Gonorrhea and chlamydia in the emergency department: Continued need for more focused treatment for men, women and pregnant women.

INTRODUCTION: Delay in current nucleic acid amplification testing for Neisseria gonorrhoeae and Chlamydia trachomatis has led to recommendations for presumptive treatment in patients with concern for infection and unreliable follow-up. In the urban setting, it is assumed that many patients have unreliable follow-up, therefore presumptive therapy is thought to be used frequently. We sought to measure the frequency of disease and accuracy of presumptive treatment for these infections. METHODS: This was an observational cohort study performed at an urban academic Level 1 trauma center ED with an annual census of 95,000 visits per year. Testing was performed using the APTIMA Unisex swab assay (Gen-Probe Incorporated, San Diego, CA). Presumptive therapy was defined as receiving treatment for both infections during the initial encounter without confirmation of diagnosis. RESULTS: A total of 1162 patients enrolled. Infection was present in 26% of men, 14% of all women and 11% of pregnant women. Despite high frequency of presumptive treatment, >4% of infected patients in each category went untreated. CONCLUSION: Inaccuracy of presumptive treatment was common for these sexually transmitted infections. There is an opportunity to improve diagnostic accuracy for treatment.

Reliable Rapid Assay for Gonorrhea and Chlamydia in the Emergency Department.

BACKGROUND: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are common sexually transmitted infections seen in the emergency department (ED). Due to an inability to reliably make accurate diagnosis by physical examination, concern for unreliable follow-up, and current delays in diagnostic nucleic acid amplification testing (NAAT), presumptive treatment active against CT and NG, as described by Centers for Disease Control clinical practice guidelines, is often performed. OBJECTIVES: The purpose of this study was to determine whether a rapid, urine NAAT performed in the ED is noninferior in its diagnostic sensitivity compared with a traditional, swab NAAT assay. METHODS: We performed a prospective, noninferiority study comparing two U.S. Food and Drug Administration-approved NAAT assays for CT and NG: a 90-min rapid assay, the Xpert CT/NG Assay (Cepheid, Sunnyvale, CA) using a urine sample vs. a traditional assay, the Aptima Combo 2 Assay (Gen-Probe Incorporated, San Diego, CA) using a swab sample. This study was registered on Clinicaltrials.gov (NCT02386514). RESULTS: A total of 1162 patient samples were included in the primary analysis. We observed excellent kappa agreement between assays: NG for men, 1.00 (95% confidence interval [CI] 1.00-1.00); NG for women, 0.87 (95% CI 0.79-0.94); CT for men, 0.81 (95% CI 0.59-1.00); and CT for women: 0.85 (95% CI 0.80-0.90), as well as excellent negative and positive predictive values for the rapid assay. CONCLUSION: Although the rapid Xpert CT/NG assay's diagnostic sensitivity did not meet our prespecified threshold for noninferiority, the diagnostic characteristics are robust enough to fit into a management pathway that may reduce unnecessary antibiotic use. There may be an opportunity to utilize the rapid Xpert CT/NG assay to improve accuracy of treatment in the ED.

Predictive Capacity of 3 Comorbidity Indices in Estimating Survival Endpoints in Women With Early-Stage Endometrial Carcinoma.

OBJECTIVE: The negative impact of comorbidity on survival in women with endometrial carcinoma (EC) is well-known. Few validated comorbidity indices are available for clinical use, such as the Charlson Comorbidity Index (CCI), the Age-Adjusted CCI (AACCI), and the Adult Comorbidity Evaluation-27 (ACE-27). The aim of the study is to determine which index best correlates with survival endpoints in women with EC. MATERIALS AND METHODS: We identified 1132 women with early-stage EC treated at an academic center. Three scores were calculated for each patient using CCI, AACCI, and ACE-27 at the time of hysterectomy. Univariate and multivariable modeling was used to determine predictors of survival. RESULTS: For each of the studied comorbidity indices, the highest scores were significantly correlated with poorer overall survival. The hazard ratio of death from any cause was 3.92 for AACCI, 2.25 for CCI, and 1.57 for ACE-27. All 3 indices were independent predictors of overall survival with a P value of less than 0.001 on multivariate analysis. In addition, lymphovascular space invasion, lower uterine segment involvement, and tumor grade were predictors of overall survival. Lymphovascular space invasion, grade (P < 0.001), and high AACCI score were the only significant predictors of recurrence-free survival (RFS). Lymphovascular space invasion and tumor grade were the only 2 predictors of disease-specific survival. CONCLUSIONS: Although all 3 studied comorbidity indices were significant predictors of overall survival in women with early-stage EC, AACCI showed a stronger association. It should be considered for evaluating comorbidity in women with early-stage EC.

