Biomedical subjects

Seema S Sonnad

Publications and source records attributed to Seema S Sonnad.

At least 19 recordsLinked to original sources

PubMed2007

Methodologic quality of cost-effectiveness analyses of surgical procedures.

OBJECTIVE: The purpose of this study was to evaluate the methodologic quality of economic analyses of surgical procedures and to compare quality across publications. SUMMARY BACKGROUND DATA: With healthcare resources limited and technologies rapidly advancing across specialties, including surgery, there is increasing demand for evidence of cost-effectiveness. METHODS: A MEDLINE search identified English-language articles published from 1995 to 2004 that included economic analyses of surgical procedures. Two of the authors reviewed 110 studies and scored each based on compliance with 10 methodologic criteria. Data analyses used Cohen's kappa statistic, regression models, Mann-Whitney U tests, and Kruskal-Wallis tests. RESULTS: The 110 articles appeared in 79 different journals, including 57 articles in 37 surgical journals. Most journals (75%) had only 1 article eligible for inclusion. The average number of criteria met was 4.1, with 10 articles meeting all 10 methodologic standards. Compliance rates for the 5 methodologic criteria most frequently neglected ranged from 34% to 45% in nonsurgical journals and 9% to 14% in surgical journals (P < 0.001). CONCLUSIONS: While methodologic guidelines for cost-effectiveness analyses have appeared in the medical literature, studies of cost-effectiveness in surgery often do not meet these criteria. As healthcare policy seeks to incorporate information from economic evaluations, it is increasingly important that surgical journals adhere to accepted guidelines and perform quality assurance on these studies. This may be aided by wider promulgation of the methodologic criteria in surgical journals or at surgical meetings.

Adult↗

PubMed2006

Mammographic density measured with quantitative computer-aided method: comparison with radiologists' estimates and BI-RADS categories.

PURPOSE: To retrospectively compare computer-aided mammographic density estimation (MDEST) with radiologist estimates of percentage density and Breast Imaging Reporting and Data System (BI-RADS) density classification. MATERIALS AND METHODS: Institutional Review Board approval was obtained for this HIPAA-compliant study; patient informed consent requirements were waived. A fully automated MDEST computer program was used to measure breast density on digitized mammograms in 65 women (mean age, 53 years; range, 24-89 years). Pixel gray levels in detected breast borders were analyzed, and dense areas were segmented. Percentage density was calculated by dividing the number of dense pixels by the total number of pixels within the borders. Seven breast radiologists (five trained with MDEST, two not trained) prospectively assigned qualitative BI-RADS density categories and visually estimated percentage density on 260 mammograms. Qualitative BI-RADS assessments were compared with new quantitative BI-RADS standards. The reference standard density for this study was established by allowing the five trained radiologists to manipulate the MDEST gray-level thresholds, which segmented mammograms into dense and nondense areas. Statistical tests performed include Pearson correlation coefficients, Bland-Altman agreement method, kappa statistics, and unpaired t tests. RESULTS: There was a close correlation between the reference standard and radiologist-estimated density (R = 0.90-0.95) and MDEST density (R = 0.89). Untrained radiologists overestimated percentage density by an average of 37%, versus 6% for trained radiologists (P < .001). MDEST showed better agreement with the reference standard (average overestimate, 1%; range, -15% to +18%). MDEST correlated better with percentage density than with qualitative BI-RADS categories. There were large overlaps and ranges of percentage density in qualitative BI-RADS categories 2-4. Qualitative BI-RADS categories correlated poorly with new quantitative BI-RADS categories, and 16 (6%) of 260 views were erroneously classified by MDEST. CONCLUSION: MDEST compared favorably with radiologist estimates of percentage density and is more reproducible than radiologist estimates when qualitative BI-RADS density categories are used. Qualitative and quantitative BI-RADS density assessments differed markedly.

Adult↗

PubMed2006

Multiple variables affecting blood usage in lung transplantation.

