Disparities in trauma: the impact of socioeconomic factors on outcomes following traumatic hollow viscus injury

Background

This piece aims to examine the relationships between hollow viscus injury (HVI) and socioeconomic factors in determining outcomes. HVI has well-defined injury patterns with complex postoperative convalescence and morbidity, representing an ideal focus for identifying potential disparities among a homogeneous injury population.

Materials and methods

A retrospective review included patients admitted to a level I trauma center with HVI from 2000–2009, as identified in the Trauma Registry of the American College of Surgeons. Patients with concomitant significant solid organ or vasculature injury were excluded. US Census (2000) median household income by zip code was used as socioeconomic proxy. Demographic and injury-related variables were also included. Endpoints were mortality and outcomes associated with HVI morbidity.

Results

A total of 933 patients with HVI were identified and 256 met inclusion criteria. There were 23 deaths (9.0%), and mortality was not associated with race, gender, income, or payer source. However, lower median household income was significantly associated with longer intervals to ostomy takedown (P = 0.032). Additionally, private payers had significantly lower rates of anastomotic leak (0% [0/73] versus 7.1% [13/183], P = 0.019) and fascial dehiscence (5.5% [4/73] versus 16.9% [31/183], P = 0.016), while self-payers had significantly higher rates of abscess formation, both overall (24% [24/100] versus 10.2% [16/156], P = 0.004) and among penetrating injuries (27.4% [23/84] versus 13.6% [12/88], P = 0.036).

Conclusions

Socioeconomic status may not impact overall mortality among trauma patients with hollow viscus injuries, but private insurance appears to be protective of morbidity related to anastomotic leak, fascial dehiscence, and abscess formation. This supports that socioeconomic disparity may exist within long-term outcomes, particularly regarding payer source.     

Adiposity and estrogen receptor-positive,postmenopausal breast cancer risk: Quantification of the mediating effects of fasting insulin and free estradiol

Adiposity increases estrogen receptor (ER)-positive postmenopausal breast cancer risk. While mechanisms underlying this relationship are uncertain, dysregulated sex-steroid hormone production and insulin signaling are likely pathways. Our aim was to quantify mediating effects of fasting insulin and free estradiol in the adiposity and ER-positive postmenopausal breast cancer association. We used data from a case–cohort study of sex hormones and insulin signaling nested within the Melbourne Collaborative Cohort Study. Eligible women, at baseline, were not diagnosed with cancer, were postmenopausal, did not use hormone therapy and had no history of diabetes or diabetes medication use. Women with ER-negative disease or breast cancer diagnosis within the first follow-up year were excluded. We analyzed the study as a cumulative sampling case–control study with 149 cases and 1,029 controls. Missing values for insulin and free estradiol were multiply imputed with chained equations. Interventional direct (IDE) and indirect (IIE) effects were estimated using regression-based multiple-mediator approach. For women with body mass index (BMI) >30 kg/m² compared to women with BMI 18.5–25 kg/m², the risk ratio (RR) of breast cancer was 1.75 (95% confidence interval [CI] 1.05–2.91). The estimated IDE (RR) not through the mediators was 1.03 (95% CI 0.43–2.48). Percentage mediated effect through free estradiol was 72% (IIE-RR 1.56; 95% CI 1.11–2.19). There was no evidence for an indirect effect through insulin (IIE-RR 1.12; 95% CI 0.68–1.84; 28% mediated). Our results suggest that circulating free estradiol plays an important mediating role in the adiposity–breast cancer relationship but does not explain all of the association.     

Theoretical potential for endometrial cancer prevention through primary risk factor modification: Estimates from the EPIC cohort

Endometrial cancer (EC) incidence rates vary ~10-fold worldwide, in part due to variation in EC risk factor profiles. Using an EC risk model previously developed in the European EPIC cohort, we evaluated the prevention potential of modified EC risk factor patterns and whether differences in EC incidence between a European population and low-risk countries can be explained by differences in these patterns. Predicted EC incidence rates were estimated over 10 years of follow-up for the cohort before and after modifying risk factor profiles. Risk factors considered were: body mass index (BMI, kg/m²), use of postmenopausal hormone therapy (HT) and oral contraceptives (OC) (potentially modifiable); and, parity, ages at first birth, menarche and menopause (environmentally conditioned, but not readily modifiable). Modeled alterations in BMI (to all ≤23 kg/m²) and HT use (to all non-HT users) profiles resulted in a 30% reduction in predicted EC incidence rates; individually, longer duration of OC use (to all ≥10 years) resulted in a 42.5% reduction. Modeled changes in not readily modifiable exposures (i.e., those not contributing to prevention potential) resulted in ≤24.6% reduction in predicted EC incidence. Women in the lowest decile of a risk score based on the evaluated exposures had risk similar to a low risk countries; however, this was driven by relatively long use of OCs (median = 23 years). Our findings support avoidance of overweight BMI and of HT use as prevention strategies for EC in a European population; OC use must be considered in the context of benefits and risks.     

