Likelihood Of Surgical Intervention Research Articles

Plaque hemorrhage in carotid artery disease: Pathogenesis, clinical and biomechanical considerations

Stroke remains the most prevalent disabling illness today, with internal carotid artery luminal stenosis due to atheroma formation responsible for the majority of ischemic cerebrovascular events. Severity of luminal stenosis continues to dictate both patient risk stratification and the likelihood of surgical intervention. But there is growing evidence to suggest that plaque morphology may help improve pre-existing risk stratification criteria. Plaque components such a fibrous tissue, lipid rich necrotic core and calcium have been well investigated but plaque hemorrhage (PH) has been somewhat overlooked. In this review we discuss the pathogenesis of PH, its role in dictating plaque vulnerability, PH imaging techniques, marterial properties of atherosclerotic tissues, in particular, those obtained based on in vivo measurements and effect of PH in modulating local biomechanics.

Commentary to ‘Analysis of indications for ureteral reimplantation in 3738 children with vesicoureteral reflux: A single institutional cohort’

Arriving upon a decision to proceed with surgery for vesicoureteral reflux is often difficult and fraught with uncertainty. And the authors of this study concede that families often depend on the pediatric urologist to drive the decision toward surgery (Reference 15). This onerous role mandates studies such as this one that assess practice patterns and the likelihood of surgical intervention for vesicoureteral reflux (VUR) at individual referral centers. The present study included four broad indications in its modeling to calculate the probability that surgery would be performed to treat VUR: breakthrough urinary tract infection (UTI), non-resolution over three years, renal scan abnormality and parent/surgeon preference. Nearly as many children underwent ureteral reimplantation for the last category of parent preference as did those for breakthrough UTI or non-resolution. Clearly, that category is susceptible to bias predicated upon institutional trends and a surgeon’s practice pattern and personal preference, and a reality that will be more rigorously measured under the rubric of health care reform. The logistic regression analysis of 1364 children undergoing surgery in this study includes patients treated between

Abstract B87: The impact of insurance and treatment on racial differences in uterine cancer survival: A study of patients in the National Cancer Database

Abstract Introduction: Among uterine cancer patients, the age-adjusted mortality for African Americans is substantially higher relative to white patients. Previous studies have attributed this survival disparity to an elevated rate of aggressive tumors and advanced stage of disease among African Americans. However, the role of access to care in this racial disparity has not been fully elucidated. The aim of this study is to examine the impact of insurance status and treatment on racial/ethnic survival disparities among a large cohort of uterine cancer patients from the National Cancer Database (NCDB). Methods: Women diagnosed with stage I-III uterine cancer between 2000-2007 were selected from the NCDB. The association between race/ethnicity and all cause mortality was analyzed adjusting for patient demographic and clinical factors, health insurance, treatment (which included categories for no surgery, surgery alone, and surgery plus systemic treatment), area-level education, and facility characteristics. Kaplan Meir (KM) and multivariate Cox proportional hazards were used to estimate 4 year survival rates and hazard ratios (HR) and 95% confidence intervals (CI) among patients diagnosed between 2000-2002, respectively. Log binomial models were used to estimate risk ratios (RR) and 95% CI of likelihood of surgical treatment and among patients receiving surgery, the risk of lymphadectomy and systemic (radiation and/or chemotherapy) therapy. Results: Among the 178,891 evaluable patients, 73.79%, 4.39% 8.66%, 3.07% and 10.08% were white, Hispanic, African American, Other and missing race. The 4 year survival rate was 81.81% for whites, 81.50% for Hispanic, 63.19% for African American and 85.62% for other races. African Americans had a higher risk of death compared to whites (HR=1.43 95%CI1.31 −1.56) after adjusting for all covariates except treatment and insurance. After additional adjustment of treatment the risk death decreased among African Americans (HR=1.32 95%CI1.21 −1.45) and subsequent adjustment for insurance further reduced the hazard of death (HR=1.28 95% CI1.16-1.40). Patients with insurance other than private had an increased risk of death (Uninsured HR= 1.46 95%CI1.22-1.75, Medicaid HR=1.74,95%CI1.49-2.02, Medicare among patients aged 18-64 HR=2.52,95% CI 2.13-2.99, Medicare among patients aged 65-99 HR=1.26,95% 1.16-1.38). African Americans (RR= 0.96 95% CI 0.96-0.97) and Hispanics (RR=0.99 95% CI 0.99-1.00) had similar surgical treatment rates compared to whites and among patients receiving surgical treatment, similar rates of lymphadectomy and systemic treatment by race/ethnicity were observed. Conclusions: Our results suggest that a portion of the survival disparity between African Americans and whites is attributable to variations in access to care; the hazard ratios of death decreased 11% when treatment was accounted for and an additional 4% when insurance was accounted for. Despite accounting for these and other factors, African American patients had 32% greater risk of death. Future studies examining the role of lifestyle factors and non insurance related barriers to medical care, such as lower income, prior experiences and trust in the health care system, language and geographic barriers, cultural and communication barriers are warranted. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B87.