Recurrence patterns and survival endpoints in women with stage II uterine endometrioid carcinoma: a multi-institution study.

OBJECTIVE: There is paucity of data in regard to prognostic factors and outcome of women with 2009 FIGO stage II disease. The objective of this study was to investigate prognostic factors, recurrence patterns and survival endpoints in this group of patients. METHODS: Data from four academic institutions were analyzed. 130 women were identified with 2009 FIGO stage II. All patients underwent hysterectomy, oophorectomy and lymph node evaluation with or without pelvic and paraaortic lymph node dissections and peritoneal cytology. The Kaplan-Meier approach and Cox regression analysis were used to estimate recurrence-free (RFS), disease-specific (DSS) and overall survival (OS). RESULTS: Median follow-up was 44months. 120 patients (92%) underwent simple hysterectomy, 78% had lymph node dissection and 95% had peritoneal cytology examination. 99 patients (76%) received adjuvant radiation treatment (RT). 5-year RFS, DSS and OS were 77%, 90%, and 72%, respectively. On multivariate analysis of RFS, adjuvant RT, the presence of lymphovascular space invasion (LVSI) and high tumor grades were significant predictors. For DSS, LVSI and high tumor grades were significant predictors while older age and high tumor grade were the only predictors of OS. CONCLUSIONS: In this multi-institutional study, disease-specific survival for women with FIGO stage II uterine endometrioid carcinoma is excellent. High tumor grade, lymphovascular space invasion, adjuvant radiation treatment and old age are important prognostic factors. There was no significant difference in the outcome between patients who received vaginal cuff brachytherapy compared to those who received pelvic external beam radiation treatment.

An early appointment to outpatient cardiac rehabilitation at hospital discharge improves attendance at orientation: a randomized, single-blind, controlled trial.

BACKGROUND: Outpatient cardiac rehabilitation (CR) decreases mortality rates but is underutilized. Current median time from hospital discharge to enrollment is 35 days. We hypothesized that an appointment within 10 days would improve attendance at CR orientation. METHODS AND RESULTS: At hospital discharge, 148 patients with a nonsurgical qualifying diagnosis for CR were randomized to receive a CR orientation appointment either within 10 days (early) or at 35 days (standard). The primary end point was attendance at CR orientation. Secondary outcome measures were attendance at ≥1 exercise session, the total number of exercise sessions attended, completion of CR, and change in exercise training workload while in CR. Average age was 60±12 years; 56% of participants were male and 49% were black, with balanced baseline characteristics between groups. Median time (95% confidence interval) to orientation was 8.5 (7-13) versus 42 (35 to NA [not applicable]) days for the early and standard appointment groups, respectively (P<0.001). Attendance rates at the orientation session were 77% (57/74) versus 59% (44/74) in the early and standard appointment groups, respectively, which demonstrates a significant 18% absolute and 56% relative improvement (relative risk, 1.56; 95% confidence interval, 1.03-2.37; P=0.022). The number needed to treat was 5.7. There was no difference (P>0.05) in any of the secondary outcome measures, but statistical power for these end points was low. Safety analysis demonstrated no difference between groups in CR-related adverse events. CONCLUSIONS: Early appointments for CR significantly improve attendance at orientation. This simple technique could potentially increase initial CR participation nationwide. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01596036.

Intraoperative clinical assessment and pressure measurements of sentinel lymph nodes in breast cancer.