BACKGROUND: A few publications have reported on the role of variables affecting blood component usage during lung transplantation. METHODS: Transfusion records for lung transplantation patients at the Hospital of the University of Pennsylvania (November 1991 to July 2004) were reviewed. Bivariate analyses and regression models were used to correlate usage of packed red blood cells (RBC), fresh-frozen plasma (FFP) and platelets (PLT) with variables such as disease, number of pulmonary lobes (1 or 2), cardiopulmonary bypass (CPB) status and time on bypass. RESULTS: Among 376 patients examined during the study period, blood product usage (in units) was significantly higher in double- than in single-lung recipients (RBC, 5.76 vs 1.21; FFP, 5.55 vs 1.10; PLT, 1.15 vs 0.16; p < 0.001). Patients on CPB also used significantly more units (RBC, 8.28 vs 1.45; FFP, 9.70 vs 0.73; PLT, 1.86 vs 0.14; p < 0.001), correlating with time on bypass. Patients transplanted for Eisenmenger syndrome (ES) and cystic fibrosis (CF) received significantly more blood products than those transplanted for other diseases (RBC, ES = 17.91 vs CF = 7.31 vs all others <2.00; FFP, ES = 19.18 vs CF = 5.72 vs others <2.00; PLT, ES = 4.73 vs CF = 1.22 vs others <0.40; p < 0.001). A regression model identified variables predictive of blood product usage, including the number of lungs transplanted, CPB status, disease and patient age. CONCLUSIONS: Patients receiving double-lung transplantations, on CPB, or transplanted for ES and CF exhibited a very highly statistically significant demand (p < 0.001) for more blood products. Additional selected variables differentially predicted usage. These data will help transplant surgeons and transfusion medicine specialists better anticipate and prepare blood products for use in lung transplantation.

Adult↗

PubMed2006

Statistical methods in the surgical literature.

BACKGROUND: It is important that clinicians understand statistical methods to incorporate statistics into their own research and to correctly translate published literature into improved patient care. The purpose of this study was to identify frequency and appropriate use of statistical methods in clinical surgical publications during the past 18 years. STUDY DESIGN: The study included randomly selected issues from odd-numbered years of Annals of Surgery (Annals) and Archives of Surgery (Archives) between 1985 and 2003, and issues in 2003 from Journal of the American College of Surgeons (JACS), Journal of Surgical Research (JSR), and Surgery. We identified all statistical procedures reported in each article, examined correctness of methods, and reported trends in publication of statistical methods over time. RESULTS: The proportion of publications incorporating statistics has increased over time. Declining trends were seen in the proportion of articles with no statistics (p < 0.0001). Approximately 35% of articles in 1985 did not use statistics compared with < 10% in 2003. Nonparametric tests increased (p < 0.0001) during the study period. In Archives of Surgery, nonparametric tests increased from 0% in 1985 to 33% in 2003, and in Annals of Surgery, from 12% in 1985 to 49% in 2003. Twenty-seven percent of studies included incorrect selection or reporting of statistical methods. CONCLUSIONS: Overall, the statistical complexity of research in clinical surgery journals is increasing. It is important that clinicians reading this literature have sufficient knowledge of statistical methods to facilitate interpretation of increasingly sophisticated statistical analyses.

General Surgery↗

PubMed2006

Stereotactic biopsy of brain stem masses: Decision analysis and literature review.

BACKGROUND: Adult brain stem tumors are rare, and diverse pathology can be found in this location. Stereotactic biopsy of lesions in the brain stem has been performed since the 1960s with high diagnostic and low complication rates. Advances in imaging technology have raised questions regarding the utility of biopsy. We perform decision analysis to aid clinicians in their approach to management of adult brain stem lesions. METHODS: A structured literature search revealed 20 publications with 457 patients who had undergone brain stem lesion biopsy. These publications were reviewed to determine diagnostic rates and the incidence of complications. Standard decision analytic techniques were applied to the case of a virtual adult patient with a lesion in the brain stem. RESULTS: A 1-way sensitivity analysis revealed the likelihood that the preoperative diagnosis was correct and the rate at which incorrect treatment was based on faulty empirical diagnosis as the 2 factors with the greatest effects on patient outcome. The diagnostic rate and complication rate of biopsy, within the ranges reported in the literature, had lesser effects. A threshold analysis was constructed to compare outcomes from stereotactic biopsy vs empiric therapy for a brain stem lesion. The probability that the preoperative diagnosis is correct is plotted vs the probability that empirical treatment based on an incorrect diagnosis will have adverse effect. CONCLUSIONS: Management of lesions in the adult brain stem requires careful consideration of multiple preoperative factors including clinical and radiographic diagnostic certainty, consequences of empiric therapy, and the surgeon's complication rate.

