Laparoscopic live donor nephrectomy: debating the benefits. Pro: similar costs to traditional surgery and procedure wins donors.
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Costs and Cost Analysis↗
Biomedical subjects
J A Sosa
Publications and source records attributed to J A Sosa.
Imaging of the adrenal gland.
CT scanning remains the principal imaging technique for delineating adrenal gland lesions. Additional modalities complement CT by providing information about functional status and tissue-specific characteristics of adrenal pathology. They include MR imaging, radionuclide scintigraphy, selective venous sampling, angiography, ultrasound, percutaneous adrenal biopsy, and positive emission tomography.
Adrenal Gland Diseases↗
Association between extent of axillary lymph node dissection and survival in patients with stage I breast cancer.
BACKGROUND: The role of axillary lymph node dissection for stage I (T1N0) breast cancer remains controversial because patients can receive adjuvant chemotherapy regardless of their nodal status and because its therapeutic benefit is in question. The purpose of this study was to determine whether extent of axillary dissection in patients with T1N0 disease is associated with survival. METHODS: Data from 464 patients with T1N0 breast cancer who underwent axillary dissection from 1973 to 1994 were examined retrospectively. Kaplan-Meier estimates of overall survival, disease-free survival, and recurrence were calculated for patients according to the number of lymph nodes removed (<10 or > or = 10; <15 or > or = 15), and survival curves compared using the Wilcoxon-Gehan statistic. Cox proportional hazards regression modelling was used to adjust for confounding prognostic variables. RESULTS: Median follow-up time was 6.4 years. Patient groups were similar in age, menopausal status, tumor size, hormonal receptor status, type of surgery, and adjuvant therapy. There was a statistically significant improvement in disease-free survival in the > or = 10 versus <10 nodal groups (P <.01). Five-year estimates of survival were 75.7% and 86.2% for <10 nodes and > or = 10 nodes, respectively; 10-year estimates were 66.1% and 74.3%. There also was a notable improvement in the survival comparison of patients with <15 versus > or = 15 nodes (P < or = .05). These findings were confirmed in the multivariate analysis. CONCLUSIONS: These results may reflect a potential for misclassification of tumor stage among patients who had fewer nodes removed. The data, however, suggest that in patients with Stage I breast cancer, improved survival is associated with a more complete axillary lymph node dissection.
Adult↗
Cost implications of different surgical management strategies for primary hyperparathyroidism.
BACKGROUND: Controversy exists about optimal management of patients with primary hyperparathyroidism. To date, no studies have explored the cost implications of variation in practice. METHODS: Results from a national survey of endocrine surgeons were combined with results from a survey of endocrinologists and financial data from Medicare. Patterns of use of resources were identified, annual costs for the surgical management of primary hyperparathyroidism in the United States were calculated, and the financial impact of variation in practice was estimated. RESULTS: Survey respondents (n = 109) were experienced endocrine surgeons, performing an average of 33 parathyroidectomies annually. Seventy-five percent of patients undergo localization before initial exploration for primary hyperparathyroidism. In order of preference, these studies were sestamibi (43%), ultrasonography (28%), and sestamibi with single-photon emission computed tomography (26%). Although there is variation in preoperative and postoperative practice, in-hospital costs have the greatest influence on total cost. An estimated $282 million is spent annually in the United States on operations for primary hyperparathyroidism. National health expenditures could range by more than $70 million, depending on whether management strategies involving low or high use of resources are employed. CONCLUSIONS: Substantial variation among endocrine surgeons in the management of primary hyperparathyroidism has important cost implications. Implementation of evidence-based guidelines to optimize clinical and economic performance should be considered.
Female↗
The importance of surgeon experience for clinical and economic outcomes from thyroidectomy.
