Cost-effectiveness of defibrillation by emergency medical technicians

Effective emergency systems using emergency medical technicians (EMTs) trained to defibrillate or paramedics can save more lives from out-of-hospital cardiac arrest due to ventricular fibrillation than can emergency systems staffed with basic EMTs who cannot defibrillate. This article focuses on the cost-effectiveness of systems staffed with each type of EMT. Data were collected from all 50 states and from the District of Columbia to determine the number of hours and estimated cost of initial training for the three types of EMTs in the United States in 1986. The median initial training hours for basic EMTs, EMTs trained in defibrillation, and paramedics were 110, 129, and 700, respectively. Median costs for initial training at each EMT level were +123, +150, and +1580/student. According to published survival data for emergency medical systems staffed with EMTs at each level, the total initial training personnel and equipment cost per life saved from ventricular fibrillation was +7687, +2126, and +2289 for systems staffed by the respective EMTs. The initial cost per life saved from ventricular fibrillation is more than three times greater in systems staffed by basic EMTs than in systems staffed by EMTs trained in defibrillation or paramedics. From a medical and a cost-effective standpoint, all communities served by basic EMTs should consider upgrading them to at least the defibrillation-trained EMT level.     

Enhancement characteristics of papillary renal neoplasms revealed on triphasic helical CT of the kidneys.

OBJECTIVE: The purpose of this study was to determine whether renal tumor enhancement or heterogeneity on triphasic helical CT scans is predictive of the papillary cell subtype or nuclear grade of renal cell carcinoma. MATERIALS AND METHODS: We reviewed the CT scans of 90 consecutive patients with renal masses who had undergone triphasic renal helical CT before a complete or partial nephrectomy (12 with papillary renal cell carcinomas, 66 with nonpapillary renal cell carcinomas, and 12 with benign lesions). Three radiologists who were unaware of the patients' diagnoses retrospectively and independently measured the attenuation of each patient's tumor, abdominal aorta, and normal renal parenchyma on the scans obtained during all three phases. Ratios of tumor-to-aorta enhancement and tumor-to-normal renal parenchyma enhancement were calculated for both of the phases performed after contrast material had been administered. Tumor heterogeneity was calculated as the difference between the highest and lowest attenuation values divided by the value of the enhancement of the aorta. Values were correlated with cell type and nuclear grade found at surgical pathology. RESULTS: Low tumor-to-aorta enhancement and low tumor-to-normal renal parenchyma enhancement ratios on the vascular phase scans significantly correlated (p < 0.001) with papillary renal cell type carcinoma. Homogeneity and tumor-to-parenchyma enhancement ratios on the parenchymal phase scans also significantly correlated (p < 0.001) with papillary renal cell type carcinoma. Heterogeneity and tumor enhancement ratios did not correlate with the nuclear grade of the carcinoma. CONCLUSION: Papillary renal cell carcinomas are typically hypovascular and homogeneous. A high tumor-to-parenchyma enhancement ratio (> or = 25%) essentially excludes the possibility of a tumor being papillary renal cell carcinoma. A low tumor-to-aorta enhancement ratio or tumor-to-normal renal parenchyma enhancement ratio is more likely to indicate papillary renal cell carcinoma.     

Variations in Surgical Treatment and Outcomes of Patients With Pancreatic Cancer: A Population-Based Study

Background There is ongoing debate on how variations in surgical technique affect outcomes in pancreatic cancer. This population-based study examines current surgical practice and outcomes for cancer of the pancreatic head. Methods All patients 18 to 85 years old diagnosed with nonmetastatic adenocarcinoma of the pancreatic head from 1998 through 2003 were identified from the Surveillance, Epidemiology and End Results (SEER) Program registry. Multivariable regression was used to elucidate factors associated with the type of pancreaticoduodenectomy performed, extent of lymph node (LN) assessment, early mortality, and late survival. Results Overall, 2111 patients were included in the study, with 83.7% treated with a standard Whipple pancreaticoduodenectomy (PD). However, there was marked regional variation in the use of pylorus-preserving pancreaticoduodenectomy (PPPD; range, .03%–32.0%; P < .0001) and total pancreatectomy (TP; range, .04%–19.5%; P < .0001). TP was associated with significantly higher early mortality (odds ratio, 2.6; 95% confidence interval, 1.6 to 4.1; P < .0001), but late survival did not differ significantly between TP, PPPD, and PD (P = .69). Significant variation was also seen in the number of LN assessed (range across SEER regions, 7.3–13.5; P < .0001). Decreased LN assessment reduced the odds of diagnosing a patient as node positive and was associated with worse late survival. Conclusions In this population-based study, we found marked clinically important variability in the surgical treatment of adenocarcinoma of the pancreatic head, with respect to the use of TP, PPPD, or PD, and the extent of LN assessment. Further research is warranted to elucidate the underlying reasons, and to clarify the role of adequate lymphadenectomy.     

The etiology of adolescent idiopathic scoliosis

The etiology of adolescent idiopathic scoliosis (AIS), the most common form of scoliosis, is unclear. Researchers with divergent perspectives have tried to better define this etiology. Genetics, growth hormone secretion, connective tissue structure, muscle structure, vestibular dysfunction, melatonin secretion, and platelet microstructure are major areas of focus. In this article, we review the literature in these areas and present the consensus on proposed hypotheses. Studies that simplify the etiology to a single factor have been inconclusive or unsuccessful. Most likely, the etiology is multifactorial, and reported associations are links in pathogenesis rather than etiologic factors. Research is needed to better define the role of all factors in AIS development.     

