Comparison of management options for specific antibody deficiency.

Background: Specific antibody deficiency is a primary immunodeficiency characterized by normal immunoglobulins with an inadequate response to polysaccharide antigen vaccination. This disease can result in recurrent infections, the most common being sinopulmonary infections. Treatment options include clinical observation, prophylactic antibiotic therapy, and immunoglobulin supplementation therapy, each with limited clinical data about their efficacy. Objective: This study aimed to identify whether there was a statistically significant difference in the rate of infections for patients who were managed with clinical observation, prophylactic antibiotics, or immunoglobulin supplementation therapy. Methods: A retrospective chart review was conducted. Patients were eligible for the study if they had normal immunoglobulin levels, an inadequate antibody response to polysaccharide antigen-based vaccination, and no other known causes of immunodeficiency. Results: A total of 26 patients with specific antibody deficiency were identified. Eleven patients were managed with immunoglobulin supplementation, ten with clinical observation, and five with prophylactic antibiotic therapy. The frequency of antibiotic prescriptions was assessed for the first year after intervention. A statistically significant rate of decreased antibiotic prescriptions after intervention was found for patients treated with immunoglobulin supplementation (n = 11; p = 0.0004) and for patients on prophylactic antibiotics (n = 5; p = 0.01). There was no statistical difference in antibiotic prescriptions for those patients treated with immunoglobulin supplementation versus prophylactic antibiotics (p = 0.21). Conclusion: Prophylactic antibiotics seemed to be equally effective as immunoglobin supplementation therapy for the treatment of specific antibody deficiency. Further studies are needed in this area.

Evaluation of Performance Status and Hematopoietic Cell Transplantation Specific Comorbidity Index on Unplanned Admission Rates in Patients with Multiple Myeloma Undergoing Outpatient Autologous Stem Cell Transplantation.

Although outpatient autologous stem cell transplantation (ASCT) is safe and feasible in most instances, some patients undergoing planned outpatient transplantation for multiple myeloma (MM) will need inpatient admission for transplantation-related complications. We aim to evaluate the difference, if any, between outpatient and inpatient ASCT cohorts of MM patients in terms of admission rate, transplantation outcome, and overall survival. We also plan to assess whether the Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI) and Karnofsky Performance Status (KPS) can predict unplanned admissions after adjusting for confounding factors. Patients with MM (n = 448) who underwent transplantation at our institution between 2009 and 2014 were included in this retrospective analysis. Patients were grouped into 3 cohorts: cohort A, planned inpatient ASCT (n = 216); cohort B, unplanned inpatient admissions (n = 57); and cohort C, planned outpatient SCT (n = 175). The statistical approach included descriptive, bivariate, and survival analyses. There were no differences among the 3 cohorts in terms of type of myeloma, stage at diagnosis, time from diagnosis to transplantation, CD34 cell dose, engraftment kinetics, and 100-day response rates. Serum creatinine was higher and patients were relatively older in both the planned inpatient (median age, 62 years; range, 33 to 80 years) and unplanned (median age, 59 years; range, 44 to 69 years) admission cohorts compared with the outpatient-only cohort (median age, 57 years; range, 40 to 70 years) (P < .05). Performance status (cohort A: median, 90%; range, 60% to 100%; cohort B: 80%, 50% to 100%; cohort C: 80%, 60% to 100%) was lower (P < .05) and HCT-CI score (cohort A: median, 1.78; range, 0 to 8; cohort B: 2.67, 0 to 9; cohort C: 2.16, 0 to 7) was higher (P < .004) in both inpatient groups compared with the planned outpatient cohort. With a median follow up of 5 years, poor performance status (KPS <70%) appeared to be associated with worse survival (P < .002). HCT-CI >2 also appeared to be associated with worse outcomes compared with HCT-CI 0 to 1, the the difference did not reach statistical significance (hazard ratio, 1.41l 95% confidence interval, 0.72 to 2.76). Only 1 patient out of 448 died from a transplantation-related cause. Outpatient transplantation for myeloma is safe and feasible. In our experience, one-third of the patients undergoing outpatient transplantation needed to be admitted for transplantation-related toxicities. Patients in this group had lower preexisting KPS and higher HCT-CI scores. Whether planned admission for this group would have prevented unplanned admissions and undue stress on patients and the healthcare system should be tested in a prospective manner.

