Preoperative assessment using the five-factor modified frailty index: A call for standardized preoperative assessment and prehabilitation services in gynecologic oncology.

OBJECTIVE: To evaluate if the 5-factor modified frailty index (mFI) is associated with postoperative complications, readmissions or non-home discharge in gynecologic cancer patients undergoing surgery. METHODS: Patients with a diagnosis of gynecologic cancer (cervical, uterine, or ovarian cancer) who underwent surgery between 2014 and 2018 were identified through the National Surgical Quality Improvement Program (NSQIP) database. The 5-factor mFI was applied and patients classified into 6 categories (mFI groups 0,1,2, 3, 4 and 5). The incidence of 30-day complications, readmissions and non-home discharge was evaluated. Multivariable logistic regression models were used to determine the association between mFI category and readmissions/ complications. Adjusted probabilities of events were calculated based on patient characteristics. RESULTS: At total of 31,181 gynecologic cancer cases were included in the analysis: N = 2968 (9.4%) cervical, N = 20,862 (66.4%) uterine, and N = 7351 (23.4%) ovarian cancers. Of all patients, 46.1% were in category 0, 36.5% category 1, and 1% category 3-5. Factors associated with increased mFI included older age, African American race, laparoscopic surgery and obesity. A significant dose-response relationship between higher mFI and readmission and 30-day complications was noted on adjusted multivariable analysis (adjusted OR 2.37 (1.65-3.45) and 2.10 (1.59-2.75) for readmissions and complications, respectively, in mFI category 3-5). These associations were consistent within each cancer type. CONCLUSIONS: The 5-factor mFI universally predicts postoperative readmissions, 30-day complications and non-home discharge in patients with gynecologic cancer. Incorporation of mFI into routine preoperative assessment can identify patients for non-surgical treatments, prehabiliatation and short term home assessments.

Vascular Risk Factor Prevalence and Trends in Native Americans with Ischemic Stroke.

INTRODUCTION: Native Americans have a higher incidence and prevalence of stroke and the highest stroke-related mortality among race-ethnic groups in the United States. We aimed to analyze trends in the ischemic stroke (IS) vascular risk factor prevalence in Native Americans along with a comparison to the other race-ethnic groups. METHODS: National Inpatient Sample (NIS) database was used to explore the prevalence of risk factors among hospitalized IS patients during 2000 - 2016. Prevalence estimates were calculated for each risk factor within each race-ethnic group in 6 time periods. Linear trends were explored using linear regression models, with differences in trends between the Native American group and the other race-ethnic groups assessed using interaction terms. The analysis accounted for the complex sampling design, including hospital clusters, NIS stratum, and trend weights for analyzing multiple years of NIS data. RESULTS: Native Americans constituted 5472 of the 1,278,784 IS patients. The age-and-sex-standardized prevalence of hypertension (slope = 2.24, p < 0.001), hyperlipidemia (slope = 6.29, p < 0.001), diabetes (slope = 2.04, p = 0.005), atrial fibrillation/flutter (trend slope = 0.80, p = 0.011), heart failure (trend slope = 0.73, p = 0.036) smoking (trend slope= 3.65, p < 0.001), and alcohol (slope = 0.60, p = 0.019) increased among Native Americans. They showed larger increases in hypertension prevalence compared to Blacks, Hispanics, and Asian/Pacific Islanders and in smoking prevalence compared to Hispanics and Asian/Pacific Islanders. By the year 2015-2016, Native Americans had the highest overall prevalence of diabetes, coronary artery disease, smoking, and alcohol among all race-ethnic groups. CONCLUSION: The prevalence of most vascular risk factors among ischemic stroke patients has increased in Native Americans over the last two decades. Significantly larger increases in hypertension and smoking prevalence were seen in Native Americans compared to other groups along with them having the highest prevalence in multiple risk factors in recent years.

The Association of Socioeconomic Status and Discharge Destination with 30-Day Readmission after Ischemic Stroke.