BACKGROUND: Clinicians have long regarded firm enlarged axillary nodes as suspicious for metastasis, and this has been confirmed to represent increased pressure in sentinel lymph nodes (SLN) in vivo in breast cancer. We hypothesized that measuring intranodal pressure (INP) in the operating room would correlate with metastasis size and be more sensitive than clinical observation. METHODS: Intranodal pressure mmHg was measured in SLNs #1 and #2 (N = 134 and 32) in 122 patients with T1/2 cN0 and 6 controls (T0) (8 bilateral). Clinical "Level of Suspicion" (LOS) was: 0 = benign; 1 = slightly suspicious; 2 = obvious metastasis. Statistical analysis was performed to compare INP, LOS, and SLN metastasis size mm. RESULTS: Sentinel lymph nodes met size correlated with INP (r = 0.65; p < 0.001). INP was 22.0 ± 1.3 mmHg in 35 SLNs with metastases compared with 9.3 ± 0.7 mmHg in 132 without (p < 0.001). Six groups created by combining LOS 0, 1, and 2 with INP >17 or ≤17 mmHg showed a significant (p < 0.001) correlation with SLN histology; sensitivity and specificity for LOS = 2/INP >17 mmHg = 100 % at predicting metastases; LOS = 0/INP ≤17 mmHg most often correct at predicting negative nodes (sensitivity 50 %, specificity 92.9 %, positive predictive value 55 %, negative predictive value 90.7 %). INP was better than LOS at predicting positive nodes in eight patients where INP was >17 mmHg. INP and LOS correlated significantly (p < 0.001). CONCLUSIONS: Clinical suspicion of metastasis correlated well with INP particularly at predicting macrometastases. INP was slightly better at predicting micrometastases. Measurement of INP may be valuable adjunct when performing SLN biopsy when further axillary surgery is contemplated.

The prevalence of metabolic syndrome in patients with hidradenitis suppurativa.

BACKGROUND: Metabolic syndrome is a multifaceted disorder strongly associated with increased risk for development of cardiovascular disease. Chronic inflammatory diseases have been associated with metabolic syndrome. Hidradenitis suppurativa is a chronic inflammatory skin disease with significant physical and emotional sequelae. OBJECTIVE: We sought to investigate a possible association between hidradenitis suppurativa and metabolic syndrome. METHODS: A retrospective chart review of all dermatology clinic encounters over an 18-month period identified 366 patients with an appropriate diagnosis of hidradenitis suppurativa. A control population was created from patients seen in the same clinic during the same time period for the diagnoses of either keloids or verruca vulgaris using the matching criteria of age ±5 years, race, and gender. All participants were examined for characteristics of the metabolic syndrome as defined by the National Cholesterol Education Program Adult Treatment Program III guidelines. RESULTS: The prevalence of metabolic syndrome in patients with hidradenitis suppurativa was 50.6%, which was significantly higher than the control group at 30.2% (P < .001). LIMITATIONS: This was a retrospective review. Some participants could not be analyzed for metabolic syndrome presence as a result of missing data points. CONCLUSION: Our results indicate that patients with hidradenitis suppurativa may be at high risk for metabolic syndrome.

The impact of tumor grade on survival end points and patterns of recurrence of 949 patients with early-stage endometrioid carcinoma: a single institution study.

OBJECTIVES: This study aimed to determine the impact of tumor grade on patterns of recurrence and survival end points in patients with endometrioid carcinoma 2009 International Federation of Gynecology and Obstetrics stages I-II. METHODS: We identified 949 patients who underwent hysterectomy between 1988 and 2011. Patients were divided into 3 groups based on tumor grade. Kaplan-Meier plots were generated for each group for recurrence-free survival (RFS), disease-specific survival (DSS), and overall survival (OS). RESULTS: Median follow-up was 52 months. Median age was 60 years. All patients underwent total abdominal hysterectomy and salpingo-oophorectomy. Eighty percent of patients underwent lymph node dissection, 83% had peritoneal cytology. There were 76 (8%) patients who developed tumor recurrence. Tumor recurrence rates were significantly higher in patients with grade 3 tumors compared to grade 1 (P = 0.006). Additionally, patients with grade 3 tumors developed significantly more frequent distant metastases compared to patients with grade 1 (P = 0.002). Five-year RFS for the patients with grade 1, 2, and 3 were 95%, 82%, and 68%, respectively (P = <0.001). Five-year DSS was 99%, 93%, and 79%, respectively (P = <0.001). Five-year OS was 89%, 84%, and 63%, respectively (P = <0.001). Lymphovascular space involvement and grade were significant independent predictors of RFS and DSS. For OS age, lymphovascular space involvement, grade, and body mass index were significant predictors. CONCLUSIONS: International Federation of Gynecology and Obstetrics grade is a strong predictor of clinical survival end points in women with early-stage endometrioid carcinoma. The pattern of recurrence in patients with grade 3 tumors is mainly distant rather than locoregional. Further studies incorporating systemic therapy in the adjuvant settings in these patients are warranted.

