Simple index to predict likelihood of skilled nursing facility admission after coronary artery bypass grafting among older patients.

BACKGROUND: Acceptable short-term mortality rates for elderly patients undergoing coronary artery bypass grafting (CABG) are reported in the literature. However, rather than death, older patients considering CABG are generally most concerned about a postoperative loss of functional independence. To address this concern, we describe an index that predicts a patient's likelihood of admission to a skilled nursing facility (SNF) after CABG. METHODS: Logistic regression analysis of the California hospital discharge database during a 5-year period was performed to identify the most prevalent preoperative International Classification of Disease, 9th Revision Clinical Modification (ICD-9-CM) diagnoses associated with SNF admission after primary CABG in patients aged 65 years or older. Each diagnosis was weighted according to odds ratios to develop an index that predicts the likelihood of discharge to a SNF. The index was validated using our institutional database. RESULTS: A total of 26,040 patients (mean age, 74.2 years; 67.2% men) fit our criteria. They had an in-hospital mortality rate of 3.09% and a 17.3% SNF discharge rate. Our index was a summation of nine selected preoperative ICD-9-CM diagnoses, which were assigned a value of 1 point (osteoarthritis, congestive heart failure, atrial fibrillation, myocardial infarction, anemia, obesity) or 2 points (female, chronic obstructive pulmonary disease, renal failure). Validation analysis produced a C statistic and pseudo r2 value of 0.6435 and 0.0408, respectively. Cut-point analysis suggests that patients with scores of 3 or higher can be considered "high-risk." CONCLUSIONS: We describe a simple index to identify older patients at low-risk and high-risk for SNF admission after CABG. Such tools may be useful in counseling older patients considering CABG.

Multiple, simultaneous trauma patients: Are they worse off?

BACKGROUND: The simultaneous management of multiple severely injured patients has the potential to overwhelm trauma center resources. We hypothesize that trauma patients presenting in clusters of two or more patients within a short time period have worse outcomes. METHODS: From the registry at our urban Level I trauma center, we reviewed 4,619 "major" trauma patients admitted during a span of 5.5 years (January 1998 through June 2003). A multidisciplinary team led by an in-house trauma surgery attending evaluated all patients. Pairs of two patients presenting less than 10 minutes apart (PAIRS) and clusters of three patients presenting within 30 minutes (CLUSTERS) were compared with patients arriving alone presenting over 4 hours apart (ALONE) and to other patients that did not meet any of the above criteria (OTHER). Multivariate regression was performed to determine differences in likelihood of direct operating room admissions, hospital, and intensive care unit (ICU) length of stay, and mortality. RESULTS: PAIRS made up 8.9% (413) and CLUSTERS made up 2.7% (126) of patients; 42% (1,939) arrived ALONE; 48.3% (2,229) of patients were classified as OTHER. Multivariate regression showed no significant differences in ICU or hospital length of stay, or mortality for PAIRS or CLUSTERS compared with patients presenting ALONE. PAIR and CLUSTER patients were more likely to undergo immediate surgery than the ALONE group (odds ratio 1.37, 95% confidence interval 1.03-1.83 and 1.61, 95% CI 1.00-2.58, respectively). CONCLUSIONS: When PAIRS or CLUSTERS of seriously injured patients arrive in close time proximity, they are more likely to be directly admitted to the operating room than patients arriving ALONE. This difference in management does not appear to affect patient outcomes.

Lymphoscintigraphy does not enhance sentinel node identification or alter management of patients with early breast cancer.

UNLABELLED: Lymphoscintigraphy (LS) is often performed before sentinel lymph node dissection (SLND) for breast cancer. The purpose of this study was to determine whether routine LS enhances rate of identification of sentinel nodes (SN), and if findings on LS alter either the SLND procedure or the subsequent patient management. METHODS: LS using technetium-99m sulfur colloid (99mTc) was performed in 136 consecutive patients undergoing SLND for invasive breast cancer. Three equal aliquots of 99mTc were injected peritumorally, and LS images were obtained at 60 to 120 min after 99mTc injection. Data were collected on the success of LS to visualize SN. Information regarding body mass index (BMI), biopsy type (core vs excisional), tumor location (medial vs lateral), and SN positivity were recorded and comparison was made with success of operative SN identification. In all SLND cases, 1% lymphazurin blue dye was used in addition to the 99mTc. RESULTS: LS failed to identify an SN in 9 of 136 cases (6.6%). Failed mappings did not correlate with biopsy type, tumor location, or SN positivity. There was a positive correlation between increased BMI and failed LS (p = <0.001). Failed LS did not predict operative SLND failure, as an SN was identified in 100% of cases (136/136), including the 9 with a failed LS. In 67% (6/9) of the failed LS, the SN was both hot and blue at operation. Internal mammary (IM) drainage was observed in 4% (6/136) of LS. Positive SN were found in 26% (35/136) of patients. Findings on LS did not affect adjuvant treatment decisions in any patient. CONCLUSIONS: There was a correlation between failed LS and BMI, but no correlation with biopsy type or tumor location. Drainage to extraaxillary sites was rare. LS findings did not enhance success of intraoperative identification of SN or alter the postoperative management of patients with early stage breast cancer.

COX-2 induces IL-11 production in human breast cancer cells.

