Publications by authors named "C Wright Pinson"

179 Publications

Emergency Clinical Procedure Detection With Deep Learning.

Annu Int Conf IEEE Eng Med Biol Soc 2020 07;2020:158-163

Information about a patient's state is critical for hospitals to provide timely care and treatment. Prior work on improving the information flow from emergency medical services (EMS) to hospitals demonstrated the potential of using automated algorithms to detect clinical procedures. However, prior work has not made effective use of video sources that might be available during patient care. In this paper we explore the use convolutional neural networks (CNNs) on raw video data to determine how well video data alone can automatically identify clinical procedures. We apply multiple deep learning models to this problem, with significant variation in results. Our findings indicate performance improvements compared to prior work, but also indicate a need for more training data to reach clinically deployable levels of success.
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http://dx.doi.org/10.1109/EMBC44109.2020.9175575DOI Listing
July 2020

Developing an Implementation Strategy for Systematic Measurement of Patient-Reported Outcomes at an Academic Health Center.

J Healthc Manag 2020 Jan-Feb;65(1):15-28

assistant professor of medicine, biomedical informatics, and health policy and medical director for patient-reported outcomes measurement, Vanderbilt University Medical Center, Nashville, Tennessee executive vice president for population health, Vanderbilt University Medical Center, and executive director, Vanderbilt Health Affiliated Network professor of pediatrics and senior vice president of quality, safety, and risk prevention, Vanderbilt University Medical Center deputy CEO, chief health system officer, and senior associate dean for clinical affairs, Vanderbilt University Medical Center professor of medicine and director, Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center professor of medicine, executive vice president for public health and healthcare, and senior associate dean for population health sciences, Vanderbilt University Medical Center and director, geriatric research, education, and clinical center, VA Tennessee Valley Healthcare System; and professor of biomedical informatics and medicine and chief strategy officer, Vanderbilt University Medical Center.

Executive Summary: Patient-reported outcome measures (PROMs) are used in research and have the potential to improve clinical care. We sought to develop a strategy for integrating PROMs into routine clinical care at an academic health center. The implementation strategy consisted of three phases. The first, exploratory phase, focused on engaging leadership and conducting an inventory of current efforts to collect PROMs. The inventory revealed 87 patient-reported outcome efforts, 47 of which used validated PROMs (62% for research, 21% for clinical care, 17% for quality). In the second, preparatory phase, we identified three pilot implementation sites chosen with facilitators determined in the exploratory phase. Using data from local needs assessments at the pilot sites, we constructed a timeline for inclusion of PROM efforts across the clinical enterprise. In the third phase, we adapted a technology platform for capturing PROMs using the electronic health record and began implementing this platform at the pilot sites. We found that integrating PROMs into routine clinical practice is highly complex. This complexity necessitates change management at the enterprise level.
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http://dx.doi.org/10.1097/JHM-D-18-00279DOI Listing
December 2020

Increased diagnostic accuracy of giant cell arteritis using three-dimensional fat-saturated contrast-enhanced vessel-wall magnetic resonance imaging at 3 T.

Eur Radiol 2020 Apr 6;30(4):1866-1875. Epub 2019 Dec 6.

Department of Neuroradiology, Foundation Adolphe de Rothschild Hospital, 29 rue Manin, 75019, Paris, France.

Objectives: To compare the diagnostic accuracy of 3D versus 2D contrast-enhanced vessel-wall (CE-VW) MRI of extracranial and intracranial arteries in the diagnosis of GCA.

Methods: This prospective two-center study was approved by a national research ethics board and enrolled participants from December 2014 to October 2017. A protocol including both a 2D and a 3D CE-VW MRI at 3 T was performed in all patients. Two neuroradiologists, blinded to clinical data, individually analyzed separately and in random order 2D and 3D sequences in the axial plane only or with reformatting. The primary judgment criterion was the presence of GCA-related inflammatory changes of extracranial arteries. Secondary judgment criteria included inflammatory changes of intracranial arteries and the presence of artifacts. A McNemar's test was used to compare 2D to 3D CE-VW MRIs.

Results: Seventy-nine participants were included in the study (42 men and 37 women, mean age 75 (± 9.5 years)). Fifty-one had a final diagnosis of GCA. Reformatted 3D CE-VW was significantly more sensitive than axial-only 3D CE-VW or 2D CE-VW when showing inflammatory change of extracranial arteries: 41/51(80%) versus 37/51 (73%) (p = 0.046) and 35/50 (70%) (p = 0.03). Reformatted 3D CE-VW was significantly more specific than 2D CE-VW: 27/27 (100%) versus 22/26 (85%) (p = 0.04). 3D CE-VW showed higher sensitivity than 2D CE-VW when detecting inflammatory changes of intracranial arteries: 10/51(20%) versus 4/50(8%), p = 0.01. Interobserver agreement was excellent for both 2D and 3D CE-VW MRI: κ = 0.84 and 0.82 respectively.

Conclusions: 3D CE-VW MRI supported more accurate diagnoses of GCA than 2D CE-VW.

Key Points: • 3D contrast-enhanced vessel-wall magnetic resonance imaging is a high accuracy, non-invasive diagnostic tool used to diagnose giant cell arteritis. • 3D contrast-enhanced vessel-wall imaging is feasible for clinicians to complete within a relatively short time, allowing immediate assessment of extra and intracranial arteries. • 3D contrast-enhanced vessel-wall magnetic resonance imaging might be considered a diagnostic tool when intracranial manifestation of GCA is suspected.
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http://dx.doi.org/10.1007/s00330-019-06536-7DOI Listing
April 2020

No consistent evidence of data availability bias existed in recent individual participant data meta-analyses: a meta-epidemiological study.

J Clin Epidemiol 2020 02 22;118:107-114.e5. Epub 2019 Oct 22.

Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine, Kyoto, Japan. Electronic address:

Objectives: The objective of the study was to assess trial-level factors associated with the contribution of individual participant data (IPD) to IPD meta-analyses, and to quantify the data availability bias, namely the difference between the effect estimates of trials contributing IPD and those not contributing IPD in the same systematic reviews (SRs).