Sonographic evaluation of hip joint effusion in osteoarthritis with correlation to radiographic findings.

PURPOSE: Hip joint effusion is expected in rapidly destructive osteoarthritis, a diagnosis often only made retrospectively at the end stage of the disease. This study assesses whether the presence of an effusion identified during routine ultrasound-guided hip injection may suggest a more aggressive process such as rapidly destructive osteoarthritis. METHODS: After the observation of 10 index cases of rapidly destructive osteoarthritis in patients who presented with a joint effusion on ultrasound, we retrospectively reviewed 94 hips from 89 patients who underwent ultrasound-guided hip injection for pain. Preinjection longitudinal ultrasound images of the anterior capsule adjacent to the femoral neck and inferior to the femoral head were reviewed to determine if a joint effusion was present and the size of the effusion if one was there. Comparison of effusion size was then made between those hips that had a clinical and radiographic diagnosis of osteoarthritis and those who had rapidly destructive osteoarthritis by comparing the severity of joint effusion, if one was present. RESULTS: Patients with rapidly destructive osteoarthritis were more likely to have a large joint effusion 60% (3/5) than were those with osteoarthritis 6.7% (6/89) (p = 0.013). CONCLUSIONS: Large joint effusions identified sonographically correlate well with radiographic findings of rapidly destructive osteoarthritis. Given rapid onset and severity of the disease, when a large joint effusion is identified on routine hip intervention, patients should be forewarned of the potential for this disease process.

Impact of age-adjusted Charlson comorbidity score on outcomes for patients with early-stage endometrial cancer.

OBJECTIVES: To determine the impact of Age-Adjusted Charlson Comorbidity (AAC) index score on survival outcomes for patients with early stage endometrial cancer. METHODS: After IRB-approval, AAC score at time of hysterectomy was retrospectively tabulated by physician chart review for 671 patients with 2009 FIGO stage I-II endometrioid adenocarcinoma. Patients were grouped based on their AAC scores as follows: 0-1 (n=204), 2-3 (n=293) and >3 (n=174). Kaplan-Meier and log-rank test methods and univariate and multivariate modeling with Cox regression analysis was used to determine significant predictors of each survival endpoint. RESULTS: After a median follow-up of 85 months, 225 deaths were recorded (34 from EC and 191 from other causes) with a 7-year Overall (OS) and Disease-specific survival (DSS) of 77.6% and 94.0%, respectively. Based on AAC grouping, the 7-year OS, DSS, and Recurrence-free survival (RFS) were: 92.9%, 96.8%, and 94.9% for AAC 0-1; 81.7%, 95.3%, and 89.8% for AAC 2-3: and 56%, 88.2%, and 84.9% for AAC>3 (p<0.0001, p=0.005 and p=0.013, respectively). On multivariate analyses, higher AAC score, tumor grade, lower uterine segment involvement, and lymphovascular space invasion were significantly independent predictors for shorter OS, while for DSS and RFS, higher tumor grade and lymphovascular space invasion were significant predictors of worse outcome, but higher AAC score was not. CONCLUSIONS: Comorbidity score is as important as pathological features for predicting overall survival outcomes in patients with early-stage endometrioid endometrial carcinoma. Higher AAC scores accurately predicted for worse OS. Comorbidity score should be considered in prospective clinical trials of endometrial carcinoma.

Is time to recurrence after hysterectomy predictive of survival in patients with early stage endometrial carcinoma?