Adult↗

PubMed2006

Improved nurse job satisfaction and job retention with the transition from a "mandatory consultation" model to a "semiclosed" surgical intensive care unit: a 1-year prospective evaluation.

OBJECTIVE: The change from a "mandatory consultation" to a "semiclosed" surgical intensive care unit (SICU) model will impact nurses considerably. We hypothesize that nurse job satisfaction, job turnover rates, and hospital costs for temporary agency nurses will improve and these improvements will be more dramatic in SICU sections with greater involvement of a dedicated surgical critical care service (SCCS). DESIGN: Prospective longitudinal survey. SETTING: Tertiary-care university hospital. SUBJECTS: SICU staff nurses. INTERVENTIONS: Change from mandatory consultation to semiclosed SICU. MEASUREMENTS AND MAIN RESULTS: We surveyed SICU nurses during the year-long transition to a semiclosed SICU service (five time points, 3-month intervals). The first four surveys included ten questions on nurse job satisfaction. The final survey included two additional questions. All questions were on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Nurse job turnover rates and money spent on agency nurses were compared over time; 503 of a possible 914 surveys were completed (55% overall return rate). Nurse job satisfaction scores significantly improved over time for all questions (p < .05). Hospital spending on agency nurses decreased significantly (p = .0098). The yearly nurse job turnover rate dropped from 25% to 16% (p = .15). The scores for both year-end statements ("I am more satisfied with my job now than 1 year ago" and "The SCCS management of all orders has improved my job satisfaction") were significantly higher in sections with greater SCCS involvement (p = .0070 and p < .0001). CONCLUSIONS: Nurse job satisfaction improved significantly with the transition to a semiclosed SICU. This higher satisfaction was associated with a significant decrease in spending on temporary agency nurses and a trend toward increased staff nurse job retention. SICU sections with greater SCCS involvement had more dramatic improvements. This semiclosed SICU model may help retain SICU nurses in a competitive job market in which experienced nurses are in short supply.

Attitude of Health Personnel↗

PubMed2006

Risk factors and complications in free TRAM flap breast reconstruction.

METHODS: The authors retrospectively reviewed 500 free TRAM flaps performed between 1992 and 2003. This cohort was subdivided based on smoking history, obesity, preoperative chemotherapy, preoperative radiation therapy, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), and hypertension, and compared surgical complication rates. Measured complications included fat necrosis, mastectomy flap necrosis, abdominal flap necrosis, partial TRAM flap loss, wound infection, hematoma, seroma, vessel thrombosis, and abdominal hernia. Chi2 analysis and Fisher exact test were performed to determine differences between groups, and linear regression models were used to predict the risk factors of surgical complications. RESULTS: Smokers were more likely to have a higher incidence of wound infection (P = 0.01), mastectomy flap necrosis (P = 0.015), abdominal flap necrosis (P = 0.033), and fat necrosis (P = 0.01). Obese patients were more likely to have higher rates of mastectomy flap necrosis (P = 0.01) and hematoma (P = 0.01). Patients with peripheral vascular disease were more likely to have a higher incidence of wound infection (P = 0.031), and patients with preoperative radiation therapy were more likely to have a higher incidence of seroma (P = 0.043). Logistic regression showed that smoking was found to be a risk factor for fat necrosis (P = 0.006), wound infection (P = 0.002), mastectomy flap necrosis (P = 0.039), and abdominal flap necrosis (P = 0.042). Obesity was a risk factor for mastectomy flap necrosis (P = 0.002). Peripheral vascular disease was a risk factor for wound infection (P = 0.032). CONCLUSION: Awareness of risk factors and associated complications will lead to modification and individualization of surgical techniques in an attempt to limit these complications and continually improve outcomes.

