Patricia Friedmann

Radial artery conduits improve long-term survival after coronary artery bypass grafting.

BACKGROUNDnThe second best conduit for coronary artery bypass graft surgery (CABG) is unclear. We sought to determine if the use of a second arterial conduit, the radial artery (RA), would improve long-term survival after CABG using the left internal thoracic artery (LITA) and saphenous vein (SV).nnnMETHODSnWe compared the 14-year outcomes in propensity-matched patients undergoing isolated, primary CABG using the LITA, RA, and SV versus CABG using the LITA and only SV. In all, 826 patients from each group had similar propensity-matched demographics and multiple variables. The primary endpoint was all-cause mortality obtained using the Social Security Death Index.nnnRESULTSnPerioperative outcomes including in hospital mortality (0.1% for the RA patients and 0.2% for the SV patients) were similar. Kaplan-Meier survival at 1, 5, and 10 years was 98.3%, 93.9%, and 83.1% for the RA group versus 97.2%, 88.7%, and 74.3% for the SV group (log rank, p = 0.0011). Cox proportional hazards models showed a lower all-cause mortality in the RA group (hazard ratio 0.72, confidence interval: 0.56 to 0.92, p = 0.0084). Ten-year survivals showed a 52% increased mortality for the SV patients (25.7%) versus the RA patients (16.9%; p = 0.0011). For symptomatic patients, RA patency was 80.7%, which was not different than the LITA patency rate of 86.4% but was superior to the SV patency rate of 46.7% (p < 0.001).nnnCONCLUSIONSnUsing the LITA, SV, and a RA conduit for CABG results in significantly improved long-term survival compared with using the LITA and SV. The use of two arterial conduits offers a clear and lasting survival advantage, likely due to the improved patency of RA grafts. We conclude that RA conduits should be more widely utilized during CABG.

Unstable Housing as a Factor for Increased Injection Risk Behavior at US Syringe Exchange Programs

ObjectiveTo assess variation in injection risk behavior among unstably housed/homeless injecting drug users (IDUs) across programs in a national sample of US syringe exchange programs.MethodsAbout 23 syringe exchange programs were selected through stratified random sampling of moderate to very large US syringe exchange programs operating in 2001–2005. Subjects at each program were randomly sampled. Risk behavior interviews were collected using audio-computer assisted self-interviewing (A-CASI). “Unstable housing/homelessness” was operationally defined as having lived “on the street or in a shanty” or “living in a shelter or single room occupancy hotel (SRO)” at any time in the 6xa0months prior to the interview. “Receptive sharing” was operationally defined as having injected with a needle or syringe that “had been used by someone else” in the 30xa0days prior to the interview. Six very large and nine moderate-to-large programs had at least 50 subjects who reported unstable housing, and these 15 programs were used in the analyses. Results: There was considerable variation among the 15 programs in the percentages of unstably housed participants (range from 35 to 74%, Pxa0<xa00.0001), and in the percentages of unstably housed participants who reported receptive sharing (range from 8 to 52%, Pxa0<xa00.0001). At each of the 15 programs, unstably housed exchange participants were approximately twice as likely to report receptive sharing than were stably housed participants. The weighted mean odds ratio was 2.02, 95% confidence interval, 1.68–2.41 (random effects model) and there was no statistically significant variation in these odds ratios. Across the 15 programs, receptive sharing among unstably housed participants was highly correlated with receptive sharing among stably housed participants (rxa0=xa00.95, Pxa0<xa00.001, 90% of variance among unstably housed “explained” by variance among stably housed).ConclusionsThe programs clearly differ in the extent to which they are attracting unstably housed IDUs as participants. The consistency of more frequent injection risk behavior among unstably housed exchange participants and the lack of significant variation in the odds ratios for increased injection risk suggests that none of the programs were “better” or “worse” at reducing injection risk behavior among unstably housed participants. Reduction in injecting risk behavior among syringe exchange participants may require greater efforts to provide stable housing or the development of dramatically new interventions to reduce injecting risk behavior among IDUs with persistent unstable housing.

Quality Assurance Initiative at One Institution for Minimally Invasive Breast Biopsy as the Initial Diagnostic Technique

