Meera Gupta

Cost-effectiveness of Competing Strategies for Management of Recurrent Clostridium difficile Infection: A Decision Analysis

BACKGROUNDnClostridium difficile infection (CDI) is an important cause of morbidity and healthcare costs, and is characterized by high rates of disease recurrence. The cost-effectiveness of newer treatments for recurrent CDI has not been examined, yet would be important to inform clinical practice. The aim of this study was to analyze the cost effectiveness of competing strategies for recurrent CDI.nnnMETHODSnWe constructed a decision-analytic model comparing 4 treatment strategies for first-line treatment of recurrent CDI in a population with a median age of 65 years: metronidazole, vancomycin, fidaxomicin, and fecal microbiota transplant (FMT). We modeled up to 2 additional recurrences following the initial recurrence. We assumed FMT delivery via colonoscopy as our base case, but conducted sensitivity analyses based on different modes of delivery. Willingness-to-pay threshold was set at

Outcomes after resection of leiomyosarcomas of the inferior vena cava: a pooled data analysis of 377 cases.

50 000 per quality-adjusted life-year.nnnRESULTSnAt our base case estimates, initial treatment of recurrent CDI using FMT colonoscopy was the most cost-effective strategy, with an incremental cost-effectiveness ratio of

Improving Communication Skills: A Course for Academic Medical Center Surgery Residents and Faculty

17 016 relative to oral vancomycin. Fidaxomicin and metronidazole were both dominated by FMT colonoscopy. On sensitivity analysis, FMT colonoscopy remained the most cost-effective strategy at cure rates >88.4% and CDI recurrence rates <14.9%. Fidaxomicin required a cost <

Surgery for metastatic neuroendocrine tumors with occult primaries.

1359 to meet our cost-effectiveness threshold. In clinical settings where FMT is not available or applicable, the preferred strategy appears to be initial treatment with oral vancomycin.nnnCONCLUSIONSnIn this decision analysis examining treatment strategies for recurrent CDI, we demonstrate that FMT colonoscopy is the most cost-effective initial strategy for management of recurrent CDI.

Prognosis of patients with melanoma and microsatellitosis undergoing sentinel lymph node biopsy.

BACKGROUNDnPrimary leiomyosarcomas of the inferior vena cava (IVC) pose unique surgical challenges. Due to the rarity of the disease, little definitive data exists on prognosis and treatment options.nnnMETHODSnA pooled data analysis was performed on all cases of initial IVC leiomyosarcoma resection identified by literature search (n = 371) and our institutional database (n = 6). Kaplan-Meier and Cox regression analyses were performed to identify factors associated with disease-free survival (DFS) and overall survival (OS).nnnRESULTSnPatients were predominantly female (76%, n = 286); the median age of presentation was 55 years. Five-year DFS and OS were 6% and 55%, respectively. Preoperative factors independently associated with decreased OS included older age (HR:1.05, 95% CI:1.00-1.09), larger tumor size (HR:1.14, 95% CI:1.04-1.24), resection of adjacent organ(s) (HR:3.62, 95% CI:1.34-9.77), and R2 resection (HR:7.80, 95% CI:1.94-32.05). Isolated involvement of the suprarenal infrahepatic IVC was associated with longer OS (HR:0.22, 95% CI:0.06-0.78). A scoring system incorporating independent predictors of OS stratified outcomes: score 4-5 (n = 10, median OS 6 months), score 2-3 (n = 88, median OS 23 months) compared to a score of 0-1 (n = 44, median OS 29 months).nnnCONCLUSIONSnFollowing resection of IVC leiomyosarcomas, recurrence is a near certainty; long-term survival, however is possible. The dominant predictors of survival include margin status, tumor size and radical resection. These can be combined into a risk score that has prognostic value.

Preventable Mortality: Does The Perspective Matter When Determining Preventability?