OBJECTIVES: This study aimed to explore the association of socioeconomic status and discharge destination with 30-day readmission after ischemic stroke. MATERIALS AND METHODS: We examined 30-day all-cause readmission among patients hospitalized for ischemic stroke in states of Arkansas, Iowa, and Wisconsin in 2016 and 2017 and New York in 2016 using Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases. RESULTS: Among the 52301 patients included, 51.1% were female. The 30-day readmission rates were 10.2%, 8.2%, 9.3%, 10.4%, 11.6%, and 11.2% for age group 18-34, 35-44, 45-54, 55-64, 65-74, and ≥75 years, respectively (p<0.001). In Generalized Estimating Equation analysis, patients with Medicare and Medicaid insurance were more likely to be readmitted, compared with private insurance, (adjusted Odds Ratio [aOR] 1.37, 95% CI 1.23-1.53; and aOR 1.26, 95% CI 1.09-1.45, respectively). Patients in the bottom quartile of zip code level median household income had higher 30-day readmission rate (12.4%) than those in the 2nd, 3rd and 4th quartile (10.3%, 10.1%, and 10.7%, respectively, p<0.001). Compared with those discharged home with self-care which had the lowest readmission rate (8.4%), patients who left against medical advice had the highest readmission rate (18.6%; aOR 2.23, 95% CI 1.75-2.83), followed by rehabilitation and skilled nursing facilities (13.2%; aOR 1.33, 95% CI 1.22-1.46), and home with home health care (11.3%, aOR 1.18, 95% CI 1.08-1.28). CONCLUSIONS: Socioeconomic status and discharged destination affect readmission after stroke. These results provide evidence to inform vulnerable patient population as targets for readmission prevention.

The Patterns and Outcomes of Inter-Hospital Transfer Among Medicare Patients with Ischemic Stroke.

BACKGROUND AND PURPOSE: Inter-hospital transfer for ischemic stroke is an essential part of stroke system of care. This study aimed to understand the national patterns and outcomes of ischemic stroke transfer. METHODS AND RESULTS: This retrospective study examined Medicare beneficiaries aged ≥65 years undergoing inter-hospital transfer for ischemic stroke in 2012. Cox proportional hazards model was used to compare 30-day and one-year mortality between transferred patients and direct admissions from the emergency department (ED admissions). Among 312,367 ischemic stroke admissions, 5.7% underwent inter-hospital transfer. Using this value as cut-off, the hospitals were classified into receiving (n = 411), sending (n = 559), and low-transfer (n = 1863) hospitals. Receiving hospitals were larger than low-transfer and sending hospitals as demonstrated by the median bed number (371, 189, and 88, respectively, p < 0.001); more frequently to be certified stroke centers (75%, 47%, and 16%, respectively, p < 0.001); and less commonly located in the rural area (2%, 7%, and 24%, respectively, p < 0.001). For receiving hospitals, transfer-in patients and ED admissions had comparable mortality at 30 days (10% vs 10%; adjusted HR [aHR]=1.07; 95% CI, 0.99-1.14) and 1 year (23% vs 24%; aHR=1.03; 95% CI, 0.99-1.08). For sending hospitals, transfer-out patients, compared to ED admissions, had higher mortality at 30 days (14% vs 11%; aHR=1.63; 95% CI, 1.39-1.91) and 1 year (30% vs 27%; aHR=1.33; 95% CI, 1.20-1.48). For low-transfer hospitals, overall transfer-in and transfer-out patients, compared to ED admissions, had higher mortality at 30 days (13% vs 10%; aHR=1.46; 95% CI, 1.33-1.60) and 1 year (28% vs 25%; aHR=1.27; 95% CI, 1.19-1.36). CONCLUSIONS: Hospitals in the US, based on their transfer patterns, could be classified into 3 groups that shared distinct characteristics including hospital size, rural vs urban location, and stroke certification. Transferred patients at sending and low-transfer hospitals had worse outcomes than their ED admission counterpart.

Plant-based, no-added-fat or American Heart Association diets: impact on cardiovascular risk in obese children with hypercholesterolemia and their parents.

