Intraprocedural cortisol levels in the evaluation of proper catheter placement in adrenal venous sampling

Purpose

Adrenal venous sampling (AVS) is limited by technical failures that result from incorrect catheter placement or failure to catheterize the right adrenal vein. The existence of an inadequate sample may not be recognized at the time of the procedure, which can lead to nondiagnostic results. Rapid assay of serum cortisol levels allows for intraprocedural evaluation of the ratio of adrenal and peripheral cortisol concentrations and confirmation of adequate sampling.

Materials and Methods

Retrospective review was performed of 64 AVS procedures, 36 performed with digital subtraction venography (DSV) guidance alone and 28 performed with DSV guidance plus intraprocedural quantitative determinations of plasma cortisol levels.

Results

Technical success was achieved in 26 of 28 procedures (93%) that included intraprocedural cortisol measurements in addition to DSV. Analysis of cortisol ratios (adrenal vein cortisol level divided by inferior vena cava cortisol level) revealed technical success in 29 of 36 procedures (81%) that used DSV alone (P = .16). Procedure note indication of successful/unsuccessful sampling coincided with cortisol ratios in 28 of 28 cases (100%) that included cortisol measurement and 29 of 36 cases (81%) that did not (P = .01).The feedback provided by the measurement of cortisol levels allowed the operator to salvage three of five inadequate AVS procedures (60%), increasing the overall technical success rate from 82% to 93%.

Conclusions

Intraprocedural measurement of cortisol with rapid results allows for prediction of successful adrenal vein catheterization, which may increase the technical success rate of AVS.     

Increasing incidence of bilateral mastectomies: the patient perspective

Background

Numerous studies have reported increasing rates of contralateral prophylactic mastectomies (CPMs). Understanding patient rationale for the surgical choice may provide insight into this trend.

Methods

A questionnaire was mailed to 350 mastectomy patients identified from a community health system tumor registry.

Results

Two hundred fifty questionnaires were received; of these, 237 had undergone mastectomy. Fifty-two percent had unilateral mastectomy (UM), and 43% had bilateral mastectomies (BMs) (6% for bilateral disease). Women younger than 60 years of age were more likely to choose BM (P = .0046). Those who had CPM were significantly more likely to make the same surgical decision (P < .0001). Reconstruction was performed in 52%, with BM patients more likely to undergo reconstruction (P = .009). Twenty-three (19%) needed unanticipated reoperation for reconstruction complications. CPM had equivalent rates of unanticipated surgery versus UM (P = .64).

Conclusions

Patients choosing BMs are younger, have equivalent rates of reoperation because of reconstruction complications, and are significantly more satisfied with their decision than those who chose UM.     

A novel measure for pectus excavatum: the correction index

Objective

The Haller Index (HI), the standard metric for the severity of pectus excavatum, is dependent on width and does not assess the depth of the defect. Therefore, we performed a diagnostic analysis to assess the ability of HI to separate patients with pectus excavatum from healthy controls compared to a novel index.

Methods

After institutional review board approval, computed tomography scans were evaluated from patients who have undergone pectus excavatum repair and controls. The correction index (CI) used the minimum distance between posterior sternum and anterior spine and the maximum distance between anterior spine most anterior portion of the chest. The difference between the two is divided by the latter (×100) to give the percentage of chest depth the defect represents.

Results

There were 220 controls and 252 patients with pectus. Mean HI was 2.35, and the mean CI was 0.92 for the controls. The mean HI was 4.06, and the mean CI was 31.75 in the patients with pectus. In the patients with pectus, HI demonstrated a 47.8% overlap with the controls, while there was no overlap for CI.

Conclusions

The Haller index demonstrates 48% overlap between normal patients and those with pectus excavatum. However, the proposed correction index perfectly separates the normal and diseased populations.     

Controlling for quality in the hospital cost function

This paper explores the relationship between the cost and quality of hospital care from the perspective of applied microeconomics. It addresses both theoretical and practical complexities entailed in incorporating hospital quality into the estimation of hospital cost functions. That literature is extended with an empirical analysis that examines the use of 15 Patient Safety Indicators (PSIs) as measures of hospital quality. A total operating cost function is estimated on 2,848 observations from five states drawn from the period 2001 to 2007. In general, findings indicate that the PSIs are successful in capturing variation in hospital cost due to adverse patient safety events. Measures that rely on the aggregate number of adverse events summed over PSIs are found to be superior to risk-adjusted rates for individual PSIs. The marginal cost of an adverse event is estimated to be $22,413. The results contribute to a growing business case for inpatient safety in hospital services.     

Gender relations and health research: a review of current practices

Introduction  

The importance of gender in understanding health practices and illness experiences is increasingly recognized, and key to this work is a better understanding of the application of gender relations. The influence of masculinities and femininities, and the interplay within and between them manifests within relations and interactions among couples, family members and peers to influence health behaviours and outcomes.