Adjuvant radiation therapy for patients with type II endometrial carcinoma: impact on tumor recurrence and survival.

PURPOSE/OBJECTIVE: The optimal adjuvant treatment of type II endometrial carcinoma after hysterectomy remains controversial. The objective of this study was to determine the effect of adjuvant radiation therapy (RT) on recurrence-free survival (RFS), disease-specific survival (DSS), and overall survival in patients with early-stage type II endometrial carcinoma. MATERIALS AND METHODS: In this institutional review board-approved study, our database of 1450 patients with endometrial cancer was reviewed. Seventy-nine surgically staged patients with 2009 International Federation of Gynecology and Obstetrics (FIGO) stages I and II serous and clear cell carcinoma were treated from 1991 to 2010. These patients were then divided into 2 groups; one group received adjuvant RT, and the other group included patients who did not receive adjuvant RT. RESULTS: The median age of the study cohort is 65 years, and the median follow-up is 47 months. Thirty-nine patients (49%) received adjuvant RT, and 40 patients did not. The 5-year RFS was significantly improved in patients who received RT (84% vs 58%; P = 0.002). Similarly, 5-year DSS was significantly improved in patients who received RT (87% vs 58%; P = 0.023) with a trend toward improved 5-year overall survival (74% vs 58%; P = 0.088). On multivariate analysis, lack of angiolymphatic invasion (P < 0.001 and P < 0.001), adjuvant RT (P < 0.001 and P = 0.004), and lack of lower uterine segment involvement (P = 0.007 and P = 0.009) were independent predictors of improved RFS and DSS, respectively. CONCLUSIONS: In the current study of surgically staged patients with type II endometrial carcinoma International Federation of Gynecology and Obstetrics stages I and II, adjuvant radiation therapy with or without chemotherapy resulted in a significant improvement in recurrence-free and disease-specific survival.

Is resternotomy a risk for continuous-flow left ventricular assist device outcomes?

BACKGROUND: The number of patients undergoing resternotomy continues to rise. Although catastrophic hemorrhage remains a dreaded complication, most published data suggest that sternal reentrance is safe, with negligible postoperative morbidity and mortality. A significant proportion of left ventricular assist device (LVAD) implantations are reoperative cardiac procedures. The aim of our study was to compare outcomes between first time sternotomy and resternotomy patients receiving continuous-flow LVADs, as a bridge to transplantation or destination therapy. METHODS AND MATERIALS: From March 2006 through February 2012, 100 patients underwent implantation of a HeartMate II or HeartWare LVAD at our institution. Patients were stratified into two groups, primary sternotomy and resternotomy. Variables were compared using two-sided t-tests, chi-square tests, Cox proportional hazards models, and log-rank tests to determine whether there was a difference between the two groups and if resternotomy was a significant independent predictor of outcome. RESULTS: We identified 29 patients (29%) who had resternotomy and 71 patients (71%) who had first time sternotomy. The resternotomy group was significantly older (56 years vs. 51 years, p = 0.05), was more likely to have ischemic cardiomyopathy (ICM) (69% vs. 30%, p < 0.001), chronic obstructive pulmonary disease (COPD) (31% vs. 14%, p = 0.05) and had longer cardiopulmonary bypass times (135 min vs. 100 min, p = 0.011). Survival rates at 30 days (93.1% vs. 95.8%, p = 0.564), 180 days (82.8% vs. 93%, p = 0.131), and 360 days (82.8% vs. 88.7%, p = 0.398) were similar for the resternotomy and primary sternotomy groups, respectively. Postoperative complications were also comparable, except for re-exploration for bleeding which was higher for the resternotomy group (17.2% vs. 4.2%, p = 0.029), although blood transfusion requirements were not significantly different (1.4 units vs. 1.2 units, p = 0.815). Left and right heart catheterization measurements and echocardiographic (ECHO) findings after 1 and 6 months of LVAD therapy were similar between the two groups. CONCLUSIONS: Survival at 30, 180, and 360 days after LVAD implantation is similar between the resternotomy and primary sternotomy group. No major differences in complications or hemodynamic measurements were observed. Although a limited observational study, our findings agree with previously published resternotomy outcomes.

Skin-of-color epidemiology: a report of the most common skin conditions by race.