Study Design And Setting: We included SRs of randomized controlled trials (RCTs) with IPD meta-analyses since 2011. We extracted trial-level characteristics and examined their association with IPD contribution. To assess the data availability bias, we retrieved odds ratios from the original RCT articles, calculated the ratio of odds ratios (RORs) between aggregate data (AD) meta-analyses of RCTs contributing IPD and those of RCTs not contributing IPD for each SR, and meta-analytically synthesized RORs.

Results: Of 728 eligible RCTs included in 31 SRs, 321 (44%) contributed IPD, whereas 407 (56%) did not. A recent publication year, larger number of participants, adequate allocation concealment, and impact factor ≥10 were associated with IPD contribution. We found the SRs yielded widely different estimates of RORs. Overall, there was no significant difference in the pooled effect estimates of AD meta-analyses between RCTs contributing and not contributing IPD (ROR 1.01, 95% confidence interval, 0.86-1.19).

Conclusions: There was no consistent evidence of a data availability bias in recent IPD meta-analyses of RCTs with dichotomous outcomes. Higher methodological qualities of trials were associated with IPD contribution.
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http://dx.doi.org/10.1016/j.jclinepi.2019.10.004DOI Listing
February 2020

Long-Term Physical HRQOL Decreases After Single Lung as Compared With Double Lung Transplantation.

Ann Thorac Surg 2018 12 16;106(6):1633-1639. Epub 2018 Aug 16.

Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Transplant Center, Vanderbilt University Medical Center, Nashville, Tennessee.

Background: Single lung transplantation (SLT) and double lung transplantation (DLT) are associated with differences in morbidity and mortality, although the effects of transplant type on patient-reported outcomes are not widely reported and conclusions have differed. Previous studies compared mean health-related quality of life (HRQOL) scores but did not evaluate potentially different temporal trajectories in the context of longitudinal follow-up. To address this uncertainty, this study was designed to evaluate longitudinal HRQOL after SLT and DLT with the hypothesis that temporal trajectories differ between SLT and DLT.

Methods: Patients transplanted at a single institution were eligible to be surveyed at 1 month, 3 months, 6 months, and then annually after transplant using the Short Form 36 Health Survey, with longitudinal physical component summary (PCS) and mental component summary (MCS) scores as the primary outcomes. Multivariable mixed-effects models were used to evaluate the effects of transplant type and time posttransplant on longitudinal PCS and MCS after adjusting age, diagnosis, rejection, Lung Allocation Score quartile, and intubation duration. Time by transplant type interaction effects were used to test whether the temporal trajectories of HRQOL differ between SLT and DLT recipients. HRQOL scores were referenced to general population norms (range, 40 to 60; mean, 50 ± 10) using accepted standards for a minimally important difference (½ SD, 5 points).

Results: Postoperative surveys (n = 345) were analyzed for 136 patients (52% male, 23% SLT, age 52 ± 13 years, LAS 42 ± 12, follow-up 37 ± 29 months [range, 0.6 to 133]) who underwent lung transplantation between 2005 and 2016. After adjusting for model covariates, overall posttransplant PCS scores have a significant downward trajectory (p = 0.015) whereas MCS scores remain stable (p = 0.593), with both averaging within general population norms. The time by transplant type interaction effect (p = 0.002), however, indicate that posttransplant PCS scores of SLT recipients decline at a rate of 2.4 points per year over the total observation period compared to DLT. At approximately 60 months, the PCS scores of SLT recipients, but not DLT recipients, fall below general population norms.

Conclusions: The trajectory of physical HRQOL in patients receiving SLT declines over time compared with DLT, indicating that, in the longer term, SLT recipients are more likely to have physical HRQOL scores that fall substantively below general population norms. Physical HRQOL after 5 years may be a consideration for lung allocation and patient counseling regarding expectations when recommending SLT or DLT.
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http://dx.doi.org/10.1016/j.athoracsur.2018.06.072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6240480PMC
December 2018

Increasing kidney donor profile index sequence does not adversely affect medium-term health-related quality of life after kidney transplantation.

Clin Transplant 2018 Apr 30;32(4):e13212. Epub 2018 Mar 30.

Department of Surgery, Division of Kidney and Pancreas Transplantation, Vanderbilt University Medical Center, Nashville, TN, USA.

Background: The United Network for Organ Sharing system allocates deceased donor kidneys based on the kidney donor profile index (KDPI), stratified as sequences (A ≤ 20%, B > 20-<35%, C ≥ 35-≤85%, and D > 85%), with increasing KDPI associated with decreased graft survival. While health-related quality of life (HRQOL) may improve after transplantation, the effect of donor kidney quality, reflected by KDPI sequence, on post-transplant HRQOL has not been reported.

Methods: Health-related quality of life was measured using the eight scales and physical and mental component summaries (PCS, MCS) of the SF-36 Health Survey. Multivariable mixed effects models that adjusted for age, gender, rejection, and previous transplant and analysis of variance methods tested the effects of time and KDPI sequence on post-transplant HRQOL.

Results: A total of 141 waitlisted adults and 505 recipients (>1700 observations) were included. Pretransplant PCS and MCS averaged, respectively, slightly below and within general population norms (GPN; 40-60). At 31 ± 26 months post-transplant, average PCS (41 ± 11) and MCS (51 ± 11), overall and within each KDPI sequence, were within GPN. KDPI sequence was not related to post-transplant HRQOL (P > .134) or its trajectory (interaction P > .163).

Conclusion: Increasing KDPI does not adversely affect the medium-term values and trajectories of HRQOL after kidney transplantation. This may reassure patients and centers when considering using high KDPI kidneys.
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http://dx.doi.org/10.1111/ctr.13212DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5933873PMC
April 2018

Patient-reported outcomes in liver transplant recipients with hepatocellular carcinoma.

Clin Transplant 2016 09 18;30(9):1036-45. Epub 2016 Jul 18.

Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

Background: The effect of awarding MELD exception points for hepatocellular carcinoma (HCC) on patient-reported outcomes (PROs) is unknown. We evaluated the physical and mental health-related quality of life (HRQOL) and symptoms of anxiety and depression in liver transplant recipients with HCC compared to patients without HCC.

