Race and Surgical Outcomes

Maura M passed on an article released on Medscape on November 17, 2008 as a CME activity. The article featured on medscape is:

Esnaola, N.F., Hall, B.L., Hosokawa, P.W. et al. (2008). Race and surgical outcomes: It's not all black and white. Annals of Surgery, 248, 247-655.

The objective of this study was to evaluate the INDEPENDENT influence of race on morbidity and mortality following general surgher. The investigator's hypothesis was that in previous studies, the observed effect of race may have been due to confounding effects of co-morbidity.

The authors argue that most studies published on the effect of race on outcomes depend on administrative data which is limited in the amount of clinical information and therefore cannot control adequately for underlying comorbidities.

All non-Hispanic White (34,141) and African American (5068) general surgery patients who were included in the National Surgery Quality Improvement Program (NSQIP) Patient Safety in Surgery Study (2001-2004) were included in the study.

Data was collected on 97 variables (3 demographic, 41 pre-op risk factors, 13 pre-op lab variable; 15 intra-operative variables, and 25 post op occurrences.

30-day post-operative mortality (all-cause) and 30-day morbidity (neuro, cardiac, respiratory, infectious, wound complications) was primary dependent variable.

Key findings: African Americans more likely to undergo emergency surgery and to present with co-morbidities (hypertension, dyspnes, diabetes, renal failure, open wounds, or advanced American Society of Anesthesiology class). African Americans also more likely to undergo less complex procedures, but have higher 30-day morbidity. However, after controlling for comorbidities, African American race DID NOT effect race (OR = 0.95; 95% CI = 0.74 -1.23). African American race was associated with a higher risk of postoperative cardiac arrest and renal insufficency/failure (even after controlling for comorbidity.

The authors suggest that in order to improve health care disparities, the focus should be on improving peri-operative management of c0-morbid conditions.

Use of a fan during sleep and the risk of sudden infant death syndrome.

Mary K reported this study after seeing it on Fox 53 late night news (week of Oct. 13, 2008)

She tracked the report to:
Coleman-Phox, K., Odouli, R., & De-Kun, L. (2008). Use of a fan during sleep and the risk of sudden infant death syndroms. Archives of Pediatric & Adolescent Medicine, 162, 963-968.
According to Mary:

• This was a population-based case-control study that took place in 11 counties in California between 1997-2000. The objective was to examine the relationship between room ventilation during sleep and the risk of SIDS.
• Although the incidence of SIDS in the United States has been reduced by 56% over the period of 1992 - 2003, it continues to be the leading cause of post-neonatal mortality in the U.S.
  
• The authors felt that the increased risk of SIDS associated with overheating, a soft sleep surface and soft bedding is widely publicized through the "Back to Sleep" campaign, but that other modifiable risk factors in the enviornment should also be explored.
• Of note is the "pacifier study" of 2006 which supports the theory that re-breathing C02 is a fisk factor and point out that increased air movement may potentially decrease the amount of C02 accumulation around the infant's nose and mouth.
• They obtained SIDS cases from all infant deaths reported in the 11 counties to the CA Dept. of Health and to the Los Angeles County Coroner's Office (SID of an infant <>
• Letters were sent after screening; mothers were contacted by visit or telephone if they agreed to participate.
  
• Of the 396 eligible cases, 25% could not be located, 12.9% refused, 11.6% agreed but never completed interview.
• Eligible controls were identified from birth certificates; matched to county of residence, maternal race/ethnicity, and infant age.
  
• A total of 185 SIDS cases and 312 controls were included in the analysis.
• Mothers of both groups were asked about fan use, open windows, room location, sleep surface, number & types of cover, bedding under the infant and room temperature on the last day of sleep before the infant death for cases and date of interview for controls.
  
• Interviews took place a median of 3.8 months after death for cases.
  