Emergency physicians do not use more resources to evaluate obese patients with acute abdominal pain

Objective We hypothesized that emergency physicians would use more resources to evaluate acute abdominal pain in obese patients as compared with that in nonobese patients. Methods We conducted a secondary analysis of a prospective cohort of adults with acute abdominal pain. Collected data included self-reported height and weight, demographics, medical history, laboratory and x-ray results, and final diagnosis. We followed the patients until they obtained their final diagnosis or for up to 21 days. Patients were grouped according to their body mass index (BMI): nonobese (BMI < 30 kg/m 2), obese (BMI = 30-40 kg/m 2), and morbidly obese (BMI > 40 mg/m 2). The main outcome measure was laboratory and radiographic testing. χ 2 Tests and analysis of variance were used as appropriate. Results Of the 971 patients (mean age, 41 years; 62% black; 65% female), 665 (68%) were nonobese, 246 (25%) were obese, and 60 (6%) were morbidly obese. In comparing nonobese patients with obese patients, we found no difference in laboratory or radiographic testing (3.20 vs 3.21 tests; mean difference, 0.004; 95% confidence interval [CI], −0.26 to 0.27), physicians' pre–computed tomographic scan confidence level in their diagnosis (6.17 vs 6.04, mean difference, −0.13; 95% CI, −0.76 to 0.49), and emergency department (ED) length of stay (LOS; 7.40 vs 7.57 hours; mean difference, −0.17; 95% CI, −0.49 to 0.83). In comparing all 3 groups, we found no difference in diagnostic testing, ED LOS, surgical intervention (10% vs 5% vs 9%, P = .2), disposition, and final diagnosis ( P > .05). Conclusions Physicians do not use more resources to identify the etiology of acute abdominal pain in obese patients as compared with that in nonobese patients. Furthermore, ED LOS, likelihood of surgical intervention, physicians' confidence level in their preimaging diagnosis, and final diagnosis do not appear to be influenced by BMI.

Factors that affect surgical rates in Iowa.

This study analyzed insurance claims to estimate the probability of medical and surgical treatments in different Iowa communities. The likelihood of surgical treatment was associated with patient characteristics of age and gender as well as hospital characteristics of size (number of beds), occupancy rate, and number of staff. Our findings are being used by a study group of 25 physicians to understand the causes of variation in surgical rates for low back pain. Medical education and other interventions are being implemented. Hospitalization rates for lower back operations in the United States increased by more than 20% from 1978 to 1985. Consequently, several studies in Iowa and the US have been initiated to examine the medical effectiveness of these treatments. A logistic regression model was used to determine the factors associated with the likelihood of having a low back surgery in a population of Blue Cross/Blue Shield (BCBS) subscribers in Iowa. The outcome, or dependent variable, of interest was a hospitalization that resulted in a surgical procedure on a low back pain patient. Surgical rates for the treatment of low back pain are likely to be increased if a BCBS Iowa subscriber is female, older than 44 years of age, or if the surgery is performed in a hospital with either an occupancy rate less than 62%, with fewer than 774 staff members, fewer than 267 beds, or no residency programs.