OBJECTIVE: To determine whether individual surgeon experience is associated with improved short-term clinical and economic outcomes for patients with benign and malignant thyroid disease who underwent thyroid procedures in Maryland between 1991 and 1996. SUMMARY BACKGROUND DATA: There is a prevailing belief that surgeon experience affects patient outcomes in endocrine surgery, but there is a paucity of objective evidence outside of clinical series published by experienced surgeons that supports this view. METHODS: A cross-sectional analysis of all patients who underwent thyroidectomy in Maryland between 1991 and 1996 was conducted using a computerized statewide hospital discharge data base. Surgeons were categorized by volume of thyroidectomies over the 6-year study period: A (1 to 9 cases), B (10 to 29 cases), C (30 to 100 cases), and D (>100 cases). Multivariate regression was used to assess the relation between surgeon caseload and in-hospital complications, length of stay, and total hospital charges, adjusting for case mix and hospital volume. RESULTS: The highest-volume surgeons (group D) performed the greatest proportion of total thyroidectomies among the 5860 discharges, and they were more likely to operate on patients with cancer. After adjusting for case mix and hospital volume, highest-volume surgeons had the shortest length of stay (1.4 days vs. 1.7 days for groups B and C and 1.9 days for group A) and the lowest complication rate (5.1 % vs. 6.1% for groups B and C and 8.6% for group A). Length of stay and complications were more determined by surgeon experience than hospital volume, which had no consistent association with outcomes. CONCLUSIONS: Individual surgeon experience is significantly associated with complication rates and length of stay for thyroidectomy.
Clinical Competence↗
Importance of hospital volume in the overall management of pancreatic cancer.
OBJECTIVE: To determine whether hospital volume is associated with clinical and economic outcomes for patients with pancreatic cancer who underwent pancreatic resection, palliative bypass, or endoscopic or percutaneous stent procedures in Maryland between 1990 and 1995. SUMMARY BACKGROUND DATA: Previous studies have demonstrated that outcomes for patients undergoing a Whipple procedure improve with higher surgical volume, but only 20% to 35% of patients with pancreatic cancer qualify for curative resection. Most patients undergo palliative procedures instead with a surgical bypass or biliary stent. METHODS: Analysis of hospital discharge data from all nonfederal acute care hospitals in Maryland identified all patients with pancreatic cancer who underwent a pancreatic resection, palliative bypass, or stent procedure between 1990 and 1995. Hospitals (n = 48) were categorized as high-, medium-, and low-volume providers according to their average annual volume of these procedures. Multivariate regression was used to examine the association between hospital volume and in-hospital mortality rate, length of stay, and hospital charges, after adjusting for differences in case mix and surgeon volume. RESULTS: Increased hospital volume is associated with markedly decreased in-hospital mortality rates and a decreased or similar length of stay for all three types of procedures and with decreased or similar hospital charges for resections and stents. After adjustment for case mix differences, the relative risk (RR) of in-hospital death after pancreatic resection was 19.3 and 8 at the low- and medium-volume hospitals, respectively, versus the high-volume hospital; after bypasses, the RR of death was 2.7 and 1.9, respectively; and after stents, the RR was 4.3 and 4.8, respectively. CONCLUSIONS: Patients with pancreatic cancer who are to be treated with curative or palliative procedures appear to benefit from referral to a high-volume provider.
Aged↗
Profile of a clinical practice: Thresholds for surgery and surgical outcomes for patients with primary hyperparathyroidism: a national survey of endocrine surgeons.
