Biomedical subjects

Benjamin K Poulose

Publications and source records attributed to Benjamin K Poulose.

8 recordsLinked to original sources

PubMed2007

Optimizing choledocholithiasis management: a cost-effectiveness analysis.

HYPOTHESIS: Endoscopic retrograde cholangiopancreatography (ERCP) is more cost-effective for managing incidental choledocholithiasis (CDL) after laparoscopic cholecystectomy and intraoperative cholangiogram (LC/IOC) than laparoscopic common bile duct exploration (LCBDE). DESIGN: A cost-effectiveness analysis was performed to compare ERCP with LCBDE. Sensitivity analyses were performed to determine the key contributors to cost-effectiveness between the 2 treatment options. SETTING: Costs were approached from the institutional perspective considering a typical patient undergoing LC/IOC at a large referral center. PATIENTS: The base case patient evaluated was a woman 18 years of age or older with symptomatic cholelithiasis and incidental CDL discovered at the time of LC/IOC. INTERVENTIONS: Endoscopic retrograde cholangiopancreatography with drainage procedure performed after LC/IOC or LCBDE during LC/IOC. MAIN OUTCOME MEASURES: Costs, quality-adjusted life years gained, mean cost-effectiveness ratios, and incremental cost-effectiveness ratios. RESULTS: In the base case analysis, ERCP was the optimal treatment choice with a cost of $24 300 for 0.9 quality-adjusted life years gained compared with $28 400 and 0.88 quality-adjusted life years for LCBDE. Endoscopic retrograde cholangiopancreatography remained the optimal strategy for CDL in multiway probabilistic sensitivity analysis. If LCBDE were performed and the cost of a potential operative case lost was $3100 or less and the cost of ERCP hospitalization was $18 000 or more, then LCBDE became the preferred treatment for CDL. CONCLUSIONS: Endoscopic retrograde cholangiopancreatography was both less costly and more effective than LCBDE. Factors important to choosing the best strategy for CDL management included the cost of a potential case lost due to LCBDE performance and the cost of ERCP hospitalization.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMed2005

Risk factors for post-operative mortality in bariatric surgery.

BACKGROUND: Appropriate patient selection is crucial to the success of bariatric surgery (BaS). The objective of this study was to identify risk factors for increased post-operative mortality in patients undergoing BaS using a nationally representative sample. MATERIALS AND METHODS: BaS patients > or = 18 years old in the United States were identified from the 2001 Nationwide Inpatient Sample (NIS). The effect of gender, age, insurance status, and need for re-operation on post-operative mortality was examined using a multivariate logistic regression model. RESULTS: A national cohort of 54,878 patients was identified with age 41 +/- 0.2 years (mean +/- SE), 84% women, length of stay (LOS) 3.9 +/- 0.2 days, and overall mortality of 4 per 1,000 BaS patients. Mean LOS of those who died was 17.6 +/- 3.7 days. Adjusting for comorbidities and demographics, men had increased likelihood of death [odds ratio (OR) 2.1, 95% confidence interval (CI) 1.1-4.3, P < 0.05]. Compared to younger patients, those aged above 39 years had over two-fold risk of death [ages 40-49: OR 2.6, 95% CI 1.1-6.5, P < 0.05; ages 50-59: OR 4.3, 95% CI 1.7-11, P < 0.05]. Medicaid patients [OR 4.7, 95% CI 1.2-13, P < 0.05 compared to privately insured] and those requiring re-operation [OR 22, 95% CI 5.4-88, P < 0.05] had higher odds of dying. CONCLUSION: Based on national data, risk factors for increased post-operative mortality in BaS patients include male gender, age > 39 years, Medicaid insured, and need for re-operation. These data can assist in optimizing BaS patient outcomes.

Adult↗

PubMed2005

Cervical spine evaluation in urban trauma centers: lowering institutional costs and complications through helical CT scan.

