Maternal health insurance coverage as a determinant of obstetrical anesthesia care.

This study measures the association between health insurance and the likelihood of receiving different obstetrical anesthesia protocols among 121,351 singleton live births in upstate New York during 1992. Mothers receiving a cesarean under Medicaid were approximately twice as likely to receive general anesthesia as those with traditional private coverage. Those receiving a cesarean under an HMO were least likely to receive general anesthesia with adjusted odds of 0.73 (confidence interval [CI] = 0.68-0.79), compared to those with traditional private insurance. Those delivering vaginally under Medicaid, HMO, or no coverage had adjusted odds of receiving an epidural of 0.45 (CI = 0.43-0.48), 0.68 (CI = 0.64-0.71), and 0.44 (CI = 0.38-0.52), respectively, compared to those under traditional private insurance. Although there was some differences by race, the strongest determinant of anesthesia remained insurance type. Insurance-mediated disparities in obstetrical anesthesia care are evident in upstate New York and warrant further study nationally.

Controlling for the effects of hospital attributes. The efficacy of factor analysis.

PURPOSE: The assessment of risk often requires controlling for the potentially confounding effects of hospital attributes. This paper (1) describes the use of factor analysis as a means of quantifying hospitals' obstetrical care, and (2) compares within respective unconditional logistic regression models the performance of factor scores with that of the "obstetrical unit service level" (OBUSL) classification as defined by the American Hospital Association (AHA).METHODS: A principal components factor analysis was performed on fourteen variables from 116 hospitals in Upstate New York. These variables, descriptive of hospitals' obstetrical care, were obtained from the 1992 AHA's Annual Survey of Hospitals. Factor scores were correlated with the OBUSL. Factor scores were matched to 89,341 women with vaginal deliveries in the 1992 Live Birth Registry for Upstate New York. The performance of factor scores and the OBUSL variable was compared in separate unconditional logistic regression analysis designed to identify determinants of obstetrical anesthesia care.RESULTS: Principal components factor analysis with varimax rotation identified three factors which were strongly correlated with hospital OBUSL. In a model which included the OBUSL variable, the adjusted odds ratios (AORs) or receiving an epidural for vaginal delivery were lower among mothers with Medicaid, HMO, or no insurance coverage (i.e., 0.45 [95% CI, 0.43-0.48], 0.68 [0.64-0.71], and 0.44 [0.38-0.52], respectively) than among those with private coverage. In a model in which factor scores were substituted for the OBUSL variable, respective AORs were 0.48 (0.45-0.52), 0.63 (0.60-0.66), and 0.45 (0.39-0.53).CONCLUSIONS: Factor analysis provided a parsimonious description of 14 hospital variables, was useful as a control within the regression model, and may prove similarly useful in other areas of clinical care.

Magnetic resonance colonography and virtual magnetic resonance colonoscopy with the 1.0-T system: a feasibility study.

RATIONALE AND OBJECTIVES: An ex vivo study and a clinical, prospective, patient study were undertaken to evaluate the feasibility of magnetic resonance (MR) colonography with a 1.0-T system. METHODS: An ex vivo colon model was scanned. A cleaned pig colon was prepared with six simulated sessile polyps (diameters of 4-12 mm) and one simulated pedunculated polyp (diameter of 5 mm). Subsequently, five patients (aged 39-81 years; four women, one man) were examined with MR colonography, immediately followed by endoscopic colonoscopy. After preparation for colonoscopy, the colon was filled with a Gd-DTPA/water solution (1:100). A breath-hold 3D gradient-echo sequence was acquired in both the prone and supine positions and after intravenous Gd-DTPA administration. Images were analyzed interactively by using multiplanar projections, maximum-intensity projection, and a virtual endoscopic view. The MR results were compared with the findings of the fiberoptic endoscopy. RESULTS: All seven simulated lesions of the colon model could be detected by MR imaging. In one patient, an advanced colon cancer as well as an additional small polyp was depicted. In the other four patients, single polyps with a diameter of 1 to 2.5 cm and a large adenoma were visualized by MR colonography. Contrast enhancement of the polyps was noted only after subtraction. CONCLUSIONS: The 1.0-T system is feasible for MR colonography. Reduced requirements for hardware could contribute to establish the novel technique as a screening method for colorectal polyps.

Detection of micrometastases in sentinel lymph nodes of the breast applying monoclonal antibodies AE1/AE3 to pancytokeratins.

Sentinel lymph node excision in breast cancer is a minimally invasive diagnostic procedure for accurate staging of the axilla and for avoiding unnecessary axillary dissection. In patients with palpable breast cancer we injected microcolloidal particles of human serum albumin labelled with technetium-99m the day before surgery. The sentinel node was detected intraoperatively with a handheld gammaprobe and then removed. Complete axillary dissection was performed and the nodes inspected by routine histological examination. The axillary lymph node status was correctly predicted by the sentinel node technique in 32 of 33 breast cancer patients. Two cases of micrometastases escaped routine histopathological detection but were identified by immunohistochemical analysis applying the antibody AE1/AE3 to pancytokeratins. Immunohistochemical examination of the sentinel node improves the diagnostic security of patients with breast carcinoma by detection of micrometastases.

The role of surgery in the treatment of liver metastases for colorectal cancer patients.

BACKGROUND/AIMS: Liver metastases deriving from colorectal cancer can be treated with curative intention in a select number of patients. Controversy does, however, persist pertaining to the impact of adjuvant treatment strategies. The aim of this study is to elucidate upon the various treatment modalities for patients suffering from liver metastases of colorectal primary tumor as well as to provide a rationale for surgical and adjuvant treatment. METHODOLOGY: From November 1987 to September 1998, a total of 449 consecutive patients suffering from liver metastases deriving from a colorectal cancer were documented at our institution in a prolective study. Prognostic factors providing the most beneficial outcome (whether with surgical and/or adjuvant treatment modalities) were analyzed by univariate and multivariate analysis. RESULTS: Whenever possible, curative (R0) surgical resection of colorectal liver metastases provides the most benefit to the patient. Multivariate analysis revealed tumor infiltration of the lymph nodes of the hepatoduodenal ligament and metachronous occurrence of liver metastases as most independent factors related to survival. CONCLUSIONS: Adjuvant post-operative chemotherapy fails to significantly improve survival following resection of liver metastases when compared to the liver resection only group. In patients with unresectable metastases, regional arterial chemotherapy did not improve survival significantly when compared with systemic chemotherapy.

The national distribution of Certified Registered Nurse Anesthetists across metropolitan and nonmetropolitan settings.

The purpose of this study is to describe the metropolitan and nonmetropolitan distribution of Certified Registered Nurse Anesthetists actively practicing across the United States. More than 3,000 counties of the United States were categorized according to degree of urbanization by utilizing the rural-urban continuum codes for metropolitan and nonmetropolitan counties developed within the U.S. Department of Agriculture. Zip code information was used to locate all actively practicing CRNAs by county of residence. Applying the rural-urban continuum codes to this database revealed a descriptive national distribution of CRNAs across geographical areas. Data show that 81.3% (18,086) of CRNAs reside in metropolitan counties and that 18.7% (4,182) reside in nonmetropolitan areas. The greatest number of CRNAs (8,519) are found in central counties of metropolitan areas of one million population or more. The lowest number of CRNAs (90) are found in completely rural counties of fewer than 2,500 urban population adjacent to a metropolitan area, and 160 CRNAs reside in counties of fewer than 2,500 population not adjacent to a metropolitan area. Differences in age, gender distribution, educational credentials, and population ratios are also noted between metropolitan and nonmetropolitan CRNAs.