Methods: The single-center sample measured PROs before and after transplant, which included 1521 multisurvey measurement points among 502 adults (67% male, 28% HCC, follow-up time: <1-131 months). Data were analyzed using multivariable mixed-effects models.

Results: Longitudinal PRO values did not differ between persons who received HCC exception points and those who did not have HCC. Patients with HCC who did not receive exception points had reduced physical HRQOL (P=.016), a late decline in mental HRQOL, and delayed reduction in anxiety (time-by-outcome interaction P<.050) compared to patients with HCC who received exception points.

Conclusion: Transplant recipients who received HCC exception points had PROs that were comparable to those of patients without HCC, and reported better physical HRQOL and reduced symptoms of anxiety compared to patients with HCC who did not receive exception points. These analyses demonstrate the impact of HCC exception points on PROs, and may help inform policy regarding HCC exception point allocation.
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http://dx.doi.org/10.1111/ctr.12785DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5273862PMC
September 2016

Magnetization transfer ratio for the assessment of perianal fistula activity in Crohn's disease.

Eur Radiol 2017 Jan 16;27(1):80-87. Epub 2016 Apr 16.

Department of Radiology, Rouen University Hospital-Charles Nicolle, 1 rue de Germont, F-76031, Rouen cedex, France.

Objectives: Assessment of perianal fistulas is important to guide management of Crohn's disease (CD). Our objectives were to analyze the feasibility of magnetization transfer (MT) imaging to assess fistulas and to evaluate its contribution in assessing disease activity.

Methods: During 15 months, all patients referred for perianal fistulas in CD underwent 3T-MRI including diffusion, T2/T1-weighted gadolinium-enhanced sequences and MT sequences (one with an off-resonance saturation pulse of 800 and one with 1200 Hz). We collected Van Assche score, fistula activity signs by analyzing T2, diffusion and contrast enhancement. We calculated MT ratio (MTR) with a ROI in the largest fistula.

Results: Twenty-nine patients (mean 34.9 years, range 17-53) were included. Van Assche score was 11.7, range 4-21. In 22 patients, the fistula presented with a bright T2 and diffusion signal with contrast enhancement, and was characterized as active. Mean MTR was respectively 47.2 (range 12-68) and 34.3 (range 11-57) at 800 and 1200 Hz. MTR at 800 Hz was significantly lower in non-active (34, range 12-55) than in active fistulas (51, range 24-68) (p < 0.02).

Conclusions: MTR is feasible for the assessment of fistulas in CD and in the future could be used to help identify active and non-active fistulas.

Key Points: • MTR is feasible for the assessment of perianal fistulas in CD. • MT allows quantitative imaging of perianal fistula activity in CD. • MTR could be used to help identify active and non-active fistulas in CD.
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http://dx.doi.org/10.1007/s00330-016-4350-2DOI Listing
January 2017

Validation of the Written Administration of the Short Literacy Survey.

J Health Commun 2015 14;20(7):835-42. Epub 2015 Jun 14.

a Vanderbilt Transplant Center , Vanderbilt University Medical Center , Nashville , Tennessee , USA.

Most health literacy assessments are time consuming and administered verbally. Written self-administration of measures may facilitate more widespread assessment of health literacy. This study aimed to determine the intermethod reliability and concurrent validity of the written administration of the 3 subjective health literacy questions of the Short Literacy Survey (SLS). The Rapid Estimate of Adult Literacy in Medicine (REALM) and the shortened test of Functional Health Literacy in Adults (S-TOFHLA) were the reference measures of health literacy. Two hundred ninety-nine participants completed the written and verbal administrations of the SLS from June to December 2012. Intermethod reliability was demonstrated when (a) the written and verbal SLS score did not differ and (b) written and verbal scores were highly correlated. The written items were internally consistent (Cronbach's α = .733). The written total score successfully identified persons with sixth-grade equivalency or less for literacy on the REALM (AUROC = 0.753) and inadequate literacy on the S-TOFHLA (AUROC = 0. 869). The written administration of the SLS is reliable, valid, and is effective in identifying persons with limited health literacy.
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http://dx.doi.org/10.1080/10810730.2015.1018572DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4698961PMC
December 2015

Reply to Domínguez-Rosado et al.

HPB (Oxford) 2014 May;16(5):501

Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

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http://dx.doi.org/10.1111/hpb.12172DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4008170PMC
May 2014

Cationic amphiphilic macromolecule (CAM)-lipid complexes for efficient siRNA gene silencing.

J Control Release 2014 Jun 13;184:28-35. Epub 2014 Apr 13.

Rutgers, The State University of New Jersey, Department of Chemistry and Chemical Biology, 610 Taylor Road, Piscataway, NJ 08854, United States; Rutgers, The State University of New Jersey, Department of Biomedical Engineering, 599 Taylor Road, Piscataway, NJ 08854, United States. Electronic address:

The accumulated evidence has shown that lipids and polymers each have distinct advantages as carriers for siRNA delivery. Composite materials comprising both lipids and polymers may present improved properties that combine the advantage of each. Cationic amphiphilic macromolecules (CAMs) containing a hydrophobic alkylated mucic acid segment and a hydrophilic poly(ethylene glycol) (PEG) tail were non-covalently complexed with two lipids, 1,2-dioleoyl-sn-glycero-3-phosphoethanolamine (DOPE) and 1,2-dioleoyl-3-trimethylammonium-propane (DOTAP), to serve as a siRNA delivery vehicle. By varying the weight ratio of CAM to lipid, cationic complexes with varying compositions were obtained in aqueous media and their properties evaluated. CAM-lipid complex sizes were relatively independent of composition, ranging from 100 to 200nm, and zeta potentials varied from 10 to 30mV. Transmission electron microscopy confirmed the spherical morphology of the complexes. The optimal N/P ratio was 50 as determined by electrophoretic mobility shift assay. The ability to achieve gene silencing was evaluated by anti-luciferase siRNA delivery to a U87-luciferase cell line. Several weight ratios of CAM-lipid complexes were found to have similar delivery efficiency compared to the gold standard, Lipofectamine. Isothermal titration calorimetry revealed that siRNA binds more tightly at pH=7.4 than pH=5 to CAM-lipid (1:10 w/w). Further intracellular trafficking studies monitored the siRNA escape from the endosomes at 24h following transfection of cells. The findings in the paper indicate that CAM-lipid complexes can serve as a novel and efficient siRNA delivery vehicle.
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http://dx.doi.org/10.1016/j.jconrel.2014.04.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4090228PMC
June 2014

Urinary stones: the contribution of dual energy CT and material decomposition.