Infectious postoperative complications decrease long-term survival in patients undergoing curative surgery for colorectal cancer: a study of 12,075 patients.

OBJECTIVE: We sought to characterize the effect of postoperative complications on long-term survival after colorectal cancer (CRC) resection. BACKGROUND: The impact of early morbidity on long-term survival after curative-intent CRC surgery remains controversial. METHODS: The Veterans Affairs Surgical Quality Improvement Program and Central Cancer Registry databases were linked to acquire perioperative and cancer-specific data for 12,075 patients undergoing resection for nonmetastatic CRC (1999-2009). Patients were categorized by presence of any complication within 30 days and by type of complication (noninfectious vs infectious). Univariate and multivariate survival analyses adjusted for patient, disease, and treatment factors were performed, excluding early deaths (<90 days). Subset analysis was performed to determine the specific impact of severe postoperative infections. RESULTS: The overall morbidity and infectious complication rates were 27.8% and 22.5%, respectively. Patients with noninfectious postoperative complications were older, had lower preoperative serum albumin, had worse functional status, and had higher American Society of Anesthesiologists scores than patients with infectious complications and without complications (all P < 0.001). The presence of any complication was independently associated with decreased long-term survival [hazard ratio, 1.24; 95% confidence interval (1.15-1.34)]. Multivariate analysis by complication type demonstrated increased risk only with infectious complications [hazard ratio, 1.31; 95% confidence interval (1.21-1.42)]. Subset analysis demonstrated this effect predominantly in patients with severe infections [hazard ratio, 1.41; 95% confidence interval (1.15-1.73)]. CONCLUSIONS: The presence of postoperative complications after CRC resection is associated with decreased long-term survival, independent of patient, disease, and treatment factors. The impact on long-term outcome is primarily driven by infectious complications, particularly severe postoperative infections.

The incidence of esophageal adenocarcinoma in a national veterans cohort with Barrett's esophagus.

OBJECTIVES: The increasing incidence of esophageal adenocarcinoma (EA) in the United States may have leveled off in recent years. The risk of EA among patients with Barrett's esophagus (BE) seems to be decreasing in several European cohorts, but these estimates are unknown in the United States. We aimed to determine the risk of developing EA in a national cohort of BE patients in the US Veterans Health Administration and to account for the use of endoscopic ablation and esophagectomy. METHODS: This was a retrospective cohort study from a total of 121 facilities in the Veterans Health Administration. Veteran patients with BE diagnosed between 1 October 2003 and 30 September 2009 were included and followed until esophageal cancer diagnosis, death or 30 September 2011. All EA diagnoses were verified in detailed structured reviews of medical records. RESULTS: We identified 29,536 patients with BE who met our eligibility criteria. Most were men (96.9%) and White (83.2%), with a mean age of 61.8 years. During 144,949 person-years of follow-up, 466 patients developed EA, yielding an incidence rate of 3.21 per 1,000 person-years (95% confidence interval (CI) 2.94-3.52). Excluding those who developed EA within 1 year of their index BE date lowered the incidence rate to 1.75 per 1,000 person-years. However, including additional patients who underwent endoscopic ablation or esophagectomy for HGD or EA increased the incidence rate to 4.79 (95% CI 4.44-5.16). CONCLUSIONS: The incidence of EA in a US national cohort of mostly male veterans may be lower than previous estimates. Almost half of the EA cases were diagnosed within 1 year of their BE index date.

Late-life depression and cardiovascular disease burden: examination of reciprocal relationship.