OBJECTIVE: To perform a randomized trial to determine whether there is cardiovascular disease (CVD) risk reduction from a plant-based (PB), no-added-fat diet and the American Heart Association (AHA) diet in children. STUDY DESIGN: A 4-week (April 20, 2013 to May 18, 2013), prospective randomized trial was undertaken in a large, Midwestern hospital system's predominantly middle class outpatient pediatric practices. Thirty children (9-18 years of age) parent pairs with a last recorded child body mass index >95th percentile and child cholesterol >169 mg/dL were randomized to PB or AHA with weekly 2-hour classes of nutrition education. RESULTS: Children on PB had 9 and children on AHA had 4 statistically significant (P < .05) beneficial changes from baseline (mean decreases): body mass index z-score(PB) (-0.14), systolic blood pressure(PB) (-6.43 mm Hg), total cholesterol(PB) (-22.5 mg/dL), low-density lipoprotein(PB) (-13.14 mg/dL), high-sensitivity C-reactive protein(PB) (-2.09 mg/L), insulin(PB) (-5.42 uU/mL), myeloperoxidase(PB/AHA) (-75.34/69.23 pmol/L), mid-arm circumference(PB/AHA) (-2.02/-1.55 cm), weight(PB/AHA) (-3.05/-1.14 kg), and waist circumference(AHA) (-2.96 cm). Adults on PB and AHA had 7 and 2, respectively, statistically significant (P < .05) beneficial changes. The significant change favoring AHA was a 1% difference in children's waist circumference. Difficulty shopping for food for the PB was the only statistically significant acceptability barrier. CONCLUSIONS: PB and the AHA in both children and adults demonstrated potentially beneficial changes from baseline in risk factors for CVD. Future larger, long-term randomized trials with easily accessible PB foods will further define the role of the PB in preventing CVD.

Serious fall injuries in hospitalized patients with and without cancer.

Characteristics of adults hospitalized with and without cancer were compared to determine factors of serious injuries after fall events. More patients with cancer who had a serious injury received corticosteroids (P = .005) and were treated on a palliative care floor. More patients without cancer had higher prevalence of stroke (P = .026) and diabetes (P = .041) history and were treated on a surgical floor. Future research is needed to identify interventions that could prevent serious injuries after fall events.

Survival rates of children with acute lymphoblastic leukemia presenting to a pediatric rheumatologist in the United States.

BACKGROUND: Approximately 30% of pediatric acute lymphoblastic leukemia patients present with musculoskeletal symptoms and are often referred first to a pediatric rheumatologist. We examined the survival and causes of death of these patients presenting to a pediatric rheumatologist and compared the rates with that reported in the hematology-oncology literature. PROCEDURE: We used the Pediatric Rheumatology Disease Registry, including 49,023 patients from 62 centers, newly diagnosed between 1992 and 2001. Identifiers were matched with the Social Security Death Index censored for March 2005. Deaths were confirmed by death certificates, referring physicians, and medical records. Causes of death were derived by chart review or from the death certificate. RESULTS: There were 7 deaths of 89 patients (7.9%, 95% confidence interval: 3.9%-15.4%) with acute lymphoblastic leukemia with a 5-year survival rate of 95.5% (88.3 to 98.3) and 10-year survival rate of 89.8% (79.0% to 95.2%). The causes of death were sepsis (bacterial and/or fungal) in 4 (57%) patients, the disease in 2 (29%) and post bone-marrow transplantation in 1 (14%). CONCLUSION: The overall survival of patients with acute lymphoblastic leukemia seen first by pediatric rheumatologists is higher than the range reported in the pediatric oncology literature for the same period of diagnosis.

Nighttime noise issues that interrupt sleep after cardiac surgery.

Patients' perceptions of noise events that prevent/interrupt nighttime sleep after cardiac surgery and sleep promotion aids were studied for associations with patient characteristics. Overhead paging, equipment, and loud communication prevented/interrupted nighttime sleep; however, most patient characteristics were not associated with the presence or absence of these noise events. Patients selected pain medication to promote sleep. Other sleep aids were used infrequently. Behavioral and structural noise reduction interventions are needed to minimize sleep interruptions.