Diagn Interv Imaging 2013 Nov 12;94(11):1165-8. Epub 2013 Sep 12.

Radiodiagnostics and Medical Imaging, Rouen University Hospital, Charles-Nicolle Hospital, 1, rue de Germont, 76031 Rouen cedex, France.

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http://dx.doi.org/10.1016/j.diii.2013.08.003DOI Listing
November 2013

The long-term effect of bile duct injuries on health-related quality of life: a meta-analysis.

HPB (Oxford) 2013 Apr 22;15(4):252-9. Epub 2012 Oct 22.

Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232-2730, USA.

Background: The reported effects of biliary injury on health-related quality of life (HRQOL) have varied widely. Meta-analysis methodology was applied to examine the collective findings of the long-term effect of bile duct injury (BDI) on HRQOL.

Methods: A comprehensive literature search was conducted in March, 2012. Because the HRQOL surveys differed among reports, BDI and uncomplicated laparoscopic cholecystectomy (LC) groups' HRQOL scores were expressed as effect sizes (ES) in relation to a common, general population, standard. A negative ES indicated a reduced HRQOL, with a substantive reduction defined as an ES ≤ -0.50. Weighted logistic regression tested the effects of BDI (versus LC) and follow-up time on whether physical and mental HRQOL were substantively reduced.

Results: Data were abstracted from six publications, which encompass all reports of HRQOL after BDI in the current, peer-reviewed literature. The analytic database comprised 90 ES computations representing 831 patients and 11 unique study groups (six BDI and five LC). After controlling for follow-up time (P ≤ 0.001), BDI patients were more likely to have reduced long-term mental [odds ratio (OR) = 38.42, 95% confidence interval (CI) = 19.14-77.10; P < 0.001] but not physical (P = 0.993) HRQOL compared with LC patients.

Discussion: This meta-analysis of findings from six peer-review reports indicates that, in comparison to LC, there is a long-term detrimental effect of BDI on mental HRQOL.
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http://dx.doi.org/10.1111/j.1477-2574.2012.00586.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3608978PMC
April 2013

Is liver transplantation using organs donated after cardiac death cost-effective or does it decrease waitlist death by increasing recipient death?

HPB (Oxford) 2013 Mar 4;15(3):182-9. Epub 2012 Jul 4.

Departments of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232-4753, USA.

Objectives: The aim of this study was to evaluate the cost-effectiveness in liver transplantation (LT) of utilizing organs donated after cardiac death (DCD) compared with organs donated after brain death (DBD).

Methods: A Markov-based decision analytic model was created to compare two LT waitlist strategies distinguished by organ type: (i) DBD organs only, and (ii) DBD and DCD organs. The model simulated outcomes for patients over 10 years with annual cycles through one of four health states: survival; ischaemic cholangiopathy; retransplantation, and death. Baseline values and ranges were determined from an extensive literature review. Sensitivity analyses tested model strength and parameter variability.

Results: Overall survival is decreased, and biliary complications and retransplantation are increased in recipients of DCD livers. Recipients of DBD livers gained 5.6 quality-adjusted life years (QALYs) at a cost of US$69 000/QALY, whereas recipients on the DBD + DCD LT waitlist gained 6.0 QALYs at a cost of US$61 000/QALY. The DBD + DCD organ strategy was superior to the DBD organ-only strategy.

Conclusions: The extension of life and quality of life provided by DCD LT to patients on the waiting list who might otherwise not receive a liver transplant makes the continued use of DCD livers cost-effective.
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http://dx.doi.org/10.1111/j.1477-2574.2012.00524.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3572278PMC
March 2013

Negative effects of pretransplant body mass index on physical health-related quality of life after lung transplant.

Prog Transplant 2012 Dec;22(4):363-8

Vanderbilt Transplant Center, Nashville, TN, USA.

Background: Although current national data show improved graft and patient survival following lung transplant, the effects of several modifiable preexisting comorbid conditions on health-related quality of life after transplant have not been evaluated. This study examines the effects of 3 comorbid conditions present before lung transplant (reduced bone density, diabetes mellitus, and elevated body mass index) on health-related quality of life after lung transplant.

Methods: The Short Form 36 Health Survey was completed by 92 adult recipients at various times after lung transplant (mean, 41 months; range, 1-127 months). Multiple linear regression models that controlled for underlying disease, chronic rejection, and time after transplant tested the independent effects of the 3 pretransplant conditions on posttransplant health-related quality of life.

Results: The effects of pretransplant reduced bone density and diabetes mellitus were not statistically significant in these models. However, pretransplant body mass index had a significant negative effect (β = -.29, P = .007) on posttransplant physical health-related quality of life. Additionally, overweight status and obesity exerted comparable independent negative effects (P = .01 and P = .03, respectively) on the physical function scale of the Short-Form 36 Health Survey compared with persons who were underweight or normal weight before transplant.

Conclusions: Reevaluation of elevated body mass index before transplant as a risk for reduced physical quality of life after lung transplant should be considered.
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http://dx.doi.org/10.7182/pit2012582DOI Listing
December 2012

A cost-effectiveness analysis of early vs late reconstruction of iatrogenic bile duct injuries.

J Am Coll Surg 2012 Jun 10;214(6):919-27. Epub 2012 Apr 10.

Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232-4753, USA.

Background: Controversy exists regarding the optimal timing of repair after iatrogenic bile duct injuries (BDI). Several studies advocate late repair (≥6 weeks after injury) with mandatory drainage and resolution of inflammation. Others indicate that early repair (<6 weeks after injury) produces comparable or superior clinical outcomes. Additionally, although most studies have reported inferior outcomes with primary surgeon repair, this practice continues. With disparate published recommendations and rising health care costs, decision analysis was used to examine the cost-effectiveness of BDI repair.