OBJECTIVES: Empirical studies of the relationship between depression and cardiovascular disease (CVD) tend to be limited to examination of one-way relationships. This study assessed both cross-sectional association and longitudinal reciprocal relationships between late-life depressive symptoms and CVD. METHODS: The National Health and Aging Trends Study waves 1 (T1) and 2 (T2, one year later) provided the data. The study sample (N = 5,414) represented Medicare beneficiaries aged 65 years or older. We fit structural equation models to examine: 1) cross-sectional association between depression and CVD at each wave; and 2) longitudinal reciprocal relationship between T1 depression and T2 CVD and between T1 CVD and T2 depression. RESULTS: At T1, 28.6% reported a CVD diagnosis, and at T2, 4.9% reported having had a new diagnosis or new episode of heart attack or heart disease and 2.2% reported having had a stroke since T1. In addition to significant cross-sectional relationships between depression and CVD, T1 CVD had significant impact on T2 depressive symptoms, and T1 depressive symptoms had significant impact on T2 CVD, with a 1-point increase in depressive symptom score increasing the odds of having a new CVD diagnosis or episode by 21%. CONCLUSIONS: The care of older adults with CVD and/or depression needs to include interventions focusing on lifestyle and psychological factors that can reduce risks for both CVD and depression. Depression prevention and treatment also needs to be an integral part of CVD prevention and management.

Cost-effectiveness of antenatal fetal surveillance for medication-treated gestational diabetes.

OBJECTIVE: To evaluate the relative cost-effectiveness of starting antenatal fetal surveillance at 32 vs. 36 weeks, in medication-treated gestational diabetes. METHODS: We performed a 2017-2022 retrospective cohort study of patients with medication-treated GDM who underwent BPPs. Patients diagnosed before 24 weeks, those delivered before 32 weeks, and those without BPPs or delivery data were excluded. Demographic and outcome data were abstracted by chart review. We performed a cost-effectiveness analysis regarding two outcomes: stillbirth, and decision to alter delivery timing following abnormal BPPs. RESULTS: A total of 652 pregnancies were included. Patients were 49% privately insured, 25% publicly insured, and 26% uninsured. We assumed that each BPP cost $145. In total, 1,284 BPPs occurred after 36 weeks, costing $186,180, and 2,041 BPPs occurred between 32 and 36 weeks, costing an additional $295,945. Twelve deliveries resulted from abnormal BPPs, all after 36 weeks. No stillbirths occurred. The cost to attempt to avoid one stillbirth was $40,177 across all patients. In our sample, starting surveillance at 36 weeks would have theoretically avoided all stillbirths, with cost savings per avoided stillbirth of $51,572 for privately insured patients, $14,123 for publicly insured patients, and $17,799 for patients without insurance. CONCLUSION: Based on this population with no stillbirths and no BPPs dictating delivery before 36 weeks, surveillance after 36 weeks may be safe and cost-effective. Our findings reflect opportunities for shared decision making and potential practice change, with greatest impact for low socioeconomic status patients and those without insurance.

Practice patterns of surveillance endoscopy in a Veterans Affairs database of 29,504 patients with Barrett's esophagus.

