Yael Vin

African-American Ethnicity, Socioeconomic Status, and Breast Cancer Survival A Meta-Analysis of 14 Studies Involving Over 10,000 African-American and 40,000 White American Patients with Carcinoma of the Breast

African‐American women are at increased risk for breast cancer mortality compared with white American women, and the extent to which socioeconomic factors account for this outcome disparity is unclear.

Management and Outcomes of Postpancreatectomy Fistula, Leak, and Abscess: Results of 908 Patients Resected at a Single Institution Between 2000 and 2005

BACKGROUND Anastomotic fistula, leak, and abscess are common complications of pancreatectomy. The goal of this study was to describe our current management and outcomes of clinically significant postpancreatectomy fistula, leak, and abscess. STUDY DESIGN Review of a prospectively maintained database identified 908 patients who underwent pancreatectomy between January 2000 and August 2005. Complication data were prospectively entered into a validated postoperative complication database. Patients were included if they were identified as having a clinically significant (>/=grade 2) pancreatic fistula, leak, or abscess. Multivariate analyses were performed to identify factors predictive of prolonged drainage (> 30 days). RESULTS Clinically significant postoperative fistula, leak, or abscess occurred in 158 of 908 resected patients (17%) and included 63 culture-positive pancreatic fistulas, 29 noninfected pancreatic fistulas, 42 abscesses, and 24 other collections (biliary fistula, culture-negative collection). Surgical drains were placed at the time of initial resection in 88 of these 158 patients (56%). Adequate drainage was obtained by prolonged use of surgical drains in 16 patients (16 of 88 [18%]). Reoperation was required in 26 of the 158 patients (16%). ICU admission was required in 22%. Within this group of 158 patients the mortality rate was 5% (8 of 158; 90 days). At the time of discharge a home health aide was required in 56% of patients, 8% were discharged to a rehabilitation facility, and readmission was required in 50% of patients. Mean drainage time was 38 days (range 3 to 228). Predictors of prolonged drainage included drain output > 200 mL during the first 48 hours (odds ratio = 2.88; p = 0.02) and distal (versus proximal) pancreatectomy (odds ratio = 4.29; p = 0.01). CONCLUSIONS Although mortality after pancreatectomy has decreased to approximately 2%, the morbidity associated with pancreatic fistula, leak, and abscess remains substantial.

Fistula First Is Not Always the Best Strategy for the Elderly

Whether placing a fistula first is the superior predialysis approach among octogenarians is unknown. We analyzed data from a cohort of 115,425 incident hemodialysis patients ≥67 years old derived from the US Renal Data System with linked Medicare claims, which allowed us to identify the first predialysis vascular access placed rather than the first access used. We used proportional hazard models to evaluate all-cause mortality outcomes based on first vascular access placed, considering the fistula group as the reference. In the study population, 21,436 patients had fistulas as the first predialysis access placed, 3472 had grafts, and 90,517 had catheters. Those patients with a catheter as the first predialysis access placed had significantly inferior survival compared with those patients with a fistula (HR=1.77; 95% CI=1.73 to 1.81; P<0.001). However, we did not detect a significant mortality difference between those patients with a graft as the first access placed and those patients with a fistula (HR=1.05; 95% CI=1.00 to 1.11; P=0.06). Analyzing mortality stratified by age groups, grafts as the first predialysis access placed had inferior mortality outcomes compared with fistulas for the 67 to ≤79-years age group (HR=1.10; 95% CI=1.02 to 1.17; P=0.007), but differences between these groups were not statistically significant for the 80 to ≤89- and the >90-years age groups. In conclusion, fistula first does not seem to be clearly superior to graft placement first in the elderly, because each strategy associates with similar mortality outcomes in octogenarians and nonagenarians.

Arteriovenous Fistula Placement in the Elderly: When Is the Optimal Time?

Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis (HD). However, many AVFs fail before starting dialysis. To assess the optimal time for AVF placement in the elderly, we linked data from the US Renal Data System with Medicare claims data to identify 17,511 patients ≥67 years old on incident HD who started dialysis between January 1, 2005, and December 31, 2008, with an AVF placed as the first predialysis access. AVF success was defined as dialysis initiation using the AVF, with time between AVF placement and dialysis start as our primary variable of interest. The mean age was 76.1±6.0 years, and 58.3% of subjects were men. Overall, 54.9% of subjects initiated dialysis using an AVF, and 45.1% of subjects used a catheter or graft. The success rate increased as time from AVF creation to HD initiation increased from 1-3 months (odds ratio [OR], 0.49; 95% confidence interval [95% CI], 0.44 to 0.53) to 3-6 months (OR, 0.93; 95% CI, 0.85 to 1.02) to 6-9 months (OR, 0.99; 95% CI, 0.88 to 1.11) but stabilized after that time. Furthermore, the number of interventional access procedures increased over time starting at 1-3 months, with a mean of 0.64 procedures/patient for AVFs created 6-9 months predialysis compared with 0.72 for AVFs created >12 months predialysis (P<0.001). Although limited by the observational nature of this study, our results suggest that placing an AVF >6-9 months predialysis in the elderly may not associate with a better AVF success rate.