Study Design: A Markov model was developed to evaluate primary surgeon repair (PSR), late repair by a hepatobiliary surgeon (LHBS), and early repair by a hepatobiliary surgeon (EHBS). Baseline values and ranges were collected from the literature. Sensitivity analsyses were conducted to test the strength of the model and variability of parameters.

Results: The model demonstrated that EHBS was associated with lower costs, earlier return to normal activity, and better quality of life. Specifically, 1 year after repair, PSR yielded 0.53 quality adjusted life years (QALYs) ($120,000/QALY) and LHBS yielded 0.74 QALYs ($74,000/QALY); EHBS yielded 0.82 QALYs ($48,000/QALY). Sensitivity analyses supported these findings at clinically meaningful probabilities.

Conclusions: This cost-effectiveness model demonstrates that early repair by a hepatobiliary surgeon is the superior strategy for the treatment of BDI in properly selected patients. Although there is little clinical difference between early and late repair, there is a great difference in cost and quality of life. Ideally, costs and quality of life should be considered in decisions regarding strategies of repair of injured bile ducts.
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http://dx.doi.org/10.1016/j.jamcollsurg.2012.01.054DOI Listing
June 2012

Comparison of open live donor nephrectomy, laparoscopic live donor nephrectomy, and hand-assisted live donor nephrectomy: a cost-minimization analysis.

J Surg Res 2012 Aug 10;176(2):e89-94. Epub 2012 Mar 10.

Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.

Background: Live donor kidney transplantation is the treatment of choice for end-stage renal disease. Open donor nephrectomy (ODN) was the standard until the introduction of the laparoscopic donor nephrectomy (LDN) in 1995. Hand-assisted laparoscopic donor nephrectomy (HALDN) was added shortly thereafter. The laparoscopic techniques are associated with increased operating room times and equipment costs; however, these techniques speed patient return to normal activity. The aim of this study is to evaluate the cost of these techniques.

Materials And Methods: A decision analysis model was developed to simulate outcomes for donors undergoing ODN, LDN, and HALDN. Outcomes were simulated from both the institutional perspective (IP) and the societal perspective (SP). Baseline values and ranges were determined from a systematic review of the literature. Sensitivity analyses were conducted to test model strength.

Results: From the IP, ODN is the least costly strategy with a cost of $11,000, while the cost is $15,200 for HALDN and $15,800 for LDN. From the SP, HALDN is the least costly strategy costing $27,800, while the cost for LDN is $29,000 and for ODN is $41,000. In sensitivity analysis, ODN only became the dominant strategy if the days till return to work exceeded 58 in the HALDN strategy. LDN and HALDN were nearly equivalent as the rate of open conversion of LDN approached zero.

Conclusions: HALDN is the least costly donor nephrectomy strategy, especially from the SP. The primary determinants of cost in this model are conversion to open and days till return to work.
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http://dx.doi.org/10.1016/j.jss.2011.12.013DOI Listing
August 2012

Reduction in corticosteroids is associated with better health-related quality of life after liver transplantation.

J Am Coll Surg 2012 Feb 3;214(2):164-73. Epub 2011 Dec 3.

Department of Surgery and Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA.

Background: Corticosteroid use during post-transplant immunosuppression contributes to documented long-term complications in liver transplant recipients. However, the effects of steroids on post-transplant physical and mental health-related quality of life (HRQOL) have not been established. We aimed to test the association between steroid-based immunosuppression and post-transplant HRQOL in liver transplant recipients.

Study Design: We performed a retrospective analysis of prospective, longitudinal HRQOL measured using the Short Form 36 Health Survey physical and mental component summary scores, Beck Anxiety Inventory, and Center for Epidemiologic Studies Depression Scale. Steroid use (none, low [<10 mg/d], high [≥10 mg/d]) and temporally associated acute rejection (within previous 6 weeks, previous 7 to 12 weeks, and never or >12 weeks before HRQOL measurement) were determined at every post-transplant HRQOL data point. Linear mixed-effects models tested the effects of contemporaneous steroid use and dosing on post-transplant HRQOL.

Results: The sample included 186 adult liver transplant recipients (mean age 54 ± 8 years, 70% male) with pre- and at least 1 post-transplant HRQOL data point. Individual follow-up post-transplant averaged 21 ± 18 months (range 1 to 74 months). After controlling for pre-transplant HRQOL, time post-transplant, pre-transplant diagnosis group, and temporally associated episodes of rejection, post-transplant high-dose steroid use (≥10 mg/d) was associated with lower physical component summary (p < 0.001) and mental component summary (p = 0.049) scores and increased Beck Anxiety Inventory (p = 0.015) scores. Low-dose steroid use (<10 mg/d) was not associated with post-transplant HRQOL in any model (all p ≥ 0.28).

Conclusions: High-dose steroid use for post-transplant immunosuppression in liver transplant recipients was associated with reduced physical and mental HRQOL, and increased symptoms of anxiety. There was an association between better HRQOL and steroid reduction to <10 mg/d in liver transplant recipients during a broad follow-up period.
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http://dx.doi.org/10.1016/j.jamcollsurg.2011.10.006DOI Listing
February 2012

Which is more cost-effective under the MELD system: primary liver transplantation, or salvage transplantation after hepatic resection or after loco-regional therapy for hepatocellular carcinoma within Milan criteria?

HPB (Oxford) 2011 Nov 19;13(11):783-91. Epub 2011 Aug 19.

Department of Surgery, Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA.

Objective: The optimal strategy for treating hepatocellular carcinoma (HCC), a disease with increasing incidence, in patients with Child-Pugh class A cirrhosis has long been debated. This study evaluated the cost-effectiveness of hepatic resection (HR) or locoregional therapy (LRT) followed by salvage orthotopic liver transplantation (SOLT) vs. that of primary orthotopic liver transplantation (POLT) for HCC within the Milan Criteria.