BACKGROUND: Practice guidelines recommend surveillance endoscopy every 2 to 3 years among patients with Barrett's esophagus (BE) to detect early neoplastic lesions. Although surveys report that >95% of gastroenterologists recommend or practice BE surveillance, the extent and patterns of surveillance in clinical practice are unknown. OBJECTIVE: To identify the extent and determinants of endoscopic surveillance among BE patients. DESIGN: Retrospective cohort study. SETTING: A total of 121 Veterans Affairs facilities nationwide. PATIENTS: Veteran patients with BE diagnosed from 2003 to 2009, with follow-up through September 30, 2010. INTERVENTION: Not an interventional study. MAIN OUTCOME MEASUREMENTS: The proportions of patients with BE who received any EGD after the index BE EGD date. In the subgroup of patients with at least 6 years of follow-up, we also calculated proportions for regular (EGD during both 3-year intervals), irregular (EGD in only 1 interval), and no surveillance. We examined differences in demographics and clinical and facility factors among these groups in unadjusted and adjusted analyses. RESULTS: We identified 29,504 patients with BE; 97% were men, 83% white, and their mean age was 61.8 years. During a 3.8-year median follow-up period, 45.4% of patients with BE received at least one EGD. Among the subgroup of 4499 patients with BE who had at least 6 years of follow-up, 23.0% had regular surveillance, and 26.7% had irregular surveillance. There was considerable facility-level variation in percentages with surveillance EGD across the 112 facilities and by geographic region of these facilities. Demographic and clinical factors did not explain these variations. Patients with at least one EGD were significantly more likely to be white; to be aged <65 years, with a low level of comorbidity; to have GERD, obesity, dysphagia, or esophageal strictures; to have more outpatient visits; and to be seen in smaller hospitals (<87 beds) than those without any EGD. LIMITATIONS: There might be misclassification of BE and surveillance EGD. Lack of pathology data on dysplasia, which dictates surveillance intervals. CONCLUSION: Endoscopic surveillance for BE is considerably less commonly practiced in Veterans Affairs facilities than is self-reported by physicians. Although several clinical factors are associated with variations in surveillance, facility-level factors play a large role. The comparative effectiveness of the different practice-based surveillance patterns needs to be examined.

Racial/ethnic differences in upper-tract urothelial cancer.

OBJECTIVES: Information on clinical characteristics, pattern of initial treatment and survival in patient with upper-tract urothelial carcinomas (UTUC) is scarce. Our study examined the racial/ethnic differences in patients diagnosed with incident UTUC. DESIGN: Observational study. The data analyses included: proportion and ANOVA for categorical and continuous variables, respectively; Kaplan-Meier method for calculating overall survival; and Cox-proportional hazards models for obtaining adjusted hazard-ratios. SETTING: Regions of the Surveillance, Epidemiology and End Results (SEER). PATIENTS OR PARTICIPANTS: 16,702 incident UTUC patients identified from the SEER dataset 1988-2007 (14,192 White, 967 Hispanic, 718 African American and 825 Asian). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Race/ethnicity-specific distributions of demographics, tumor characteristics, patterns of initial treatment, and survival. RESULTS: African American and Hispanic patients were diagnosed at a younger age than Whites and Asians (P = .001). Hispanics were more likely to be diagnosed with larger tumor size than Whites and Asians (P < .0001). Asians were more likely to be diagnosed with advanced stage and higher tumor grade. Cox-regression revealed that Whites and Asians were significantly less likely to die after UTUC diagnosis than African Americans (HR = .78, 95% Cl = .67-.91 and HR = .75, 95% CI = .61-.91, respectively; all P = < .01). CONCLUSIONS: Our study found that Asians had worse tumor characteristics at the initial presentation than the other groups in this study, but that their risk of dying was lower. Further research is needed to include a larger number of Asian patients to examine subgroup differences and to confirm the paradoxical finding of higher survival with poor clinical characteristics.

Effectiveness of AFP and ultrasound tests on hepatocellular carcinoma mortality in HCV-infected patients in the USA.