PURPOSE/OBJECTIVE(S): To determine the prognostic significance of time to recurrence (TTR) on overall survival (OS) and disease-specific survival (DSS) following recurrence in patients with stage I-II uterine endometrioid carcinoma. MATERIALS/METHODS: After IRB approval, we retrospectively identified 57 patients with recurrent endometrioid carcinoma who were initially treated for FIGO 1988 stages I-II between 1987 and 2009. The Kaplan-Meier approach and Cox regression analysis were used to estimate OS and DSS following recurrence and identify factors impacting outcomes. RESULTS: Median follow-up times were 54.8 months from hysterectomy and 19.8 months after recurrence. Median time to recurrence was 20.2 months. Twenty-eight (47%) patients had a recurrence<18 months after hysterectomy and 29 (53%) had a recurrence≥18 months. Both groups were evenly matched regarding initial pathological features and adjuvant treatments. The median OS and DSS in patients with TTR<18 months was shorter than those with TTR≥18 months, but not statistically significant (p=0.216). TTR did not impact outcomes after loco-regional recurrence, but for extrapelvic recurrence, a shorter TTR resulted in worse OS and DSS (p=0.03). On multivariate analysis, isolated loco-regional recurrence (HR 0.28, p=0.001) and salvage radiation therapy (HR 0.47, p=0.045) were statistically significant independent predictors of longer OS following recurrence. TTR as a continuous variable or dichotomized was not predictive of OS or DSS. CONCLUSIONS: In our study, the prognostic impact of time to recurrence was less important than the site of recurrence. While not prognostic for the entire cohort or for patients with loco-regional recurrence, TTR<18 months was associated with shorter OS and DSS after extrapelvic recurrence.

Photoprotection counseling of non-white ethno-racial groups: a survey of the practice of expert dermatologists.

The morbidity of skin cancer in non-white, ethno-racial populations is well established, yet no specific guidelines exist addressing the manner in which this population should be counseled on photoexposure. We conducted a 20-item survey to assess the behavior of specialized dermatologists when providing photoprotection recommendations to non-white, ethno-racial patients as well as the perceived relevance of counseling for this group. Our study demonstrated that key opinion leaders within the fields of photodermatology and ethnic dermatology believe that photoprotection counseling is beneficial for ethno-racial minorities. Based on these preliminary data and other recently published reports, the development of photoprotection guidelines specific to non-white, ethno-racial groups may be warranted.

Sentinel lymph node pressure in breast cancer.

BACKGROUND: Leakiness of angiogenic tumor vessels results in elevated pressure in primary breast cancers and increased lymphatic flow to sentinel lymph node(s) (SLNs). We hypothesized that a similar pathophysiology in metastatic axillary SLNs would result in increased intranodal pressure (INP). METHODS: SLNs were "hot" and "blue" after intramammary injection of dilute methylene blue and filtered Tc99 sulfur colloid. Intraoperative pressure was measured in SLNs by a noncoring needle and recording device in 114 breast cancer patients. Excised axillary SLNs were examined by standard pathological techniques and metastases measured, recorded, and compared with INP measurements for SLN #1 and sometimes #2. RESULTS: INP in 131 SLNs with no tumor (SLN #1, n = 93; SLN #2, n = 38) was 9.1 ± 6.2 (SD; range -2, 35) mmHg and 21.4 ± 15.4 mmHg (range 0-50) in 35 tumor-containing SLNs (SLN #1, n = 29; SLN #2, n = 6) (P = 0.0066). Elevated INPs significantly correlated with SLN tumor metastasis sizes (P = 0.0038; r = 0.4904). In two patients, tumor-laden SLNs with high INP were not blue or "hot" while a blue lymphatic bypassed these nodes and was traced to the next echelon tumor-free blue and "hot" nodes with low INP. CONCLUSIONS: Breast cancer metastasis in axillary SLNs was associated with significantly higher INP than in tumor-free lymph nodes. When "true" SLNs were replaced by tumor, and the INP levels were very high, lymph flow direction changed; lymphophilic particles (blue dye and radiocolloid) were redirected to the next echelon of nodes, where the pressures were much lower. Mechanical factors may increase the likelihood of metastasis to neighboring lymph nodes with lower INP.

Screening for diabetes in an African American community: identifying characteristics associated with abnormal blood glucose readings.

OBJECTIVE: To identify characteristics associated with abnormal blood glucose readings among African Americans and to determine the potential value of a more targeted approach to community-based screenings for type 2 diabetes. METHODS: Data were collected from 7113 participants with no previous diagnosis of diabetes at mobile screening events in Detroit, Michigan. Data collected included gender, race, age, self-reported height and weight, total diabetes risk score, blood pressure, and random capillary blood glucose. RESULTS: Nearly 9% of participants had abnormal random plasma glucose readings (RPG>or=160 mg/dL). Results indicated that higher age, elevated blood pressure, and body mass index (BMI) were significantly associated with abnormal glucose readings. CONCLUSION: These findings suggest that community-based screenings for diabetes that are targeted to adults aged more than 50 years who have high blood pressure or a BMI of at least 25 may enhance detection of abnormal glucose levels among African Americans.