Methods: A Markov-based decision analytic model simulated outcomes, expressed in costs and quality-adjusted life years (QALYs), for the three treatment strategies. Baseline parameters were determined from a literature review. Sensitivity analyses tested model strength and parameter variability.

Results: Both HR and LRT followed by SOLT were associated with earlier recurrence, decreased survival, increased costs and decreased quality of life (QoL), whereas POLT resulted in decreased recurrence, increased survival, decreased costs and increased QoL. Specifically, HR/SOLT yielded 3.1 QALYs (at US$96 000/QALY) and LRT/SOLT yielded 3.9 QALYs (at US$74 000/QALY), whereas POLT yielded 5.5 QALYs (at US$52 000/QALY). Sensitivity analyses supported these findings at clinically meaningful probabilities.

Conclusions:  Under the Model for End-stage Liver Disease (MELD) system, in patients with HCC within the Milan Criteria, POLT increases survival and QoL at decreased costs compared with HR or LRT followed by SOLT. Therefore, POLT is the most cost-effective strategy for the treatment of HCC.
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http://dx.doi.org/10.1111/j.1477-2574.2011.00355.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3238012PMC
November 2011

An urban-rural blight? Choledocholithiasis presentation and treatment.

J Surg Res 2012 Apr 15;173(2):193-7. Epub 2011 Jun 15.

Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.

Background: Exploration of urban-rural (UR) and regional differences is critical to developing effective healthcare delivery systems. Choledocholithiasis (CDL) remains a common problem with a range of therapeutic options and potentially severe complications. This study evaluated UR and regional differences of CDL presentation and treatment. We hypothesized that UR status contributes to differences in treatment of CDL.

Methods: This study examined patients from the 2007 Healthcare Cost and Utilization Project dataset. Inpatient discharges and interventions for CDL patients were identified. UR and regional designations were determined from National Center for Health Statistics guidelines. Patients with pancreatitis or cholangitis were designated as complicated CDL (cCDL) patients. Interventions for CDL were classified as endoscopic, surgical, or percutaneous. Complex-sample proportion analyses were performed.

Results: A total of 111,021 patients with CDL were identified; 81% of these patients lived in urban areas compared with 19% in rural areas; 61% had uncomplicated choledocholithiasis (uCDL) and 39% had cCDL. The overall distribution of uCDL and cCDL did not differ by UR status or region. A higher proportion of rural patients did not receive an intervention 45.1% (95%CI 41.8%-48.4%) versus urban patients 30.5% (28.8%-32.2%), P < 0.05. Interventions for urban patients were more likely endoscopic 87.7% (86.8%-88.6%) compared with rural 82.0% (79.3%-84.7%), P < 0.05. Rural patients were more likely to undergo surgery 10.5% (8.6%-12.4%) than urban patients 4.9% (4.4%-5.4%), P < 0.05. Regional variations did not impact the type of intervention received.

Conclusion: Rural patients received CDL interventions less often and had a higher proportion of surgical interventions regardless of severity of presentation.
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http://dx.doi.org/10.1016/j.jss.2011.05.031DOI Listing
April 2012

Health insurance status affects staging and influences treatment strategies in patients with hepatocellular carcinoma.

Ann Surg Oncol 2010 Dec 29;17(12):3104-11. Epub 2010 Jun 29.

Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.

Background: Lack of health insurance is associated with poorer outcomes for patients with cancers amenable to early detection. The effect of insurance status on hepatocellular carcinoma (HCC) presentation stage and treatment outcomes has not been examined. We examined the effect of health insurance status on stage of presentation, treatment strategies, and survival in patients with HCC.

Methods: The Tennessee Cancer Registry was queried for patients treated for HCC between January 2004 and December 2006. Patients were stratified by insurance status: (1) private insurance; (2) government insurance (non-Medicaid); (3) Medicaid; (4) uninsured. Logistic, Kaplan-Meier, and Cox models tested the effects of demographic and clinical covariates on the likelihood of having surgical or chemotherapeutic treatments and survival.

Results: We identified 680 patients (208 private, 356 government, 75 Medicaid, 41 uninsured). Uninsured patients were more likely to be men, African American, and reside in an urban area (all P < 0.05). The uninsured were more likely to present with stage IV disease (P = 0.005). After adjusting for demographics and tumor stage, Medicaid and uninsured patients were less likely to receive surgical treatment (both P < 0.01) but were just as likely to be treated with chemotherapy (P ≥ 0.243). Survival was significantly better in privately insured patients and in those treated with surgery or chemotherapy (all P < 0.01). Demographic adjusted risk of death was doubled in the uninsured (P = 0.005).

Conclusions: Uninsured patients with HCC are more likely to present with late-stage disease. Although insurance status did not affect chemotherapy utilization, Medicaid and uninsured patients were less likely to receive surgical treatment.
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http://dx.doi.org/10.1245/s10434-010-1181-2DOI Listing
December 2010

Pre-transplant overweight and obesity do not affect physical quality of life after kidney transplantation.

J Am Coll Surg 2010 Mar 1;210(3):336-44. Epub 2010 Feb 1.

Department of Surgery and Vanderbilt Transplant Center, Vanderbilt University Medical Center, Nashville, TN 37232-2730, USA.

Background: Recent studies demonstrate that obesity does not affect survival after kidney transplantation. However, overweight and obesity impair health-related quality of life (HRQOL) in patients with chronic illnesses. We wished to examine the effects of pre-transplant overweight and obesity on post-transplant physical HRQOL in kidney transplant recipients.

Study Design: Patient-reported HRQOL data were systematically collected in kidney transplant recipients receiving post-transplant follow-up at Vanderbilt Transplant Center. Patients who received kidney transplants between 1998 and 2008, had at least 1 post-transplant physical component summary (PCS) measurement, and did not receive other solid organ transplants were included in this retrospective cohort study. Pre-transplant body mass index was stratified as normal, overweight, obese class I, and obese class II/extremely obese. HRQOL was measured primarily with the PCS scale of the Medical Outcomes Study Short Form 36 Health Survey. Multivariate linear and logistic regression models were used to test the effects of body mass index and demographic and clinical covariates on post-transplant HRQOL.