Breast↗

PubMed2006

An acute care surgery model improves outcomes in patients with appendicitis.

OBJECTIVE: To compare outcomes of appendectomy in an Acute Care Surgery (ACS) model to that of a traditional home-call attending surgeon model. SUMMARY BACKGROUND DATA: Acute care surgery (ACS, a combination of trauma surgery, emergency surgery, and surgical critical care) has been proposed as a practice model for the future of general surgery. To date, there are few data regarding outcomes of surgical emergencies in the ACS model. METHODS: Between September 1999 and August 2002, surgical emergencies were staffed at the faculty level by either an in-house trauma/emergency surgeon (ACS model) or a non-trauma general surgeon taking home call (traditional [TRAD] model). Coverage alternated monthly. Other aspects of hospital care, including resident complement, remained unchanged. We retrospectively reviewed key time intervals (emergency department [ED] presentation to surgical consultation; surgical consultation to operation [OR]; and ED presentation to OR) and outcomes (rupture rate, negative appendectomy rate, complication rate, and hospital length of stay [LOS]) for patients treated in the ACS and TRAD models. Questions of interest were examined using chi tests for discrete variables and independent sample t test for comparison of means. RESULTS: During the study period, 294 appendectomies were performed. In-house ACS surgeons performed 167 procedures, and the home-call TRAD surgeons performed 127 procedures. No difference was found in the time from ED presentation to surgical consultation; however, the time interval from consultation to OR was significantly decreased in the ACS model (TRAD 7.6 hours vs. ACS 3.5 hours, P < 0.05). As a result, the total time from ED presentation to OR was significantly shorter in the ACS model (TRAD 14.0 hours vs. ACS 10.1 hour, P < 0.05). Rupture rates were decreased in the ACS model (TRAD 23.3% vs. ACS 12.3%, P < 0.05); negative appendectomy rates were similar. The complication rate in the ACS model was decreased (TRAD 17.4% vs. ACS 7.7%, P < 0.05), as was the hospital LOS (TRAD 3.5 days vs. ACS 2.3 days, P < 0.001). CONCLUSIONS: In patients with acute appendicitis, the presence of an in-house acute care surgeon significantly decreased the time to operation, rupture rate, complication rate, and hospital length of stay. The ACS model appears to improve outcomes of acute appendicitis compared with a TRAD home-call model. This study supports the efficacy and efficiency of the ACS model in the management of surgical emergencies.

Adult↗

PubMed2006

Racial differences in attitudes toward innovative medical technology.

BACKGROUND: New medical technologies are used at different rates among whites and blacks. This variation may be partially explained by racial differences in patient innovativeness-the propensity of patients to adopt unfamiliar therapies. OBJECTIVE: To measure how innovativeness varies among patients and how it may influence patients' attitudes toward new medical technologies. DESIGN: Cross-sectional survey. PARTICIPANTS: Primary care patients (n=171-108 blacks, 63 whites) at an urban Veterans Affairs medical center. MEASUREMENTS: Respondents answered questions about their general innovativeness and innovativeness regarding medical technology, and they responded to a vignette describing either a hypothetical new prescription drug or implantable device. RESULTS: There were no significant racial differences in general innovativeness, but whites had higher medical technology innovativeness (P=.001). Whites were also more likely to accept the new prescription drug (P=.003), but did not differ from blacks in acceptance of the new implantable device. In multivariate analyses, lower medical technology innovativeness scores among blacks were significantly associated with less favorable reactions to both the prescription drug (P<.001) and the medical device (P<.001). In contrast, although whites with lower medical technology innovativeness were similarly less inclined to accept the new implantable device (P=.02), there was no significant association between medical technology innovativeness and positive attitudes to the new prescription drug among whites. CONCLUSIONS: Blacks and whites have differing attitudes toward medical innovation. These differences are associated with significant racial differences in response to particular health care technologies. These findings suggest potentially remediable causes for racial differences in the utilization of innovative medical technologies.

