Alfred I Neugut

Georgetown University, Washington, Washington, D.C., United States

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Publications (493)3206.31 Total impact

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    ABSTRACT: Video-assisted thorcacic surgery (VATS) is considered an alternative to open lobectomy for the treatment of non-small-cell lung cancer (NSCLC). Limited data are available, however, regarding the equivalence of open versus VATS segmental resections, particularly among elderly patients. From the Surveillance, Epidemiology, and End Results-Medicare database we identified 577 stage I NSCLC patients aged more than 65 years treated with VATS or open segmentectomy. We used propensity score methods to control for differences in the baseline characteristics of patients treated with VATS versus open segmentectomy. Outcomes included perioperative complications, need for intensive care unit, extended hospital stay, perioperative mortality, and survival. Overall, 27% of patients underwent VATS. VATS-treated patients had lower rates of postoperative complications (odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.37-0.83), intensive care unit admissions (OR: 0.18, 95% CI: 0.12-0.28), and decreased length of stay (OR: 0.41, 95% CI: 0.21-0.81) after adjusting for propensity scores. Postoperative outcomes were not significantly different across groups after adjusting for surgeon characteristics. Overall (hazard ratio: 0.80, 95% CI: 0.60-1.06) and lung cancer-specific (hazard ratio: 0.71, 95% CI: 0.45-1.12) survival was similar across groups. VATS segmentectomy can be safely performed among elderly NSCLC patients and is associated with equivalent postoperative and oncologic outcomes.
    Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 02/2014; · 4.55 Impact Factor
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    ABSTRACT: Inadequate bowel preparation prior to colonoscopy compromises the medical value of the procedure. The aim of this study is to explore the factors associated with pre-colonoscopy sub-optimal bowel preparation from the perspective of the physician. Using a cross-sectional study design, we examined the role of various factors thought to be associated with sub-optimal bowel preparation as reported by a sample of practicing Gastroenterologists across the United States. We conducted a survey among active members of the American College of Gastroenterology to assess Gastroenterologists' perceptions about barriers faced by the patients in the bowel preparation process. Descriptions of factors associated with sub-optimal bowel preparation prior to screening colonoscopy were identified and described, including health conditions, patient cognitive/behavioral characteristics and medication use. Health conditions (including constipation and diabetes) and particular patient characteristics (including older age) were the most common perceived determinants of sub-optimal bowel preparation. Although some barriers to colonoscopy preparation (e.g., older age), cannot be modified, many are amenable to change through education. This study indicates the potential value of a personalized approach to bowel preparation, which addresses the specific needs of an individual patient like chronic constipation and diabetes and those with poor literacy skills or poor fluency in English. Development and evaluation of educational interventions to address these factors warrants investment.
    International journal of preventive medicine 02/2014; 5(2):233-7.
  • Article: Response.
    Journal of Neurosurgery 02/2014; 120(2):298-9. · 3.15 Impact Factor
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    ABSTRACT: Observational studies comparing neoadjuvant chemotherapy to primary surgery for advanced-stage ovarian cancer are limited by strong selection bias. Multiple methods were used to control for confounding and selection bias to estimate the effect of primary treatment on survival for ovarian cancer. The Surveillance, Epidemiology, and End Results (SEER)-Medicare database was used to identify women ≥ 65 years of age with stage II-IV epithelial ovarian cancer who survived > 6 months from the date of diagnosis and received treatment from 1991 through 2007. Traditional regression analysis, propensity score-based analysis, and an instrumental variable analysis (IVA) using geographic location as an instrument were used to compare survival between neoadjuvant chemotherapy and primary surgery. A total of 9587 patients with stage II-IV ovarian cancer were identified. Use of primary surgery decreased from 63.2% in 1991 to 49.5% by 2007, whereas primary chemotherapy increased from 19.7% in 1991 to 31.8% in 2007 (P < .0001). In the observational cohort survival (hazard ratio [HR] = 1.27; 95% confidence interval [CI] = 1.19-1.35) was inferior for patients treated with neoadjuvant chemotherapy; both median survival (15.8 versus 28.8 months) and 2-year survival (36% versus 56%) were lower in the neoadjuvant chemotherapy group compared to those who underwent surgery. In the IVA, primary treatment had minimal effect on overall survival (HR = 1.04; 95% CI = 0.67-1.60). The median survival for patients with a value of the instrument less than the median (24.0 months, 95% CI = 23.0-25.0) and greater than or equal to median value of the IV (24.0 months, 95% CI = 23.0-26.0) were similar. Use of neoadjuvant therapy has increased over time. Survival with neoadjuvant chemotherapy did not differ significantly from primary surgery in elderly women in the United States. Cancer 2013. © 2013 American Cancer Society.
    Cancer 01/2014; · 5.20 Impact Factor
