- ABOUT THIS JOURNAL: About This Journal
- COMMENTARY: Opioid Contribution to Decreased Cortisol Levels in Critical Care Patients
- ANNOUNCEMENT: Image of the Year for 2008
- ORIGINAL ARTICLE: Perioperative Carcinoembryonic Antigen Measurements to Predict Curability After Liver Resection for Colorectal Metastases: A Prospective Study
Hypothesis Perioperative carcinoembryonic antigen (CEA) blood level is a predictor of outcome after resection of colorectal liver metastases (CLMs).
Design Prospective clinical study.
Setting Department of digestive surgery and transplantation.
Patients Between January 1, 2000, and December 31, 2004, CEA levels were routinely measured 1 week before and 6 weeks after CLM resection in 213 patients. The patients were divided into the following 3 groups: group A (n = 69) with normal preoperative and postoperative CEA levels, group B (n = 111) with elevated preoperative and normal postoperative CEA levels, and group C (n = 33) with elevated preoperative and postoperative CEA levels.
Main Outcome Measures The use of perioperative CEA levels to predict outcome after resection.
Results The median survival was 45.4 months. The 5-year overall and disease-free survival rates were 50.2% and 21.9%, respectively, in group A, 38.5% and 18.3% in group B, and 0.0% and 0.0% in group C (P < .001). Univariate analysis showed that patients with elevated preoperative and postoperative CEA levels, multiple CLMs, large CLMs (≥5 cm), advanced Fong clinical risk score, bilobar distribution, and hepatic pedicle lymph node involvement had significantly poorer overall and disease-free survival. By multivariate analysis, only perioperative CEA level, hepatic pedicle lymph node involvement, and number and size of CLMs were independent prognostic factors. The 5-year survival rates showed good correlation with perioperative CEA levels in all 3 patient groups.
Conclusions The predictive value of perioperative CEA levels is demonstrated. Carcinoembryonic antigen levels as early as 6 weeks after surgery may be helpful in assigning patients to adjuvant chemotherapy after resection of CLMs.
- INVITED CRITIQUE: Perioperative Carcinoembryonic Antigen Measurements to Predict Curability After Liver Resection for Colorectal Metastases--Invited Critique
- ORIGINAL ARTICLE: Effect of Race and Insurance Status on Presentation, Treatment, and Mortality in Patients Undergoing Surgery for Diverticulitis
Objective To determine the effect of race and insurance status on patient presentation, treatment, and mortality in individuals who underwent surgery for diverticulitis.
Design Retrospective analysis of the Nationwide Inpatient Sample file from 1999 to 2003.
Setting A 20% representative sample of all hospitals in 37 states in the United States.
Patients Patients admitted with a primary diagnosis of diverticulitis who subsequently underwent either colectomy and/or colostomy (n = 45 528).
Main Outcome Measures Odds ratios (ORs) for association of race (black vs white) and insurance status (Medicaid or self-pay [inadequate insurance] vs other insurance) with (1) complicated presentation, (2) colostomy, and (3) in-hospital mortality.
Results On multivariate analysis, black race was significantly associated with complicated presentation (OR, 1.16; 95% confidence interval [CI], 1.04-1.30) and mortality (OR, 1.41; 95% CI, 1.06-1.86) but not with receiving a colostomy. In contrast, insurance status was significantly associated with complicated presentation (OR, 1.21; 95% CI, 1.08-1.36), receiving a colostomy (OR, 2.10; 95% CI, 1.89-2.32), and mortality (OR, 2.64; 95% CI, 1.82-3.82).
Conclusions Black patients were no more likely than white patients to undergo colostomy; however, race was a significant variable on patient presentation. Therefore, racial differences in outcome can be attributed to differences in patient presentation and not to differences in treatment received. Lack of adequate health insurance is a more powerful predictor of disease severity, suboptimal surgical treatment, and mortality.
- INVITED CRITIQUE: Effect of Race and Insurance Status on Presentation, Treatment, and Mortality in Patients Undergoing Surgery for Diverticulitis--Invited Critique
- ORIGINAL ARTICLE: Improved Survival Following Pancreaticoduodenectomy to Treat Adenocarcinoma of the Pancreas: The Influence of Operative Blood Loss
Hypothesis Although the safety of pancreaticoduodenectomy has notably improved over the past several decades, the reported survival of patients with pancreatic cancer remains poor. We hypothesized that, in recent years, the survival of patients with pancreatic adenocarcinoma following pancreaticoduodenectomy has substantially improved.
Design Retrospective case series.
Setting Major academic medical and pancreatic surgery center.
Patients A total of 182 consecutive patients underwent pancreaticoduodenectomy for various diagnoses between 1987 and 2005. Patients from 1987-1995 were compared with patients from 1996-2005.
Interventions Pancreaticoduodenectomy for patients with a diagnosis of pancreatic adenocarcinoma.
Main Outcome Measures Survival after pancreaticoduodenectomy and patient outcomes.
Results During the time period analyzed, 182 patients underwent pancreaticoduodenectomy to treat ductal adenocarcinoma. There were no operative deaths, and 86.3% of patients had an R0 resection. The 5-year survival rate for the entire group was 27.4%. However, survival improved from 15.8% to 35.5% during the study period. Both groups had equivalent demographic and pathological characteristics, and the only predictors of poor survival in multivariate analysis were operative blood loss of more than 400 mL (hazard ratio, 2.17), poorly differentiated tumors (3.03), lymph node metastases (1.92), perineural invasion (2.66), and undergoing an operation before 1996 (1.42).
Conclusions The survival rate for patients undergoing pancreaticoduodenectomy to treat pancreatic cancer has substantially improved. This finding is partially owing to improved operative technique and limited operative blood loss.
- ORIGINAL ARTICLE: Attrition During Graduate Medical Education: Medical School Perspective
Objective To identify predictors of attrition during graduate medical education (GME) in a single medical school cohort of contemporary US medical school graduates.
Design Retrospective cohort study.
Setting Single medical institution.
Participants Recent US allopathic medical school graduates.
Main Outcome Measure Attrition from initial GME program.
Results Forty-seven of 795 graduates (6%) did not complete the GME in their initial specialty of choice. At bivariate analysis, attrition was associated with election to the Alpha Omega Alpha Honor Medical Society, being an MD-PhD degree holder, and specialty choice (all P < .05). Attrition was not associated with graduation year (P = .91), sex (P = .67), or age (P = .12). In a multivariate logistic regression model, MD-PhD degree holder (odds ratio, 3.43; 95% confidence interval, 1.27-9.26; P = .02), election to Alpha Omega Alpha (2.19; 1.04-4.66; P = .04), choice of general surgery for GME (5.32; 1.98-14.27; P < .001), and choice of 5-year surgical specialty including those surgical specialties with a GME training requirement of 5 years or longer (2.74; 1.16-6.44; P = .02) each independently predicted greater likelihood of attrition.
Conclusion Academically highly qualified graduates and graduates who chose training in general surgery or in a 5-year surgical specialty were at increased risk of attrition during GME.
- INVITED CRITIQUE: Attrition During Graduate Medical Educa
