Association of Insulin Resistance and Higher Oncotype DX™ Recurrence Score

Annals of Surgical Oncology - Black women with breast cancer have a worse overall survival compared with White women; however, no difference in Oncotype DX? (ODX) recurrence scores has been...     

Hospital volume differences and five-year survival from breast cancer.

OBJECTIVES: The purpose of this study was to determine the effect of hospital volume on long-term survival for women with breast cancer. METHODS: Survival analysis and proportional-hazard modeling were used to assess 5-year survival and risk of death, adjusting for clinical and sociodemographic variables. RESULTS: At 5 years, patients from very low-volume hospitals had a 60% greater risk of all-cause mortality than patients from high-volume hospitals. CONCLUSIONS: Hospital volume of breast cancer surgical cases has a strong positive effect on 5-year survival. Research is needed to identify whether processes of care, especially postsurgical adjuvant treatments, contribute to survival differences.     

Influence of time on risk of bowel resection in complete small bowel obstruction

BACKGROUND: Little is known about the effect of passing time on risk of resection among patients with complete small bowel obstruction. We sought to provide a benchmark of the relationship of time from symptom onset to surgical treatment on the need for resection in patients with complete small bowel obstruction. STUDY DESIGN: We performed an observational study of patients with surgically treated complete small bowel obstruction at an inner-city urban tertiary referral center and a municipal hospital. Patients were sampled randomly retrospectively (n=60), and prospectively (n=81), for a final sample of 141. Detailed clinical and time data were abstracted from medical records including out-of-hospital examinations. Risk of resection was calculated using actuarial life table methods. Linear regression was used to determine factors affecting time to treatment. RESULTS: All patients were treated surgically for obstruction; 45% underwent resection. Resected patients had longer (11 days versus 8 days; p=0.01) and more complicated (31% versus 14% in ICU; p=0.01) hospital stays. The risk of resection was 4% among patients with 24 hours of unresponsive symptoms; it increased to 10% to 14% through 96 hours, then dropped slightly but did not disappear. Patients treated first with a tube had longer times between first examination and operation, system-time (40.6 hours versus 10.2 hours; p=0.0007), but this was not associated with an increased resection risk. System-times were shorter among patients seen first in the emergency department (median: 25.7 hours versus 59.7 hours; p=0.0001). CONCLUSIONS: Physicians should be cautious in postponing surgery beyond 24 hours in patients with unresponsive symptoms from complete obstruction. The risk of resection rises dramatically, remains elevated through 96 hours of unresolved symptoms, then declines but does not disappear.     

The detrimental effects of intravenous crystalloid after aortotomy in swine

We tested the hypothesis that, after aortotomy, rapidly replacing three times the blood volume deficit with intravenous crystalloid will increase hemorrhage and decrease survival. Sixteen anesthetized Yorkshire swine underwent splenectomy and stainless steel wire placement in the infrarenal aorta and were instrumented with pulmonary artery and carotid artery catheters. The wire was pulled, producing a 5 mm aortotomy and spontaneous intraperitoneal hemorrhage. The animals had been alternately assigned to either an untreated control group (n = 8) or a treatment group (n = 8), which received 80 ml/kg lactated Ringer's solution intravenously. The volume of hemorrhage and the mortality rate were significantly increased (p less than 0.05) in the treatment group receiving lactated Ringer's solution relative to the control animals (2142 +/- 178 ml versus 783 +/- 85 ml, and eight of eight animals versus zero of eight animals, respectively). From these data we conclude that, in this model of uncontrolled arterial hemorrhage resulting from abdominal aortotomy, rapidly administering lactated Ringer's solution intravenously significantly increases hemorrhage and death.     

Community hospital level II trauma center outcome.