BACKGROUNDnIn 2005, the American College of Surgeons Consensus Conference issued a statement about the diagnostic workup of image-detected breast abnormalities. Guidelines include use of image-guided percutaneous needle biopsy as the gold standard for diagnosing image-detected breast abnormalities. In this study, we evaluate a method to audit use of excisional biopsy among different breast surgeons at our institution.nnnSTUDY DESIGNnFrom March to September 2007, 465 patients undergoing breast operation for benign or malignant lesions at our institution were interviewed by a surgical resident or physicians assistant. If an excisional biopsy was scheduled for initial diagnosis, the patient and surgeon were asked whose preference it was to perform the operation. Three attending groups were designated: academic breast surgeons, private practice breast surgeons on clinical faculty, and general surgeons who perform breast operations in addition to other procedures. Use of excisional biopsy was compared between these groups.nnnRESULTSnCompliance for preoperative interview completion was 79%, differing substantially between surgeon groups with rates of 91%, 74%, and 58% for the academic breast, private practice, and general surgeons, respectively. Excisional biopsy for diagnosis made up 10%, 35%, and 37% of the case load for academic breast, private practice, and general surgeons, respectively. Patient and surgeon agreed 85% of the time for preference of performing diagnostic excisional biopsies.nnnCONCLUSIONSnExcisional biopsies continue to be performed as the initial diagnostic procedure for 40% of patients. Tracking biopsy practices by surgeon can improve adherence with current recommendations.

Psychiatric histories of drug using mothers: Treatment implications

One hundred forty six crack/cocaine using mothers in New York City were interviewed in a cross sectional study about life histories and drug related behaviors. Forty one (28%) reported histories of previous psychiatric medication or hospitalization. These women were significantly more likely than the rest of the sample to currently be in drug treatment; to have sexual abuse histories; and to be currently involved with men who urged them to use crack during pregnancy. Within this group, two subgroups were distinguishable: one, who had been sexually abused and initiated drug use early, and the other whose psychiatric and drug use histories were not associated with sexual abuse. The implications of these findings for screening, treatment planning, and future research are discussed.

Impact of monetary incentives on adherence to referral for screening chest X-rays after syringe exchange-based tuberculin skin testing

IntroductionSyringe-exchange programs (SEPs) have proven to be valuable sites to conduct tuberculin skin testing among active injection drug users. Chest x-rays (CXRs) are needed to exclude active tuberculosis prior to initiating treatment for latent tuberculosis infection. Adherence of drug users to referral for off-site chest x-rays has been incomplete. Previous cost modeling demonstrated that a monetary incentive to promote adherence could be justified on the cost basis if it had even a modest effect on adherence.MethodsWe compared adberence to referral for chest x-rays among injection drug users undergoing syringe exchange-based tuberculosis screening in New York City before and after the implementation of monetary incentives.ResultsFrom 1995 to 1998, there were 119 IDUs referred for CXRs based on tuberculin skin testing at the SEP. From 1999 to 2001, there were 58 IDUs referred for CXRs with a S25 incentive based on adherence. Adherence to CXR referral within 7 days was 46/58 (79%) among individuals who received the monetary incentive versus 17/119 (14%) prior to the implementation of the monetary incentive (P<.0001; odds ratio [OR]=23; 95% confidence interval [CI]=9.5-5.7). The median time to obtaining a CXR was significantly shorter among those given the incentive than among those referred without the incentive (2 vs. 11 days, P<.0001). In multivariate logistic regression analysis, use of the incentive was highly independently associated with increased adherence (OR=22.9;95% CI=10–52).ConclusionsMonetary incentives are highly effective in increasing adherence to referral for screening CXRs to exclude active tuberculosis after syringe exchangebased tuberculin skin testing. Prior cost modeling demonstrated that monetary incentives could be justified on the cost basis if they had even a modest effect on adherence. The current data demonstrated that monetary incentives are highly effective at increasing adherence in this setting and therefore are justifiable on a cost basis. When heath care interventions for drug users require referral off site, monetary incentives may be particularly valuable in promoting adherence.

Patterns of HIV prevalence among injecting drug users in the cross-border area of Lang Son Province, Vietnam, and Ning Ming County, Guangxi Province, China.

BackgroundTo assess patterns of injecting drug use and HIV prevalence among injecting drug users (IDUs) in an international border area along a major heroin trans-shipment route.MethodsCross-sectional surveys of IDUs in 5 sites in Lang Son Province, Vietnam (n = 348) and 3 sites in Ning Ming County, Guangxi Province, China (n = 308). Respondents were recruited through peer referral (snowball) methods in both countries, and also from officially recorded lists of IDUs in Vietnam. A risk behavior questionnaire was administered and HIV counseling and testing conducted.ResultsParticipants in both countries were largely male, in their 20s, and unmarried. A majority of subjects in both countries were members of ethnic minority groups. There were strong geographic gradients for length of drug injecting and for HIV seroprevalence. Both mean years injecting and HIV seroprevalence declined from the Vietnamese site farthest from the border to the Chinese site farthest from the border. 10.6% of participants in China and 24.5% of participants in Vietnam reported crossing the international border in the 6 months prior to interview. Crossing the border by IDUs was associated with (1) distance from the border, (2) being a member of an ethnic minority group, and (3) being HIV seropositive among Chinese participants.ConclusionReducing the international spread of HIV among IDUs will require programs at the global, regional, national, and local cross border levels. At the local cross border level, the programs should be coordinated on both sides of the border and on a sufficient scale that IDUs will be able to readily obtain clean injection equipment on the other side of the border as well as in their country of residence.

