Crossbow Injuries: Predictors of Mortality.

INTRODUCTION: Crossbow injuries are rare but carry significant morbidity and mortality, and there is limited evidence in the medical literature to guide care. This paper reviews the case reports and case series of crossbow injuries and looks for trends regarding morbidity and mortality based on the type of arrow, anatomic location of injury, and intent of injury. METHODS: Multiple databases were searched for cases of crossbow injuries and data were abstracted into a spreadsheet. Statistics were done in SPSS. RESULTS: 358 manuscripts were returned in the search. After deduplication and removal of nonclinical articles, 101 manuscripts remained. Seventy-one articles describing 90 incidents met the inclusion criteria. The mean age was 36.5 years. There were 10 female and 79 male victims. Fatality was 36% for injuries by field tip arrows and 71% for broadhead arrows, p = .024. Assaults were fatal in 84% of cases, suicides in 29%, and accidental injuries in 17%, p < .001. Mortality was similar for wounds to the head and neck (41%), chest (42%), abdomen (33%), extremities (50%), and multiple regions, p = .618. CONCLUSIONS: Crossbows are potentially lethal weapons sold with fewer restrictions than firearms. Injuries caused by broadhead arrows are more likely to be fatal than injuries from field tip arrows. The anatomic location of injury does not correlate with fatality. More than half of crossbow injuries are due to attempted suicide, with a high case-fatality rate.

Arrhythmia in chronic hemodialysis as a function of predialysis electrolytes and interdialytic interval.

INTRODUCTION: People with end-stage renal disease on hemodialysis are at increased risk for death due to arrhythmia associated with the prolonged interdialytic interval that typically spans the weekend, with bradycardia being the arrhythmia most closely associated with sudden death. In this prospective observational study we assessed whether predialysis fluid and electrolytes values including hyperkalemia are risk factors for the arrhythmias associated with the prolonged interdialytic interval. METHODS: Sixty patients on hemodialysis with a history of hyperkalemia underwent cardiac monitoring for 1 week. Arrhythmia frequency, average QTc interval, and average root mean square of successive differences (rMSSD) per 4-h period were reported. Predialysis electrolytes and electrocardiograms were collected prior to pre- and post-weekend dialysis sessions. Clinical variables were assessed for correlation with arrhythmias. FINDINGS: Predialysis hyperkalemia occurred in 29 subjects and was more common at the post-weekend dialysis session. Bradycardia occurred in 11 subjects and increased before and during the post-weekend dialysis session, but was not correlated with any electrolyte or clinical parameter. Ventricular ectopy occurred in 50 subjects with diurnal variation unrelated to dialysis. Pre-dialysis prolonged QTc was common and not affected by interdialytic interval. Average QTc increased and rMSSD decreased during dialysis sessions and were not correlated with clinical parameters. DISCUSSION: The results confirm that arrhythmias are prevalent in dialysis subjects with bradycardia particularly associated with the longer interdialytic interval; EKG markers of arrhythmia risk are increased during dialysis independent of interdialytic interval. Larger sample size and/or longer recording may be necessary to identify the clinical parameters responsible.

Presumed adrenal insufficiency in neonates treated with corticosteroids for the prevention of bronchopulmonary dysplasia.

OBJECTIVE: To determine if extremely preterm (EPT) neonates receiving dexamethasone for the prevention of BPD have a higher incidence of presumed adrenal insufficiency (PAI). STUDY DESIGN: Retrospective cohort study of neonates <28 weeks gestation examining PAI after dexamethasone use and PAI after intratracheal budesonide with surfactant administration. RESULT: Of 332 neonates, 38% received dexamethasone. The incidence of PAI was higher in neonates who had received dexamethasone (20.8% vs 2.9%, p < 0.001). However, for intubated babies receiving surfactant, dexamethasone was not independently associated with increased PAI after adjusting for gestational age, birthweight, and race (aOR 2.92, 95% CI: 0.79-10.85). Dexamethasone was independently associated with increased PAI in infants previously receiving budesonide/surfactant treatment (aOR 5.38, 95% CI: 1.38-20.90). CONCLUSION: The use of dexamethasone alone was not associated with increased PAI, when adjusted for prematurity-related factors. The combination of budesonide with dexamethasone was significantly associated with increased PAI.