Results: The study cohort included 464 adults (mean body mass index 27.5 +/- 5.1; range 18.5 to 47.4). After controlling for gender (p = 0.148), pre-transplant dialysis (p = 0.003), previous kidney transplantation (p = 0.255), donor type (p = 0.455), steroid avoidance immunosuppression (p = 0.070), and follow-up time (p = 0.352), there was no effect of pre-transplant overweight or obesity on post-transplant PCS (all p > or = 0.112). Kidney transplant recipients who did not require dialysis pre-transplant and those who were managed with steroid avoidance after transplantation were more likely to achieve post-transplant PCS scores at or above the general population average (both p < or = 0.011).

Conclusions: Pre-transplant overweight and obesity do not affect physical quality of life after kidney transplantation.
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http://dx.doi.org/10.1016/j.jamcollsurg.2009.11.009DOI Listing
March 2010

Effects of clinical factors on psychosocial variables in renal transplant recipients.

J Adv Nurs 2009 Dec;65(12):2585-96

College of Nursing, University of Cincinnati, Cincinnati, Ohio, USA.

Aim: This paper is a report of a study investigating the effects of clinical factors (side effects of immunosuppressive medications, transplant-related hospitalizations, donor type, duration of dialysis before transplantation and time post-transplant) on cognitive appraisal of health, perceived self-efficacy, perceived social support, coping and health-related quality of life after renal transplantation.

Background: Some clinical factors such as hospitalizations, side effects of medications, donor type and dialysis, which influence the health-related quality of life of renal transplant recipients, have been investigated. However, the effects of these clinical factors on psychosocial variables after renal transplantation have not been well documented. Method. Using a descriptive cross-sectional design, a convenience sample of 160 renal transplant recipients was recruited (N = 55 < 1 year post-transplant; N = 105 1-3 years post-transplant) from May, 2005 to January, 2006. Standardized instruments were used to measure the key constructs. Multivariate analysis of variance was used to examine the effects of clinical factors on the psychosocial outcome measures.

Results: Participants reporting more (>17) immunosuppressive medication-associated side effects appraised their health more negatively, used more disengagement coping, had lower degrees of perceived self-efficacy, and reported lower physical and mental health-related quality of life than those with fewer symptoms (
Conclusion: Interventions aimed at alleviating bothersome medication side effects are needed to help these patients cope with transplantation and improve their health-related quality of life.
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http://dx.doi.org/10.1111/j.1365-2648.2009.05111.xDOI Listing
December 2009

Exsanguination protocol improves survival after major hepatic trauma.

Injury 2010 Jan;41(1):30-4

Department of Surgery, Vanderbilt University Medical Center, D-4314 Medical Center North, Nashville, TN 37232-2730, USA.

Background: Hepatic injury remains an important cause of exsanguination after major trauma. Recent studies have noted a dramatic reduction in mortality amongst severely injured patients when trauma exsanguinations protocols (TEP) are employed. We hypothesised that utilisation of our institution's TEP at the initiation of hospital resuscitation would improve survival in patients with significant hepatic trauma.

Patients And Methods: All patients who (1) sustained intra-abdominal haemorrhage with Grades III-V hepatic injury and (2) underwent immediate operative intervention between February 2004 and January 2008 were included in the study. TEP was instituted in February 2006, and all subsequent patients who met inclusion criteria and were treated with TEP constituted the study group. Patients who met inclusion criteria, were treated before introduction of TEP, and received at least 10 units packed red blood cells in the first 24h constituted pre-TEP comparison group. Univariate and multivariate analyses evaluated the effects of TEP on the study population.

Results: Seventy-five patients were included in the study: 39 in the pre-TEP cohort (31% 30-day survival) and 36 in the TEP cohort (53% 30-day survival). There were no differences in demographics, extent of hepatic injury, or operative approach between the patient groups (all p > or = 0.27). Injury Severity Scores were significantly higher in the TEP group (41+/-18 vs. 28+/-15, p<0.01). TEP patients received more plasma and platelets during operative intervention and significantly less crystalloid (all p<0.01). Occurrence of cardiac dysfunction and abdominal compartment syndrome was significantly lower in TEP patients who survived 24-h post-injury (both p < or = 0.04). After adjusting for the significant negative effects of Grade V injury and involvement of major hepatic vasculature (both p < or = 0.02), TEP significantly improved 30-day survival: OR=0.22, 95% CI: 0.06-0.81, p=0.02.

Conclusions: TEP allows for an effective use of plasma and platelets during intra-operative management of severe hepatic injury. Utilisation of TEP is associated with significant reductions of cardiac dysfunction and development of abdominal compartment syndrome, as well as, significant improvement in 30-day survival.
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http://dx.doi.org/10.1016/j.injury.2009.09.019DOI Listing
January 2010

Ciliated hepatic foregut cysts in children.

Pediatr Surg Int 2010 Jul 16;26(7):753-7. Epub 2009 Sep 16.

Department of Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, TN, USA.

Ciliated hepatic foregut cyst (CHFC) is a rare foregut developmental malformation usually diagnosed in adulthood; however, rare cases have been reported in the pediatric population. CHFC can transform into a squamous cell carcinoma resulting in death despite surgical resection of the isolated malignancy. We report the presentation, evaluation, and surgical management of a symptomatic 17-year-old girl found to have a 6.5 x 4.5 cm CHFC and suggest that all patients with suspected CHFC undergo prompt evaluation and complete cyst excision.
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http://dx.doi.org/10.1007/s00383-009-2468-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3718281PMC
July 2010

Drain use after open cholecystectomy: is there a justification?

Langenbecks Arch Surg 2009 Nov;394(6):1011-1017

Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37232-2730, USA

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http://dx.doi.org/10.1007/s00423-009-0549-xDOI Listing
November 2009

Implementation of a real-time compliance dashboard to help reduce SICU ventilator-associated pneumonia with the ventilator bundle.

Arch Surg 2009 Jul;144(7):656-62

Department of Surgery, Vanderbilt University Medical Center, D-4314 Medical Center North, Nashville, TN 37232-2730, USA.

Background: Ventilator-associated pneumonia (VAP) causes significant morbidity and mortality in critically ill surgical patients. Recent studies suggest that the success of preventive measures is dependent on compliance with ventilator bundle parameters.