To quantify and compare diagnoses according to race in pediatric Health Maintenance Organization (HMO) health plan patients seen in a general dermatology clinic over a 10-year period. Retrospective cohort of health plan pediatric patients seen in the dermatology clinic between 1997 and 2007 was established using an electronic medical record database. Diagnoses and diagnostic codes were recorded according to International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes grouped on their first three digits. The proportion of patients with each diagnosis was determined according to race and sex, and the 10 most common diagnoses were determined. The most common diagnoses observed in all pediatric patients were acne (28.6%), dermatitis (19.4%), and warts (16.2%), accounting for more than 60% of dermatologic visits by children. Although acne (29.9%), warts (22.6%), and dermatitis (13.1%) were also the most common diagnoses for Caucasian children, African American pediatric patients were most commonly seen for dermatitis (29.0%), acne (27.5%), and dermatophytosis (10.2%). The three most common diagnoses for Asian patients were dermatitis (29.1%), acne (22.2%), and warts (12.6%). Acne remains one of the most common dermatologic diagnoses in children of all races. Differences in frequency of office visits for dermatitis, warts, and dermatophytosis were seen when comparing children of other races with Caucasian children.

Distal pancreatectomy with or without splenectomy: comparison of postoperative outcomes and surrogates of splenic function.

OBJECTIVES: Published data on splenic preservation during distal pancreatectomy have been inconsistent. We hypothesized that patients undergoing spleen-preserving distal pancreatectomy (SPDP) would have fewer infectious and non-infectious complications than those undergoing en bloc distal pancreatectomy with splenectomy (DPS), and that their haematological parameters would be consistent with splenic function. METHODS: Of 97 patients who underwent either SPDP using the Warshaw technique or en bloc DPS, 78 met our study inclusion criteria. Records were reviewed for data on age, gender, resection, indications for resection, operative time, blood loss, transfusion requirements, hospital stay, infectious complications, any other complications, postoperative white blood cell (WBC) and platelet counts. Data were analysed using the chi-squared test, the two-sided Mann-Whitney-Wilcoxon text, and simple and multiple logistic regression analyses. A P-value of <0.05 was considered significant. RESULTS: Patients undergoing SPDP had a shorter length of stay and shorter operative time, were more likely to be completed laparoscopically, less likely to require re-operation, and had fewer infectious and non-infectious complications. However, these differences were not statistically significant. In multiple logistic regression analyses, patient age and length of hospital stay were both significant predictors of the occurrence of non-infectious complications (P= 0.04 and P= 0.006, respectively). Blood transfusion was a significant predictor of postoperative morbidity (P= 0.013 for infectious complications; P= 0.018 for non-infectious complications). White blood cell count was a statistically significant predictor of infectious (P= 0.02) and non-infectious (P= 0.04) complications, whereas platelet count was not. Patients who underwent DPS had statistically significantly higher WBC and platelet counts immediately postoperatively and at 6 months compared with SPDP patients. Postoperative mortality in both the SPDP and DPS groups was 0%. None of the 30 SPDP patients had evidence of splenic infarction. Pancreatic leaks occurred in 18% of patients in the SPDP group, compared with 8% in the DPS group (P < 0.05). CONCLUSIONS: Spleen-preserving distal pancreatectomy using the Warshaw technique is associated with lower postoperative morbidity than DPS. Lower WBC and platelet counts suggest better splenic function in SPDP patients.

Morbidity but not mortality is decreased after off-pump coronary artery bypass surgery.