BACKGROUND AND AIMS: The effectiveness of surveillance for hepatocellular carcinoma (HCC) in the USA is largely unknown. The objective of this study was to evaluate the effectiveness of HCC surveillance in a national Veterans Administration (VA) practice setting, using the national VA hepatitis C virus (HCV) Clinical Case Registry. METHOD: The cohort consisted of 1480 HCV-infected patients who developed HCC during 1998-2007. The timing and intensity of receiving α-fetoprotein (AFP) and abdominal ultrasound (US) for HCC surveillance were evaluated. Overall mortality risk was examined using Cox proportional hazards regression models adjusting for demographics, clinical features and receipt of HCC-specific treatment. RESULTS: The mean survival was 1.8 years following the HCC diagnosis date. Surveillance AFP or US were recorded in 77.8% of patients within 2 years prior to HCC diagnosis. Annual surveillance with both AFP and US was observed in only 2% of patients. The presence of either AFP or US surveillance during both 0-6 month and 7-24 month periods before HCC diagnosis was associated with a lower mortality risk (HR 0.71, 95% CI 0.62 to 0.82) compared with no surveillance. Receipt of two or more surveillance tests in the 0-6 months (HR 0.76 95% CI 0.66 to 0.88) and to a lesser extent in the 7-12 months (HR 0.81 95% CI 0.1 to 0.99) prior to HCC diagnosis was also associated with reduced mortality risk. CONCLUSIONS: Most patients with HCV-related cirrhosis do not receive regular imaging-based surveillance. The effectiveness of HCC surveillance tests in current clinical practice is rather modest in reducing HCC-related mortality.

Minimally invasive surgery is underutilized for colon cancer.

BACKGROUND: The Clinical Outcomes of Surgical Therapy Group (COST) trial published in 2004 demonstrated that minimally invasive surgery (MIS) for colorectal cancer provided equivalent oncologic results and better short-term outcomes when compared to open surgery. Before this, MIS comprised approximately 3% of colorectal cancer cases. We hypothesized that there would be a dramatic increase in the use of MIS for colon cancer after this publication. METHODS: The National Inpatient Sample database was used to retrospectively review MIS and open colon resections from 2005 through 2007. ICD-9-specific procedure codes were used to identify open and MIS colon cancer resections. Statistical analyses performed included Pearson χ(2) tests and dependent t tests, and Cramer's V was used to measure the strength of association. RESULTS: A total of 240,446 colon resections were performed between 2005 and 2007. The percentage of resections performed laparoscopically increased from 4.7% in 2005 to 6.7% in 2007 for colon cancer and remained relatively unchanged for benign disease (25.2% in 2005 vs. 27.4% in 2007, P < 0.007). Patients undergoing laparoscopic colectomy were younger, had lower comorbidity scores, had lower rates of complications (20.1 vs. 25.1%, P < 0.001), had shorter lengths of stay (7.2 vs. 9.6 days, P < 0.001), and had lower mortality (1.5 vs. 3.0%, P < 0.001). Furthermore, when evaluating adoption trends, urban teaching hospitals adopted laparoscopy more rapidly than rural nonteaching centers. CONCLUSIONS: Adoption of MIS for the treatment of colorectal cancer has been slow. Additional studies to evaluate barriers in the adoption of MIS for colon cancer resection are warranted.

Rural-Urban Differences in Esophagectomy for Cancer.

INTRODUCTION: Patients who are disadvantaged socioeconomically or live in rural areas may not pursue surgery at high-volume centers where outcomes are better for some complex procedures. The objective of this study was to compare rural and urban patient differences directly by location of residence and outcomes after undergoing esophagectomy for cancer. METHODS: An analysis of the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) database was performed, capturing adult patients with esophageal cancer who underwent esophagectomy. Patients were stratified into rural or urban groups by the National Center for Health Statistics Urban-Rural Classification Scheme. Demographics, hospital variables, and outcomes were compared. RESULTS: A total of 2,877 patients undergoing esophagectomy for esophageal cancer were captured by the database, with 228 (7.92%) rural and 2,575 (89.50%) urban patients. The rural and urban groups had no differences in age, race, and insurance status, and shared many common comorbidities. Major outcomes of mortality (3.95% versus 4.27%, p = 0.815) and length of stay (15.75 ± 13.22 vs. 15.55 ± 14.91 days, p = 0.828) were similar for both rural and urban patients. There was a trend for rural patients to more likely be discharged home (35.96% vs. 29.79%, OR 0.667 [95% CI 0.479 - 0.929]; p = 0.0167). CONCLUSIONS: This retrospective administrative database study indicated that rural and urban patients received equivalent postoperative care after undergoing esophagectomy. The findings were reassuring as there did not appear to be a disparity in major outcomes depending on the location of residence, but further studies are necessary to assure equitable treatment for rural patients.