Combination therapy with ACE inhibitors and angiotensin II receptor blockers to halt progression of chronic renal disease: pathophysiology and indications

It is no a secret that we are confronted by an alarmingly increasing number of patients with progressive renal disease. There is ample evidence for the notion that angiotensin II (Ang II) is a major culprit in progression. The vasopeptide Ang II turned out to have also multiple nonhemodynamic pathophysiologic actions on the kidney, including proinflammatory and profibrogenic effects. Diverse complex Ang II generating systems have been identified, including specifically local tissue-specific renin-angiotensin systems (RAS). For example, proximal tubular cells have all components required for a functional RAS capable of synthesizing Ang II. On the other hand, Ang II is not the only effector of the RAS and other peptides generated by the RAS influence renal function and structure as well. Moreover, the discoveries that Ang II can be generated by enzymes other than angiotensin-converting enzyme (ACE) and that Ang II and other RAS derived peptides bind to various receptors with different functional consequences have further added to the complexity of this system. Several major clinical trials have clearly shown that ACE inhibitor treatment slows the progression of renal diseases, including in diabetic nephropathy. Well-controlled studies demonstrated that this effect is in part independent of blood pressure control. More recently, with Ang II type 1 receptor (AT(1)) receptor antagonists a similarly protective effect on renal function was seen in patients with type 2 diabetes. Neither ACE inhibitor treatment nor AT(1) receptor blockade completely abrogate progression of renal disease. A recently introduced novel therapeutic approach is combination treatment comprising both ACE inhibitor and AT(1) receptor antagonists. The rationale for this approach is based on several considerations. Small-scale clinical studies, mainly of crossover design, documented that combination therapy is more potent in reducing proteinuria in patients with different chronic renal diseases. Blood pressure as an important confounder was, however, significantly lower in the majority of this studies in the combination treatment arms compared to the respective monotherapies. In a recent prospective study Japanese authors avoided this confounder and demonstrated that combination therapy reduced hard end-points (end stage renal failure or doubling of serum creatinine concentration) by 50% compared to the respective monotherapies. This effect could not be explained by a more pronounced reduction of blood pressure in the combination therapy group. Although these results are encouraging, administration of combination therapy should be reserved currently to special high risk groups. Further studies are necessary to confirm these promising results. It is possible that combination therapy may increase the risk of hyperkalemia, particularly when with coadministered with medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) or spironolactone. In our opinion patients with proteinuria >1 g/day despite optimal blood pressure control under RAS-blocking monotherapy are a high-risk group which will presumably benefit from combination therapy.     

2.2 Continuous quality improvement

Continuous quality improvement (CQI) can be envisaged as a circular process of goal-setting, followed by external and internal evaluations resulting in improvements that can serve as goals for a next cycle. The need for CQI is apparent, because of public accountability, maintaining European standards and the improvement of dental education. Many examples are known where recommendations from both external and internal evaluation are used for the improvement of dental education. Unfortunately, the implementation of the recommendations is inconsistent, rarely systematic and usually not transparent. This section agreed that it is essential to apply CQI in a structured, systematic and transparent way if we are to improve and maintain the quality of dental education. A model is proposed which includes three aspects: a) the process of CQI; b) the subjects to which CQI should be applied; and c) the management tools to govern CQI. It is stressed, that CQI is a process that can be applied in any dental school irrespective of curriculum or educational approach within the relevant context of the country or the region. The approach needs to recognize the complexity and the need to balance a quality improvement with accountability. A CQI system is also constrained in any organization by the attitudes and values of the staff. Inevitably there has to be a wide range in the application of CQI. Nevertheless, an agreed model on CQI might enhance convergence towards higher standards of dental education. The process of CQI can be supported by developments in information and communication technology (ICT): collection of data, identifying the steps in CQI, formats of reports, etc. The section was set, as one of its tasks, to advise on the development of a network based on a number of case studies on the application of CQI in dental education.     

Low level of response to alcohol as associated with serotonin transporter genotype and high alcohol intake in adolescents.