• Unconditional logistic regression was used to examine the room ventilation at last sleep and risk for SIDS relationship.
• Cases and controls were similar for race/ethnicity, age at reference date, region of residence, use of non-use of soft-bedding and room temperature.
• The groups differed in maternal age (SIDS group younger); marital status (SIDS group more likely unmarried), parity (SIDS group more likely to be multiparous), smoking (SIDS more likely to smoke during pregnancy); prenatal care (SIDS less likely), education (SIDS less likely to have completed high school), birthweight (SIDS more like low birth weight), gestational age (SIDS more likely pre-term). SIDS also had increase in infants with fever 48 hr. before death, positioning on side or abdomen, did not use pacifier, found with bedding blankets over heads, slept on soft surface, or shared bed with non-parent.
  
• After adjusting for matching variables, confounders, and known risk factors, having a fan in the room was associated with a 72% reduction in the risk of SIDS.
  
• The authors noted limitations a/w recall bias, selection bias.
• Authors suggest that a fan may be simple and effective in addition to supine positioning. Interestingly, 24.4%of care providers do not regularly place their infants in this position, while counseling their high-risk mothers to do so.
  

Urinary Bisphenol A, medical disorders, and laboratory abnormalities

Scott shared an article published in JAMA re: the association between urinary BPA concentrations and health status. BPA is a widely used epoxy resin that lines food and beverage containers.

Citation: Lang, I.A., Galloway, T.S., Scarlett, A. et al., (2008). Association of Urinary Bisphenol concentration with medical disorders and laboratory abnormalities in adults. JAMA, 300, 1303-1310.

This is a cross-sectional analysis of 1455 adults (18-74 years) in the general population who participated in the National Health and Nutrition Examination Survey (2003-4)

Key independent variable: urinary BPA concentrations

Dependent variables: chronic disease diagnoses; liver function; glucose homeostasis, inflammation, lipids

Analysis: regression models controlling for age, sex, race/ethnicity, education, income, smoking, body mass index, waist circumference, and urinary creatinine concentration.

Main findings: Higher urinary BPA was associated with cardiovascular diagnoses (OR per 1 SD increase in BPA = 1.39, p<.001) and diabetes (OR = 1.39, p<.001), but no other studied diseases. It was also associated with elevated liver enzymes.

Anti-dementia drugs may prolong life in Alzheimer's patients

Mary shared the following information based on a report in Family Practice News summarizing a presentation by Dr. Susan Rountree (Baylor College of Medicine) at the International Conference on Alzheimer's Disease.
Citation: Sullivan, M.G. (2008) Antidementia drugs may prolong life in Alzheimer's patients. Family Practice News, 38, pp. 1 & 4.

The purpose of the study was to determine whether currently prescribed anti-dementia drugs have an effect on survival rates among the elderly. Five drugs available during the study were evaluated: tacrine, donepezil, rivastigmine, galantamine, and memantine). The study tracked use of drugs over time and evaluated whether the length of use and type of medication influenced survival.

This was a prospective observational study of 641 patients seen at the Alzheimer's disease and memory disorders center at Baylor College and evaluated annually until death.

The independent variable was "medication persistency" which captured the amount of time the person spend on medication relative to the duration of their illness. Patients were classified into quartiles (on medication for up to 33% of illness; 34-55% of illness; 56-70% of illness; >70% of illness).

The dependent variable was survival.

Co-variates included age, sex, years of education, duration of symptoms, and severity of disease. If the patient was on anti-dementia drugs prior to enrollment, a "pre-progression rate" was calculated.

Findings: Patients who took medications for greater than 70% of the time since their diagnosis (those in the upper quartile) lived an average of three years longer than those in the first quartile. Compared to those in the upper quartile, those in the lower 2 quartiles were more than twice as likely to die.

Take home message: as practitioners, we need to encourage families to view the available medications as positive treatment although they are not a cure.

Food for thought: The current USPSTF notes that there is insufficient evidence to recommend for or against routine screening for Alzheimer's. Would early diagnosis and therefore early treatment improve survival ABOVE that seen in this study when patients were presumable started on meds after presenting with symptoms?