Anya Romanoff

Payer status and access to laparoscopic subtotal colectomy for ulcerative colitis.

BACKGROUND: Medicaid populations have been shown to have inferior surgical outcomes, but less is known about their access to advanced surgical procedures. OBJECTIVE: The aim of this study was to evaluate if patients with Medicaid and ulcerative colitis who presented for subtotal colectomy would have reduced access to the laparoscopic approach in comparison with a similar population with private insurance. DESIGN/SETTINGS/PATIENTS: Using the Nationwide Inpatient Sample database from 2008 to 2010, we identified all patients who underwent subtotal colectomy for ulcerative colitis. The &khgr;2 test and multivariable logistic regression were used to identify predictors for laparoscopic subtotal colectomy for ulcerative colitis. MAIN OUTCOME MEASURES: The primary end point was the use of open or laparoscopic subtotal colectomy. Secondary end points included hospital length of stay and surgical outcomes. RESULTS: We identified a total of 2589 subtotal colectomy hospitalizations for ulcerative colitis (435 with Medicaid and 2154 with private insurance). The private insurance and Medicaid groups did not have significantly different mean age, sex, or Charlson scores (p > 0.05). Although 43% of the private insurance cohort received laparoscopic subtotal colectomy during their hospitalization, only 23% of the Medicaid population received equivalent care (p < 0.001). In a multivariate analysis that included age, sex, emergency status, hospital location, hospital size, teaching status, income, and Charlson score, urban teaching hospital status (p < 0.01), emergency status (p = 0.045), age <40 (p < 0.01), northeast location (p = 0.01), and private insurance status (p < 0.01) were independent predictors of the laparoscopic approach. LIMITATIONS: Administrative data have the potential for unrecognized miscoding or incomplete risk adjustment. Disease severity is not accounted for in the Nationwide Inpatient Sample database. CONCLUSION: Medicaid payer status was associated with reduced use of laparoscopic subtotal colectomy for ulcerative colitis. Although this finding may be due in part to physician preference or patient characteristics, health system factors appear to contribute to selection of the surgical approach.

Breast cancer method of detection, stage at diagnosis, and delay in treatment in La Libertad province, Peru.

15 Background: The majority of breast cancer deaths occur in low- and middle-income countries, as a result of late stage disease presentation and inadequate access to diagnosis and treatment. Delay from development of symptomatology to initiation of treatment is associated with more advanced breast cancer, and delays greater than three months have been associated with reduced survival. We investigated method of detection, disease stage, and time to diagnosis and treatment in breast cancer patients in Peru. METHODS This investigation was conducted at the Instituto Regional de Enfermedades Neoplasicas del Norte, in Trujillo, Peru. All women with a pathologic or clinical diagnosis of breast cancer who visited a breast surgeon from February-May 2015 were eligible to participate. Trained personnel conducted individual patient interviews in Spanish, utilizing a validated breast cancer delays questionnaire. RESULTS Of the 159 women who qualified for inclusion, 113 (71%) agreed to participate in the study. Mean age was 54 years (range 30-85). Patients lived an average of 3 hours from the oncology institute (range 0-36). Most households earned less than minimum wage, and most (66%) were covered by Seguro Integral de Salud, the government-funded medical insurance for citizens with limited financial resources. One hundred and five (93%) participants reported initially detecting their breast cancer as a result of symptoms. One cancer (1%) was detected during screening clinical breast examination, and 7 (6%) by screening mammography. Ninety-three patients had available stage at time of diagnosis, with the following distribution: stage 0- 2%, stage 1-3%, stage 2-44%, stage 3-48%, and stage 4-3%. Based on patient report, mean patient delay (symptom development to first medical visit at any facility) was 211 days. Mean provider delay (first medical visit until treatment initiation) was 241 days. Mean total delay (symptom development to treatment initiation) was 407 days. CONCLUSIONS Almost all study participants initially detected their breast cancer as a result of symptoms. More than half presented with stage 3 or 4 disease. Average delay from symptom onset to start of treatment was greater than one year.