Elevated neutrophil-lymphocyte ratios in extremely preterm neonates with histologic chorioamnionitis.

OBJECTIVE: Histologic chorioamnionitis (HCA) is a placental inflammation linked to preterm birth and adverse neonatal outcome. The neutrophil-lymphocyte ratio (NLR) can identify various inflammatory disorders, however its utility in HCA is not clear. Our goal was to examine NLR values and HCA diagnoses in at-risk pregnancies and neonates. STUDY DESIGN: We retrospectively analyzed the EHR of mothers and preterm (<33 wk GA) neonates with or without HCA (identified by placental histology). The NLR was calculated from complete blood counts in laboring women and in their neonates (0-24 h of life). RESULT: In 712 consecutive gestations, 50.8% had HCA (26.5% fetal HCA). The neonatal NLR (0-12 h, 13-24 h) predicted fetal HCA better than chance alone (p = 0.01 and 0.002, respectively). CONCLUSION: Early NLR elevation in preterm neonates is consistent with a diagnosis of fetal HCA. The NLR may identify preterm neonates at risk for HCA-related complications.

Testing the Cognitive Reserve Index Questionnaire in an Alzheimer's Disease Population.

BACKGROUND: Alzheimer's disease (AD) is the 6th leading cause of death in the United States and has no cure or progression prevention. The Cognitive Reserve (CR) theory poses that constant brain activity earlier in life later helps to deter pathological changes in the brain, delaying the onset of disease symptoms. OBJECTIVE: To determine the reliability and validity of the Cognitive Reserve Index questionnaire (CRIq) in AD patients. METHODS: Primary data collection was done using the CRIq to quantify CR in 90 participants. Correlations and multivariable linear regressions were used to assess reliability and validity. RESULTS: Reliability was tested in 34 participants. A Pearson correlation coefficient of 0.89 (p < 0.001) indicated a strong positive correlation. Validity was tested in 33 participants. A Pearson correlation coefficient of 0.30 (p = 0.10) indicated an insignificant weak positive correlation. CONCLUSION: The CRIq was found reliable. Gaining a better understanding of how CR tools can be used in various cognitive populations will help with the establishment of a research tool that is universally accepted as a true CR measure.

Shear wave elastography correlates with liver fibrosis scores in pediatric patients with liver disease.

BACKGROUND: While liver biopsy remains the gold standard, given the procedure risks and sampling errors, there is a need for reliable noninvasive biomarkers of hepatic fibrosis. OBJECTIVE: Determine the accuracy of two-dimensional shear wave elastography (2-D SWE) in predicting the histological severity of liver fibrosis in pediatric patients with known or suspected liver disease. MATERIALS AND METHODS: Subjects 0-18 years old with known or suspected liver disease and liver biopsy within 30 days (n=70) were included. Comparisons by 2-D SWE were made to a control group (n=79). Two-dimensional SWE was performed using the GE LOGIQ E9 system. Liver biopsy specimens were scored according to METAVIR and Ishak scoring systems using Spearman's Rho correlation. Receiver operator characteristic (ROC) analysis, Kruskal-Wallis and Mann-Whitney U tests were conducted. RESULTS: Control group median 2-D SWE measurements were lower than in subjects with any degree of liver fibrosis (P<0.001). Those with METAVIR F0 and Ishak 0 scores had significantly lower median 2-D SWE measurements (1.35 m/s; 1.36 m/s) than those with more advanced liver disease (F1-F3: 1.49-1.62 m/s; 1-4: 1.45-1.63 m/s) (P<0.05 for all), whereas the 2-D SWE in the higher scores were similar. Results did not differ between METAVIR and Ishak scores for any degree of fibrosis. Fibrosis scores moderately correlated with median 2-D SWE measurements (rs=0.43). The area under the curve for F1 compared to combined control/F0 was 0.89 (95% confidence interval [CI] 0.83-0.95; P<0.001) with sensitivity of 94.6% and specificity of 78.6%. Results for Ishak score 1 were similar. The ideal cutoff value for identifying fibrosis was determined to be 1.29 m/s. CONCLUSION: The liver 2-D SWE measurements correlated with the histological liver fibrosis scores, regardless of the histopathological scoring system, although 2-D SWE was better at identifying patients with early fibrosis, not at distinguishing among the individual fibrosis levels. Two-dimensional SWE using the GE LOGIQ US system is useful for identifying pediatric patients at risk for liver fibrosis.