Arthroscopic subacromial decompression: Results according to the degree of rotator cuff tear

We evaluated the results of arthroscopic subacromial decompression according to the degree of rotator cuff tear in 71 patients, available for follow-up for at least 1 year (average 19 months). Of the patients with stage II disease, 82% were satisfied regardless of whether they had no rotator cuff tear (nine of 11) or had a partial tear (28 of 34) of the rotator cuff. Of patients with stage III disease (complete rotator cuff tear), 88% (23 of 26) were satisfied. An acceptable objective UCLA shoulder rating greater than or equal to 28 points was seen in 82% (nine of 11) of the patients without a rotator cuff tear, 76% (26 of 34) with a partial tear, and 77% (20 of 26) with a complete tear. All four of the patients with complete tears less than 1 cm obtained excellent results. Three of the six failures were in patients with complete tears who had a narrowed acromial-humeral distance of less than 7 mm. The average UCLA pain score showed significant improvement from 2.8 (constant pain) to 8.6 (occasional pain) at 1-2 years postoperatively. The function, strength, and active forward flexion scores also increased at 1-2 years from their preoperative values. The overall patient satisfaction rate of 85% and the objective success rate of 77% are within the range of that seen with open rotator cuff repair.     

Surgically Managed Gastrointestinal Stromal Tumors: A Comparative and Prognostic Analysis

BACKGROUND: Tyrosine kinase inhibitors have been shown to have marked clinical efficacy in patients with unresectable or metastatic gastrointestinal stromal tumors (GIST). We performed a comparative and prognostic analysis of our experience with surgically managed GIST to determine factors associated with adverse oncologic outcomes. METHODS: Oncologic outcomes of 191 patients with primary GIST surgically managed between 1978 and 2004 at a single institution were reviewed. Prognostic factors were analyzed by Cox analysis (hazard ratio [HR] and 95% confidence interval [95% CI]) and included age, sex, disease presentation (asymptomatic vs. symptomatic), tumor site (stomach, small bowel, colorectal), disease extent (localized vs. metastatic) and risk levels (high, intermediate, low, very-low) assigned on the basis of size and number of mitoses according to current National Institutes of Health recommendations. Primary end points were disease-free survival (DFS) and disease-specific survival (DSS). RESULTS: A total of 186 patients (97%) had c-kit-positive GIST. There were 54% high, 22% intermediate, 18% low, and 8% very low risk GIST originating from the stomach (54%), small bowel (36%), and colon and rectum (10%). Median patient age was 65 (range, 13-91) years, and 108 subjects (57%) were male. Seventy-two percent of patients had symptomatic local disease, and 21% patients had synchronous metastases. Most (95%) underwent R0 resections of their primary tumor. Among 146 patients (76%) with localized disease at presentation undergoing R0 resection, the 5-year DFS was 65%. High-risk GIST (HR 12, 95% CI, 5-32, P < .0001), symptomatic presentation (HR 2.5, 95% CI, 1.1-6, P = .04), and GIST in the small bowel (HR 2.8, 95% CI, 1-5, P = .003) were independently associated with decreased DFS. After a median follow-up of 63 months among survivors, the 5-year DSS was 68%. High-risk disease (HR 14.3, 95% CI, 5-41, P < .0001), symptomatic presentation (HR 3.1, 95% CI, 1.2-7.9, P = .02), and GIST in the small bowel (2.6,3 95% CI, 1-5, P = .006) were independently associated with decreased DSS. CONCLUSIONS: High-risk GIST are associated with increased disease recurrence and decreased survival despite complete surgical resection. These patients should receive adjuvant therapy in the form of tyrosine kinase inhibitors.     

Neuroendocrine Tumors of the Colon and Rectum: Prognostic Relevance and Comparative Performance of Current Staging Systems

Background

With increasing interest in neuroendocrine tumors (NETs), three staging systems for NETs of the colon and rectum have been published. Their prognostic relevance has not been examined and compared in an independent clinical database.

Methods

From the National Cancer Database (NCDB), 5457 patients diagnosed with colorectal neuroendocrine tumor (CRNETs) between 1998 and 2002 were staged according to the staging systems from (1) European Neuroendocrine Tumor Society (ENETS, 2006; n = 1537); (2) American Joint Committee on Cancer (AJCC, 2009; n = 1140); and (3) location-specific staging systems from the Surveillance Epidemiology and End Results (SEER, 2008; n = 942). Stage-stratified overall survival (OS) and Cox-specific concordance indices were calculated for each system. Independent prognostic factors were identified by multivariate analysis.

Results

Five-year OS for stage I, II, III, and IV CRNETs as defined by the ENETS staging system were 90.8, 77.3, 53.1, and 14.8 %, respectively. For well-differentiated CRNETs, the 5-year OS for stage I, II, III, and IV as defined by the AJCC staging system were superior: 90.6, 83.9, 64.8, and 24.9 %, respectively. Both staging systems had a concordance index of 0.72. After specifying location in the colon versus rectum, all three systems demonstrated acceptable performance. Histologic grade was a significant independent predictor of OS not currently incorporated in the staging systems.

Conclusions

The three staging systems showed comparable prognostic stratification of CRNETs, while the AJCC and ENETS systems are the most parsimonious. The current analysis supports the use of the AJCC for well-differentiated disease and ENETS systems for all CRNETs until there is further evidence for modification.