A 1991 NIH Consensus Development Conference statement provided recommendations for the management of patients with asymptomatic and minimally symptomatic primary hyperparathyroidism (primary HPT), but adherence to these guidelines has not been documented. We conducted a cross-sectional survey of North American members of the American Association of Endocrine Surgeons inquiring about surgeon and primary HPT patient characteristics, thresholds for surgery, and clinical outcomes. Multivariate regression was used to assess the relationship of physician characteristics to practice patterns and outcomes. Of 190 surgeons surveyed, 147 (77%) responded; 109 provided complete responses (57%). These surgeons spend 66% of their time in patient care and perform an average of 33 (range, 1-130) parathyroidectomies/yr. More than 72% of primary HPT patients who underwent surgery were asymptomatic or minimally symptomatic. High volume surgeons (>50 cases/yr) had significantly lower thresholds for surgery with respect to abnormalities in preoperative creatinine clearance, bone densitometry changes, and levels of intact PTH and urinary calcium compared to their low volume colleagues (1-15 cases/yr). Overall reported surgical cure rates were 95.2% after primary operation and 82.7% after reoperation. Compared to high volume surgeons, low volume endocrine surgeons had significantly higher complication rates after primary operation (1.9% vs. 1.0% respectively; P < 0.01) and reoperation (3.8% vs. 1.5%; P < 0.001) as well as higher in-hospital mortality rates (1.0% vs. 0.04%; P < 0.05). Endocrine surgeons operate on a large number of asymptomatic or minimally symptomatic primary HPT patients. Even among a group of highly experienced surgeons who typically see patients after referral from endocrinologists, clinical outcomes and criteria for surgery vary widely and appear to be associated with surgeon experience. Their criteria for surgery diverge from NIH guidelines. These results implore the endocrine community to examine the evidential basis for decisions made in the management of primary HPT.
Female↗
Involving students in curriculum reform.
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Attitude↗
Five-year angiographic follow-up of factors associated with progression of coronary artery disease in the Coronary Artery Surgery Study (CASS). CASS Participating Investigators and Staff.
OBJECTIVES: The Coronary Artery Surgery Study (CASS) required participants to undergo follow-up angiography at 5 years to identify clinical and angiographic features associated with progression of coronary artery disease. BACKGROUND: The CASS randomized 780 patients at 11 participating clinical centers between an initial strategy of medical therapy versus bypass surgery. Five clinical sites accomplished follow-up angiography in > 50% of their randomized subjects within a 42- to 66-month period after the entry arteriogram (n = 314). METHODS: Qualified clinical site angiographers, using side by side film review, evaluated an average of 13 segments/patient on both arteriograms for initial stenosis severity, morphologic features, lesion location and occurrence of disease progression or occlusion. Progression was defined as further definite narrowing by > or = 15% and occlusion as lesion progression to > or = 98%. Lesions were subcategorized as to whether they were univariate and had or had not been treated with bypass surgery. Multivariate logistic regression analyses were performed. RESULTS: For nonbypassed segments, right coronary artery and left anterior descending artery proximal and midlocations were associated with disease progression. For stenosis-containing segments, the initial severity, a non-left anterior descending artery location and increased treadmill duration predicted progression. Segment occlusion was associated with initial lesion severity, right coronary artery location and subsequent interval myocardial infarction. There were few predictors of progression or occlusion in bypassed arteries, other than initial lesion severity. CONCLUSIONS: Univariate and multivariate associations with lesion progression and occlusion included diabetes, lesion location, elevated cholesterol level, interval infarction and lesion morphology. These angiographic results, collected in a prospective trial, are consistent with known risk factors.
Coronary Angiography↗
Measuring time to the doctorate: reinterpretation of the evidence.
There has been increasing concern that the length of time it takes to earn a doctorate in this country has increased dramatically over the last 20 years. The regularly cited evidence--organized by the year in which recipients of doctorates were awarded their degrees--is seriously misleading, however. The application of stable population theory to the problem suggests that the steady fall in the sizes of entering cohorts to graduate school has inflated both the measure of the absolute level of median time to degree and the increase in time to degree. When the same underlying data are reorganized by the year in which recipients of doctorates received their baccalaureate, the statistical bias is eliminated, and the median total time to degree in the humanities is shown to have risen 15-20% rather than the reported 40%.
Journal Article↗
Spontaneous resolution of a dissection of the descending aorta after medical treatment with a beta blocker and a calcium antagonist.
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Aortic Dissection↗
Coronary artery bypass grafting and hyperlipidaemia.