Automated External Defibrillator Application Before EMS Arrival in Pediatric Cardiac Arrests.

BACKGROUND: Little is known about the predictors of pre-emergency medical service (EMS) automated external defibrillator (AED) application in pediatric out-of-hospital cardiac arrests. We sought to determine patient- and neighborhood-level characteristics associated with pre-EMS AED application in the pediatric population. METHODS: We reviewed prospectively collected data from the Cardiac Arrest Registry to Enhance Survival on pediatric patients (age >1 to ≤18 years old) who had out-of-hospital nontraumatic arrest (2013-2015). RESULTS: A total of 1398 patients were included in this analysis (64% boys, 45% white, and median age of 11 years old). An AED was applied in 28% of the cases. Factors associated with pre-EMS AED application in univariable analyses were older age (odds ratio [OR]: 1.9; 12-18 years old vs 2-11 years old; P < .001), white versus African American race (OR: 1.4; P = .04), public location (OR: 1.9; P < .001), witnessed status (OR: 1.6; P < .001), arrests presumed to be cardiac versus respiratory etiology (OR: 1.5; P = .02) or drowning etiology (OR: 2.0; P < .001), white-populated neighborhoods (OR: 1.2 per 20% increase in white race; P = .01), neighborhood median household income (OR: 1.1 per $20 000 increase; P = .02), and neighborhood level of education (OR: 1.3 per 20% increase in high school graduates; P = .006). However, only age, witnessed status, arrest location, and arrests of presumed cardiac etiology versus drowning remained significant in the multivariable model. The overall cohort survival to hospital discharge was 19%. CONCLUSIONS: The overall pre-EMS AED application rate in pediatric patients remains low.

Value of, Attitudes Toward, and Implementation of Evidence-Based Practices Based on Use of Self-Study Learning Modules.

BACKGROUND: It is unknown if completing educational modules on understanding, reviewing, and synthesizing research literature is associated with higher value of, attitudes toward, and implementation of evidence-based practices. METHOD: Nurses completed valid, reliable questionnaires on the value of, attitudes toward, and implementation of evidence-based practice 6 months after four educational modules were introduced. Multivariable modeling was used to learn associations of education modules and evidence-based practice themes. RESULTS: Of 1,033 participants, 54% completed at least one education module; 22% completed all modules. Value and attitude about evidence-based practice were moderately high, but implementation was low (mean = 15.15 ± 15.72; range = 0 to 72). After controlling for nurse characteristics and experiences associated with evidence-based practice value, attitudes, and implementation scores, education modules completion was associated with the implementation of evidence-based practice (p = .001), but not with value or attitude of evidence-based practices scores. CONCLUSION: Education on reviewing and synthesizing literature strengthened implementation of evidence-based practices. J Contin Educ Nurs. 2017;48(5):209-216.

From Bad to Worse: Anemia on Admission and Hospital-Acquired Anemia.

BACKGROUND: Anemia at hospitalization is often treated as an accompaniment to an underlying illness, without active investigation, despite its association with morbidity. Development of hospital-acquired anemia (HAA) has also been associated with increased risk for poor outcomes. Together, they may further heighten morbidity risk from bad to worse. OBJECTIVES: The aims of this study were to (1) examine mortality, length of stay, and total charges in patients with present-on-admission (POA) anemia and (2) determine whether these are exacerbated by development of HAA. DESIGN/SETTING/PATIENTS: In this cohort investigation, from January 1, 2009, to August 31, 2011, a total of 44,483 patients with POA anemia were admitted to a single health system compared with a reference group of 48,640 without POA anemia or HAA. MEASUREMENTS: Data sources included the University HealthSystem Consortium database and electronic medical records. Risk-adjustment methods included logistic and linear regression models for mortality, length of stay, and total charges. Present-on-admission anemia was defined by administrative coding. Hospital-acquired anemia was determined by changes in hemoglobin values from the electronic medical record. RESULTS: Approximately one-half of the patients experienced worsening of anemia with development of HAA. Risk for death and resource use increased with increasing severity of HAA. Those who developed severe HAA had 2-fold greater odds for death; that is, mild POA anemia with development of severe HAA resulted in greater mortality (odds ratio, 2.57; 95% confidence interval, 2.08-3.18; P < 0.001), increased length of stay (2.23; 2.16-2.31; P < 0.001), and higher charges (2.09; 2.03-2.15; P < 0.001). CONCLUSIONS: Present-on-admission anemia is associated with increased mortality and resource use. This risk is further increased from bad to worse when patients develop HAA. Efforts to address POA anemia and HAA deserve attention.