Diagnostic accuracy of non-contrast magnetic resonance enterography in detecting active bowel inflammation in pediatric patients with diagnosed or suspected inflammatory bowel disease to determine necessity of gadolinium-based contrast agents.

BACKGROUND: Pediatric patients with inflammatory bowel disease (IBD) are at increased risk of gadolinium deposition given the potential need for multiple contrast-enhanced magnetic resonance enterography (MRE) exams over their lifetime. OBJECTIVE: To determine whether gadolinium-based contrast agents are necessary in assessing active bowel inflammation on MRE in pediatric patients with known or suspected IBD. MATERIALS AND METHODS: We conducted a retrospective study of 77 patients (7-18 years; 68.8% male) with known (n=58) or suspected (n=19) IBD and endoscopy with biopsy performed within 30 days of MRE without and with contrast evaluated bowel and non-bowel findings. During three visual analysis sessions, two radiologists reviewed pre-, post-, and pre-/post-contrast MRE images. A third radiologist independently reviewed 27 studies to assess inter-reader reliability. We used Cohen kappa (κ), Fleiss kappa, (κF), McNemar test, and sensitivity and specificity to compare MRE readings to combined endoscopic/histopathological findings (the reference standard). RESULTS: The pre- and pre-/post-contrast-enhanced MRE vs. combined endoscopic/histopathological results had moderate agreement (85.7%; κ 0.713, P<0.001; P-value 0.549). Compared to combined endoscopy/histopathology, pre- vs. pre-/post-contrast sensitivity (67%, confidence interval [CI] 0.53-0.79 vs. 67%, CI 0.53-0.79) and specificity (80%, CI 0.59-0.92 vs. 68%, CI 0.46-0.84) varied little (κ 0.42, P<0.001 and κ 0.32, P=0.003, respectively). The three readers had moderate agreement (85.2%; κ 0.695, P=0.001; P-value 0.625). More penetrating complications were identified following contrast administration (P-value 0.04). CONCLUSION: Use of a contrast agent does not improve the detection of active inflammation in the terminal ileum and colon compared to non-contrast MRE, although use of a contrast agent does aid in the detection of penetrating disease.

Factors Associated With Head and Neck Cancer Hospitalization Cost and Length of Stay-A National Study.

OBJECTIVES: The aim of the study was to estimate hospitalization cost, and factors associated with hospitalization costs and length of stay (LOS) of patients treated for head and neck cancer in the United States. METHODS: Data on 71,440 weighted hospital admissions from the 2014 National Inpatient Sample with a diagnosis of head and neck cancer were examined. Multivariable linear regression models estimated factors associated with hospitalization costs, and negative binomial regression models were used to identify factors associated with hospital LOS. Factor variables included characteristics of the patient, clinical, and hospital characteristics. RESULTS: The average hospitalization cost was US $18,371 and the average LOS was 6.6 days. LOS was significantly associated with admissions involving bacterial infection, major operating procedures, chemo procedure, and radiation procedure as well as admissions at medium or small bed size hospitals, and rural hospitals. Admissions among black patients, elective admissions, admissions involving bacterial infection, major operating procedures, chemo procedure, radiation procedure, and advance comorbidities were associated with increased hospitalization costs. In contrast, admissions at urban nonteaching or rural had increased hospitalization costs. CONCLUSIONS: Admissions that involve higher number of comorbidities, metastasis, bacterial infection, radiation, and chemo procedures had longer hospital stay and higher cost whereas admissions are rural hospitals had shorter hospital stay and lower cost. Understanding these factors associated with increased LOS and hospitalization cost will help efforts to decrease health care cost and improve quality of care.

