Association of Geographic Distance and Hospital Characteristics With Use of Interhospital Transfer by Air: A Multicenter Retrospective Study.

OBJECTIVE: Interhospital transfer by air (IHTA) represents the majority of helicopter air ambulance transports in the United States, but the evaluation of what factors are associated with utilization has been limited. We aimed to assess the association of geographic distance and hospital characteristics (including patient volume) with the use of IHTA. METHODS: This was a multicenter, retrospective study of helicopter flight request data from 2018 provided by a convenience sample of 4 critical care transport medicine programs in 3 US census regions. Nonfederal referring hospitals located in the home state of the associated critical care transport medicine program and within 100 miles of the primary receiving facility in the region were included if complete data were available. We fit a Poisson principal component regression model incorporating geographic distance, the number of emergency department visits, the number of hospital discharges, case mix index, the number of intensive care unit beds, and the number of general beds and tested the association of the variables with helicopter emergency medical services utilization. RESULTS: A total of 106 referring hospitals were analyzed, 21 of which were hospitals identified as having a consistent request pattern. Using the hospitals with a consistent referral pattern, geographic distance had a significant positive association with flight request volume. Other variables, including emergency department visit volume, were not associated. Overall, the included variables offered poor explanatory power for the observed variation between referring facilities in the use of IHTA (r2 = 0.09). Predicted flights based on the principal component regression model for all referring hospitals suggested the majority of referring hospitals used multiple flight programs. CONCLUSION: Geographic distance is associated with the use of IHTA. Unexpectedly, most basic hospital characteristics are not associated with the use of IHTA, and the degree of variation between referring facilities that is explained by patient volume is limited. The evaluation of nonhospital factors, such as the density and availability of critical care or advanced life support ground emergency medical services resources, is needed.

Impact of rural-urban status on survival after mastectomy without reconstruction versus mastectomy with reconstruction.

BACKGROUND: Disparities in access to care exist for breast cancer patients, including access to surgeons performing reconstruction. We hypothesized rural patients have delayed time to surgery after mastectomy with reconstruction with implications on survival. METHODS: An observational study was conducted using the National Cancer Database on patients with breast cancer from 2003 to 2007 who underwent mastectomy, with or without reconstruction from 2003 to 2007 (n = 90,319). RESULTS: Patients with, and without, reconstruction varied by demographics, facility type and stage. Time to surgery was longer for mastectomy with reconstruction. Unadjusted analysis demonstrated marginally decreased survival for rural patients undergoing mastectomy alone but not for mastectomy with reconstruction. Cox proportional hazards analysis revealed no significant differences by rural-urban status, but a survival advantage was seen after mastectomy with reconstruction, which persisted up to a delay of 180 days. CONCLUSION: Patients who underwent reconstruction had improved survival. Time to surgery is shorter for rural patients (for all types of mastectomy). We found no significant rural-urban disparity in survival.

Native Nephrectomy in Renal Transplant Recipients with Autosomal Dominant Polycystic Kidney Disease.

BACKGROUND: Native nephrectomy (NNx) is often done in patients with autosomal dominant polycystic kidney disease (ADPKD). Controversy exists concerning the need and timing of nephrectomy in transplant candidates. We hypothesize that post-transplant NNx does not negatively impact patient and graft survival. METHODS: Among 470 ADPKD transplant recipients included in the study, 114 (24.3%) underwent pre- (30.7%) or post-transplant (69.3%) NNx. Clinical data was retrieved from electronic records. Follow up was until death, graft loss or June 2014. Perioperative complications were compared between the surgical techniques (open or laparoscopic) and between the pre- and post-transplant nephrectomy groups. The effect of nephrectomy on graft survival was analyzed as a time-dependent covariate when performed post-transplant. RESULTS: Mean age at transplant was 52.4 years, 53.8% were male, 93% white, 70% were from living donors and 56.8% were pre-emptive. Nephrectomy was done laparoscopically in 31% and 86% in the pre- and post- transplant nephrectomy groups, respectively. Complications were less common in those who underwent nephrectomy post-transplant (26.6% vs. 48%, p=0.03) but were similar regardless of surgical technique (open, 33.3% vs. laparoscopic 33%, p=0.66). Patient and graft survival were similar between those who underwent pre-transplant nephrectomy and the rest of the recipients. In the post-transplant nephrectomy group, nephrectomy did not affect patient (HR 0.77, CI 0.38-1.54, p=0.45) or graft survival (HR 1.0, CI 0.57-1.76, p=0.1). CONCLUSIONS: Nephrectomy does not adversely affect patient or graft survival. Post-transplant nephrectomy is feasible when indicated without compromising long term graft outcome and has fewer complications than pre-transplant nephrectomy.