Effectiveness of Shared Medical Appointments Versus Traditional Clinic Visits for Adolescents With Type 1 Diabetes.

Shared medical appointments began in the United States in 1996 to advance quality of care and enhance patients' ability to self-manage. Group visits gather patients with the same diagnosis for individual examinations followed by group education sessions taught by the provider. This leads to the opportunity to learn from the experiences of others. The Cleveland Clinic Department of Pediatric Endocrinology offers a shared medical appointment group for pediatric patients with type 1 diabetes called the ESCALAIT clinic (Enrichment Services and Care for Adolescents Living with Autoimmune Insulin Dependent Type 1 Diabetes). The objective of this study was to compare the effectiveness of traditional clinic visits with shared medical appointments for adolescents with type 1 diabetes in terms of hemoglobin A1c (HbA1c) improvement. Eighty ESCALAIT patients, aged 11 to 19 years were compared with 516 clinic controls of the same age. Visits were approximately 3 months apart for both patient groups. Changes in HbA1c between groups were calculated from the first to fourth visits. There was a statistically significant difference between the ESCALAIT clinic patients and the control patients. Our results revealed that the group visit patients had less improvement in HbA1c values at the last visit approximately 1 year later, but we would argue that the difference is not clinically significant. However, there were many benefits to shared medical appointment visits including increased access to care as well as peer support. Shared medical appointments are therefore a valid alternative to traditional clinic visits in this patient population.

Contemporary bloodletting in cardiac surgical care.

BACKGROUND: Health care providers are seldom aware of the frequency and volume of phlebotomy for laboratory testing, bloodletting that often leads to hospital-acquired anemia. Our objectives were to examine the frequency of laboratory testing in patients undergoing cardiac surgery, calculate cumulative phlebotomy volume from time of initial surgical consultation to hospital discharge, and propose strategies to reduce phlebotomy volume. METHODS: From January 1, 2012 to June 30, 2012, 1,894 patients underwent cardiac surgery at Cleveland Clinic; 1,867 had 1 hospitalization and 27 had 2. Each laboratory test was associated with a test name and blood volume. Phlebotomy volume was estimated separately for the intensive care unit (ICU), hospital floors, and cumulatively. RESULTS: A total of 221,498 laboratory tests were performed, averaging 115 tests per patient. The most frequently performed tests were 88,068 blood gas analyses, 39,535 coagulation tests, 30,421 complete blood counts, and 29,374 metabolic panels. Phlebotomy volume differed between ICU and hospital floors, with median volumes of 332 mL and 118 mL, respectively. Cumulative median volume for the entire hospital stay was 454 mL. More complex procedures were associated with higher overall phlebotomy volume than isolated procedures; eg, combined coronary artery bypass grafting (CABG) and valve procedure median volume was 653 mL (25th/75th percentiles, 428 of 1,065 mL) versus 448 mL (284 of 658 mL) for isolated CABG and 338 mL (237 of 619) for isolated valve procedures. CONCLUSIONS: We were astonished by the extent of bloodletting, with total phlebotomy volumes approaching amounts equivalent to 1 to 2 red blood cell units. Implementation of process improvement initiatives can potentially reduce phlebotomy volumes and resource utilization.

Predictors of a fall event in hospitalized patients with cancer.