Attitude to Health↗

PubMed2005

Women authors of surgical research.

HYPOTHESIS: The number of women authors in the surgical literature has increased during the past 20 years. DESIGN: Randomly selected issues of odd-year journals in Archives of Surgery and Annals of Surgery from January 1, 1985, to December 31, 2003, were reviewed. We determined the gender of each author and reported trends in the occurrence of women authors over time. RESULTS: The percentage of women authors has increased over time and parallels the percentage of women faculty in academic surgery positions. A much higher percentage of women authors than men authors are nonphysicians. The trend for increased authorship by women over time was significant in Archives of Surgery. CONCLUSION: Although the number of women first authors is low, their contributions to the field of surgery should be acknowledged, and efforts to provide women with the resources and opportunities to conduct research and publish their findings should be a focus for surgical departments looking to increase their research productivity.

Authorship↗

PubMed2005

Diffusion of published cost-utility analyses in the field of health policy and practice.

OBJECTIVES: The diffusion of cost-utility analyses (CUAs) through the medical literature was examined, documenting visible patterns and determining how they correspond with expectations about the diffusion of process innovations. METHODS: This study used 539 CUAs from a registry. It includes data elements comprising year of publication, the research center in which the study was performed, the clinical area covered by the CUA, and the specific journal. Finally, each paper was assigned to a journal type that could be one of the three categories: health services research, general medicine, or clinical specialty. RESULTS: When the average number of publications is plotted against time, the plot reveals an S-shaped curve. It appears that, whereas CUAs initially were published more frequently in general medical or health services research journals, there was a clear increase in the diffusion of CUA into subspecialty journals over time. The concentration ratio for research centers as measured by the Herfindhal-Hirschman Index decreased over time. CONCLUSIONS: The spread of CUA through the medical literature follows patterns identified for the diffusion of other new technologies and processes. Future research should focus on what impact this spread has had on the practice of medicine and formulation of health policy.

Cost-Benefit Analysis↗

PubMed2005

Prophylaxis for deep venous thrombosis in craniotomy patients: a decision analysis.

OBJECTIVE: We sought to determine the most efficient perioperative prophylactic strategy for deep venous thrombosis (DVT) in craniotomy patients by use of a decision analysis model. METHODS: We conducted a structured review of the relevant literature and compiled the reported incidences of DVT, pulmonary embolism, and postoperative intracranial hemorrhage (ICH) in craniotomy patients. We also obtained from the literature estimates of the likelihood and the impact of various outcomes of these complications. Data from 810 craniotomies performed at our own institution were also examined. The decision analytic model was then used to compare the effectiveness of pneumatic compression boots with pneumatic compression boots combined with either unfractionated or low-molecular-weight heparin. The model dealt with variability by using both sensitivity analysis and Monte Carlo simulation. RESULTS: As expected, the addition of heparin lowered the incidence of both DVT and pulmonary embolism, but at the cost of increasing ICH. Because the deleterious effects of ICH were so much greater than the benefits from heparinization, overall outcomes were best with mechanical prophylaxis alone. This was especially true for low-molecular-weight heparin, which is associated with a relatively high risk of ICH. Our own institutional data support the findings in the literature. Although the differences are modest, they reach statistical significance in the case of low-molecular-weight heparin. CONCLUSION: Using decision analytic modeling, we have shown that mechanical prophylaxis yields outcomes in craniotomy patients superior to those of either unfractionated or low-molecular-weight heparin.

Anticoagulants↗

PubMed2005

Cost-effectiveness of intraoperative imaging in carotid endarterectomy.