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Coronary Artery Bypass↗
Internal mammary artery: a "live" conduit for coronary bypass.
An angiographic study of the internal mammary artery graft 8 years postoperatively illustrates the physiological nature of this conduit. Changes in the caliber of the internal mammary artery graft are seen to occur in response to changes in the size of the coronary vascular bed, a phenomenon of autoregulation. This physiological adaptability differentiates the internal mammary artery graft from the saphenous vein graft and may be one of the reasons for excellent long-term performance of this conduit.
Coronary Circulation↗
Internal mammary artery versus saphenous vein graft. Comparative performance in patients with combined revascularisation.
Thirty three patients with coronary artery disease undergoing combined myocardial revascularisation with internal mammary artery and saphenous vein grafts underwent angiographic studies up to 10 years after operation. Each patient had one internal mammary artery graft and one or more saphenous vein grafts. Eleven symptom-free patients, studies one month to five years (mean 1.9 years) after operation, had intact internal mammary artery and saphenous vein grafts in a good state of preservation. Of the six patients developing symptoms within the first year after surgery, three had evidence of poor flow in the internal mammary artery graft because of large side branches and the other three had stenosis or occlusion of the saphenous vein grafts. Sixteen patients developed symptoms after several years free of symptoms and were studied three to 10 years (mean six years) after operation. Of the 23 saphenous vein grafts in this group, 17 (74%) were either occluded or severely stenosed and six (26%) were in good condition. One internal mammary artery graft was occluded and the remaining 15 were in good condition. Saphenous vein graft failure was the predominant cause of late development of symptoms in patients with combined revascularisation. Long term performance of the internal mammary artery grafts is far superior to the saphenous vein grafts.
Adult↗
Long-term fate of the internal mammary artery and saphenous vein grafts.
Thirty-four patients, each receiving internal mammary artery (IMAG) as well as saphenous vein grafts (SVGs), returned with symptoms 3 to 12 years after operation and underwent angiographic studies. At a mean follow-up period of 6.8 years, two (6%) IMAGs were occluded and 33 (94%) were in excellent condition. Of the 57 SVGs, 28 (48%) were totally occluded, 12 (22%) had severe atherosclerosis, and only 17 (30%) were in good condition. Seven patients (20%) had new significant lesions in the ungrafted coronary arteries. Failure of SVGs was the predominant cause of symptoms in this group of patients. Late failure of the SVGs appears to be due to progressive atherosclerosis in the grafts. The IMAGs tend to remain free from atherosclerosis and perform much better than the SVGs in the long run.
Angiography↗
Internal mammary artery graft.
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Coronary Disease↗
Internal mammary artery--coronary artery anastomosis. Influence of the side branches on surgical result.
Five of 20 (25%) symptomatic patients with internal mammary artery (IMA) grafts were found to have unusually enlarged side branches on arteriographic studies. One had a large lateral costal branch and four had large pericardial branches with collaterals draining into the pulmonary circulation. In these patients there was significant reduction (mean 44% +/- 3%) in the lumen of the distal IMA compared to its proximal part, with poor filling of the grafted coronary artery. This appeared to be the only cause of anginal symptoms in three of these five patients. The other 15 patients (75%) with small or no side branches had little or no reduction (mean 10% +/- 2%) of the distal IMA lumen. There was good coronary filling in these cases. The enlargement of the side branches indicates large flow in these branches with consequent reduction of flow in the grafted coronary artery. The marked reduction of the distal IMA lumen is a useful sign of reduced graft flow. This phenomenon may be one of the causes of poor results following IMA grafting.
Adult↗
Pressurized contrast delivery for coronary arteriography.
A system is described for eliminating negative pressure source of air bubbles within a closed-circuit arrangement for dye delivery in coronary angiography. Replacing the usual manual pressure created by an aspirating syringe, this system pressurizes the reservoir bottle by means of a cuffed bag, double-lumen, one-way piercing spike and a 0.2 micron filter.
Angiocardiography↗