Laparoscopic ileocolic resection for perforated Crohn's disease in pregnancy

Dear Sir, A morbidly obese 26-year-old female at a gestational age of 21 weeks presented with progressive right lower quadrant pain, nausea, vomiting, and fevers over three weeks. She had a recent pulmonary embolism and a history of Crohns disease (CD) treated with ciprofloxacin, metronidazole, and prednisone. On exam, she was febrile to 101 °F and tachycardic to 130 bpm. Her abdomen was gravid and tender diffusely with guarding over a palpable epigastric mass. Magnetic resonance imaging demonstrated a 15 cm complex fluid collection anterior to the uterus, a thick-walled segment of terminal ileum, and ascites (Figure 1). These findings suggested perforated Crohns ileitis with phlegmon …

Physician preference and patient satisfaction with radioactive seed versus wire localization

BACKGROUND Nonpalpable breast lesions require localization before excision. This is most commonly performed with a wire (WL) or a radioactive seed (SL), which is placed into the breast under radiographic guidance. Although there are advantages of each modality, there are no guidelines to address which patients should undergo WL versus SL. We investigated factors influencing the selection of SL versus WL at our institution and assessed patient satisfaction with each procedure. METHODS Patients undergoing preoperative localization of nonpalpable breast lesions from May 2014 through August 2015 were included. Physicians were surveyed on surgical scheduling to evaluate factors influencing the decision to perform SL or WL. Patient satisfaction was evaluated with a survey at the first postoperative visit. Retrospective chart review was performed. RESULTS 341 patients were included: 104 (30%) patients underwent SL and 237 (70%) underwent WL. There was no difference in patient age, benign versus malignant disease, or need for concomitant axillary surgery comparing the SL versus WL groups. Physician survey indicated that 18% of patients were candidates for WL only. Of the patients who were eligible for both, 88 (41%) ultimately underwent SL and 126 (59%) had WL. The most commonly cited reason for selection of one localization method or the other was physician preference, followed by patient preference or avoiding additional visit. There was no significant difference in self-reported preoperative anxiety level, convenience of the localization procedure, pain of the localization procedure, operative experience, postoperative pain level or medication requirement, or overall patient satisfaction comparing patients who underwent SL and WL. CONCLUSIONS SL and WL offer patients similar comfort and satisfaction. Factors influencing selection of one modality over the other include both logistic and clinical considerations.

A case report of necrotizing fasciitis of the abdominal wall: A rare, life-threatening complication of a common disease process

Highlights • A patient presented with sepsis and a necrotizing infection of the abdominal wall.• Upon operative exploration he was found to have perforated appendicitis.• Maintain a high index of suspicion as diagnosis is often delayed.• Necrotizing fasciitis results in significant mortality; immediate intervention is paramount.

Ultrasound-guided wire localization of focal ductal dilatation in the evaluation and treatment of pathologic nipple discharge

Patients presenting with pathologic nipple discharge (PND) often pose a diagnostic and therapeutic challenge. We used ultrasound to identify focal ductal dilatation—hypothesized to be a radiographic manifestation of the causative lesion—in patients with PND and no relevant clinical or radiographic findings. Twenty‐two excisions guided by ultrasound wire localization of focal duct dilation were performed. Surgical pathology revealed papilloma in 20 cases (91%); atypia or carcinoma was detected in 7 cases (32%). The ultrasound finding of focal duct dilatation enables excision of otherwise occult though clinically significant lesions and is worthy of further study.

Who is ordering breast MRIs in newly diagnosed breast cancer patients

24 Background: Utilization of breast MRI has increased dramatically in recent years, and there is ongoing debate regarding the role of MRI in patients with breast cancer. Guidelines for MRI use in newly diagnosed breast cancer patients have not been established; therefore, provider ordering of MRI in this population is variable. We investigated patterns of MRI ordering by healthcare providers in the setting of newly diagnosed breast cancer and analyzed predictors of MRI utilization. METHODS All newly diagnosed breast cancer patients presenting for surgical management at a single tertiary care breast center from January 2011 through December 2013 were reviewed. Cases were evaluated for the use of preoperative MRI, and medical specialty of the ordering provider was determined. Patients who presented to a specialized breast center with MRI already completed were compared to those who had MRIs ordered by their treating breast surgeon. RESULTS A total of 423 women with newly diagnosed breast cancer underwent MRI during the study period. In this group, 253/423 patients (60%) presented to our institution with an MRI already completed. Of MRIs performed prior to presentation, 73% were ordered by a primary care provider, and 27% were ordered by a breast specialist seen previously. Race was a significant predictor of having an MRI before presentation to a breast center (64% of white patients, 41% of black patients, 25% of Asians, and 65% of Hispanic patients, p < .001). Women with commercial insurance were significantly more likely to have an MRI completed before presentation than those with Medicaid (62% versus 37%, p = .002). Age, family history of breast cancer, genetic testing, breast density, mode of diagnosis, and biopsy pathology were not significant factors in determining whether a patient underwent MRI prior to presentation to a breast surgeon. CONCLUSIONS In our experience, the majority of MRIs performed in newly diagnosed patients with breast cancer were ordered by primary care providers as part of their patients initial workup. Patient race and insurance status were significant predictors of having an MRI ordered prior to seeing a breast specialist. Further research is needed to develop guidelines for breast MRI use in newly diagnosed cancer patients.