1,720,977 research outputs found
Patterns of readmission among the elderly after hepatopancreatobiliary surgery
No full textBackground: The objective of this study was to examine risk factors and outcomes of hospital readmission following complex hepatopancreatobiliary (HPB) surgery among the elderly. Methods: The Nationwide Readmissions Database was queried for patients ≥ 60 years who underwent HPB surgery during 2010–2015. Results: The incidence of 30- and 90-day readmission was similar among patients 60–74 vs. ≥75 (P > 0.05). Patients age 60–74 years with ≥2 comorbidities had an increased odds of 30-day (OR 1.13, p = 0.021) and 90-day (OR 1.13, p = 0.005) readmission. Patients ≥75 years with ≥2 comorbidities had the highest in-hospital mortality (5%) whereas patients 60–74 years with 0 or 1 comorbidity had the lowest in-hospital mortality on readmission (3%). Conclusion: Following an HPB procedure, roughly 1 in 7 elderly patients were readmitted within 30 days and 1 in 4 patients within 90 days. Elderly patients with multiple comorbidities were more likely to be readmitted at non-index hospitals
Impact of skilled nursing facility quality on postoperative outcomes after pancreatic surgery
No full textBackground: Data on skilled nursing facility utilization among patients undergoing pancreatic surgery remain scarce. We sought to define the incidence of utilization of skilled nursing facilities and determine the impact of skilled nursing facility quality markers on postoperative outcomes among patients who underwent pancreatic surgery. Methods: Medicare Standard Analytic Files were used to identify patients who underwent pancreatic resection during 2013–2015. Nursing Home Compare datasets were used to examine the influence of skilled nursing facility quality as estimated by quality markers (Medicare star ratings) on postoperative outcomes. Results: Among 13,018 patients who underwent pancreatectomy, 2,247 (17.3%) were discharged to a skilled nursing facility. Compared with patients discharged home, patients discharged to a skilled nursing facility were older (median age: 72 [interquartile range 68–76] vs 76 [interquartile range 71–80]), more likely female (44.4% vs 56.8%), and had greater Charlson comorbidity index scores (median score: 3 [interquartile range 2–8] vs 4 [interquartile range 2–8]) (all P < .001). Most patients were discharged to an above-average skilled nursing facility (N = 1,463, 65.1%), and a lesser subset was discharged to a skilled nursing facility with a below-average (N = 490, 21.8%) or average (N = 294, 13.1%) star rating. The 30-day hospital readmission was greatest among patients discharged to a below-average skilled nursing facility (below average N = 217, 44.3%; average N = 110, 37.4%; above average N = 517, 35.3%; P = .002). On multivariate analysis, patients discharged to below-average skilled nursing facilities remained 64% more likely to be readmitted within 30 days (OR 1.64, 1.29–2.02, P < .001). In contrast, 30-day mortality was comparable across the skilled nursing facility star rating categories (P = .08). Conclusion: Roughly 1 in 6 patients undergoing pancreatic surgery were discharged to a skilled nursing facility. Patients discharged to a below-average skilled nursing facility were more likely to be readmitted compared with patients discharged to an above-average skilled nursing facility
Trends in the Incidence, Treatment and Outcomes of Patients with Intrahepatic Cholangiocarcinoma in the USA: Facility Type is Associated with Margin Status, Use of Lymphadenectomy and Overall Survival
No full textIntroduction: Intrahepatic cholangiocarcinoma (ICC) remains an uncommon disease with a rising incidence worldwide. We sought to identify trends in therapeutic approaches and differences in patient outcomes based on facility types. Methods: Between January 1, 2004, and December 31, 2015, a total of 27,120 patients with histologic diagnosis of ICC were identified in the National Cancer Database and were enrolled in this study. Results: The incidence of ICC patients increased from 1194 in 2004 to 3821 in 2015 with an average annual increase of 4.16% (p < 0.001). Median survival of the cohort improved over the last 6 years of the study period (2004–2009: 8.05 months vs. 2010–2015: 9.49 months; p < 0.001). Among surgical patients (n = 5943, 21.9%), the incidence of R0 resection, lymphadenectomy and harvest of ≥6 lymph nodes increased over time (p < 0.001). Positive surgical margins (referent R0: R1, HR 1.49, 95% CI 1.24–1.79, p < 0.001) and treatment at community cancer centers (referent academic centers; HR 1.24, 95% CI 1.04–1.49, p = 0.023) were associated with a worse prognosis. Patients treated at academic centers had higher rates of R0 resection (72.4% vs. 67.7%; p = 0.006) and lymphadenectomy (55.6% vs. 49.5%, p = 0.009) versus community cancer centers. Overall survival was also better at academic versus community cancer programs (median OS: 11 months versus 6 months, respectively; p < 0.001). Conclusions: The incidence of ICC has increased over the last 12 years in the USA with a moderate improvement in survival over time. Treatment at academic cancer centers was associated with higher R0 resection and lymphadenectomy rates, as well as improved OS for patients with ICC
Minimally Invasive Liver Resection for Early-Stage Hepatocellular Carcinoma: Inconsistent Outcomes from Matched or Weighted Cohorts
No full textThe aim of the current study was to re-evaluate the role of minimally invasive liver resection (MILR) among patients with early-stage (stage I or II) hepatocellular carcinoma (HCC) undergoing partial hepatectomy
Predictors and outcomes of nonroutine discharge after hepatopancreatic surgery