BACKGROUND: Cyclooxygenase-2 (COX-2) is overexpressed in 40% of human invasive breast cancers. Interleukin-11 (IL-11), a potent mediator of osteoclastogenesis, is involved in breast cancer metastasis to bone. Since breast cancers that overexpress COX-2 are associated with a higher rate of metastasis to bone, we hypothesized that COX-2 expression in tumor cells would induce IL-11. MATERIALS AND METHODS: We transfected MCF-7 (poorly metastatic) and MDA-231 (highly metastatic) human breast cancer cell lines with COX-2 expression vectors. COX-2 overexpression was confirmed by Western blot and PGE(2) immunoassay, and IL-11 production was measured by immunoassay. We also used a nude mouse model to study COX-2 and IL-11 production from breast cancer cells that metastasized to bone. The bone-seeking clones (BSC) were isolated and cultured from the long bone metastases. RESULTS: COX-2 transfection caused an approximately 5- to 6-fold increase in IL-11 production in both MCF-7 and MDA-231 cells. MDA-435S-COX2-BSC (cells isolated from bone metastasis) produced elevated levels of IL-11 and PGE2 (an important mediator of COX-2) as compared to the parental MDA-435S-COX2 cells. Furthermore, a treatment with low 1- to 2-microm concentration NS-398 or Celecoxib significantly reduced the production of IL-11 in COX-2-transfected MDA-231 cells, thus confirming the involvement of COX-2 in IL-11 induction. CONCLUSION: COX-2-mediated production of IL-11 in breast cancer cells may be vital to the development of osteolytic bone metastases in patients with breast cancer, and a COX-2 inhibitor may be useful in inhibiting this process.

COX-2 overexpression increases motility and invasion of breast cancer cells.

Cyclooxygenase-2 (COX-2), an inducible enzyme involved in prostaglandin (including PGE(2)) biosynthesis, is overexpressed in several epithelial malignancies including breast cancer. We tested the hypothesis that COX-2 overexpression in breast cancer cells results in increased cell motility and invasion. COX-2 overproducing cells were generated by stable transfection of several human breast cancer cells with pSG5-COX2 vector. We confirmed the overexpression of COX-2 protein by western blotting, and by measuring PGE(2) in the medium with an immunoassay. We measured cell motility by counting the number of cells crossing an 8-micron pore size PET membrane, and cell invasion by counting the number of cells invading through a Matrigel-coated membrane that simulates basement membrane. COX-2 transfected MDA-231 cells produced 30-43-fold more PGE2 as compared to parental cells. COX-2 overexpression increased cell migration approximately 2.2-fold and cell invasion through Matrigel approximately 5.1-fold. Addition of 50 microM NS-398, a COX-2 inhibitor, inhibited Matrigel invasion of MDA-231 cells by 54% as compared to solvent confirming the role of COX-2 in cell invasion. It is known that an increase in cell migration and invasion can be brought about by cytoskeletal alterations and basement membrane degradation due to increased expression of pro-urokinase plasminogen activator (pro-uPA). To investigate the mechanism of our observed increase in cell invasion by COX-2, we found by western blotting that the level of pro-uPA was significantly higher (approximately 5-fold) in COX-2 transfected MDA-231 cells than untransfected MDA-231 cells. Similar to our observations in cell culture, we found evidence that increased COX-2 activity correlates with uPA in a mouse model of breast cancer metastasis to bone. In this study, we conclude that COX-2 overexpression in human breast cancer cells enhances cell motility and invasiveness thus suggesting a mechanism of COX-2 mediated metastasis.

Assessment of the current Medicare reimbursement system for breast cancer operations.

BACKGROUND: Medicare determines procedural reimbursement by means of formulas considering physician work, practice, and liability expenses. Since no mechanism exists to consider outcomes in calculating reimbursements, we hypothesized that Medicare reimbursements do not correlate with outcomes for different breast cancer operations. METHODS: We prospectively studied 240 patients with T1, 2N0M0 breast cancer in three surgical treatment arms: segmental mastectomy with axillary node dissection (SM&ALND ; n = 42); SM with sentinel node dissection (SM&SLND ; n = 96); and mastectomy without reconstruction (MRM; n = 102). Outcome parameters of complications, hospital stay, analgesic usage, and days to return to work were correlated with procedure reimbursements. RESULTS: Median follow-up was 26 months. SM&SLND patients rarely required hospital stays (14%) in comparison with either SM&ALND (96%) or MRM patients (99%) (P < 0.001). SM&ALND and MRM patients required 9 and 10 median days of narcotics, respectively, versus 1 day in the SLND group (P < 0.001). SM&SLND patients returned to work at a median of 3 days, in comparison with 19 for SM&ALND and 26 for MRM patients (P < 0.001). Complications were more common in the MRM group (67% numbness/10% pain) and the SM&ALND group (56%/9%) than in the SM&SLND group (0%/1%). Reimbursements were inversely correlated with outcomes. MRM was reimbursed the highest, at an average of 1,075.03 dollars, with SM&ALND at 882.72 dollars. SM&SLND was reimbursed at 642.00 dollars. CONCLUSIONS: Medicare reimbursements for breast cancer operations do not correlate with outcomes. Less-invasive procedures are paid for at lower rates despite better outcomes and fewer complications. The data from this study raise the question of the impact of reimbursement on breast procedure selection.