Lue-Yen Tucker

Ten-year results of endovascular abdominal aortic aneurysm repair from a large multicenter registry

OBJECTIVE To assess outcomes after endovascular abdominal aortic aneurysm repair (EVAR) in an integrated health care system. METHODS Between 2000 and 2010, 1736 patients underwent EVAR at 17 centers. Demographic data, comorbidities, and outcomes of interest were collected. EVAR in patients presenting with ruptured or symptomatic aneurysms was categorized as urgent; otherwise, it was considered elective. Primary outcomes were mortality and aneurysm-related mortality (ARM). Secondary outcomes were change in aneurysm sac size, endoleak status, major adverse events, and reintervention. RESULTS Overall, the median age was 76 years (interquartile range, 70-81 years), 86% were male, and 82% were Caucasian. Most cases (93.8%) were elective, but urgent use of EVAR increased from 4% in the first 5 years to 7.3% in the last 5 years of the study period. Mean aneurysm size was 5.8 cm. Patients were followed for an average of 3 years (range, 1-11 years); 8% were lost to follow-up. Intraoperatively, 4.5% of patients required adjunctive maneuvers for endoleak, fixation, or flow-limiting issues. The 30-day mortality rate was 1.2%, and the perioperative morbidity rate was 6.6%. Intraoperative type I and II endoleaks were uncommon (2.3% and 9.3%, respectively). Life-table analysis at 5 years demonstrated excellent overall survival (66%) and freedom from ARM (97%). Postoperative endoleak was seen in 30% of patients and was associated with an increase in sac size over time. Finally, the total reintervention rate was 15%, including 91 instances (5%) of revisional EVAR. The overall major adverse event rate was 7.9% and decreased significantly from 12.3% in the first 5 years to 5.6% in the second 5 years of the study period (P < .001). Overall ARM was worse in patients with postoperative endoleak (4.1% vs 1.8%; P < .01) or in those who underwent reintervention (7.6% vs 1.6%; P < .001). CONCLUSIONS Results from a contemporary EVAR registry in an integrated health care system demonstrate favorable perioperative outcomes and excellent clinical efficacy. However, postoperative endoleak and the need for reintervention continue to be challenging problems for patients after EVAR.

Epidemiologic trends in pediatric tinea capitis: A population-based study from Kaiser Permanente Northern California

BACKGROUND Epidemic levels of tinea capitis (TC) have previously been reported in children. OBJECTIVE We sought to determine new epidemiologic trends for TC among northern California children from 1998 through 2007. METHODS Annual incidence of TC was based on diagnosis code or first-time antifungal prescriptions in all children up to age 15 years at Kaiser Permanente Northern California. RESULTS An average of 672,373 children/y met the inclusion criteria. Trend analyses showed decreases in TC by diagnosis code and by prescriptions (73.7% and 23.7%, respectively). Girls had lower incidence rates than boys by diagnosis (111.9 vs 146.4, P < .001 for 1998, and 27.9 vs 39.9, P < .001 for 2007). African Americans had the highest incidence rates by diagnosis (447.3 in 1998 and 184.1 in 2007) compared with other ethnic groups. Trichophyton tonsurans was the predominant organism (89.4% of all positive fungal cultures in 1998 and 91.8% in 2007). Prescriptions for griseofulvin declined, whereas the prescriptions for other antifungals increased. LIMITATIONS This was a retrospective study. CONCLUSIONS In this cohort, there was a significant decrease in incidence of TC over the study period. Trichophyton tonsurans continued to be the predominant organism. These trends may be a result of improved education, recognition, diagnosis, and treatment of TC and increased use of new oral antifungals.

Occult Uterine Sarcoma and Leiomyosarcoma: Incidence of and Survival Associated With Morcellation.

OBJECTIVE: To estimate the incidence of occult uterine sarcoma and leiomyosarcoma in hysterectomies for leiomyomas and the risk associated with their morcellation. METHODS: We conducted a population-based cohort study. All uterine sarcomas from 2006–2013 in an integrated health care system were identified. Age- and race-specific incidences of occult uterine sarcoma were calculated. Kaplan-Meier survival analysis was performed. Crude and adjusted risk ratios of recurrence and death associated with morcellation at 1, 2, and 3 years were estimated using Poisson regression with inverse probability weighting. RESULTS: There were 125 hysterectomies with occult uterine sarcomas identified among 34,728 hysterectomies performed for leiomyomas. The incidence of occult uterine sarcoma and leiomyosarcoma was 1 of 278 or 3.60 (95% confidence interval [CI] 2.97–4.23) and 1 of 429 or 2.33 (95% CI 1.83–2.84) per 1,000 hysterectomies. For stage I leiomyosarcoma (n=111), eight (7.2%) were power and 27 (24.3%) nonpower-morcellated. The unadjusted 3-year probability of disease-free survival for no morcellation, power and nonpower morcellation was 0.54, 0.19, and 0.51, respectively (P=.15); overall survival was 0.64, 0.75, and 0.68, respectively (P=.97). None of the adjusted risk ratios for recurrence or death were significant except for death at 1 year for power and nonpower morcellation groups combined (6/33) compared with no morcellation (4/76) (5.12, 95% CI 1.33–19.76, P=.02). We had inadequate power to infer differences for all other comparisons including 3-year survival and power morcellation. CONCLUSION: Morcellation is associated with decreased early survival of women with occult leiomyosarcomas. We could not accurately assess associations between power morcellation and 3-year survival as a result of small numbers.

