving techniques are indispensable in the management of Jehovah's Witnesses who have massive blood loss. Maximizing oxygen transport, minimizing blood loss, using a cell saver when permissible, providing optimal ventilatory support, performing tracheostomy early if prolonged mechanical ventilation is expected, and augmenting hemoglobin production with administration of iron and erythropoietin are techniques that can facilitate successful outcome in patients who refuse blood transfusion.

Intraoperative breast problem--focused sonography a valuable tool in the training of surgical residents.

INTRODUCTION: In surgical residency education, "hands-on" learning is important in the operating room. Mastering the interpretation of preoperative data is a must for intraoperative decisions. Because preoperative evaluations of breast masses by ultrasound are performed and interpreted in the Department of Radiology, our study aimed to assess and improve surgical residents' ability to perform ultrasound and to interpret their results before performing breast mass biopsies. METHODS: Between January 2000 and May 2007, 128 female patients found to have palpable breast masses were scheduled for biopsy. An on-table ultrasound was performed by a surgical resident under the supervision of an attending surgeon. The resident was unaware of the result reported by the Department of Radiology. The parameters used to evaluate on-table ultrasound were the echogenicity, diameter (transverse vs vertical), and margins (regular vs irregular) of patients' lesions. Based on these criteria, residents classified lesions as benign, malignant, or indeterminate. The results were compared with the preoperative ultrasound evaluations provided by the Department of Radiology and pathology reports. RESULTS: Eliminating the 10 indeterminate lesions on ultrasound, the residents found that 87 lesions were benign and 31 lesions were malignant. The residents' assessment of the breast lumps had a sensitivity of 90.32% and a specificity of 96.55%, with a positive predictive value of 90.32% and a negative predictive value of 96.55%. CONCLUSIONS: The residents' overall accuracy of 94.91% approximates that of the radiologists in differentiating between benign and malignant lesions. The study allowed us to assess the knowledge and skills of residents who responded as required by Accreditation Council for Graduate Medical Education core competencies.