Recent Publications by CFE Educators

BACKGROUND

The Leapfrog Group is a consortium of Fortune 500 corporations and healthcare purchasers whose intent is to harness their purchasing power to improve the quality of care by regionalizing high complexity operations at high volume hospitals (HVH). The Whipple resection has been designated a "Leapfrog" procedure and the recommendation issued that it be performed at HVH. However, alternatives to the Leapfrog Initiative are likely necessary because regionalization has been difficult to implement, as the number of Leapfrog sites is low in rural areas, and the initiative's relevance to facilities that care for the uninsured is unclear. We hypothesized that defining exportable elements of the Whipple resection could allow a low volume hospital (LVH) to improve upon its processes of care to safely attempt these procedures.

STUDY DESIGN

We describe the surgical experience of the University of California, San Francisco at the San Mateo Medical Center (SMMC) from 2002 to 2004. A quality improvement program was introduced at this LVH, focusing on enhancing structure and processes of care. High-volume UCSF pancreas surgeons were polled to define exportable elements of Whipple resection. A senior pancreas consultant assisted in the perioperative preparation of SMMC.

RESULTS

Of the nine patients who underwent exploratory surgery for an intended Whipple resection, four had a successful resection, and five were unresectable. Morbidity was minimal and 30-d mortality was zero.

CONCLUSIONS

Whipple resections can be safely performed at a LVH after exporting surgical excellence. The structure and process changes allowed the LVH to improve its quality of care. Alternatives to the Leapfrog Initiative are feasible and can extend its original intent.

Moderate alcohol intake has been consistently associated with a modest (30-50%) increase in breast cancer risk, but it remains unclear if certain individuals have higher susceptibility to the harmful effects of alcohol intake. Individuals differ in their ability to metabolize alcohol through genetic differences in alcohol dehydrogenase (ADH), the enzyme that catalyzes the oxidation of approximately 80% of ethanol to acetaldehyde, a known carcinogen. Using data from the Breast Cancer Family Registry (n = 811 sister sets), we examined whether sisters with breast cancer differ with respect to alcohol consumption and alcohol metabolism (measured by polymorphisms in ADH1B and ADH1C) compared to their sisters without breast cancer. Neither alcohol drinking nor alcohol metabolizing ADH1B and ADH1C genotypes were associated with breast cancer risk. However, only 19% and 42% of sisters were discordant by ADH1B and ADH1C, respectively, and even fewer were discordant by both genotype and alcohol intake, making it difficult to detect differences if they existed.

BACKGROUND

Acquired hypertrichosis lanuginosa (AHL) is a rare cutaneous disorder that involves spontaneous growth of lanugo-type hair in association with overt or occult malignant neoplasms. Bronchopulmonary and gastrointestinal malignancies are most commonly associated.

CASE PRESENTATION

We report the occurrence of AHL associated with metastatic prostate cancer and its abrupt resolution after bilateral orchiectomy. To our knowledge, this is the first reported case of an association with prostate cancer.

LIMITATIONS

The case presented represents a single patient; therefore, the findings and results reported may not be applicable to all patient populations.

CONCLUSION

A variety of cutaneous findings are considered warning indicators of underlying neoplastic disease. Physician awareness of such signs can prompt timely and potentially life-saving investigations and interventions. AHL is regarded as such a sign. Physician awareness of the addition of prostate cancer to the growing list of AHL-associated malignancies provides rationale for appropriate testing and referral.

OBJECTIVE

We sought to estimate when rates of maternal pregnancy complications increase beyond 37 weeks of gestation.

STUDY DESIGN

We designed a retrospective cohort study of all low-risk women delivered beyond 37 weeks' gestational age from 1995 to 1999 within a mature managed care organization. Rates of mode of delivery and maternal complications of labor and delivery were examined by gestational age with both bivariate and multivariable analyses.

RESULTS

We found that, among the 119,254 women who delivered at 37 completed weeks and beyond, the rates of operative vaginal delivery (OR 1.15, 95% CI 1.09, 1.22), 3rd- or 4th-degree perineal laceration (OR 1.15, 95% CI 1.06, 1.24), and chorioamnionitis (OR 1.32, 95% CI 1.21, 1.44) all increased at 40 weeks as compared to 39 weeks of gestation (P .001), and rates of postpartum hemorrhage (OR 1.21, 95% CI (1.10, 1.32), endomyometritis (OR 1.46, 95% CI 1.14, 1.87), and primary cesarean delivery (1.28, 95% CI 1.20, 1.36) increased at 41 weeks of gestation (P .001). The cesarean indications of nonreassuring fetal heart rate (OR 1.81, 95% CI 1.49, 2.19) and cephalo-pelvic disproportion (OR 1.64, 95% CI 1.40, 1.94) increased at 40 weeks of gestation (P .001).

CONCLUSION

We found that the risk of maternal peripartum complications increase as pregnancy progresses beyond 40 weeks of gestation. Management of pregnancies that progress past their EDC should include counseling regarding the risks of increasing gestational age.

PURPOSE

We report outcomes and complications of the use of porcine small intestine submucosa for correcting penile curvature due to Peyronie's disease.

MATERIALS AND METHODS

A retrospective study was performed in patients with severe penile curvature (greater than 60 degrees) requiring surgical correction for sexual function. Preoperatively all patients underwent evaluation, including history, physical and penile duplex ultrasound. Of these patients 19 underwent tunical grafting with 1-layer Surgisis small intestine submucosa. Postoperatively patients were evaluated with clinic visits and telephone interviews to assess results.

RESULTS

A total of 19 patients 46 to 69 years old (mean age 54) were treated with tunical incision or excision and grafting with small intestine submucosa between March 2002 and July 2005. Average followup was 15 months (range 3 to 43). Patients reported less penile pain with intercourse after surgery. There was no difference in Sexual Health Inventory for Men scores. Preoperatively 12 men (63%) had erectile dysfunction, defined as Sexual Health Inventory for Men less than 21, while 10 (53%) reported postoperative erectile dysfunction. Seven of the 19 patients (37%) had recurrent penile curvature (greater than 10 degrees) and 5 (26%) had recurrent Peyronie's disease plaque. Our complication rate was 37%, including hematoma at the graft site in 5 cases (26%), graft infection in 1 (5%) and Peyronie's disease recurrence requiring plication in 1 (5%).

CONCLUSIONS

Small intestine submucosa carries potential for grafting applications because it is easy to use and readily available. Our experience resulted in a 37% complication rate, which exceeds those previously reported with saphenous vein graft repair.