Evaluating the Needs of Patients Living With Solid Tumor Cancer: A Survey Design.

PURPOSE: To describe the unmet needs of adult patients living with solid tumor cancer. DESIGN: Survey design. METHOD: Adult patients living with solid tumor cancer from two outpatient clinics were mailed the Sheffield Profile for Assessment and Referral to Care, a holistic screening questionnaire for assessing palliative care needs, and a demographics questionnaire. One hundred fifteen patients returned the instruments, corresponding to a 62% response rate. FINDINGS: There were no significant differences by cancer type (breast, non-breast) or gender. However, Caucasians reported significantly more psychological issues, such as anxiety, than non-Caucasians ([ n = 101 (87.8%)] and [ n = 14 (12.2%)], respectively, p = .032). Older patients reported more concerns about loss of independence/activity ( p = .012) compared with younger age groups. Patients living with Stage III/IV cancer reported more distressed about independence/activity ( p = .034), family/social issues ( p = .007), and treatment side effects ( p = .027) than patients living with Stage I/II cancer. CONCLUSION: Patients living with solid tumor cancer have a myriad of unmet needs regardless of age, gender, cancer type, or cancer stage. There appears to be important differences by cancer stage. The Sheffield Profile for Assessment and Referral to Care questionnaire provides a holistic approach for nurses to identify unmet needs and concerns. Future research should explore the preferred methods of receiving support and information.

Self-Directed Rater Training for Pediatric History and Physical Exam Evaluation (P-HAPEE) Rubric, a Validated Written H&P Assessment Tool.

INTRODUCTION: We developed, revised, and implemented self-directed rater training materials in the course of a validity study for a written Pediatric History and Physical Exam Evaluation (P-HAPEE) rubric. METHODS: Core training materials consist of a single-page instruction sheet, sample written history and physical (H&P), and detailed answer key. We iteratively revised the materials based on reviewer comments and pilot testing. Eighteen attending physicians and five senior residents underwent self-directed training, scored 10 H&Ps, and completed a rubric utility survey in the course of the validity study. We have since implemented the P-HAPEE rubric and self-directed rater training in a pediatric clerkship. Based on input from reviewers, study raters, faculty members, and medical student users, we have also developed and implemented additional optional supplemental training materials. RESULTS: Pilot testing indicated that training takes approximately 1 hour. While reviewers endorsed the training format, several suggested having optional supplemental materials available. Nineteen out of 23 volunteer study raters completed the rubric utility survey. All described the rubric as good or very good and indicated strong to very strong interest in continued use. DISCUSSION: The P-HAPEE rubric offers a novel, practical, reliable, and valid method for supervising physicians to assess pediatric written H&Ps and can be implemented using brief, self-directed rater training.

Developing Validity Evidence for the Written Pediatric History and Physical Exam Evaluation Rubric.