OBJECTIVEnTo improve physician/patient communication and familiarize surgeons with contemporary skills for and metrics assessing communication, courses were developed to provide academic general surgery residents and faculty with a toolkit of information, behaviors, and specific techniques. If academic faculty are expected to mentor residents in communication and residents are expected to learn good communication skills, then both should have the necessary education to accomplish such a goal.nnnDESIGNnDidactic lectures introduced current concepts of physician-patient communication including information on better patient care, fewer malpractice suits, and the move toward transparency of communication metrics. Next, course participants viewed and critiqued Surgi-Drama videos, with actors simulating before and after physician-patient communication scenarios. Finally, participants were provided with a toolkit of techniques for improving physician-patient communication including 2-3-4-a semiscripted short communication tool residents and other physicians can use in patient encounters-and a number of other acronymic approaches.nnnRESULTSnEach participant was asked to complete an anonymous evaluation to assess course content satisfaction. Overall, 86% of residents participated (68/79), with a 52% response rate (35/68) for the evaluation tool. Overall, 88% of faculty participated (84/96), with an 84% response rate (71/84). Residents voiced satisfaction with all domains. For faculty, satisfaction was quantitatively confirmed (Likert score 4 or 5) in 4 of 7 domains, with the highest satisfaction in communication of goals and understanding of the HCAHPS metric. The percentage of top box Doctor Communication Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and national percentile ranking showed a sustained increase more than 1 and 2 years from the dates of the courses.nnnCONCLUSIONSnThe assessment of communication skills is increasing in importance in the practice of surgery. A course in communication, as developed here, quantitatively confirms the effectiveness of this approach to teaching communication skills as well as identifying areas for improvement. Such a course was part of a plan to increase the percentage of top box HCAHPS scores and percentile rankings. Faculty can impart the skills gained from such a course to residents attempting to successfully navigate the Accreditation Council for Graduate Medical Education (ACGME) Milestones and future careers as practicing surgeons.

Repeat Kidney Transplantation After Failed First Transplant in Childhood: Past Performance Informs Future Performance.

INTRODUCTIONnNeuroendocrine tumors (NETs) frequently metastasize prior to diagnosis. Although metastases are often identifiable on conventional imaging studies, primary tumors, particularly those in the midgut, are frequently difficult to localize preoperatively.nnnMATERIALS AND METHODSnPatients with metastatic NETs with intact primaries were identified. Clinical and pathologic data were extracted from medical records. Primary tumors were classified as localized or occult based on preoperative imaging. The sensitivities and specificities of preoperative imaging modalities for identifying the primary tumors were calculated. Patient characteristics, tumor features, and survival in localized and occult cases were compared.nnnRESULTSnSixty-one patients with an intact primary tumor and metastatic disease were identified. In 28 of these patients (46%), the primary tumor could not be localized preoperatively. A median of three different preoperative imaging studies were utilized. Patients with occult primaries were more likely to have a delay (>6 mo) in surgical referral from time of onset of symptoms (57% versus 27%, P = 0.02). Among the 28 patients with occult primary tumors, 18 (64%) were found to have radiographic evidence of mesenteric lymphadenopathy corresponding, in all but one case, to a small bowel primary. In all but three patients (89%), the primary tumor could be identified intraoperatively.nnnCONCLUSIONnThe primary tumor can be identified intraoperatively in a majority of patients with metastatic NETs, irrespective of preoperative localization status. Referral for surgical management should not, therefore, be influenced by the inability to localize the primary tumor.

Type I-polarized BRAF-pulsed dendritic cells induce antigen-specific CD8+ T cells that impact BRAF-mutant murine melanoma.