Survival outcomes and patterns of failure in women with stage IIIC2 endometrial carcinoma.

OBJECTIVES: Para-aortic lymph node involvement in women with endometrial carcinoma (EC) is a poor prognostic factor. Many studies have included women with stage IIIC2 in cohorts of patients with advanced stage disease. The aim of this study was to analyze survival outcomes and patterns of failure in women with solely stage IIIC2 EC. METHODS: We identified women with FIGO stage IIIC2 EC who underwent surgical staging at our institution. In addition to descriptive analyses of patient demographics, tumor characteristics, and adjuvant treatment received, univariate log-rank analyses and Cox regression multivariate analyses (MVA) were performed to identify predictors of recurrence-free (RFS), disease-specific (DSS) and overall survival (OS). RESULTS: A total of 72 women were included in this study cohort. The median follow-up time was 43 months. The median number of positive para-aortic lymph nodes was one. Of the 61 women (84.7%) who received adjuvant therapy, 40 women (65.6%) received chemotherapy and radiation therapy (CRT), 17 women (27.9%) received chemotherapy alone (CT), and only 4 women (6.6%) received radiation therapy alone. Thirty-seven women (51.4%) experienced disease recurrence. Distant metastasis was the most common pattern of failure (73%). Five-year RFS, DSS, and OS were 48%, 51%, and 48%, respectively. Due to small study size, our exploratory multivariate analysis demonstrated that histologic grade was the only significant prognostic factor for DSS (p=0.03) and OS (p=0.02). The type of adjuvant therapy did not sustain its independent predictive significance for RFS, DSS and OS. CONCLUSIONS: Our findings suggest that almost half of women with stage IIIC2 can be cured with surgical staging and adjuvant therapies. The most common pattern of failure was distant metastasis calling for further optimization of systemic therapy.

Stereotactic Body Radiotherapy for Elderly Patients With Medically Inoperable Pancreatic Cancer.

OBJECTIVES: People over the age of 75 years account for approximately 40% of patients diagnosed with pancreatic cancer, many with comorbidities that may limit their treatment options. This study reports on the use of stereotactic body radiation therapy (SBRT) in this population. MATERIALS AND METHODS: Twenty consecutively treated patients over the age of 75 with pathologically proven localized pancreatic cancer were included in this retrospective review. All had been evaluated by a multidisciplinary team as unable to tolerate surgery or combined chemoradiation therapy. Patient outcomes were analyzed to determine the safety and efficacy of SBRT in this elderly cohort. RESULTS: The median age was 83.2 years (minimum 77 y, maximum 90 y). Eighteen patients were treated at time of initial diagnosis, and 2 for recurrence after surgery. Eleven (55%) of the patients had an Adult Comorbidity Evaluation-27 comorbidity index score of 3 (severe) and 6 (30%) had a score of 2 (moderate). Fourteen patients were treated with 35 Gy in 5 fractions, 5 with 30 Gy in 5 fractions, and 1 patient with 36 Gy in 3 fractions. Seven (35%) patients had common terminology criteria for adverse events (CTCAE) V4.0 toxicity grade of 1-2, and 3 patients had a CTCAE V4.0 toxicity grade of 3-4, 2 with dehydration, and 1 had episodes of gastrointestinal bleeding. Three patients recurred locally, 10 had distant metastases, 4 of whom were found on the first posttreatment scan. Median overall survival was 6.4 months (95% confidence interval, 3.5-10.8 mo). Median recurrence-free survival was 6.8 months (95% confidence interval, 1.3-23.5 mo). Two patients survived >23 months. CONCLUSION: SBRT for pancreatic cancer appears to be a safe and effective method for treatment of elderly patients, even in the setting of severe comorbidities.

The impact of lymphadenectomy on survival endpoints in women with early stage uterine endometrioid carcinoma: A matched analysis.