OBJECTIVE: The written history and physical examination (H&P) is an underutilized source of medical trainee assessment. The authors describe development and validity evidence for the Pediatric History and Physical Exam Evaluation (P-HAPEE) rubric: a novel tool for evaluating written H&Ps. METHODS: Using an iterative process, the authors drafted, revised, and implemented the 10-item rubric at 3 academic institutions in 2014. Eighteen attending physicians and 5 senior residents each scored 10 third-year medical student H&Ps. Inter-rater reliability (IRR) was determined using intraclass correlation coefficients. Cronbach α was used to report consistency and Spearman rank-order correlations to determine relationships between rubric items. Raters provided a global assessment, recorded time to review and score each H&P, and completed a rubric utility survey. RESULTS: Overall intraclass correlation was 0.85, indicating adequate IRR. Global assessment IRR was 0.89. IRR for low- and high-quality H&Ps was significantly greater than for medium-quality ones but did not differ on the basis of rater category (attending physician vs. senior resident), note format (electronic health record vs nonelectronic), or student diagnostic accuracy. Cronbach α was 0.93. The highest correlation between an individual item and total score was for assessments was 0.84; the highest interitem correlation was between assessment and differential diagnosis (0.78). Mean time to review and score an H&P was 16.3 minutes; residents took significantly longer than attending physicians. All raters described rubric utility as "good" or "very good" and endorsed continued use. CONCLUSIONS: The P-HAPEE rubric offers a novel, practical, reliable, and valid method for supervising physicians to assess pediatric written H&Ps.

Augmented Th17-type immune responses in preterm neonates exposed to histologic chorioamnionitis.

BACKGROUND: Histologic chorioamnionitis (HCA) is a placental inflammatory disorder that frequently precedes preterm delivery. HCA increases risk for long-standing inflammatory injury and may influence immune programming, particularly in preterm (PT) neonates. We hypothesized that HCA exposure is associated with an increased circulating frequency of proinflammatory, Th17-type responses. METHODS: Placental cord blood was collected from HCA-exposed or control neonates (23-41 wk gestation). Frequencies of Th17 and T regulatory (Treg) cells and assessments of Th17-type features in CD4 and Treg cells were determined by flow cytometric analysis. RESULTS: Cord blood samples from 31 PT and 17 term neonates were analyzed by flow cytometry. A diagnosis of HCA in extremely PT (EPT, GA ≤ 30 wk) gestations was associated with the highest cord blood frequencies of progenitor (pTh17, CD4+CD161+) and mature (mTh17, CD4+CD161+CCR6+) Th17 cells. Preterm neonates exposed to HCA also exhibited elevated cord blood frequencies of IL-17+ Treg cells, as well as T cells with effector memory phenotype (TEM) that coexpressed Th17-type surface antigens. CONCLUSION: Th17-type responses are amplified in preterm neonates exposed to HCA. We speculate that a Th17 bias may potentiate the inflammatory responses and related morbidity observed in preterm neonates whose immune systems have been "primed" by HCA exposure.

Preserved Gut Microbial Diversity Accompanies Upregulation of TGR5 and Hepatobiliary Transporters in Bile Acid-Treated Animals Receiving Parenteral Nutrition.

BACKGROUND: Parenteral nutrition (PN) is a lifesaving therapy but is associated with gut atrophy and cholestasis. While bile acids (BAs) can modulate intestinal growth via gut receptors, the gut microbiome likely influences gut proliferation and inflammation. BAs also regulate the bile salt export pump (BSEP) involved in cholestasis. We hypothesized that the BA receptor agonist oleanolic acid (OA) regulates gut TGR5 receptor and modulates gut microbiota to prevent PN-associated injury. MATERIALS AND METHODS: Neonatal piglets were randomized to approximately 2 weeks of isocaloric enteral nutrition (EN), PN, or PN + enteral OA. Serum alanine aminotransferase, bilirubin, BAs, hepatic BSEP, gut TGR5, gut, liver morphology, and fecal microbiome utilizing 16S rRNA sequencing were evaluated. Kruskal-Wallis test, pairwise Mann-Whitney U test, and multilevel logistic regression analysis were performed. RESULTS: PN support resulted in gut atrophy substantially prevented by OA. The median (interquartile range) for villous/crypt ratio was as follows: EN, 3.37 (2.82-3.80); PN, 1.73 (1.54-2.27); and OA, 2.89 (2.17-3.34; P = .006). Pairwise comparisons yielded P = .002 (EN vs PN), P = .180 (EN vs OA), P = .026 (PN vs OA). OA upregulated TGR5 and BSEP without significant improvement in serum bilirubin ( P = .095). A decreased microbial diversity and shift toward proinflammatory phylum Bacteroidetes were seen with PN, which was prevented by OA. CONCLUSIONS: OA prevented PN-associated gut mucosal injury, Bacterioides expansion, and the decreased microbial diversity noted with PN. This study demonstrates a novel relationship among PN-associated gut dysfunction, BA treatment, and gut microbial changes.