No full textBackground: Data on predictors of nonroutine discharge among patients undergoing hepatopancreatic surgery remain poorly defined. We sought to define factors associated with nonroutine discharge to home with home health care or to a skilled nursing facility or intermediate care facility and determine the impact of discharge destination on outcomes after hepatopancreatic surgery. Methods: The Nationwide Readmissions Database was queried for individuals who underwent hepatopancreatic surgeries 2010–2014 and were discharged home with home health care or to a skilled nursing facility/intermediate care facility. Results: A total of 42,189 patients underwent hepatopancreatic surgery. Of those, 2,825 (6.70%) were discharged to a skilled nursing facility or intermediate care facility, whereas 10,925 (25.9%) were discharged with home health care. A majority of patients underwent major hepatectomy (N = 14,516, 34.4%) or minor pancreatectomy (N = 13,824, 32.8%). Compared with patients discharged home, patients discharged to a skilled nursing facility or intermediate care facility were older (median age: 60 years, interquartile range: 50–68 vs 73, 67–79) and had more comorbidities (median score: 3, interquartile range: 1–8 vs 4, interquartile range: 2–8; P < .001). Type of operative procedure was not associated with discharge to a skilled nursing facility versus with home health care. Rather, patients with extreme loss of function, based on preoperative assessment, had 2.76 times higher odds of discharge to a skilled nursing facility or intermediate care facility versus with home health care (odds ratio 2.76, 95% confidence interval 1.98–3.85). Similarly, older (odds ratio 1.06, 95% confidence interval 1.06–1.07) and female patients (odds ratio 1.37, 95% confidence interval 1.25–1.51) were more likely to be discharged to a skilled nursing facility or intermediate care facility versus with home health care. Conclusion: One in four patients undergoing hepatopancreatic surgery were readmitted within 90 days of surgery. Age, severity of comorbidities, and perioperative course, including incidence of complications, were associated with nonroutine discharge
Use of Machine Learning for Prediction of Patient Risk of Postoperative Complications After Liver, Pancreatic, and Colorectal Surgery
No full textBackground: Surgical resection is the only potentially curative treatment for patients with colorectal, liver, and pancreatic cancers. Although these procedures are performed with low mortality, rates of complications remain relatively high following hepatopancreatic and colorectal surgery. Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program was utilized to identify patients undergoing liver, pancreatic and colorectal surgery from 2014 to 2016. Decision tree models were utilized to predict the occurrence of any complication, as well as specific complications. To assess the variability of the performance of the classification trees, bootstrapping was performed on 50% of the sample. Results: Algorithms were derived from a total of 15,657 patients who met inclusion criteria. The algorithm had a good predictive ability for the occurrence of any complication, with a C-statistic of 0.74, outperforming the ASA (C-statistic 0.58) and ACS-Surgical Risk Calculator (C-statistic 0.71). The algorithm was able to predict with high accuracy thirteen out of the seventeen complications analyzed. The best performance was in the prediction of stroke (C-statistic 0.98), followed by wound dehiscence, cardiac arrest, and progressive renal failure (all C-statistic 0.96). The algorithm had a good predictive ability for superficial SSI (C-statistic 0.76), organ space SSI (C-statistic 0.76), sepsis (C-statistic 0.79), and bleeding requiring transfusion (C-statistic 0.79). Conclusion: Machine learning was used to develop an algorithm that accurately predicted patient risk of developing complications following liver, pancreatic, or colorectal surgery. The algorithm had very good predictive ability to predict specific complications and demonstrated superiority over other established methods
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Variations on the Author
Full text link“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
The Impact of Dedicated Cancer Centers on Outcomes Among Medicare Beneficiaries Undergoing Liver and Pancreatic Cancer Surgery
No full textBackground: The Alliance of Dedicated Cancer Centers (DCCs) is comprised of 11 institutions that are exempt from the prospective payment system utilized by Medicare for hospital reimbursement. Objective: The aim of this study was to compare short- and long-term outcomes of patients undergoing liver and pancreatic surgery for cancer at DCCs versus non-DCCs. Methods: Patients who underwent a liver or pancreatic operation for a malignant indication between 2013 and 2015 were identified using the Medicare Inpatient Standard Analytic Files. Regression analyses and the Kaplan–Meier method were used to assess short- and long-term outcomes of patients at DCCs versus non-DCCs. Results: Among 13,256 patients, 7.0% of patients were treated at a DCC. Median patient age and complexity of surgical procedures were comparable among DCCs and non-DCCs (all p > 0.05). Overall complications (16.5% vs. 23.6%), 90-day readmission (26.2% vs. 30.2%), and 90-day mortality (3.0% vs. 8.7%) were lower at DCCs compared with non-DCCs (all p < 0.001). In addition, long-term hazards of death among patients undergoing hepatectomy [hazard ratio (HR) 0.64, 95% confidence interval (CI) 0.54–0.75] and pancreatectomy (HR 0.66, 95% CI 0.56–0.78) were lower among patients treated at DCCs (both p < 0.05). While Medicare payments for patients undergoing pancreatic surgery (DCC: 22,100; p = 0.772) were comparable among DCC and non-DCC hospitals, Medicare payments for liver resection at DCCs were 13.9% lower than non-DCCs (DCC: 19,400; p < 0.001). Conclusions: Patients undergoing hepatopancreatic surgery at DCCs had better short- and long-term outcomes for the same/lower level of Medicare expenditure as non-DCC hospitals. DCCs provide higher-value surgical care for patients undergoing liver and pancreatic cancer operations
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