Surveillance for hepatocellular carcinoma: development and validation of an algorithm to classify tests in administrative and laboratory data.

BACKGROUND: The purpose of alpha-fetoprotein (AFP) and abdominal ultrasound (US) cannot be discerned in administrative data. AIM: We developed an algorithm to identify AFP and US used as surveillance tests for hepatocellular carcinoma (HCC). METHODS: We evaluated 300 AFP and 301 US tests from a VA database. Surveillance predictors in the administrative files (diagnoses, labs) were examined in logistic regression models. We calculated model-based probabilities of HCC surveillance status, and developed classification procedures using single and multiple imputation methods. RESULTS: The predictors of surveillance intent for AFP were absence of alcoholism, abdominal pain, ascites, diabetes and high AST levels. For US, the predictors of surveillance were prior AFP testing and HIV status and absence of abdominal pain, ascites, or drug dependence. For AFP classification, single imputation compared favorably with multiple imputation, both showing robustness in discrimination and calibration. For US both approaches were less robust in discrimination and calibration which was more moderate in multiple imputation than single imputation. CONCLUSIONS: Predictive algorithms in administrative files can be used to identify AFP performed for HCC surveillance, however, the intent of US is more difficult to identify.

Barriers and Facilitators to the Use of Genomic-Based Targeted Lung Cancer Therapies in the VA: Qualitative Findings.

Reflexive testing, standardization of the mutation test ordering procedure and results reporting, and elimination of the preauthorization requirements could facilitate the utilization of targeted therapies.

Utilization of genomic testing in advanced non-small cell lung cancer among oncologists in the Veterans Health Administration.

Current national guidelines recommend genomic testing on all stage 4 non-small cell lung cancers (NSCLC) of adenocarcinoma histology. Mutations are most often found among young, Asian, females without a history of smoking. As these characteristics are uncommon in the Veterans Health Administration (VHA) patient population, we sought to understand oncologists' decision-making processes regarding utilization of genomic testing in the VHA. We conducted in-depth qualitative interviews with 30 VHA-based medical oncologists. Interviews aimed to elicit oncologists' experiences and decision-making processes regarding genomic testing in patients with stage 4 non-small cell lung cancer with adenocarcinoma histology. Analysis was guided by principles of framework analysis. Sample size was determined by thematic saturation. We identified a wide variation in medical oncologists' genomic testing practices. Consistent with guidelines, advanced stage and adenocarcinoma histology most often influenced practice patterns among our participants. However, patient characteristics like gender, age, smoking status, and performance status were also taken in to account by some oncologists when making testing decisions. This does not reflect a widespread adoption of national guidelines for genomic testing in the VHA. Qualitative interviews with VHA-based oncologists demonstrated that genomic testing decisions are not always consistent with current national guidelines. Efforts should be made to address modifiable barriers to genomic testing in the VHA setting.

Health-related quality of life and cost-effectiveness components of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial: rationale and design.