AbstractIntroductionnMelanoma microsatellitosis is classified as stage IIIB/C disease and is associated with a poor prognosis. Prognostic factors within this group, however, have not been well characterized.MethodsWe performed a retrospective analysis of 1,621 patients undergoing sentinel lymph node (SLN) biopsy at our institution (1996–2011) to compare patients with (nxa0=xa098) and patients without (nxa0=xa01,523) microsatellites. Univariate and multivariate logistic and Cox regression analyses were used to identify factors associated with SLN positivity and melanoma-specific survival (MSS) in patients with microsatellites.ResultsPatients with microsatellites were older and had lesions with higher Clark level and greater thickness that more frequently had mitoses, ulceration, and lymphovascular invasion (LVI) (all pxa0<xa00.0001). In microsatellite patients, the SLN positivity rate was 43xa0%. Lesional ulceration (odds ratio [OR]xa0=xa02.9, 95xa0% confidence interval [CI] 1.5–8.6), absent tumor infiltrating lymphocytes (ORxa0=xa02.8, 95xa0% CI 1.1–7.1), and LVI (ORxa0=xa03.3, 95xa0% CI 1.7–10) were significantly associated with SLN positivity by multivariate analysis. With a median follow-up of 4.5xa0years in survivors, ulceration (hazards ratio [HR]xa0=xa03.4, 95xa0% CI 1.5–7.8) and >1 metastatic LN (HRxa0=xa02.7, 95xa0% CI 1.1–6.6) were significantly associated with decreased MSS by multivariate analysis. In patients without these prognostic factors, the 5-year MSS was 90xa0% (nxa0=xa049) compared with 50xa0% (nxa0=xa023) among patients with ulceration only, 51xa0% (nxa0=xa012) in those with >1 metastatic LN only, or 25xa0% in those with both (nxa0=xa014, pxa0<xa00.01).DiscussionMicrosatellitosis was frequently associated with multiple adverse pathologic features. In the absence of ulceration and >1 metastatic LN; however, the outcome for patients with microsatellites compared favorably to stage IIIB patients overall.

Adverse childhood experiences among youth reported to child welfare: Results from the national survey of child & adolescent wellbeing

BACKGROUNDnWe report a novel approach to mortality review using a 360° survey and a multidisciplinary mortality committee (MMC) to optimize efforts to improve inpatient care.nnnMETHODSnIn 2009, a 16-item, 360° compulsory quality improvement survey was implemented for mortality review. Descriptive statistics were performed to compare the responses by provider specialty, profession, and level of training using the Fisher exact and chi-square tests, as appropriate. We compared the agreement between the MMC review and provider-reported classification regarding the preventability of each death using the Cohen kappa coefficient. A qualitative review of 360° information was performed to identify the quality opportunities.nnnRESULTSnCompleted surveys (n = 3095) were submitted for 1683 patients. The possibility of a preventable death was suggested in the 360° survey for 42 patients (1.40%). We identified 502 patients (29.83%) with completed 360° surveys who underwent MMC review. The inter-rater reliability between the provider opinions regarding preventable death and the MMC review was poor (kappaxa0=xa00.10, P < 0.001). Of the 42 cases identified by the 360° survey as preventable deaths, 15 underwent MMC review; 3 were classified as preventable and 12xa0were deemed unavoidable. Qualitative analyses of the 12 discrepancies did reveal quality issues; however, they were not deemed responsible for the patients death.nnnCONCLUSIONSnThe mortality survey yielded important information regarding inpatient deaths that historically was buried with the patient. Poor agreement between the 360° survey responses and an objective MMC review support the need to have a multipronged approach to evaluating inpatient mortality.

Outcomes in pediatric hepatitis C transplant recipients: analysis of the UNOS database.

Background and Objectives Kidney transplant graft survival is almost uniformly superior for initial transplants compared to repeat transplants. We investigate the association between first second kidney transplant graft survival in patients who underwent initial transplant during their pediatric years whether age at second transplant is associated with outcome. Design, Setting, Participants, and Measurements This is a retrospective analysis of Organ Procurement and Transplantation Network data from October 1987 to May 2009 examining second kidney graft survival in 2281 patients who received their first transplant at younger than 18 years using Kaplan-Meier statistics. Factors associated with second graft survival were identified using a multivariable Cox proportional hazards model. Results Patients with first kidney graft survival of less than 5 years had better second graft survival compared to patients with first graft survival of 30 days to 5 years (P < 0.01). Patients with first kidney graft survival less than 30 days had similar second kidney graft outcomes(P = 0.50) as those with longer than 5 years first kidney graft survival, demonstrating that very early first graft loss is not associated with poor second transplant outcome. Patients 15 to 20 years of age at second transplant have lower second graft survival compared to other age groups; P less than 0.01, regardless of other recipient/donor characteristics and recurrent disease. Conclusions Poor second transplant outcomes are identified among patients with previous pediatric kidney transplant with first graft survival longer than 30 days, but shorter than 5 years, and those receiving second transplants at a high-risk age category (15-20 years). These groups may benefit from increased attention both before and after transplantation.