Pineal Gland Calcification in Kurdistan: A Cross-Sectional Study of 480 Roentgenograms.

OBJECTIVE: The goal of this study was to compare the incidence of Pineal Gland Calcification (PGC) by age group and gender among the populations living in the Kurdistan Region-Iraq. METHODS: This prospective study examined skull X-rays of 480 patients between the ages of 3 and 89 years who sought care at a large teaching public hospital in Duhok, Iraq from June 2014 to November 2014. Descriptive statistics and a binary logistic regression were used for analysis. RESULTS: The overall incidence rate of PGC among the study population was 26.9% with the 51-60 age group and males having the highest incidence. PGC incidence increased after the first decade and remained steady until the age of 60. Thereafter the incidence began to decrease. Logistic regression analysis revealed that both age and gender significantly affected the risk of PGC. After adjusting for age, males were 1.94 (95% CI, 1.26-2.99) times more likely to have PGC compared to females. In addition, a one year increase in age increases the odds of developing PGC by 1.02 (95% CI, 1.01-1.03) units after controlling for the effects of gender. CONCLUSION: Our analysis demonstrated a close relationship between PGC and age and gender, supporting a link between the development of PGC and these factors. This study provides a basis for future researchers to further investigate the nature and mechanisms underlying pineal gland calcification.

The quality of care provided to patients with varices in the department of Veterans Affairs.

OBJECTIVES: Practice guidelines define the criteria and standards of care in patients with cirrhosis and varices. However, the extent to which the patients receive recommended care is largely unknown. We evaluated the quality of varices related care and factors associated with receipt of such care. METHODS: We conducted a retrospective cohort study of 550 patients with cirrhosis who sought care at three VA facilities between 2000 and 2007. Using administrative and clinical data, we assessed quality of varices care as measured by eight explicit Delphi panel-derived quality indicators. We also conducted a structured implicit review of patients' medical records to explore the role of patients' refusal, receipt of care outside the VA, or justifiable exclusions to certain care processes as explanations for non-adherence to the quality indicators. RESULTS: Quality scores (max. 100%) varied across individual indicators, ranging from 24.3% for upper endoscopy for varices screening to 72.4% for secondary prophylaxis for variceal bleeding. Justifiable exclusions to indicated care documented in charts were common for primary prophylaxis in patients with varices; receipt of endoscopy; and endoscopic treatment in patients with active bleeding. In contrast, significant shortfalls remained in the receipt of screening endoscopy, use of beta-blockers (in the absence of varices), and use of somatostatin analogs, antibiotics, and secondary prophylaxis in patients with variceal bleeding. Younger patients (<60 vs. >60 year, odds ratio (OR)=1.29, 95% confidence interval (CI) 1.01-1.68), those who saw a gastroenterologist (OR=1.55, 95% CI=1.09-2.21), or those who were seen in the facility with academic affiliation (OR=1.26, 95% CI=1.01-1.58) received higher quality care. CONCLUSIONS: Health-care quality, measured according to whether patients received recommended varices-related care, was suboptimal in this health-care setting. Care that included gastroenterologists was associated with high quality.

Costs and Outcomes of Privately-Insured Kidney Transplant Recipients by Body Mass Index.