Diabetes mellitus affects not only life expectancy but also quality of life. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial's health-related quality of life (HRQOL) and cost-effectiveness components will enable the assessment of the relative importance of the various outcomes from the point of view of patients, provide an understanding of the balance between the burdens and benefits of the intervention strategies, and offer valuable insights into adherence. The HRQOL measures used include the Diabetes Symptoms Distress Checklist; the 36-Item Short Form Health Survey, Version 2 (SF-36) (RAND Corporation, Santa Monica, CA); the Patient Health Questionnaire (PHQ) depression measure (Pfizer Inc, New York, NY); the World Health Organization (WHO) Diabetes Treatment Satisfaction Questionnaire (DTSQ); and the EuroQol Feeling Thermometer (EuroQol Group, Rotterdam, Netherlands). The cost-effectiveness analysis (CEA) in ACCORD will provide information about the relative economic efficiency of the different interventions being compared in the trial. Effectiveness will be measured in terms of cardiovascular event-free years gained and quality-adjusted life-years gained (using the Health Utilities Index Mark 3 [HUI-3] [Health Utilities Inc., Dundas, Ontario, Canada] to measure health-state utility). Costs will be direct medical costs assessed from the perspective of a single-payer health system collected by means of patient and clinic cost forms and hospital discharge summaries. The primary HRQOL and CEA hypotheses mirror those in the main ACCORD trial, addressing the effects of the 3 main ACCORD interventions considered separately. There are also secondary (pairwise reference case) comparisons that do not assume independence of treatment effects on HRQOL. CEA will be done on a subsample of 4,311 ACCORD participants and HRQOL on a subsample of 2,053 nested within the CEA subsample. Most assessments will occur through questionnaires at baseline and at 12, 36, and 48 months.

Adherence to Guideline Recommendations in Patients with Thyroid Nodules.

INTRODUCTION: Thyroid nodules are common and fine-needle aspiration (FNA) biopsy is the standard of care for work-up to exclude thyroid cancer. In this study, we examined the discrepancy between daily practice and recommended diagnostic approach for management of thyroid nodules, based on history taking, laboratory, and imaging studies. METHODS: This was a retrospective chart review of 199 patients who had ultrasound-guided fine needle aspiration (UGFNA) performed at a Midwest academic medical center from January 2010 to December 2011. The quality measures were selected based on recommended clinical practice guidelines, including family history, history of neck radiation, neck symptoms, TSH test, and thyroid ultrasound. RESULTS: The majority of patients were Caucasian females. Family history of thyroid cancer and childhood neck radiation exposure were documented in 79 subjects (40%) and 76 subjects (38%), respectively. Neck symptoms were documented in most subjects, including dysphonia (56.8%), dysphagia (69.9%), and dyspnea (41.2%). Most subjects had a TSH measured and an ultrasound performed prior to biopsy (75% and 86%, respectively). CONCLUSIONS: It appears there is a gap between current patient care and clinical practice guidelines for management of thyroid nodules. Clinical history and ultrasound features for risk stratification of UGFNA were lacking, which could reflect physicians' unfamiliarity with the guidelines. As thyroid nodules are common, enhancing knowledge of the current guidelines could improve appropriate work-up. Further studies are needed to identify factors associated with the poor compliance with clinical guidelines in management of thyroid nodules.

Stroke volume guided resuscitation in severe sepsis and septic shock improves outcomes.

To determine whether stroke volume (SV) guided fluid resuscitation in patients with severe sepsis and septic shock alters Intensive Care Unit (ICU) fluid balance and secondary outcomes, this retrospective cohort study evaluated consecutive patients admitted to an ICU with the primary diagnosis of severe sepsis or septic shock. Cohorts were based on fluid resuscitation guided by changes in SV or by usual care (UC). The SV group comprised 100 patients, with 91 patients in the UC group. Net fluid balance for the ICU stay was lower in the SV group (1.77L) than in the UC group (5.36L) (p=0.022). ICU length of stay was 2.89days shorter (p=0.03) and duration of vasopressors was 32.8h less (p=0.001) in the SV group. SV group required less mechanical ventilation (RR, 0.51; p=0.0001). The SV group was less likely to require acute hemodialysis (6.25%) compared with the UC group (19.5%) (RR, 0.32; p=0.01). In multivariable analysis, SV was an independent predictor of lower fluid balance, LOS, time on vasopressors, and not needing mechanical ventilation. This study demonstrated that SV guided fluid resuscitation in patients with severe sepsis and septic shock was associated with reduced fluid balance and improved secondary outcomes.

Using a collaborative approach to reduce postoperative complications for hip-fracture patients: a three-year follow-up.