Knowledge of Tuberculosis Among Drug Users Relationship to Return Rates for Tuberculosis Screening at a Syringe Exchange

Tuberculosis is an important health issue among drug users. We sought to evaluate active drug users (DUs) knowledge of tuberculosis (TB) and to assess the relationship between TB knowledge and attitudes and tuberculin skin test (TST) return rates at a syringe exchange program. DUs were recruited at a syringe exchange program in New York City, were interviewed and offered TSTs, and received

Differences in diagnostic evaluation and clinical outcomes in the care of patients with chest pain based on admitting service: the benefits of a dedicated chest pain unit.

15.00 upon returning for TST reading. The questionnaire evaluated knowledge of TB transmission, prevention, and treatment. From March 13, 1995 to January 31, 1996, 610 of 650 (94%) of DUs approached agreed to participate. Of these, 80% had previous TSTs within the past 2 years and 20% were known to be HIV infected. Almost all knew that TB is contagious and more than two thirds knew that TB is treatable and that TB preventive therapy existed. However, fewer than half knew that HIV-related TB could be treated, 30% thought TB could be treated without a medical doctor, and the majority (70%) thought a reactive TST implied infectivity. The rate of return for TST reading was 93%. In multivariate analysis, those who knew that HIV-related TB was curable were more likely to return for TST reading (odds ratio 2.0; 95% confidence interval 1.04 to 3.95; p = .03). The high acceptance and return rates suggest that TB services can be incorporated into syringe exchange programs. However, several important gaps in TB knowledge existed in this population at high risk of TB, which may impact on adherence and which support the need for TB education for drug users.

Shotgunning as an Illicit Drug Smoking Practice

BackgroundChest pain is one of the most common complaints of patients presenting at emergency departments. However, the most appropriate diagnostic evaluation for patients with chest pain but without acute coronary syndrome remains controversial, and differs greatly among institutions and physicians. At our institution, patients with chest pain can be admitted to an internist-run hospitalist service, a private attending service, or a cardiologist-run Chest Pain Unit. The goal of the present study was to compare the management and outcomes of patients admitted with chest pain based on admitting service.MethodsThe charts of 750 patients (250 consecutive patients per service) with a discharge diagnosis of chest pain were studied retrospectively.ResultsPatients admitted to the Chest Pain Unit were younger and had a lower prevalence of known coronary artery disease, hypertension, or diabetes, but a similar prevalence of other risk factors compared with the other groups. Sixty percent of the patients in the Chest Pain Unit underwent stress myocardial perfusion imaging as their primary diagnostic modality (vs 22% and 12% of patients in the hospitalist and private services, respectively; P<.001). In contrast, 35% of the patients admitted to the hospitalist service underwent rest echocardiography (vs 8% and 17% of patients in the Chest Pain Unit and private services, respectively; P<.001). Finally, 47% of the patients in the private service underwent coronary angiography as their primary diagnostic modality (vs 6% and 10% of patients in the Chest Pain Unit and hospitalist services, respectively; P<.001). The length of stay was shortest for patients in the Chest Pain Unit (1.4±1.2 days vs 3.9±3.4 days and 3.5±3.6 days in the hospitalist and private services, respectively; P<.001), even when corrected for patient age and number of risk factors. Readmission within 6 months was lowest for patients in the Chest Pain Unit (4.4% vs 17.6% and 15.2% in the hospitalist and private services, respectively; P<.001).ConclusionsThe results of this study demonstrate that a highly protocolized chest pain unit, using myocardial perfusion imaging as primary diagnostic modality, results in a decreased length of stay and readmission rate.

Lymph nodes: Is total number or station number a better predictor of lymph node metastasis in endometrial cancer?

There has been a rise in illicit drug smoking in the United States. Shotgunning drugs (or doing a shotgun) refers to the practice of inhaling smoke and then exhaling it into another individuals mouth, a practice with the potential for the efficient transmission of respiratory pathogens. Three hundred fifty-four drug users (239 from a syringe exchange and 115 from a drug detoxification program) were interviewed about shotgunning and screened for tuberculosis (TB). Fifty-nine (17%; 95% CI 12.9%-20.9%) reported shotgunning while smoking crack cocaine (68%), marijuana (41%), or heroin (2%). In multivariate analysis, age < or = 35 years (OR 2.0, 95% CI 1.05-3.9), white race (OR 1.2, 95% CI 1.2-4.8), drinking alcohol to intoxication (OR 2.2, 95% CI 1.1-4.3), having engaged in high-risk sex (OR 2.6, 95% CI 1.04-6.7), and crack use (OR 6.0, 95% CI 3.0-12) were independently associated with shotgunning. Shotgunning is a frequent drug smoking practice with the potential to transmit respiratory pathogens, underscoring the need for education of drug users about the risks of specific drug use practices, and the ongoing need for TB control among active drug users.