Impact of provider characteristics on use of endovenous ablation procedures in Medicare beneficiaries.

OBJECTIVE: The objective of this study was to assess the association between provider characteristics and intensity of endovenous therapy (EVT) utilization in the Medicare population. METHODS: The Medicare Provider Utilization and Payment Data Public Use Files (2012-2014) were queried to construct a database of providers performing EVT using laser or radiofrequency ablation techniques for treatment of lower extremity venous reflux. A utilization index (UI; EVT procedure per patient treated per year) was calculated for each provider, and median services per county were determined. Provider specialty, geographic region, and site of service (facility vs outpatient) were determined for each patient. Multivariate regression analysis was used to identify provider characteristics associated with a UI above the 75th percentile. RESULTS: There were 6599 providers who performed EVT in 405,232 Medicare beneficiaries during the study period. Intensity of EVT use by providers was assessed by the calculated UI, the average number of EVT procedures performed in treated patients per year (range, 1-4). Vascular surgeons had the lowest UI among all provider specialties (1.32). By multivariate analysis, the likelihood of a provider's UI being >1.8 (top 25%) was associated with provider training in a field other than surgery, cardiology, or radiology (odds ratio [OR], 3.35; 2.74-4.09); services performed in an outpatient setting (OR, 2.62; 1.97-3.47); and providers who perform high annual volume of EVT (OR, 8.68; 7.59-9.91). A high annual volume provider was defined as one whose EVT volume was ≥75th percentile nationally. CONCLUSIONS: There is great variation in intensity of vein ablation procedures performed on Medicare beneficiaries by geographic location and provider specialty. High-volume providers and those with a specialty not traditionally associated with the management of lower extremity chronic venous disease are more likely to perform more EVT procedures per patient.

Matrix metalloproteinases in liver injury, repair and fibrosis.

The liver is a large highly vascularized organ with a central function in metabolic homeostasis, detoxification, and immunity. Due to its roles, the liver is frequently exposed to various insults which can cause cell death and hepatic dysfunction. Alternatively, the liver has a remarkable ability to self-repair and regenerate after injury. Liver injury and regeneration have both been linked to complex extracellular matrix (ECM) related pathways. While normal degradation of ECM components is an important feature of tissue repair and remodeling, irregular ECM turnover contributes to a variety of liver diseases. Matrix metalloproteinases (MMPs) are the main enzymes implicated in ECM degradation. MMPs not only remodel the ECM, but also regulate immune responses. In this review, we highlight some of the MMP-attributed roles in acute and chronic liver injury and emphasize the need for further experimentation to better understand their functions during hepatic physiological conditions and disease progression.

A 20-year experience with liver transplantation for polycystic liver disease: does previous palliative surgical intervention affect outcomes?

BACKGROUND: Although it is the only curative treatment for polycystic liver disease (PLD), orthotopic liver transplantation (OLT) has been reserved for severely symptomatic, malnourished, or refractory patients who are not candidates for palliative disease-directed interventions (DDI). Data on the effect of previous DDIs on post-transplant morbidity and mortality are scarce. We analyzed the outcomes after OLT for PLD recipients, and determined the effects of previous palliative surgical intervention on post-transplantation morbidity and mortality. STUDY DESIGN: We performed a retrospective analysis of factors affecting perioperative outcomes after OLT for PLD between 1992 and 2013, including comparisons of recipients with previous major open DDIs (Open DDI, n = 12) with recipients with minimally invasive or no previous DDIs (minimal DDI, n = 16). RESULTS: Over the 20-year period, 28 recipients underwent OLT for PLD, with overall 30-day, 1-, and 5-year graft and patient survivals of 96%, 89%, 75%, and 96%, 93%, 79%, respectively. Compared with the minimal DDI group, open DDI recipients accounted for all 5 deaths, had inferior 90-day and 1- and 5-year survivals (83%, 83%, and 48% vs 100%, 100%, 100%; p = 0.009), and greater intraoperative (42% vs 0%; p = 0.003), total (58% vs 19%; p = 0.031), and Clavien grade IV or greater (50% vs 6%; p = 0.007) postoperative complications, more unplanned reoperations (50% vs 13%; p = 0.003), and longer total hospital (27 days vs 17 days; p = 0.035) and ICU (10 days vs 4 days; p = 0.045) stays. CONCLUSIONS: In one of the largest single-institution experiences of OLT for PLD, we report excellent long-term graft and patient survival. Previous open DDIs are associated with increased risks of perioperative morbidity and mortality. Improved identification of PLD patients bound for OLT may mitigate perioperative complications and potentially improve post-transplantation outcomes.

The effect of HLA mismatch on highly sensitized renal allograft recipients.

INTRODUCTION: We examined the effects of increasing human leukocyte antigen (HLA) mismatches (MM) on long-term graft outcomes in patients transplanted with a panel reactive antibody (PRA) >80% over a 10-yr period. METHODS: A total of 142 recipients were divided into three groups based on the number of HLA MM with their allograft (0-2, 3-4 and 5-6 MM; Groups I, II and III). All patients received the same immunosuppression protocol. RESULTS: The higher MM groups had a higher incidence of rejection (4.4% vs. 11.4% vs. 31.3%, p < 0.01). A multivariate analysis showed that rejection was the only significant variable affecting graft loss (OR = 7.45, p = 0.01). There was a trend toward more CMV infection and worse graft function with higher MM. Kaplan-Meier five-yr graft survival estimates were 100% vs. 81% vs. 74% for Groups I, II and III, respectively (p = 0.14). CONCLUSIONS: In patients with PRA levels >80%, a higher HLA MM is associated with higher incidence of acute rejection. Acute rejection was the only significant variable affecting graft loss. We found a trend toward more CMV infections and worse graft outcomes with higher MM. Closer HLA matching and immunologic monitoring needs to be considered to improve graft outcomes among sensitized recipients.