Kristin Chrouser

Bladder cancer risk following primary and adjuvant external beam radiation for prostate cancer

PURPOSE Increased rates of secondary bladder malignancies have been reported after external beam radiation therapy (EBRT) for gynecological malignancies with relative risks of 2 to 4. This study was designed to determine if there was an increase in bladder cancer after EBRT for prostate cancer. MATERIALS AND METHODS We retrospectively reviewed the Mayo Clinic Cancer Registry for patients who received EBRT for prostate cancer (1980 to 1998). Patients diagnosed with bladder cancer were identified. Comparative incidence rates were obtained from the national Surveillance, Epidemiology and End Results database. Subset analysis included patients treated with adjuvant radiation and those residing locally. Medical histories of patients with bladder cancer were reviewed. RESULTS A total of 1,743 patients received EBRT for prostate cancer at our institution. In more than 12,353 man-years of followup no increase in bladder cancer risk was encountered. Subset analysis of men who received adjuvant radiation demonstrated that the relative risk of bladder cancer was increased but was not statistically significant. When the analysis was restricted to patients residing in the local area, the number of patients in whom subsequent bladder cancer developed was similar to Surveillance, Epidemiology and End Results rates. However, in the adjuvant radiation subset there was a statistically significant increase in subsequent bladder cancer. Patients in whom bladder cancer develops after EBRT often present with low grade disease but many have recurrence and progression. CONCLUSIONS This retrospective review suggests there is not evidence of increased risk of bladder cancer after radiation therapy, assuming unbiased followup and complete ascertainment of cases. The natural history of bladder cancer in this population does not seem to be altered by a history of radiation.

Analysis of 23 million US hospitalizations: uninsured children have higher all-cause in-hospital mortality

BACKGROUND The number of uninsured children in the USA is increasing while the impact on childrens health of being uninsured remains largely uncharacterized. We analyzed data from more than 23 million US children to evaluate the effect of insurance status on the outcome of US pediatric hospitalization. METHODS In our analysis of two well-known large inpatient databases, we classified patients less than 18 years old as uninsured (self-pay) or insured (including Medicaid or private insurance). We adjusted for gender, race, age, geographic region, hospital type, admission source using regression models. In-hospital death was the primary outcome and secondary outcomes were hospital length of stay and total hospital charges adjusted to 2007 dollars. RESULTS The crude in-hospital mortality was 0.75% for uninsured versus 0.47% for insured children, with adjusted mortality rates of 0.74 and 0.46%, respectively. On multivariate analysis, uninsured compared with insured patients had an increased mortality risk (odds ratio: 1.60, 95% CI: 1.45-1.76). The excess mortality in uninsured children in the US was 37.8%, or 16,787, of the 38,649 deaths over the 18 period of the study. CONCLUSION Children who were hospitalized without insurance have significantly increased all-cause in-hospital mortality as compared with children who present with insurance.

Extended and saturation needle biopsy for the diagnosis of prostate cancer

The diagnosis of prostate cancer hinges on the use of systematic ultrasound-guided transrectal needle biopsy. The choice of technique is important, especially for patients with a history of a negative biopsy. Saturation biopsy can be considered for patients at risk of cancer who are willing to accept the side effects and who understand that clinically insignificant cancers can be detected. For patients with previous negative sextant biopsies, expanding the zones sampled and increasing the number of biopsy cores can help detect significant cancers while they are still confined. However, as extended biopsy becomes more commonly performed for initial diagnosis, there likely will be less need for saturation biopsy protocols.

A Novel Multispecialty Surgical Risk Score for Children

BACKGROUND AND OBJECTIVE: There is a lack of broadly applicable measures for risk adjustment in pediatric surgical patients necessary for improving outcomes and patient safety. Our objective was to develop a risk stratification model that predicts mortality after surgical operations in children. METHODS: The model was created by using inpatient databases from 1988 to 2006. Patients younger than 18 years who underwent an inpatient surgical procedure as identified by using the International Classification of Diseases, Ninth Revision, Clinical Modification, coding were included. A 7-point scale was developed with 70 variables selected for their predictive value for mortality using multivariate analysis. This model was evaluated with receiver operating characteristic (ROC) analysis and compared with the Charlson Comorbidity Index (CCI) in two separate validation data sets. RESULTS: A total of 2 087 915 patients were identified in the training data set. Generated risk scores positively correlated with inpatient mortality. In the training data set, the ROC was 0.949 (95% confidence interval [CI]: 0.947, 0.950). In the first validation data set, the ROC was 0.959 (95% CI: 0.952, 0.967) compared with the CCI ROC of 0.596 (95% CI: 0.575, 0.616). In the second validation data set, the ROC was 0.901 (95% CI: 0.885, 0.917) and the CCI ROC was 0.587 (95% CI: 0.562, 0.611). CONCLUSIONS: This study depicts creation of a broadly applicable model for risk adjustment that predicts inpatient mortality with more reliability than current risk indexes in pediatric surgical patients. This risk index will allow comorbidity-adjusted outcomes broadly in pediatric surgery.