BACKGROUND: Off-pump coronary bypass surgery (CABG) has been advocated to avoid the physiologic perturbations related to cardiopulmonary bypass and improve outcomes compared with on-pump CABG. Previous reports have been inconsistent, and thus its benefits remain uncertain. This retrospective study compared outcomes between on-pump and off-pump CABG from a large multicenter cohort of propensity-matched patients. METHODS: The study consisted of 21,640 patients (19,639 [90.8%] on-pump, 2,001 [9.2%] off-pump) who underwent isolated CABG between January 1, 2008, and June 30, 2011, and were entered into a statewide collaborative database. Univariate analysis compared 37 baseline characteristics between on-pump and off-pump procedures. Patients were matched 1:1 based on similarities in propensity scores derived from statistically significant baseline characteristics. Propensity scores and surgery type were used in conditional logistic regression models for predicting each of 14 postoperative outcomes using the sample of 3,898 matched procedures. RESULTS: Patients undergoing off-pump CABG had significantly fewer complications overall, including decreased red blood cell transfusion, stroke, intensive care unit and ventilator time, reoperation for bleeding, and length of stay. There was no difference in renal failure, wound infection, discharge location, or 30-day readmission rate. Although off-pump patients received fewer bypass grafts per patient (2.5 ± 1.2 versus 3.0 ± 1.1; p < 0.001), operative mortality was similar for the two groups (1.8% on-pump versus 2.3% off-pump; p = 0.30). CONCLUSIONS: Off-pump CABG was associated with less morbidity, shorter length of stay, and similar mortality compared with on-pump procedures, suggesting that it can be a safe and effective alternative to standard on-pump CABG. However, the limited use of off-pump CABG in this multicenter analysis may restrict the generalizability of these results, and realistically defines the limited degree of acceptance of this technique in a real-world environment.

Transfusion of 1 and 2 units of red blood cells is associated with increased morbidity and mortality.

BACKGROUND: This study examined the relationship between transfusion of 1 or 2 units of red blood cells (RBCs) and the risk of morbidity and mortality after isolated on-pump coronary artery bypass grafting (CABG). METHODS: A total of 22,785 consecutive patients underwent isolated on-pump CABG between January 1, 2008, and December 31, 2011 in Michigan. We excluded 5,950 patients who received three or more RBC units. Twenty-one preoperative variables significantly associated with transfusion by univariate analysis were included in a logistic regression model predicting transfusion, and propensity scores were calculated. Transfusion and the propensity score covariate were included in additional logistic regression models predicting mortality and each of 11 postoperative outcomes. RESULTS: Operative mortality for the study cohort of 16,835 patients was 0.8% overall, 0.5% for the 10,884 patients with no transfusion, and 1.3% for the 5,951 patients who received transfusion of 1 or 2 units (odds ratio 2.44; confidence interval 1.74 to 3.42; p < 0.0001). The association between transfusion and mortality lessened after propensity adjustment but remained highly significant (odds ratio 1.86; confidence interval 1.21 to 2.87; p = 0.005). Of the 11 postoperative outcomes studied, all but sternal wound infection and need for dialysis were also significantly associated with transfusion. CONCLUSIONS: Transfusion of as little as 1 or 2 units of RBCs is common and is significantly associated with increased morbidity and mortality after on-pump CABG. The relationship persists after adjustment for preoperative risk factors. These results suggest that aggressive attempts at blood conservation and avoidance of even small amounts of RBC transfusion may improve outcomes after CABG.

Significance of postoperative acute renal failure after continuous-flow left ventricular assist device implantation.

BACKGROUND: Deteriorating renal function is common in patients with advanced heart failure and is associated with poor outcomes. The relationship between renal function and left ventricular assist device (LVAD) implantation is complex and has been explored in multiple studies with contradictory results. The aim of our study is to examine the significance of postoperative renal failure after implantation of a continuous-flow LVAD and its relationship to outcomes. METHODS: From March 2006 to July 2011, 100 patients underwent implantation of a HeartMate II (Thoratec Corp, Pleasanton, CA) or HeartWare (Heart International, Inc, Framingham, MA) LVAD at our institution. Patients were stratified based on postoperative development of acute renal failure (ARF). Variables were compared using 2-sided t tests, χ(2) tests, Cox proportional hazards models, and log-rank tests to determine whether there was a difference between the 2 groups and whether postoperative renal failure was a significant independent predictor of outcome. RESULTS: We identified 28 patients (28%) with postoperative ARF and 72 patients (72%) without postoperative ARF. The 2 groups were similar with regard to demographics and comorbidities. The patients with ARF were more likely to be intubated preoperatively (14.3% versus 1.4%; p = 0.021) and had higher preoperative central venous pressure (CVP) (14.3 mm Hg versus 10.7 mm Hg; p = 0.015). Postoperatively patients with ARF had a longer hospital stay (32.4 versus 18.7; p = 0.05), were more likely to experience right ventricular (RV) failure (25% versus 5.6%; p = 0.01) and ventilator-dependent respiratory failure (VDRF) (28.6% versus 6.9%; p = 0.007). There was a significant difference when comparing the ARF and non-ARF groups for 30-day (17.9% versus 0%; p < 0.001), 180-day (28.6% versus 2.8%; p < 0.001), and 360-day mortality (28.6% versus 6.9%; p = 0.012). CONCLUSIONS: Patients in whom ARF developed after LVAD implantation had a higher rate of VDRF and RV failure and a longer length of stay (LOS). Postoperative ARF was associated with higher mortality at the 30-day, 180-day, and 360-day intervals. ARF after LVAD may be an early marker of poor outcome, particularly RV failure, and may be an opportunity for early intervention and rescue.