OBJECTIVE: There has never been a large, randomized controlled trial to assess the impact of intraoperative imaging on the success of carotid endarterectomy (CEA). This comparison involves cost-effectiveness analysis. METHODS: We constructed a decision-analytic model to compare effectiveness and costs of intraoperative ultrasound (IUS) and completion angiography as adjuncts to CEA. Data on procedural mortality, morbidity, and costs were obtained from the English-language literature. The review included a total of 52 reports, encompassing more than 22,000 patients. The main components of costs were those of the monitoring interventions and the care of perioperative stroke. RESULTS: Mean perioperative outcome without completion imaging is approximately 96.7% of what it would be in the absence of perioperative stroke or death. IUS and completion angiography each result in approximately 2% improvement in expected outcome. Mean perioperative costs are 396.50 dollars for IUS, 721.30 dollars for no monitoring, and 840.90 dollars for completion angiography. Because IUS is significantly more effective at detecting technical errors that would likely result in perioperative stroke than no imaging and is significantly less costly than angiography, this strategy dominates the other two (i.e., it provides greater effectiveness at lower cost). CONCLUSION: Although surgical complications are uncommon, IUS substantially lowers the rate of perioperative stroke and mortality and thus is significantly more cost-effective than either completion angiography or no operative imaging.

Angiography↗

PubMed2004

Implementation of the ACC/AHA guidelines for preoperative cardiac risk assessment in a general medicine preoperative clinic: improving efficiency and preserving outcomes.

BACKGROUND: The American College of Cardiology/American Heart Association (ACC/AHA) publishes recommendations for cardiac assessment of patients undergoing noncardiac surgery with the intent of promoting evidence-based, efficient preoperative screening and management. We sought to study the impact of guideline implementation for cardiac risk assessment in a general internal medicine preoperative clinic. METHODS: The study was an observational cohort study of consecutive patients being evaluated in an outpatient preoperative evaluation clinic before and after implementation of the ACC/AHA guideline. Data was gathered by retrospective abstraction of hospital and clinic charts using standard definitions. 299 patients were reviewed prior to guideline implementation and their care compared to 339 consecutive patients after the guideline was implemented in the clinic. RESULTS: Guideline implementation led to a reduction in exercise stress testing (30.8% before, 16.2% after; p<0.001) and hospital length of stay (6.5 days before, 5.6 days after; p=0.055). beta-Blocker therapy increased after the intervention (15.7% before; 34.5% after; p<0.001) and preoperative test appropriateness improved (86% before to 94.1% after; p<0.001). CONCLUSIONS: Implementation of the ACC/AHA guidelines for cardiac risk assessment prior to noncardiac surgery in an internal medicine preoperative assessment clinic led to a more appropriate use of preoperative stress testing and beta-blocker therapy while preserving a low rate of cardiac complications.

Adrenergic beta-Antagonists↗

PubMed2004

Combined orthotopic heart and liver transplantation: the need for exception status listing.

Through May 2004, 33 combined orthotopic heart-liver transplants (OHT/OLT) have been performed nationwide. No published data exist to date regarding outcomes of patients awaiting such transplants, although progression of two organ disease processes may contribute to premature death for waiting patients. Retrospective data were collected on patients listed for combined OHT/OLT from both an individual tertiary care transplant center and the national UNOS registry to delineate listing criteria and evaluate patient outcomes in both the pre- and post-MELD eras. All patients who survived to transplantation or died on the waiting list were included in the analysis. Results show that 29.6% of patients registered nationally and 42% of patients listed institutionally survived to transplantation. Survival to transplantation was associated with less severe liver disease, though patients with MELD scores ranging from 19 to 26 had significantly higher wait list mortality than expected when compared to single-organ liver transplants. Following combined orthotopic heart-liver transplantation, 80% and 70% of patients survive 1 and 3 years, respectively. In conclusion, combined OHT/OLT is a successful therapy, but current organ allocation policies may not ensure expeditious transplantation in critically ill patients with dual vital organ failure. Providing exception status listing to these patients would ensure more expeditious transplantation and potentially contribute to improved survival.