Cost of Inpatient Care and its Association with Hospital Competition

BACKGROUND Conventional economic principles suggest that increases in competition are associated with price decreases. The purpose of this study is to determine whether this association holds true between objective measures of hospital competition and gross charges, by analyzing standardized operations where variations in costs should be minimal. STUDY DESIGN Hospital Market Structure file (from Agency for Healthcare Research and Quality, available for years 2000 and 2003) was linked to Nationwide Inpatient Sample database. Appendectomy, carotid endarterectomy, bariatric surgery, radical prostatectomy, and pyloromyotomy were analyzed, after excluding patients with possible complications. Primary outcomes included total hospital charges. Primary independent variable was Herfindahl-Hirschman Index (HHI) calculated by the Agency for Healthcare Research and Quality for each hospital based on its patient-flow market. Higher HHI represents the presence of more dominant hospitals in the market or lower competition. RESULTS A total of 162,823 patients from 1,492 hospitals (85,791 appendectomies, 38,619 carotid endarterectomies, 18,383 bariatric operations, 16,784 radical prostatectomies, 3,246 pyloromyotomies) were analyzed. Single linear regression analyses demonstrated higher HHI was significantly associated with lower hospital gross charges in all cases. On multivariate analysis, a 1 percentage-point increase on HHI was associated with -

Population-based comparison of open vs laparoscopic esophagogastric fundoplication in children: application of the Agency for Healthcare Research and Quality pediatric quality indicators

114 for appendectomy, -

Rectal complications after modern radiation for prostate cancer: A colorectal surgical challenge

163 for carotid endarterectomy, and -

Priapism in the United States: the changing role of sickle cell disease

193 for radical prostatectomy (all p ≤ 0.001), and were independent of hospital urbanicity, teaching status, and payer mix. In contrast, no association was found between competition and hospital costs. CONCLUSIONS Higher level of hospital competition is associated with higher hospital gross charges, although competition intensity is not associated with hospital costs. These data are important as health policy makers consider possible cost-control measures.

Penile Measurements in Tanzanian Males: Guiding Circumcision Device Design and Supply Forecasting

BACKGROUND/PURPOSE Increasing national focus on patient safety has promoted development of the pediatric quality indicators (PDIs), which screen for preventable events during provision of health care for children. Our objective is to apply these safety metrics to compare 2 surgical procedures in children, specifically laparoscopic and open esophagogastric fundoplication for gastroesophageal reflux. METHODS A retrospective analysis using 20 years of data from national representative state inpatient databases through the Healthcare Cost and Utilization Project was conducted. Patients younger than 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification, codes for open or laparoscopic esophagogastric fundoplication were included. Pediatric quality indicators were linked to each patients profile. Demographics, comorbidities, outcomes, and 8 selected PDIs between open and laparoscopic fundoplications were compared using Pearson χ(2) tests and t tests. RESULTS Of 33,533 patients identified, 28,141 underwent open and 5392 underwent laparoscopic fundoplication. Comorbidities occurred more frequently in open surgery. In-hospital mortality, length of stay, and hospital charges were less in laparoscopic surgery. Of the 8 PDIs evaluated, decubitus ulcer (P = .04) and postoperative sepsis (P = .003) had decreased rates with laparoscopic surgery compared with open. CONCLUSION Laparoscopic fundoplication for gastroesophageal reflux in children can be performed safely compared with the open approach with equivalent or improved rates of PDIs.

The agency for healthcare research and quality (ahrq) pediatric quality indicators (pdis): Accidental puncture or laceration during surgery in children

The operative management of rectal complications after radiation for prostate cancer has been incompletely studied. Our aim was to determine a logical surgical approach to these severe rectal complications. From an institutional database, we identified 5719 patients who were evaluated between 1990 and 2003 with a history of prostate cancer that was treated with radiation. Fourteen patients were identified from this group who underwent operative intervention for complications stemming from radiation. Charts were retrospectively reviewed for demographics, prostate cancer treatment, rectal symptoms, diagnostic techniques, operative interventions, and outcome. Ten patients (71%) had documented rectourethral fistulas. An additional four patients (29%) had either transfusion-dependent rectal bleeding or intractable fecal incontinence. Using a surgical algorithm, we proceeded with fecal diversion alone (20%), urinary and fecal diversion alone (50%), and primary repair with or without a tissue fiap and fecal diversion (29%) in the 14 affected patients. Symptomatic improvement and resolution of these three complications occurred in 12 (85%) of patients. However, only 2 (15%) were able to retain their intestinal continuity to achieve this outcome. The introduction of a step-wise approach to this problem has resulted in symptomatic resolution in the majority of patients. However, this is achieved at the cost of permanent fecal and sometimes urinary diversion.