Transfusion rate as a quality metric: is blood conservation a learnable skill?

BACKGROUND: Between January 2008 and December 2012, a multicenter quality collaborative initiated a focus on blood conservation as a quality metric, with educational presentations and quarterly reporting of institutional-level perioperative transfusion rates and outcomes. This prospective cohort study was undertaken to determine the effect of that initiative on transfusion rates after isolated coronary artery bypass grafting (CABG). METHODS: Between January 1, 2008, and December 31, 2012, 30,271 patients underwent isolated CABG in Michigan. Evaluated were annual crude and adjusted trends in overall transfusion rates for red blood cells (RBCs), fresh frozen plasma (FFP), and platelets, and in operative death. RESULTS: Transfusion rates continuously decreased for all blood products. RBC use decreased from 56.4% in 2008 (baseline) to 38.3% in 2012, FFP use decreased from 14.8% to 9.1%, and platelet use decreased from 20.5% to 13.4% (ptrend < 0.001 for all). A significant reduction occurred in deep sternal wound infection, reoperation for bleeding, renal failure, prolonged ventilation, initial ventilator time, and intensive care unit duration. The percentage of patients discharged home significantly increased (ptrend < 0.001). Mortality rates did not differ significantly (ptrend = 0.11). CONCLUSIONS: In a multicenter quality collaborative, increased attention to transfusion-related outcomes and blood conservation techniques, coincident with regular reporting and review of perioperative transfusion rates as a quality metric, was associated with a significant decrease in blood product utilization. These reductions were concurrent with significant improvement in most perioperative outcomes. This intervention was also safe, as it was not associated with any increases in mortality.

Preoperative predicted risk does not fully explain the association between red blood cell transfusion and mortality in coronary artery bypass grafting.

OBJECTIVE: Perioperative red blood cell transfusion is associated with increased morbidity and mortality after coronary artery bypass grafting (CABG). Whether transfusion is a cause of these outcomes or serves as a surrogate for a high-risk patient population remains uncertain. This retrospective study tested the hypothesis that increased preoperative risk profile of patients receiving transfusion would explain the relationship between red blood cell transfusion and operative mortality in isolated CABG. METHODS: A total of 31,818 patients undergoing isolated CABG were entered into a statewide collaborative database between January 2006 and June 2010. With the Society of Thoracic Surgeons risk calculator, patient cohorts were stratified into 4 groups by predicted risk of mortality (PROM) of less than 2%, 2% to 5%, more than 5% to 10% and more than 10%. The association between blood transfusion and mortality was tested at each stratum with a χ(2) test. A Breslow-Day test for homogeneity of odds ratios was used to test whether the 4 odds ratios of the strata were similar, and a Cochran-Mantel-Haenszel test was used to test the association between blood transfusion and mortality while controlling for predicted risk mortality strata. RESULTS: In all, 17,720 (55.7%) of all patients were transfused during the hospitalization. Incidence of transfusion increased stepwise with risk level; 93.3% of patients with PROM greater than 10% received blood. Operative mortality was 2.1% overall, 0.6% among the 44.3% of patients who were not transfused, and 3.3% in the transfused group (odds ratio, 6.19; P < .0001). The association between blood transfusion and mortality was significant within each predicted risk stratum. Increased mortality associated with transfusion was statistically equivalent across all predicted risk strata (P = .1778). The association between blood transfusion and mortality for all patients lessened somewhat when controlling for PROM (odds ratio, 2.99 vs 6.19), yet remained highly significant (P < .0001). CONCLUSIONS: The association between red blood cell transfusion and mortality after CABG is highly significant and independent of increased preoperative risk status. The correlation persists after controlling for increased PROM.