Factors predicting failure of AV "fistula first" policy in the elderly

An arteriovenous fistula (AVF) is the preferential hemodialysis (HD) access. The goal of this study was to identify factors associated with pre‐dialysis AVF failure in an elderly HD population. We used United States Renal Data System + Medicare claims data to identify patients ≥67 years old who had an AVF as their initial vascular access placed pre‐dialysis. Failure of the AVF to be used for initial HD, was used as the outcome. Logistic regression model was used to identify factors associated with AVF failure. The study cohort consisted of 20,360 subjects (76.2 ± 6.02 year old, 58.5% men). Forty‐eight percent of patients initiated dialysis using an AVF, while 52% used a catheter or an AVG. The following variables found to be associated with AVF failure when an AVF was created at least 4 months pre‐HD initiation: older age (odds ratio [OR] 1.01; 95% confidence interval [CI] 1.00–1.02), female gender (OR 1.69; 95% CI 1.55–1.83), black race (OR 1.41; 95% CI 1.26–1.58), history of diabetes (OR 1.22; 95% CI 1.06–1.39), cardiac failure (OR 1.26; 95% CI 1.15–1.37), and shorter duration of pre–end‐stage renal disease (ESRD) nephrology care (OR for a nephrology care of less than 6 months prior to ESRD of 1.22 compared with a pre‐ESRD nephrology follow up of more than 12 months; 95% CI 1.07–1.38). OR for AVF failure for the entire cohort showed similar findings. In an elderly HD population, there is an association of older age, female gender, black race, diabetes, cardiac failure and shorter pre‐ESRD nephrology care with predialysis AVF failure.

Disparities in arteriovenous fistula placement in older hemodialysis patients

The benefits of an arteriovenous fistula (AVF) as the preferred vascular access for hemodialysis have been clearly demonstrated. However, only about 20% of patients in the United States initiate hemodialysis with an AVF. In this study, we assessed whether disparities exist in the type of first hemodialysis access placed prior to dialysis start (rather than that used at dialysis initiation), to detect whether certain disadvantaged groups might have lower likelihood of AVF placement. Study cohort of 118,767 incident hemodialysis patients ≥67 years of age (1/2005–12/2008) derived from the United States Renal Data System was linked with Medicare claims data to identify the type of initial access placed predialysis. We used logistic regression model with outcome being the initial predialysis placement of an AVF as opposed to an arteriovenous graft or a central venous catheter. Increasing age, female sex, black race, lower body mass index, urban location, certain comorbidities, and shorter pre–end‐stage renal disease nephrology care are all associated with a significantly lower likelihood of AVF placement as initial access predialysis. Our study suggests the presence of significant disparities in the placement of an AVF as initial hemodialysis vascular access. We suggest that additional attention should be paid to these patient groups to improve disparities by patient education, earlier referral, and close follow‐up.

Geographic disparities in arteriovenous fistula placement in patients approaching hemodialysis in the United States

Arteriovenous fistula (AVF) is the preferred vascular access for hemodialysis (HD). Several factors associated with AVF placement have been identified (e.g., age, sex, race, comorbidities). We hypothesized that geographic location of patient residence might be associated with the probability of AVF placement as the initial access. We used the data from the United States Renal Data System (USRDS) database (2005–2008) linked to Medicare claims (2003–2008). Logistic regression was used to estimate specific characteristics of population associated with the AVF as first access placed or attempted for HD initiation. Our primary variable of interest was the geographic location, and the multivariate model was adjusted for age, sex, race, body mass index, primary cause of end‐stage renal disease (ESRD), duration of pre‐ESRD nephrology care, comorbidities, employment status, substance abuse, and income. Geographic location was determined using the data collected by the RUCA project and divided population into metropolitan, micropolitan, and rural categories. Patients (n = 111,953) identified from the USRDS database with linked Medicare claims were examined. Rates of fistula placement in the metropolitan, micropolitan, and rural population were 18.5%, 22.4%, and 21.6%, respectively. In comparison, patients who received catheter as the first access were 81.5%, 77.6% and 78.4%, respectively. The odds ratio of AVF placement as a first HD access in the rural and metropolitan population compared with the micropolitan population were 0.96 (0.90–1.03; P = 0.26) and 0.80 (0.76–0.84; P < 0.001), respectively. Our results indicate the presence of geographic disparities in AVF placement with decreased rates of AVF as the first access created in the metropolitan (but not rural) populations compared with the micropolitan communities.

Dialysis Access Procedures

Hemodialysis is the main modality for renal replacement therapy in patients with end-stage renal disease. Successful hemodialysis is contingent upon the creation of proper vascular access. Chronic vascular access was first established in 1960 by Scribner and colleagues, who created a shunt between the radial artery and the cephalic vein using an external Silastic device (Quinton et al. 1960). However, this device was fraught with problems such as bleeding, clotting, and infection. In 1966, Breschia and colleagues described a surgical fistula between the radial artery and the cephalic vein just proximal to the wrist, thereby eliminating the external shunt and enabling a high-flow system for hemodialysis. To this day, it remains the procedure of choice for patients with end-stage renal disease in need of chronic hemodialysis.