PURPOSE/OBJECTIVES: To determine predictors of fall events in hospitalized patients with cancer and develop a scoring system to predict fall events. DESIGN: Retrospective medical record review. SETTING: A 1,200-bed tertiary care hospital in northeastern Ohio. SAMPLE: 145 patients with cancer who did not have a fall event were randomly selected from all oncology admissions from February 2006-January 2007 and compared to 143 hospitalized patients with cancer who had a fall event during the same period. METHODS: Multivariable logistic regression models predicting falls were fit. Risk score analysis was completed using bootstrap samples to evaluate discrimination between patients who did or did not fall and agreement between predicted and actual fall status. A nomogram of risk scores was created. MAIN RESEARCH VARIABLES: Fall episodes during hospitalization and patient characteristics that predict falls. FINDINGS: While patients were hospitalized for cancer care, their predictors of a fall episode were low pain level, abnormal gait, cancer type, presence of metastasis, antidepressant and antipsychotic medication use, and blood product use (all p < 0.02); risk model c-statistic was 0.89. CONCLUSIONS: For hospitalized patients with cancer, predictors reflecting greater fall episode risk can be assessed easily by nursing staff and acted on when the risk is sufficiently high. IMPLICATIONS FOR NURSING: Understanding specific risk factors of falls in an adult oncology population may lead to interventions that reduce fall risk.

Chronic disease risks in young adults with autism spectrum disorder: forewarned is forearmed.

An emerging, cost-effective method to examine prevalent and future health risks of persons with disabilities is electronic health record (EHR) analysis. As an example, a case-control EHR analysis of adults with autism spectrum disorder receiving primary care through the Cleveland Clinic from 2005 to 2008 identified 108 adults with autism spectrum disorder. In this cohort, rates of chronic disease included 34.9% for obesity, 31.5% for hyperlipidemia, and 19.4% for hypertension. Compared with a control cohort of patients from the same health system matched for age, sex, race, and health insurance status, adults with autism spectrum disorder were more likely to be diagnosed with hyperlipidemia (odds ratio  =  2.0, confidence interval  =  1.2-3.4, p  =  .012). Without intervention, adults with autism spectrum disorder appear to be at significant risk for developing diabetes, coronary heart disease, and cancer by midlife.

Electronic Health Record Analysis of the Primary Care of Adults with Intellectual and Other Developmental Disabilities.

BACKGROUND AND AIMS: Adults with intellectual and other developmental disabilities (IDD) are at risk for sub-optimal primary health care. Electronic Health Record (EHR) analyses are an under-utilized resource for studying the health and primary care of this population. METHODS: This was a case-control EHR analysis of adults with IDD provided primary care through the Cleveland Clinic between 2005 and 2008. The IDD cohort was identified by relevant ICD-9 codes in problem list and encounter diagnoses. A comparison cohort matched by age, sex, race, and insurance was also specified. Demographic, health and health service characteristics of the two cohorts were compared. FINDINGS: The IDD cohort consisted of 1267 individuals, mean age 39 years, 54% male, 78% Caucasian. Age, sex, racial, and health insurance characteristics were similar in the 2534 individuals in the comparison cohort. Individuals with IDD were significantly more likely to carry diagnoses of epilepsy, constipation, osteoporosis, obesity, and hyperlipidemia; but were significantly less likely to bear diagnoses of hypertension, diabetes, osteoarthritis, heart failure, coronary heart disease, and COPD. Despite a lower mean BMI, individuals with IDD were more likely to be labeled obese. Only genetic consultation rates were higher in the IDD cohort. DISCUSSION: Health services research related to persons with IDD is becoming more feasible as large health systems adopt EHRs. Further analyses from this dataset will investigate whether variations in disease rates in adults with IDD represent true differences in disease prevalence versus disparities in health care.

Effect of Medicare Part D on potentially inappropriate medication use by older adults.