BACKGROUND: To reduce perioperative complications for hip fracture, (1) patients were assigned admitting service using a simple clinical algorithm, (2) evidence-based guidelines and order sets were implemented for perioperative care; (3) a nurse specialist facilitated adherence to evidence-based interventions and mobility goals; and (4) patients and families were given an educational brochure highlighting the daily hospital course. METHODS: A case series with pre/post intervention comparison was conducted for all patients with hip fracture (preintervention n = 97, postintervention n = 589) at 9 months before and 33 months after the intervention. RESULTS: The algorithm assigned approximately one-third of patients to each of the three general services, with few to subspecialty services. Miscellaneous complications were almost eliminated, and significant reductions were observed in the proportion of patients with iatrogenic complications and postprocedure hemorrhage and hematoma. The percentage of patients with any postoperative complication fell from almost 60% to less than 10% by the end of the study. CONCLUSIONS: This study provides preliminary data from which to investigate the effectiveness of collaborative approaches to management on the outcomes of care for medically complex and geriatric surgical patients.

Acute coronary syndrome national statistics: challenges in definitions.

BACKGROUND: Increasing convergence in the management of acute myocardial infarction (AMI) and unstable angina (UA) has led some to consider whether these 2 diagnoses should be consolidated into acute coronary syndrome (ACS) for the purpose of coronary heart disease surveillance. METHODS: We used the 1988-2001 Nationwide Inpatient Sample, which has demographic and diagnosis data on 6 to 7 million discharges per year from a sample of US nonfederal hospitals. We identified discharges with a first- or all-listed diagnosis of AMI ( International Classification of Diseases, Ninth Revision, Clinical Modification 410) or UA (International Classification of Diseases, Ninth Revision, Clinical Modification 411) and defined ACS-first as a primary diagnosis of either condition and all-listed ACS as codes 410 or 411 among any diagnoses. Sampling weights were applied to produce yearly national discharge estimates; annual population estimates were used to calculate yearly hospital discharge rates; rates were then adjusted to the 2000 standard population. RESULTS: Rates of first- and all-listed AMIs changed little. Rates of first-listed UA fell 87% from 29.7/10,000 in 1988 to 3.9/10,000 in 2001. This sharp decline was seen among all age and sex groups. Consequently, rates of ACS as a primary diagnosis declined 44%. In contrast, discharge rates for all-listed UA and ACS declined only modestly. CONCLUSIONS: As a primary diagnosis, UA is disappearing. Rates of first-listed ACS are quite sensitive to the decline in UA. Although discharge data based on first-listed diagnoses have been used to estimate the national incidence of AMI, they may not provide accurate data regarding current trends for ACS.

The cutaneous surgery experience of multiple specialties in the Medicare population.

BACKGROUND: There has been tremendous growth in the performance of ambulatory surgical procedures. Traditional forms of peer review, commonplace for hospital-based procedures, are not typically performed in the office-based setting. Hospital credentialing of physicians has been suggested to be a means of assuring patient safety. Credentialing committees may be unaware of the level of experience of typical office-based physicians who perform cutaneous surgery. PURPOSE: To compare the levels of cutaneous surgery experience of dermatologists and other surgical specialists. METHODS: Medicare claims data on number of cutaneous surgery procedures performed by various medical disciplines, including dermatologists, plastic surgeons, general surgeons, and others, were obtained from the 1998-1999 Medicare Current Beneficiary Survey (MCBS) and analyzed. The number of physicians in each specialty was used to normalize the data to a per physician basis. RESULTS: Dermatologists performed half (50%) of the complex repairs and most of the excisions (58%) and intermediate repairs (62%). Dermatologists performed more flaps (40% of all flaps) than any other specialty, while plastic surgeons performed more total grafts (38%) than any other specialty. Dermatologists and plastic surgeons performed similar numbers of full-thickness skin grafts, while plastic surgeons performed more split-thickness skin grafts. CONCLUSION: As dermatologists seek hospital credentials for performing cutaneous surgery procedures, these data should help surgical colleagues understand the typical level of experience of their dermatologist colleagues.