BACKGROUND: Obesity presents an additional challenge to the procedure of and recovery from kidney transplantation. As the prevalence of transplant candidates with an elevated body mass index (BMI) grows, researchers need to examine and quantify the increased risks and additional costs associated with the full spectrum of body composition. STUDY DESIGN: A retrospective cohort study design was used. SETTING & PARTICIPANTS: Data from a private health insurance provider were linked with records from the Organ Procurement and Transplantation Network to examine costs and health outcomes following kidney transplantation. FACTOR: BMI was used to predict costs and outcomes. OUTCOMES: The primary outcome of interest was posttransplant cost defined as insurance charges. Secondary outcomes of interest included delayed graft function, graft failure, patient survival, and length of transplant hospitalization. MEASUREMENTS: Categories of BMI followed selected cutoffs from World Health Organization International Classifications. Charges from recipient dialysis center, health providers, and treatment centers following transplant were summed during transplant hospitalization as well as each of three years following transplantation. RESULTS: Rates of graft failure were significantly increased for underweight, overweight, obese, and morbidly obese recipients. Recipients with elevated BMI had a significantly longer length of transplant hospitalization and an increased rate of delayed graft function. LIMITATIONS: Our analysis was limited to the quality and availability of the data included in the registry. Though inexpensive and easy to calculate, BMI may not be the best measure of body composition. Finally, BMI measurement is cross-sectional at time of transplant thereby limiting the potential for fluctuation of BMI before and after transplantation. CONCLUSIONS: The study results highlight the exponential concern associated with non-normal BMI for kidney transplant recipients. Transplant centers and insurance companies should consider funding weight management programs for transplant candidates as a means of obtaining preferred BMI and reducing costs associated with follow-up care.

The clinical and financial burden of early dialysis after deceased donor kidney transplantation.

BACKGROUND: The economic implications of dialysis-requiring allograft dysfunction early after kidney transplantation are not well-described. METHODS: Data for Medicare-insured adult kidney transplant recipients in 1995-2004 who did not develop permanent graft failure in the first 90 days were drawn from the United States Renal Data System. We identified dialysis treatment records from Medicare claims and categorized patients according to frequency and duration of post-transplant dialysis as: first week (delayed graft function, DGF), second week, weeks 3 or 4, second month, or third month. Associations of dialysis requirements with Medicare payments for the transplant hospitalization and over the next three years were estimated with multivariable linear regression. Graft and patient survival according to early dialysis requirements were examined with multivariable survival analysis. RESULTS: Among 37,533 recipients, 15,314 (41%) experienced DGF and 3,184 (21% of those with DGF) received dialysis beyond the first week. Compared with no dialysis in the first 3 months, adjusted marginal first-year costs associated with early post-transplant dialysis ranged from $6,467 for dialysis requirement limited to first week to $27,606 for dialysis in multiple periods (p<0.0001). Patients who experienced DGF and received dialysis in >2 early periods were more than twice as likely to lose their grafts within 3 years as those without early dialysis requirements. CONCLUSIONS: While dialysis in the first week post-transplant is an adverse risk marker, early dialysis in weeks 2 to 12 is associated with similarly adverse, if not worse, costs and clinical consequences. This observation supports a need for broader definition of DGF.

Salvage surgery following radiation failure for laryngeal cancer in elderly patients.

OBJECTIVE: To find the survival rate of patients ≥ 80 years old who undergo salvage surgery for squamous cell carcinoma of the larynx. STUDY DESIGN: National data registry analysis. SETTING: Seventeen population-based registries comprising the National Cancer Institute's Surveillance, Epidemiology, and End Results database. SUBJECTS AND METHODS: Overall, cancer-specific, and relative survival rates were calculated from 1418 patients, stratified into 3 age cohorts, who underwent surgery following radiation therapy for treatment of laryngeal cancer. RESULTS: The 1-year overall survival of patients ≥ 80 years old (n = 57) was 76.1%. The cancer-specific survival at 1 year was 86.4%. These survival rates were significantly less than those of patients <65 years old (n = 869), who had a 1-year overall survival of 88.1% (P = .006) and cancer-specific survival of 90.5% (P = .029). Patients aged between 65 and 79 years old (n = 492) displayed 1-year overall survival of 80.7% (P = .426) and cancer-specific survival of 85.1% (P = .711), which were not significantly different from the ≥ 80 year cohort. When comparing relative survival at 5 years, the ≥ 80-year-old cohort's survival trended the highest (≥ 80 years, 62.8%; 65-79 years, 51.3%; 20-64 years, 56.2%). CONCLUSION: While patients ≥ 80 years old have a less favorable prognosis than patients <65 years old, the survival rates of patients ≥ 80 years old are not significantly different from the 65- to 79-year-old cohort. After controlling for non-cancer-related death, patients ≥ 80 years old appear to have similar 5-year survival outcomes compared with other patients.