Hypothesis: Implementation of an electronic dashboard will improve compliance with the bundle parameters and reduce rates of VAP in our surgical intensive care unit (SICU).

Design: Time series analysis of VAP rates between January 2005 and July 2008, with dashboard implementation in July 2007.

Setting: Multidisciplinary SICU at a tertiary-care referral center with a stable case mix during the study period.

Patients: Patients admitted to the SICU between January 2005 and July 2008.

Main Outcome Measures: Infection control data were used to establish rates of VAP and total ventilator days. For the time series analysis, VAP rates were calculated as quarterly VAP events per 1000 ventilator days. Ventilator bundle compliance was analyzed after dashboard implementation. Differences between expected and observed VAP rates based on time series analysis were used to estimate the effect of intervention.

Results: Average compliance with the ventilator bundle improved from 39% in August 2007 to 89% in July 2008 (P < .001). Rates of VAP decreased from a mean (SD) of 15.2 (7.0) to 9.3 (4.9) events per 1000 ventilator days after introduction of the dashboard (P = .01). Quarterly VAP rates were significantly reduced in the November 2007 through January 2008 and February through April 2008 periods (P < .05). For the August through October 2007 and May through July 2008 quarters, the observed rate reduction was not statistically significant.

Conclusions: Implementation of an electronic dashboard improved compliance with ventilator bundle measures and is associated with reduced rates of VAP in our SICU.
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http://dx.doi.org/10.1001/archsurg.2009.117DOI Listing
July 2009

Liver transplantation for iatrogenic porta hepatis transection.

Am Surg 2009 Apr;75(4):313-6

Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee 37232-2730, USA.

Iatrogenic porta hepatis transection is a rare but devastating surgical complication. There are no systematic studies examining the best treatment strategy in patients with this injury. We report two cases of transection of all three portal structures, one during an open right adrenalectomy and another during a laparoscopic cholecystectomy, both of which were transferred to our tertiary care center hours postinjury. Diagnostic imaging and exploration revealed nonsalvageable livers, and both patients underwent total hepatectomies and portocaval shunting. Donor livers were available 12 to 20 hours after United Network for Organ Sharing Status 1 listing and both patients survived their postoperative course with 2- and 6-year follow up to date. Two-stage total hepatectomy with portocaval shunting followed by liver transplantation should be considered for patients presenting with porta hepatis transection.
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April 2009

Correlation of health-related quality of life after liver transplant with the Model for End-Stage Liver Disease score.

Arch Surg 2009 Feb;144(2):167-72

Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, 1313 21st Ave S, Nashville, TN 37232-4753, USA.

Objective: To determine whether a correlation exists between the Model for End-Stage Liver Disease (MELD) score and health-related quality of life (HRQOL) after liver transplant (LT).

Design: Prospective cohort.

Setting: University hospital.

Patients: Adult LT recipients (N = 209).

Main Outcome Measures: Postoperative HRQOL over a 1-year period after LT as measured via multiple regression-based path analysis testing the effects of the MELD score, preoperative variables, and postoperative variables on scores on the physical component summary and mental component summary scales of the 36-Item Short Form Health Survey and on composite physical and mental HRQOL scores derived from multiple scales.

Results: The MELD score (beta = .16), cholestatic cirrhosis (beta = .12), autoimmune/metabolic disease (beta = .18), neoplasm (beta = .23), time after LT (beta = .16), and the Karnofsky score (beta = .49) had significant effects on the physical component summary scale score. Autoimmune/metabolic disease (beta = .16) and the Karnofsky score (beta = .25) had significant effects on the mental component summary scale score. The MELD score (beta = .15), high school education (beta = .15), college education (beta = .17), autoimmune/metabolic disease (beta = .15), neoplasm (beta = .23), time after LT (beta = .11), and the Karnofsky score (beta = .51) had significant effects on the composite physical HRQOL score. Autoimmune/metabolic disease (beta = .23), neoplasm (beta = .15), and the Karnofsky score (beta = .42) had significant effects on the composite mental HRQOL score.

Conclusions: An increasing MELD score, when computed without any diagnosis-based exception points, was associated with improved physical HRQOL in the first year after LT. The MELD score did not affect mental HRQOL.
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http://dx.doi.org/10.1001/archsurg.2008.563DOI Listing
February 2009

Improvement of survival with response to neoadjuvant radiation therapy for rectal cancer.

Arch Surg 2009 Feb;144(2):129-34; discussion 134-5

Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, 2220 Pierce Ave, Nashville, TN 37232, USA.

Objectives: To determine whether patients with a complete or near-complete response to neoadjuvant radiation therapy (XRT) have improved survival compared with those with less of a response and to compare survival between patients with disease downstaged after neoadjuvant XRT and patients with stage I disease undergoing resection alone.

Design, Setting, And Patients: Retrospective cohort of 10,971 patients (3760 patients with neoadjuvant XRT; 7211 with stage I disease with resection alone) from the Surveillance, Epidemiology, and End Results registry using data from January 1, 1994, through December 31, 2003.

Main Outcome Measures: Overall survival and disease-specific survival (DSS) of patients undergoing resection for nonmetastatic rectal adenocarcinoma receiving neoadjuvant XRT and patients with stage I disease undergoing surgical resection alone.

Results: The 5-year DSS and overall survival were 94% and 82%, respectively, for responders to neoadjuvant XRT, 78% and 60%, respectively, for nonresponders, and 97% and 79%, respectively, for patients with stage I disease undergoing resection alone. Responders had improved DSS (P < .001) and overall survival (P < .001) compared with nonresponders by Cox regression. Patients with stage I disease undergoing resection alone had improved DSS (P = .01) but not overall survival (P = .89) compared with XRT responders.

Conclusions: Patients with rectal adenocarcinoma downstaged after neoadjuvant XRT have improved survival compared with nonresponders. While DSS is excellent for responders to neoadjuvant XRT, it did not equal the DSS of patients with stage I disease undergoing resection alone.
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http://dx.doi.org/10.1001/archsurg.2008.549DOI Listing
February 2009