BACKGROUND: In the evaluation of the cervical spine (c-spine), helical CT scan has higher sensitivity and specificity than plain radiographs in the moderate- and high-risk trauma population, but is more costly. We hypothesize that institutional costs associated with missed injuries make helical CT scan the least costly approach. STUDY DESIGN: A cost-minimization study was performed using decision analysis examining helical CT scan versus radiographic evaluation of the c-spine. Parameter estimates were obtained from the literature for probability of c-spine injury, probability of paralysis after missed injury, plain film sensitivity and specificity, CT scan sensitivity and specificity, and settlement cost of missed injuries resulting in paralysis. Institutional costs of CT scan and plain radiography were used. Sensitivity analyses tested robustness of strategy preference, accounted for parameter variability, and determined threshold values for individual parameters on strategy preference. RESULTS: C-spine evaluation with helical CT scan has an expected cost of US 554 dollars per patient compared with US 2,142 dollars for plain films. CT scan is the least costly alternative if threshold values exceed US 58,180 dollars for institutional settlement costs, 0.9% for probability of c-spine fracture, and 1.7% for probability of paralysis. Plain films are least costly if CT scan costs surpass US 1,918 dollars or plain film sensitivity exceeds 90%. CONCLUSIONS: Helical CT scan is the preferred initial screening test for detection of cervical spine fractures among moderate- to high-risk patients seen in urban trauma centers, reducing the incidence of paralysis resulting from false-negative imaging studies and institutional costs, when settlement costs are taken into account.

Cervical Vertebrae↗

PubMed2005

National variations in morbid obesity and bariatric surgery use.

BACKGROUND: Exploring bariatric surgery use provides data on effective treatment allocation. This study analyzed national rates of bariatric surgery use and the burden of morbid obesity by gender, census region, and age. STUDY DESIGN: Patients 18 years of age or older undergoing bariatric surgery were identified from the US 2002 Nationwide Inpatient Sample, and the national morbidly obese population 18 years of age or older was determined using the Centers for Disease Control and Prevention 2002 Behavioral Risk Factor Surveillance System databases. General population data were obtained from 2000 census data. Annual rates of bariatric surgery procedures were determined by gender, age group, and census region (Northeast, Midwest, South, and West). Rate ratios were calculated and significance tested through 95% confidence intervals (95% CI), accounting for the Nationwide Inpatient Sample and Behavioral Risk Factor Surveillance System sampling design. RESULTS: In 2002, a national cohort of 69,490 bariatric surgery patients was identified. Of these patients 85% were women and 76% were ages 18 to 49 years. The prevalence of morbid obesity (body mass index > or = 40 kg/m(2)) in the US in 2002 was 1.8%; 60% of morbidly obese people were women, and 63% were ages 18 to 49 years. The rates of bariatric surgery procedures per 100,000 morbidly obese individuals ranged from a low of 139 in men aged 60 years and older in the Midwest to a high of 5,156 in women ages 40 to 49 years in the Northeast. For both men and women, bariatric surgery rates in the West and Northeast were 1.35 (95% CI 1.31 to 1.40, p < 0.05) to 4.51 (95% CI 4.15 to 4.89, p < 0.05) times higher than in the South, respectively; rates in the Midwest were similar to those in the South. CONCLUSIONS: National estimates suggest that bariatric surgery rates do not parallel the burden of morbid obesity by region or age. Additional evaluation of these differences is necessary for optimal bariatric surgery use.

Adolescent↗

PubMed2005

Physiologic properties of small intestine submucosa.

BACKGROUND: Porcine small intestine submucosa (SiS) has been introduced as a bioprosthesis in herniorrhaphy. This study evaluates in vivo properties of SiS that would affect clinical use. MATERIALS AND METHODS: Twelve pigs underwent implantation of SiS (perforated and nonperforated) on the peritoneal surface. Gross characteristics were evaluated and random samples harvested for histological study at 2 (n = 6) and 8 (n = 6) weeks. Collagen deposition was determined by polarized microscopy. Neovascularity (percent area blood vessels, %A(bv)) was determined by immunohistochemical staining with a polyclonal CD-31 antibody. RESULTS: Perforated SiS had a higher density of capillary ingrowth compared with nonperforated at both 2 (5.6%A(bv) versus 1.4%A(bv), P < 0.05) and 8 weeks (6.0%A(bv) versus 1.6%A(bv), P < 0.05). Compared with 2 weeks, 8-week SiS had a larger proportion of incorporation (25% versus 83%, P < 0.05) and new collagen deposition (50% versus 94%, P < 0.05). Significant contraction was observed in SiS 8 weeks after implantation (preimplant area 98 cm2 versus post-implant area 50 cm2, P < 0.05). CONCLUSION: SiS incorporated well 8 weeks after implantation, with deposition of new collagen. Perforated SiS demonstrated a more rapid and greater amount of neovascularity. The degree of contraction suggests that larger areas of SiS should be selected for herniorrhaphy than would be necessary if synthetic materials were used.

Absorbable Implants↗

PubMed2005

Resident work hour limits and patient safety.