Prostate cancer knowledge in Irish men.

Men require prostate cancer (Pca) knowledge to practice health-seeking behaviours. Nine hundred seventy-nine men participated in a Pca screening programme comprising IPSS, bother score and health belief questionnaire. Men with private insurance had greater knowledge. Forty-nine percent (481) assessed their health status as average. Seventy-five percent (735) visited the GP at least once per year. The majority (576) felt well informed about health matters. Fifty-five percent (542) knew the prostate location but only 319 (33%) could identify it on a diagram. Forty-one percent (401) could not name a symptom. Few knew risk factors but 98% would attend a Pca screening clinic and sought more information. Men lack knowledge to pursue healthier behaviours and should be targeted possibly through a men's health initiative.

Symptomatic caval penetration by a Celect inferior vena cava filter.

We report a case of penetration of the inferior vena cava (IVC) by all four primary struts of a Celect caval filter in a 17-year-old girl with Klippel-Trénaunay syndrome. The girl presented with acute lower abdominal and right leg pain 17 days after filter insertion. An abdominal radiograph demonstrated that the filter had moved caudally and that the primary struts had splayed considerably since insertion. Contrast-enhanced CT confirmed that all four primary struts had penetrated the IVC wall. There was a small amount of retroperitoneal hemorrhage. The surrounding vessels and viscera were intact. The filter was subsequently retrieved without complication.

Idiopathic suppurative pylephlebitis: interventional radiological diagnosis and management.

We report the imaging findings and management of a case of suppurative pylephlebitis of unknown cause in a 10-year-old girl. Percutaneous aspiration of frank pus from the portal vein confirmed the diagnosis and contributed to therapy. Percutaneous transhepatic thrombolysis was attempted but was unsuccessful. Because of the nonspecific presentation of this condition and the lack of familiarity of physicians with this entity, the diagnosis is often delayed. Our aim is to increase the awareness of this entity and stress the importance of early diagnosis and appropriate therapy.

Transplantation for cholangiocarcinoma: when and for whom?

Liver transplantation for cholangiocarcinoma has historically been maligned. Because of a high recurrence rate and poor patient survival, the disease has been viewed as an absolute contraindication to transplantation. Based on good results using neoadjuvant and palliative radiation, a protocol for liver transplantation in selected patients with unresectable hilar cholangiocarcinoma was developed in 1993. Neoadjuvant radiation is followed by operative staging to rule out patients with lymph node metastases before liver transplantation. This approach has achieved results superior to standard surgical therapy, with 72% 5-year survival for patients with unresectable disease.

Hepatic resection for noncolorectal, nonneuroendocrine metastases.

Resection of certain hepatic metastases of noncolorectal, nonneuroendocrine (NCNNE) origin provides actual long-term (>5 years) survival. We conducted a retrospective outcome study at a single tertiary referral institution. Between January 1988 and October 1998, 64 consecutive patients underwent resection of hepatic metastases from NCNNE primary tumors. Overall and disease-free survival rates were correlated to clinicopathologic factors and operative morbidity and mortality. Thirteen patients underwent a right hepatectomy, 6 underwent a left hepatectomy, 3 had extended right and 2 extended left hepatectomy, 2 patients had segmentectomy, 24 underwent wedge resections, and 14 underwent a combination of these forms of resection. R0 resection was achieved in 56 patients (87.5%). The operative mortality was 1.5% (1 of 64). Actual 1-, 3-, and 5-year survivals were 81%, 43%, and 30%, respectively. The factor adversely associated with overall and disease-free survival was uniformly related to the interval between primary tumor resection and the development of hepatic metastases. A 1.5% operative mortality and an actual 5-year survival of 30% justifies hepatic resection, including major hepatic resection, for certain NCNNE metastases. The factor affecting prognosis in this highly select group of patients was the biological behavior of the tumor, with tumors that metastasize earlier having poorer survival rates.