Quality of care in patients with chronic hepatitis C virus infection: a cohort study.

BACKGROUND: Medicare has proposed quality-of-care indicators for chronic hepatitis C virus (HCV) infection. The extent to which these standards are met in practice is largely unknown. OBJECTIVE: To evaluate the quality of health care that patients with HCV receive and the factors associated with receipt of quality care. DESIGN: Retrospective cohort study. SETTING: Nationwide U.S. health insurance company research database. PARTICIPANTS: 10 385 patients with HCV enrolled in the database between 2003 and 2006. Patients were included if they were eligible for at least 1 quality indicator. MEASUREMENTS: Quality of HCV care received by patients, as measured by 7 explicit quality indicators included in Medicare's 2009 Physician Quality Reporting Initiative. RESULTS: Proportions of patients meeting quality indicators varied, ranging from 21.5% for vaccination to 79% for the HCV genotype testing indicator. Overall, 18.5% of patients (95% CI, 18% to 19%) received all recommended care. Older age and presence of comorbid conditions were associated with lower quality, whereas elevated liver enzyme levels, cirrhosis, and HIV infection were associated with higher quality. Patients who saw both generalists and specialists received the best care (odds ratio of receiving care for which a patient is eligible: specialists alone, 0.79 [CI, 0.66 to 0.95]; primary care physician alone, 0.44 [CI, 0.40 to 0.48]). LIMITATIONS: The study had an observational retrospective design, used a convenience sample, and had no information on patient ethnicity. It may be that the indicators or the reporting of the indicators of HCV care--and not the care itself--is suboptimum. CONCLUSION: Health care quality, based on Medicare criteria, is suboptimum for HCV. Care that included both specialists and generalists is associated with the best quality. Our results support the development of specialist and primary care collaboration to improve the quality of HCV care. PRIMARY FUNDING SOURCE: Saint Louis University Liver Center.

Sensitivity of billing claims for cardiovascular disease events among kidney transplant recipients.

BACKGROUND AND OBJECTIVES: Billing claims are increasingly examined beyond administrative functions as outcomes measures in observational research. Few studies have described the performance of billing claims as surrogate measures of clinical events among kidney transplant recipients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We investigated the sensitivity of Medicare billing claims for clinically verified cardiovascular diagnoses (five categories) and procedures (four categories) in a novel database linking Medicare claims to electronic medical records of one transplant program. Cardiovascular events identified in medical records for 571 Medicare-insured transplant recipients in 1991 through 2002 served as reference measures. RESULTS: Within a claims-ascertainment period spanning +/-30 d of clinically recorded dates, aggregate sensitivity of single claims was higher for case definitions incorporating Medicare Parts A and B for diagnoses and procedures (90.9%) compared with either Part A (82.3%) or Part B (84.6%) alone. Perfect capture of the four procedures was possible within +/-30 d or with short claims window expansion, but sensitivity for the diagnoses trended lower with all study algorithms (91.2% with window up to +/-90 d). Requirement for additional confirmatory diagnosis claims did not appreciably reduce sensitivity. Sensitivity patterns were similar in the early compared with late periods of the study. CONCLUSIONS: Combined use of Medicare Parts A and B billing claims composes a sensitive measure of cardiovascular events after kidney transplant. Further research is needed to define algorithms that maximize specificity as well as sensitivity of claims from Medicare and other insurers as research measures in this population.