Currently, level II trauma center standards allow trauma surgeons to take call out-of-hospital. To address the concern that this practice may adversely influence outcome, we tested the hypothesis that the survival of injury victims treated at a level II trauma center is significantly different from that predicted by the Major Trauma Outcome Study (MTOS). In addition, we examined the impact of trauma surgeons taking call out-of-hospital on the survival of patients with severe thoracoabdominal injury. Over a 26-month period, a total of 3,689 consecutive injured patients who were treated at a community hospital level II trauma center were entered into this study. There was no significant difference between the MTOS survival and the actual survival in the overall population (96% vs. 97%, respectively; Z statistic = ns). Among the patients with severe thoracoabdominal injury (i.e., Abbreviated Injury Scale score greater than or equal to 3), there was no significant difference in survival between the patients whose arrival time corresponded to the presence of an in-hospital surgeon (0700-1800 hours) versus those who arrived when a surgeon was generally out-of-hospital (1801-0659 hours), (76% vs. 81%, respectively; p = ns). From these data we conclude that there was no significant difference between the survival observed and that predicted by the MTOS at our community hospital, which complies with level II trauma center standards. Furthermore, in the cohort with severe thoracoabdominal injury, the response of trauma surgeons from out-of-hospital did not adversely influence survival.     

Prospective MAST study in 911 patients

Nine hundred eleven patients with systolic blood pressures less than or equal to 90 mm Hg were randomized to MAST and No-MAST groups, and all taken to a single Level I Trauma Center. Epidemiologic analysis of etiology, age, race, sex, Trauma Scores, and Injury Severity Scores revealed the two groups to be statistically identical. Seven hundred eighty-four patients were analyzed in detail. The principal injury location was thorax in 41%, abdomen in 32%, extremity in 16%, head in 7%, and neck in 4%. In patients with head and extremity wounds, the mortality rate was clearly not a function of MAST use. In the chest, abdomen, and neck, MAST did not improve survival. Although the total prehospital time was 35.8 + 10.4 minutes for MAST patients and 32.5 +/- 10.7 minutes for No-MAST patients, 70% of patients with MAST had prehospital times greater than 30 minutes compared to 55% of the No-MAST patients. When the prehospital time was greater than 30 minutes, 31% of the MAST patients died, compared to 21% of the No-MAST patients. MAST application adversely affected the outcome most significantly for patients with cardiac and thoracic vascular injury. The overall mortality of 31% in the MAST group, compared to 25% in the No-MAST group was statistically significant (p = 0.05).     

Breast Cancer Treatment Decision-Making: Are We Asking Too Much of Patients?

OBJECTIVE

Physicians are mandated to offer treatment choices to patients, yet not all patients may want the responsibility that entails. We evaluated predisposing factors for, and long-term consequences of, too much and not enough perceived decision-making responsibility among breast cancer patients.

DESIGN

Longitudinal assessment, with measurements collected just after surgical treatment (baseline) and 6-month follow-up.

PARTICIPANTS

Women with early-stage breast cancer treated surgically at eight NYC hospitals, recruited for a randomized controlled trial of patient assistance to improve receipt of adjuvant treatment.

MEASUREMENTS

Using logistic regression, we explored multivariable-adjusted associations between perceived treatment decision-making responsibility and a) baseline knowledge of treatment benefit and b) 6-month decision regret.

RESULTS

Of 368 women aged 28–89 years, 72 % reported a “reasonable amount”, 21 % “too much”, and 7 % “not enough” responsibility for treatment decision-making at baseline. Health literacy problems were most common among those with “not enough” (68 %) and “too much” responsibility (62 %). Only 29 % of women had knowledge of treatment benefits; 40 % experienced 6-month decision regret. In multivariable analysis, women reporting “too much” vs. “reasonable amount” of responsibility had less treatment knowledge ([OR] = 0.44, [95 % CI] = 0.20–0.99; model c?=?0.7343;p?<?0.01) and more decision regret ([OR] = 2.,91 [95 % CI] = 1.40–6.06; model c?=?0.7937;p?<?0.001). Findings were similar for women reporting “not enough” responsibility, though not statistically significant.

CONCLUSION

Too much perceived responsibility for breast cancer treatment decisions was associated with poor baseline treatment knowledge and 6-month decision regret. Health literacy problems were common, suggesting that health care professionals find alternative ways to communicate with low health literacy patients, enabling them to assume the desired amount of decision-making responsibility, thereby reducing decision regret.     

Engaging clinicians in a quality improvement strategy for early-stage breast cancer treatment

Physicians are skeptical of quality improvement and obtaining their enthusiastic participation continues to be a challenge. We designed and initiated a clinician-driven quality improvement project to improve the provision of efficacious breast cancer treatments among women presenting to an academic medical center for their initial treatment of early-stage breast cancer. All 156 identified physicians agreed to participate in the project and provided access to their office records or specific medical information.