Causes of death in patients with hepatitis B: A natural history cohort study in the United States

The natural history of hepatitis B virus (HBV) infection in a U.S. population has not been well described. We identified the causes of death in 6,689 health plan members infected with HBV who were followed between March 1, 1996 and December 31, 2005. Causes of death were grouped into HBV‐related (subdivided into decompensated cirrhosis [DCC] and hepatocellular carcinoma [HCC]), cancer, cardiovascular, and other/unknown. The study cohort included 3,244 females and 3,445 males; 68.3% were of Asian‐Pacific Islander (API) descent, 11.8% were white (non‐Hispanic), and 19.9% were of other or unknown race. Exposure to HBV antivirals and preexisting comorbidities were uncommon. Males had higher overall 10‐year death rates than females, both for total deaths (8.9% versus 4.1%) and for HBV‐related deaths (4.8% versus 1.2%). The death rate rose markedly with increasing age, and approximately 40% of all deaths in subjects over the age of 40 were HBV related. The death rate from HCC was twice that of DCC. HCC deaths represented 70% of cancer deaths in males and 37% in females. On multivariable analysis, when subjects with antecedent HCC and DCC were excluded, the only significant predictor of HBV mortality in both sexes was age. Conclusion: HBV was the cause of death in over 40% of those who died during the study, and the mortality increased markedly with increasing age over 40 in males and over 50 in females. HBV‐related mortality was four times more common in males than in females and was as common in non‐Asians as in those of API origin. HBV‐related deaths were twice as common from HCC as from DCC. (HEPATOLOGY 2013)

Type II endoleak with or without intervention after endovascular aortic aneurysm repair does not change aneurysm-related outcomes despite sac growth

OBJECTIVE There is considerable controversy about the significance and appropriate treatment of type II endoleaks (T2Ls) after endovascular aneurysm repair (EVAR). We report our long-term experience with T2L management in a large multicenter registry. METHODS Between 2000 and 2010, 1736 patients underwent EVAR, and we recorded the incidence of T2L. Primary outcomes were mortality and aneurysm-related mortality (ARM). Secondary outcomes were change in aneurysm sac size, major adverse events, and reintervention. RESULTS During the follow-up (median of 32.2 months; interquartile range, 14.2-52.8 months), T2L was identified in 474 patients (27.3%). There were no late abdominal aortic aneurysm ruptures attributable to a T2L. Overall mortality (P = .47) and ARM (P = .26) did not differ between patients with and without T2L. Sac growth (median, 5 mm; interquartile range, 2-10 mm) was seen in 213 (44.9%) of the patients with T2L. Of these patients with a T2L and sac growth, 36 (16.9%) had an additional type of endoleak. Of all patients with T2L, 111 (23.4%) received reinterventions, including 39 patients who underwent multiple procedures; 74% of the reinterventions were performed in patients with sac growth. Reinterventions included lumbar embolization in 66 patients (59.5%), placement of additional stents in 48 (43.2%), open surgical revision in 14 (12.6%), and direct sac injection in 22 (19.8%). The reintervention was successful in 35 patients (31.5%). After patients with other types of endoleak were excluded, no difference in overall all-cause mortality (P = .57) or ARM (P = .09) was observed between patients with T2L-associated sac growth who underwent reintervention and those in whom T2L was left untreated. CONCLUSIONS In our multicenter EVAR registry, overall all-cause mortality and ARM were unaffected by the presence of a T2L. Moreover, patients who were simply observed for T2L-associated sac growth had aneurysm-related outcomes similar to those in patients who underwent reintervention. Our future work will investigate the most cost-effective ways to select patients for intervention besides sac growth alone.

The Disproportionate Cost of Smoking for African Americans in California

OBJECTIVES We estimated the economic impact of smoking on African Americans in California in 2002, including smoking-attributable health care expenditures and productivity losses from smoking-caused mortality. METHODS We estimated econometric models of smoking-attributable ambulatory care, prescription drugs, inpatient care, and home health care using national and state survey data. We assessed smoking-attributable mortality using epidemiological models. RESULTS Adult smoking prevalence for African Americans was 19.3% compared with 15.4% for all Californians. The health care cost of smoking was

Adherence to endovascular aortic aneurysm repair device instructions for use guidelines has no impact on outcomes.

626 million for the African American community. A total of 3013 African American Californians died of smoking-attributable illness in 2002, representing a loss of over 49,000 years of life and

The Cost of Smoking for California's Hispanic Community

784 million in productivity. The total cost of smoking for this community amounted to

Trends in Self-reported and Biochemically Tested Marijuana Use Among Pregnant Females in California From 2009-2016

1.4 billion, or

Minimally Invasive Hysterectomy and Power Morcellation Trends in a West Coast Integrated Health System

1.8 billion expressed in 2008 dollars. CONCLUSIONS Although African Americans account for 6% of the California adult population, they account for over 8% of smoking-attributable expenditures and fully 13% of smoking-attributable mortality costs. Our findings confirm the need to tailor tobacco control programs to African Americans to mitigate the disproportionate burden of smoking for this community.