Adult↗

PubMed2004

Assessing symptoms, disease severity, and quality of life in the clinical context: a theoretical framework.

Health-related quality-of-life instruments can yield important health information that is often distinct from objective measures of symptoms and disease severity that clinicians are most attuned to. Comprehensive health assessment can be difficult because there are many available measurement instruments that vary in their scope and content. The conceptual boundaries between symptom, disease severity, and health-related quality-of-life instruments are frequently blurred in practice, and what is measured may not coincide with clinical and research goals. The Assessing the Impact of Disease framework aims to clarify the process of selecting appropriate assessment instruments. Three common diseases are discussed in depth to illustrate the applicability of Assessing the Impact of Disease in distinguishing between symptom, severity, and health-related quality-of-life measurements.

Gastroesophageal Reflux↗

PubMed2003

Thoracoabdominal aortic aneurysm repair after prior aortic surgery.

PURPOSE: The purpose of this study was to determine whether the morbidity and mortality of surgery for thoracoabdominal aortic aneurysm (TAAA) in patients with prior aortic surgery are increased. METHODS: The results for all patients undergoing operation for TAAA at a single institution were reviewed. RESULTS: Over a 10-year interval, 279 patients (136 women and 143 men) underwent aortic replacement for TAAA. The mean patient age was 68 years (range, 34-90). The extent of aortic replacement was relatively evenly distributed: type I (91), type II (54), type III (78), or type IV (56). Of these 279 patients, 76 (27%) had undergone prior aortic surgery. Prior infrarenal AAA was the most common prior procedure (56, 20%). Reoperation for prior failed TAAA repair was performed in 20 (7%) patients. A history of Marfan syndrome was highly associated with the need for remedial TAAA procedures (P <.0001). Overall 30-day mortality was 11.4% (32). Mortality was independent of prior aortic surgery (P =.98), prior AAA (P =.84), prior TAAA (P =.61), and gender (P =.18). Postoperative complications were seen in 67 (24%) patients and were more likely in patients who had undergone prior AAA surgery (P =.008). TAAA repair in patients with recurrent TAAA was not associated with higher morbidity (P =.33). Paraplegia (10) occurred in type I (3), type II (2), and type III (5) aneurysms but not in type IV (0), and its development was associated with higher mortality (P =.01). Prior aortic surgery was not found to be predictive of paraplegia (P =.90), although 30% of patients who developed paraplegia had a history of prior AAA repair. CONCLUSIONS: Aortic reoperation for TAAA is required in a significant number of patients, particularly those with Marfan syndrome. Therefore, ongoing surveillance of the residual aorta is mandatory. Postoperative complications are more likely to occur in patients after prior infrarenal aortic replacement, but mortality is not significantly increased. Special technical considerations exist for remedial procedures after failed TAAA repair to provide protection for the spinal cord, kidneys, and viscera. Patients with failed TAAA procedures or progression of aneurysmal extent should be offered reoperation when indicated.

Adult↗

PubMed2003

Cost-effectiveness of pap smear screening for vaginal cancer after total hysterectomy for benign disease.

OBJECTIVE: To examine the cost effectiveness of Papanicolaou screening for cancer after total hysterectomy for benign disease. MATERIALS AND METHODS: Decision analysis including Markov modeling applied to women aged 40 or older with a history of total hysterectomy for benign disease. We derived expected discounted costs and life expectancy. RESULTS: Maximum gain in life expectancy between no screening and any screening strategy was approximately 3 weeks. Cost effectiveness in dollars per life-year gained was > or =$143,875 more than no screening for strategies starting at age 50, and over $12 million for aged 40 or more screening strategy. None of the sensitivity analyses caused the incremental cost effectiveness of any strategy to come to less than $100,000 per life year gained compared with no screening. CONCLUSIONS: Despite significant costs for any strategy, Pap smear screening after total hysterectomy for benign disease provides essentially no gain in life expectancy. In absence of risks for genital cancer, such screening is not cost effective.

Journal Article↗