Liver transplantation with neoadjuvant chemoradiation is more effective than resection for hilar cholangiocarcinoma.

OBJECTIVE: Compare survival after neoadjuvant therapy and liver transplantation with survival after resection for patients with hilar CCA. SUMMARY BACKGROUND DATA: We developed a protocol combining neoadjuvant radiotherapy, chemosensitization, and orthotopic liver transplantation for patients with operatively confirmed stage I and II hilar CCA in 1993. Since then, patients with unresectable CCA or CCA arising in the setting of PSC have been enrolled in the transplant protocol. Patients with tumors amenable to resection have undergone excision of the extrahepatic duct with lymphadenectomy and liver resection. METHODS: We reviewed our experience between January 1993 and August 2004 and compared patient survival between the treatment groups. RESULTS: Seventy-one patients entered the transplant treatment protocol and 38 underwent liver transplantation. Fifty-four patients were explored for resection. Twenty-six (48%) underwent resection, and 28 (52%) had unresectable disease. One-, 3-, and 5-year patient survival were 92%, 82%, and 82% after transplantation and 82%, 48%, and 21% after resection (P = 0.022). There were fewer recurrences in the transplant patients (13% versus 27%). CONCLUSIONS: Liver transplantation with neoadjuvant chemoradiation achieved better survival with less recurrence than conventional resection and should be considered as an alternative to resection for patients with localized, node-negative hilar CCA.

Acute nephrotoxicity of tacrolimus and sirolimus in renal isografts: differential intragraft expression of transforming growth factor-beta1 and alpha-smooth muscle actin.

BACKGROUND: Renal dysfunction early after kidney transplantation has multiple causes including ischemia-reperfusion (I/R) injury and drug-induced nephrotoxicity. This study assesses the acute nephrotoxicity of tacrolimus (Tac) and sirolimus (Sir) in a rat renal isograft model. METHODS: Lewis renal isografts and uninephrectomized rats that did not undergo transplantation were treated with various doses of Tac (0.5-5.0 mg/kg/d) or Sir (0.5-6.5 mg/kg/d). Kidneys were examined on day 14 by routine histology and immunohistochemistry for transforming growth factor (TGF)-beta1 and alpha-smooth muscle actin (SMA). RESULTS: Both Tac and Sir demonstrated evidence of nephrotoxicity in the early posttransplant period including increased serum creatinine and morphologic changes in the graft including interstitial inflammation, fibrosis, and tubular vacuolization. Nephrotoxicity was most prominent in the high-dose treatment groups for both drugs and was more severe in transplanted kidneys than in uninephrectomized animals that did not undergo transplantation, suggesting an additive effect of I/R injury and drug nephrotoxicity. Both Tac and Sir increased intragraft TGF-beta1 and alpha-SMA, but there were distinct differences in the patterns of TGF-beta1 expression. Both demonstrated TGF-beta1 in tubular epithelial cells, but Sir was associated with proximal tubular TGF-beta1 localization in a bright granular pattern, whereas Tac was associated with diffuse distal tubular staining. CONCLUSIONS: Both Tac and Sir may be nephrotoxic in the early posttransplant period, especially at high doses and when combined with I/R injury. Immunohistochemical localization of TGF-beta1 in the tubular cells was distinctly different with each drug, suggesting possible differences in the mechanism(s) of nephrotoxicity requiring further study.

Major hepatic resection for hilar cholangiocarcinoma: analysis of 46 patients.