OBJECTIVES: The role of pelvic lymphadenectomy (LA) in women with stage I endometrial carcinoma (EC) is controversial. The objective of this study is to investigate the prognostic impact of LA on survival endpoints in matched cohorts of women with stage I EC solely of endometrioid histology. Survival endpoints included recurrence-free (RFS), disease-specific (DSS) and overall survival (OS). METHODS AND MATERIALS: Patients with FIGO stage I EC who underwent hysterectomy with LA as part of their surgical staging between 1/1990 and 6/2015 were matched to a similar group that underwent hysterectomy without lymphadenectomy (NLA), based on stage, grade and adjuvant management. Univariate and multivariate modeling with Cox regression analysis was carried out for predictors of survival endpoints. RESULTS: 870 women constituted the study cohort (435 in each group). Median number of dissected lymph node in the LA group was 9 (range, 5-75). There was no statistically significant difference between the two groups in regards to 5-year OS (87.2% for LA vs. 91.7% for NLA) (p=0.36), DSS 97.7% vs. 98% (p=0.54) and RFS (93.7% vs. 90% (p=0.08), respectively. Lymphadenectomy was not a predictor of any of the studied survival endpoints. On multivariate analysis for the entire cohort, older age, deep myometrial invasion and higher tumor grade were predictors of worse RFS. For DSS, higher tumor grade, lower uterine segment (LUS) involvement and FIGO stage IB were significant predictors of worse outcome. For OS, older age and LUS involvement were the only two independent predictors for shorter OS. CONCLUSIONS: After matching for FIGO stage, grade and adjuvant management, it appears that lymphadenectomy in women with stage I EC does not impact survival endpoints.

Risk Factors for 30-Day Mortality in Patients with Methicillin-Resistant Staphylococcus aureus Bloodstream Infections.

OBJECTIVES: Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections (BSI) are a major health care problem accounting for a large percentage of nosocomial infections. The aim of this study was to identify risk factors associated with 30-day mortality in patients with MRSA BSI. METHODS: This was a retrospective study performed in Southeast Michigan. Over a 9- year period, a total of 1,168 patients were identified with MRSA BSI. Patient demographics and clinical data were retrieved and evaluated using electronic medical health records. RESULTS: 30-day mortality during the 9-year study period was 16%. Significant risk factors for 30-day mortality were age, cancer, heart disease, neurologic disease, nursing home residence and Charlson score >3 with Odds Ratio (OR) of 1.03 (CI 1.02-1.04), 2.29 (CI 1.40-3.75), 1.78 (CI 1.20-2.63), 1.65 (CI 1.08-2.25), 1.66 (CI 1.02 - 2.70) and 1.86 (CI 1.18 - 2.95) correspondingly. Diabetes mellitus, peripheral vascular disease (PVD), and readmission were protective factors for 30-day mortality with OR of 0.53 (CI 0.36-0.78), 0.46 (CI 0.26-0.84) and 0.13 (CI0.05 - 0.32) respectively. CONCLUSIONS: Our study identified significant risk factors for 30-day mortality in patients with MRSA BSI. Interestingly, diabetes mellitus, PVD and readmission were protective effects on 30-day mortality. There was no statistically significant variability in 30-day mortality over the 9-year study period.

Identifying disparity in emergency department length of stay and admission likelihood.

BACKGROUND: To assess whether insurance status has an effect on emergency department (ED) length of stay (LOS) and likelihood for admission or transfer to an operating room. METHODS: This was a retrospective cross-sectional study of all encounters from January 2011 through October 2013 at an urban, academic trauma center. Analysis included multi-variable linear regression for ED LOS and logistic regression for the likelihood of admission. RESULTS: Overall, 201 535 patients met the inclusion criteria, for which the mean age was 43.8 years, 55.9% were female, 23.4% were uninsured and 8% were of non-black race. Admission rate was 24.5% and operative rate was 1.4%. After adjusting for age, sex, triage acuity and race, the presence of insurance coverage was associated with an increased ED LOS of 575 (95%CI 552-598) vs. 567 (95%CI 543-591) minutes (P<0.01) among admitted patients and a decreased ED LOS of 456 (95%CI 381-531) vs. 499 (95%CI 423-575) minutes (P<0.01) among those transferred to an operating room. Adjusting for these same predictors, insured status remained a predictor for admission (odds ratio 1.24, 95%CI 1.20-1.28, P<0.01) and a negative predictor for transfer to the operating room (odds ratio 0.84, 95%CI 0.77-0.92, P<0.01). CONCLUSION: The insured experienced a clinically insignificant increase in ED LOS when admitted and a 43-minute decrease in ED LOS when being transferred to the operating room. The insured were more likely to be admitted and less likely to be transferred to an operating room.