OBJECTIVE: This study evaluates the effect of resident physician work hour limits on surgical patient safety. BACKGROUND: Resident work hour limits have been enforced in New York State since 1998 and nationwide from 2003. A primary assumption of these limits is that these changes will improve patient safety. We examined effects of this policy in New York on standardized surgical Patient Safety Indicators (PSIs). METHODS: An interrupted time series analysis was performed using 1995 to 2001 Nationwide Inpatient Sample data. The intervention studied was resident work hour limit enforcement in New York teaching hospitals. PSIs included rates of accidental puncture or laceration (APL), postoperative pulmonary embolus or deep venous thrombosis (PEDVT), foreign body left during procedure (FB), iatrogenic pneumothorax (PTX), and postoperative wound dehiscence (WD). PSI trends were compared pre- versus postintervention in New York teaching hospitals and in 2 control groups: New York nonteaching hospitals and California teaching hospitals. RESULTS: A mean of 2.6 million New York discharges per year were analyzed with cumulative events of 33,756 (APL), 36,970 (PEDVT), 1,447 (FB), 10,727 (PTX), and 2,520 (WD). Increased rates over time (expressed per 1000 discharges each quarter) were observed in both APL (0.15, 95% confidence interval, 0.09-0.20, P<0.05) and PEDVT (0.43, 95% confidence interval, 0.03-0.83, P<0.05) after policy enforcement in New York teaching hospitals. No changes were observed in either control group for these events or New York teaching hospital rates of FB, PTX, or WD. CONCLUSIONS: Resident work hour limits in New York teaching hospitals were not associated with improvements in surgical patient safety measures, with worsening trends observed in APL and PEDVT corresponding with enforcement.

Adult↗

PubMed2005

National analysis of adverse patient safety for events in bariatric surgery.

Identifying risk factors for adverse events after bariatric surgery (BaS) can help define high-risk groups to improve patient safety. We calculated cumulative incidence of adverse events and identified risk factors for these events using validated surgical patient safety indicators (PSIs) developed by the Agency for Healthcare Research and Quality. BaS patients > or =18 years old were identified using the 2002 Nationwide Inpatient Sample. Cumulative incidence at discharge was calculated for accidental puncture or laceration (APL), pulmonary embolus or deep venous thrombosis (PE/DVT), and postoperative respiratory failure (RF). Factors predictive of these PSIs were identified. From 7,853,982 discharges, a national cohort of 69,490 BaS patients was identified. During BaS hospitalization, the cumulative incidences per 1000 discharges of APL, PE/DVT, and RF were 12.6, 3.4, and 7.3, respectively. Risk factors for APL included male gender (odds ratio [OR] 1.6, 95% confidence interval 1.1-2.3, P < 0.05) and age of 40-49 years (OR 1.6 [1.1-2.3], P < 0.05) compared to ages 18-39 years. Patients aged 50-59 years (OR 3.5 [1.6-7.7], P < 0.05) had a higher chance of PE/DVT compared to those 18-39 years. Male gender (OR 1.8 [1.1-2.9], P < 0.05), ages 40-49 (OR 2.1 [1.1-4.2], P < 0.05) and 50-59 (OR 3.8 [2.1-6.9], P < 0.05), a history of chronic lung disease (OR 1.7 [1.1-2.7], P < 0.05), and Medicare coverage compared to private insurance (OR 2.2 [1.2-3.8], P < 0.05) were predictive of RF. This study established national measures for BaS adverse events. Further, risk factors associated with adverse events varied by gender, age, insurance status, and comorbidity. Evaluation of these higher risk BaS groups is needed to improve patient safety.

Adolescent↗

PubMed2004

New tools for laparoscopic division of the pancreas: a comparative animal study.

We tested the hypothesis that the pancreas can be safely divided laparoscopically using non-suture devices. Twelve pigs were randomized into 4 groups: 1) laparoscopic distal pancreatectomy (LDP) using an ultrasonic scalpel; 2) LDP using an ultrasonic scalpel with pancreatic stump suture reinforcement; 3) LDP using a 35-mm laparoscopic linear vascular stapler; 4) LDP using a prototype 35-mm radio-frequency laparoscopic linear vascular stapler. There were no serious complications related to distal pancreatectomy. All groups gained weight by postoperative day (POD) 14. Serum amylase, glucose, electrolytes and total bilirubin levels were measured preoperatively and on POD 1, 3, 7, and 14, and peripancreatic peritoneal fluid amylase levels were measured on POD 7 and 14; all remained normal in all groups. Fewer adhesions to the pancreatic stump were found in the ultrasonic scalpel groups as compared with the stapler groups. Ultrasonic dissection may be the superior means oflaparoscopic transection of the pancreas.

Animals↗