HYPOTHESIS: Major hepatectomy, bile duct resection, and regional lymphadenectomy for hilar cholangiocarcinoma are associated with actual long-term (>5 years) survival. DESIGN: Retrospective outcome study. SETTING: Single tertiary referral institution. PATIENTS: Between 1979 and 1997, 46 consecutive patients had resection of hilar cholangiocarcinoma by major hepatectomy, bile duct resection, and regional lymphadenectomy. MAIN OUTCOME MEASURES: Overall survival and tumor recurrence were correlated to clinicopathological factors, operative morbidity, and mortality. RESULTS: Twenty-five patients underwent left hepatectomy, 17 underwent right hepatectomy, and 4 had extended right hepatectomy. Eighteen patients underwent resection of segment 1. Negative (R0) resection margins were achieved in 37 patients (80%). The operative mortality rate was 9%, and the surgical morbidity rate was 52%. Actual 1-year, 3-year, and 5-year survival rates were 80%, 39%, and 26%, respectively. Factors adversely associated with patient survival rates included: male sex, lymph node metastases, tumor grade 3 or 4, elevated direct serum bilirubin level at diagnosis, elevated preoperative activated partial thromboplastin time, and more than 4 U of red blood cells transfused perioperatively. Tumor size and R0 resection approached significance for survival. Factors associated with tumor recurrence included: male sex, tumor grade 3 or 4, a low hemoglobin level both at diagnosis and preoperatively, and a low preoperative prothrombin time and low alkaline phosphatase level at diagnosis and preoperatively. Median time to recurrence was 3.6 years. Tumor recurrence was predominantly local and regional. CONCLUSIONS: The actual 5-year survival rate of 26% justifies major partial hepatectomy, bile duct resection, and regional lymphadenectomy for hilar cholangiocarcinoma. The high frequency of local and regional recurrence warrants investigation of adjuvant therapy.

Pancreas-after-kidney transplantation: an increasingly attractive alternative to simultaneous pancreas-kidney transplantation.

BACKGROUND: Historically, the clinical acceptability of pancreas-after-kidney (PAK) transplantation has been hampered by relatively high acute rejection rates and lower pancreas graft survival rates when compared with the more commonly performed simultaneous pancreas-kidney (SPK) transplantation. The purpose of this study was to compare PAK transplantation to SPK transplantation in the Thymoglobulin induction era. METHODS: The authors reviewed all bladder-drained PAK (n=47) transplants receiving rabbit antithymocyte globulin induction from June 1998 to June 2002 and compared them with SPK (n=25) transplants during the same time period at their institution. The authors retrospectively studied data on demographics, patient survival, graft (pancreas and kidney) survival, complications, and biopsy-proven rejection episodes. RESULTS: The actuarial 1-year patient survival was 93% for the PAK group versus 100% for the SPK group (P =not significant [NS]). The actuarial 1-year pancreas graft survival was 87% for the PAK group versus 92% for the SPK group (P =NS). Waiting time for PAK was significantly shorter than for SPK (6.3 +/- 5.2 vs. 16.2 + -13.7 months, P <0.05). Clinical acute rejection rates were similar in the two groups (4.3% for PAK vs. 4.0% for SPK). PAK recipients demonstrated a greater decline in renal function after transplantation compared with SPK. A multivariate analysis failed to elucidate the cause. CONCLUSIONS: Newer immunosuppressive regimens allow PAK transplant patients to achieve immunologic outcomes similar to SPK transplant patients. Although the shorter waiting time and the ability to use living-donor kidneys make PAK an increasingly attractive alternative to SPK transplantation, its effect on renal allograft function deserves further attention.

Decline in native renal function early after bladder-drained pancreas transplantation alone.

BACKGROUND: Pancreas transplant alone (PTA) has become accepted therapy for select nonuremic patients with type 1 diabetes mellitus. However, PTA may lead to significant complications including a decline in native renal function. This study examines trends in native renal function during the first posttransplant year in PTA recipients with a spectrum of pretransplant glomerular filtration rates (GFR). METHODS: Renal function was studied in 23 recipients of bladder-drained PTA who underwent transplantation from April 1998 through September 2001. GFR was measured by corrected iothalamate clearance at the time of transplant evaluation and 1 year posttransplant and also calculated using the Cockcroft-Gault method at the transplant evaluation; at the day of transplantation; and at 1, 6, and 12 months posttransplant. RESULTS: Iothalamate clearance decreased in the first year in 96% of patients (22 of 23). The mean measured GFR decreased from 84 +/- 33 mL/min/1.73 m2 pretransplant to 52 +/- 26 mL/min/1.73 m2 at 1 year (P <0.001). Calculated creatinine clearance declined in the majority of patients at both 1 and 12 months after PTA, but some patients, including a few with low GFR, maintained stable renal function. Calculated GFR generally correlated well with measured GFR in most patients, with a few notable exceptions. One patient (baseline GFR, 42 mL/min/1.73 m2) developed renal failure in the first year after transplant and required kidney transplantation. CONCLUSIONS: Bladder-drained PTA results in a decline in native renal function in the majority of patients regardless of the pretransplant GFR. These data suggest the need for strategies to prevent or minimize the decline in renal function after PTA.