BACKGROUND: A low level of response to alcohol has been associated with both the genetic constitution of the regulatory region (SLC6A4) of the human serotonin (5-hydroxytryptamine, 5-HT) transporter (5-HTT) and with future alcohol intake and an increased risk for alcoholism. To date, all studies of relevant polymorphisms have been carried out in populations in the United States. METHODS: Data were extracted from a subset (n = 243) of a cohort of children who have been observed since birth through evaluation of the family history of alcoholism and psychosocial risk influences. At age 16 years, the response to alcohol was assessed with the Self-Rating of the Effects of Alcohol (SRE) questionnaire, and the average amount of alcohol intake per month was assessed during the prior 6 months. Additional variables that were measured included the 5-HTT genotype, externalizing behavior, and sociodemographic variables, such as gender and age. RESULTS: The level of response to alcohol was significantly lower among carriers of two long alleles of the 5-HTT regulatory region compared with carriers of one or two short alleles (Mann-Whitney U = 5225.0, p = .005). In a multiple regression analysis, the level of response to alcohol and externalizing behavior but not psychosocial factors significantly predicted the average amount of alcohol intake per month. CONCLUSIONS: This study demonstrates that, independent of the assessed psychosocial variables, the 5-HTT genotype correlated with the level of response to alcohol and predicted alcohol intake among 16-year-old adolescents.     

A study for evaluating the effect of the deltoid-flap repair in massive rotator cuff defects

The repair of massive cuff defects by direct suture often is impossible. In these cases, a repair by musculo–tendineous flaps (latissimus-dorsi, pectoralis or deltoideus) is required. It was the goal of this study to evaluate the result of delta-flap repair in case of massive cuff defects with a diameter of 5 cm or more. Between 1998 and 2000 for all patients who were suffering from a massive rotator cuff tear more than 5 cm a deltoid transfer was performed. A total of 20 patients (14 male, 6 female; age: 60.9 ± 8.7 years) were available for a follow-up after 47.2 ± 8.0 (range, 36 to 60) month. The operation included an arthroscopic evaluation, acromioplasty with resection of the lateral clavicular end, and biceps tenodesis. The cuff defect was repaired by transfer a muscular flap from the anterior part of the deltoid (about 2×6 cm) into the defect. The patients subjectively rated their result—10 excellent, 9 good, and 1 poor. Preoperatively, the Constant amounted 26.3 ± 5.1 points. At follow-up, the score significantly increased to 74.5 ± 8.5 points. The acromiohumeral distance increased from 4.9 ± 1.1 to 9.2 ± 1.7 mm. In MRI examination of 11 patients all had an intact flap. Two complications (a wound hematoma and a deep infection) did not influence the result. The repair of massive rotator cuff tears by a deltoid transfer produces acceptable clinical and radiological results.     

Effectiveness of education for gastric cancer patients: A controlled prospective trial comparing interactive vs. lecture-based programs

Objective

Although patient education may enhance knowledge, coping with illness, and quality of life among cancer patients, it is uncertain which didactic method is most effective. We compared the impact of an interactive, patient-oriented group program to a lecture-based, information-only program in gastric cancer patients.

Methods

In this prospective, controlled trial, 121 gastric cancer patients attending inpatient rehabilitation after surgical treatment received either the interactive intervention or lectures providing information. The outcomes were patients’ disease-related knowledge, active coping with illness, and quality of life (QoL) at the end of their stay and 6 and 12 months thereafter.

Results

Both groups improved their knowledge and QoL during rehabilitation; however, knowledge was significantly higher in the interactive group compared to the lecture group. This difference was maintained at the 6- and 12-months follow-ups. In addition, the interactive group proved superior to the lecture group regarding active coping with illness and QoL at the end of rehabilitation, but not during follow-up.

Conclusions

A structured, interactive patient education program proved superior to lecture-based provision of information in regards to short-term and long-term knowledge as well as short-term coping and QoL.

Practice implications

In gastric cancer patients, interactive patient education seems preferable over lectures.     

Misplacement of a femoral venous catheter into the ascending lumbar vein: repositioning using ultrasonographic guidance

A 5-week-old infant with congenital chylothorax required long-term intravenous access for parenteral nutrition. Cannulation of the inferior vena cava via the left femoral vein was attempted, but the catheter was misplaced into the left ascending lumbar vein. Catheter removal is advised when such malposition is identified. We were able successfully to redirect the catheter into the inferior vena cava using ultrasonographic guidance. This procedure has not been described previously in children. We propose that repositioning of incorrectly placed vascular catheters can be achieved using ultrasound guidance at the bedside.