OBJECTIVES: To empirically estimate changes of potentially inappropriate medication (PIM) use attributable to the Medicare Part D prescription drug benefit. DESIGN: Difference-in-difference strategy in the quasi-experimental design with a control group. SETTING: U.S. nationally representative community-dwelling sample of older adults. PARTICIPANTS: One thousand seven hundred seventy-four adults aged 65 and older in the 2005 and 2006 Medical Expenditure Panel Surveys were followed up for 2 years with five rounds of interviews. MEASUREMENTS: PIM use was identified based on the 2002 Beers criteria. Analyses were conducted for likelihood of PIM use and number of PIM prescriptions using logit models and negative binomial models, respectively. RESULTS: There was a trend of less likelihood of PIM use for all older adults from 2005 to 2006 (odds ratio=0.67, 95% confidence interval (CI)=0.52-0.86). After accounting for this secular trend and potential confounders, no significant difference of the likelihood of PIM use was found between Part D enrollees and nonenrollees, although enrollees were found to use significantly more PIM prescriptions in round 5 (in 2006) than nonenrollees (incidence rate ratio=1.56, 95% CI=1.08-2.25). CONCLUSION: This initial evidence suggests that Medicare Part D could result in more PIM use in older enrollees than in nonenrollees, although the overall likelihood of PIM use has decreased in all older community-dwelling adults. Future research is needed to examine the effect over the longer term and focusing on particular categories of PIMs.

Mortality outcomes in pediatric rheumatology in the US.

OBJECTIVE: To describe mortality rates, causes of death, and potential mortality risk factors in pediatric rheumatic diseases in the US. METHODS: We used the Indianapolis Pediatric Rheumatology Disease Registry, which includes 49,023 patients from 62 centers who were newly diagnosed between 1992 and 2001. Identifiers were matched with the Social Security Death Index censored for March 2005. Deaths were confirmed by death certificates, referring physicians, and medical records. Causes of death were derived by chart review or from the death certificate. Standardized mortality ratios (SMRs) and 95% confidence intervals (95% CIs) were determined. RESULTS: After excluding patients with malignancy, 110 deaths among 48,885 patients (0.23%) were confirmed. Patients had been followed up for a mean +/- SD of 7.9 +/- 2.7 years. The SMR of the entire cohort was significantly decreased (0.65 [95% CI 0.53-0.78]), with differences in patients followed up for > or =9 years. The SMR was significantly greater for systemic lupus erythematosus (3.06 [95% CI 1.78-4.90]) and dermatomyositis (2.64 [95% CI 0.86-6.17]) but not for systemic juvenile rheumatoid arthritis (1.8 [95% CI 0.66-3.92]). The SMR was significantly decreased in pain syndromes (0.41 [95% CI 0.21-0.72]). Causes of death were related to the rheumatic diagnosis (including complications) in 39 patients (35%), treatment complications in 11 (10%), non-natural causes in 25 (23%), background disease in 23 (21%), and were unknown in 12 patients (11%). Rheumatic diagnoses, age at diagnosis, sex, and early use of systemic steroids and methotrexate were significantly associated with the risk of death. CONCLUSION: Our findings indicate that the overall mortality rate for pediatric rheumatic diseases was not increased. Even for the diseases and conditions associated with increased mortality, mortality rates were significantly lower than those reported in previous studies.

Breast reduction: does the tumescent technique affect reimbursement?

BACKGROUND: Breast reduction is a very common procedure within the field of plastic surgery, with many techniques. These techniques include differences in the location of the pedicles and of the scars. Another variation on the technique for breast reduction relates to preoperative infiltration of an epinephrine solution to reduce blood loss and operative time. The authors' technique for breast reduction and its effect on insurance reimbursement has not previously been discussed in a large prospective study. METHODS: The authors performed a prospective study to compare a cohort of 50 patients undergoing a traditional breast reduction without infiltration of epinephrine followed by electrocautery for resection versus 50 patients receiving tumescent infiltration of epinephrine followed by sharp resection. RESULTS: The patients who underwent the tumescent technique for breast reduction had shorter operative times and similar blood loss and pain compared with the traditional technique. The use of tumescence did not cause a significant difference in the weight of the amount resected when compared with the dry, pathologic weight. CONCLUSIONS: In the first large prospective cohort study involving this technique, the authors can demonstrate the many advantages of the tumescent technique and refute their concern that tumescence can cause inaccurate weight measurements that might interfere with insurance reimbursement based on resected weight.