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    ABSTRACT: A recent randomized trial demonstrated that for metastatic epidural spinal cord compression (MESCC), a complication of advanced prostate cancer, surgical decompression may be more effective than external beam radiation therapy (RT). We investigated predictors of MESCC, its treatment, and its impact on hospital length of stay for patients with advanced prostate cancer. We used the SEER-Medicare database to identify patients >65 years with stage IV (n = 14,800) prostate cancer. We used polytomous logistic regression to compare those with and without MESCC and those hospitalized for treatment with surgical decompression and/or RT. MESCC developed in 711 (5 %) of patients, among whom 359 (50 %) received RT and 107 (15 %) underwent surgery ± RT. Median survival was 10 months. MESCC was more likely among patients who were black (OR 1.75, 95 %CI 1.39-2.19 vs. white) and had high-grade tumors (OR 3.01, 95 %CI 1.14-7.94), and less likely in those younger; with prior hormonal therapy (OR 0.73, 95 %CI 0.62-0.86); or with osteoporosis (OR 0.63, 95 %CI 0.47-0.83). Older patients were less likely to undergo either RT or surgery, as were those with ≥1 comorbidity. Patients with high-grade tumors were more likely to undergo RT (OR 1.92, 95 %CI 1.25-2.96). Those who underwent RT or surgery spent an additional 11 and 29 days, respectively, hospitalized. We found that black men with metastatic prostate cancer are more likely to develop MESCC than whites. RT was more commonly utilized for treatment than surgery, but the elderly and those with comorbidities were unlikely to receive either treatment.
    Supportive Care in Cancer 01/2014; · 2.09 Impact Factor
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    ABSTRACT: To examine the practice patterns and predictors of VTE prophylaxis following radical prostatectomy (RP). This was a population-based observational study of 94,709 men with a diagnosis of prostate cancer (ICD-9 code 185) who underwent RP were identified from a hospital-based database from 2000 to 2010, including 68,244 (72.1 %) open RP (ORP) and 26,465 (27.9 %) robotic-assisted laparoscopic RP (RALP). VTE prophylaxis was classified as none, mechanical, pharmacologic, or combination. Following RP, 35,591 (52.2 %) received mechanical, 4,945 (7.2 %) pharmacologic, 7,720 (10.6 %) combination, and 20,438 (30.0 %) no VTE prophylaxis. A total of 245 VTE events (145 DVT, 114 PE) were identified, representing 0.25 % of all procedures. Men with >2 comorbidities (OR = 2.44; 95 % CI 1.78-3.35) and those who were black (OR = 1.44; 95 % CI 1.06-1.97) were more likely to have a VTE. Men who had RALP (OR = 0.61; 95 % CI 0.45-0.99), surgery at high-volume hospitals (OR = 0.45; 95 % CI 0.28-0.73), or received prophylaxis (OR = 0.67; 95 % CI 0.50-0.88) were less likely to develop a VTE. Despite the observation that VTE prophylaxis reduces the risk of VTE by 40 %, VTE prophylaxis was not used in almost one-third of men who underwent radical prostatectomy.
    World Journal of Urology 11/2013; · 3.42 Impact Factor
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    ABSTRACT: Object Central nervous system (CNS) hemangiopericytomas are relatively uncommon and unique among CNS tumors as they can originate from or develop metastases outside of the CNS. Significant difference of opinion exists in the management of these lesions, as current treatment paradigms are based on limited clinical experience and single-institution series. Given these limitations and the absence of prospective clinical trials within the literature, nationwide registries have the potential to provide unique insight into the efficacy of various therapies. Methods The authors queried the Surveillance Epidemiology and End Results (SEER) database to investigate the clinical behavior and prognostic factors for hemangiopericytomas originating within the CNS during the years 2000-2009. The SEER survival data were adjusted for demographic factors including age, sex, and race. Univariate and multivariate analyses were performed to identify characteristics associated with overall survival. Results The authors identified 227 patients with a diagnosis of CNS hemangiopericytoma. The median length of follow-up was 34 months (interquartile range 11-63 months). Median survival was not reached, but the 5-year survival rate was 83%. Univariate analysis showed that age and radiation therapy were significantly associated with survival. Moreover, young age and supratentorial location were significantly associated with survival on multivariate analysis. Most importantly, multivariate analysis using the Cox proportional hazards model showed a statistically significant survival benefit for patients treated with gross-total resection (GTR) in combination with adjuvant radiation treatment (HR 0.31 [95% CI 0.01-0.95], p = 0.04), an effect not appreciated with GTR alone. Conclusions The authors describe the epidemiology of CNS hemangiopericytomas in a large, national cancer database, evaluating the effectiveness of various treatment paradigms used in clinical practice. In this study, an overall survival benefit was found when GTR was accomplished and combined with radiation therapy. This finding has not been appreciated in previous series of patients with CNS hemangiopericytoma and warrants future investigations into the role of upfront adjuvant radiation therapy.
    Journal of Neurosurgery 11/2013; · 3.15 Impact Factor
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    ABSTRACT: We previously reported an inverse association between flavonoid intake and breast cancer incidence, which has been confirmed by others, but no studies have considered simultaneously potential interactions of flavonoids with multiple genetic polymorphisms involved in biologically relevant pathways (oxidative stress, carcinogen metabolism, DNA repair, and one-carbon metabolism). To estimate interaction effects between flavonoids and 13 polymorphisms in these four pathways on breast cancer risk, we used population-based data (n = 875 cases and 903 controls) and several statistical approaches, including conventional logistic regression and semi-Bayesian hierarchical modeling (incorporating prior information on the possible biologic functions of genes), which also provides biologic pathway-specific effect estimates. Compared to the standard multivariate model, the results from the hierarchical model indicate that gene-by-flavonoid interaction estimates are attenuated, but more precise. In the hierarchical model, the average effect of the deleterious versus beneficial gene, controlling for average flavonoid intake in the DNA repair pathway, and adjusted for the three other biologically relevant pathways (oxidative stress, carcinogen metabolism, and one-carbon metabolism), resulted in a 27 % increase risk for breast cancer [odds ratio = 1.27; 95 % confidence interval (CI) = 0.70, 2.29]. However, the CI was wide. Based on results from the semi-Bayesian model, breast cancer risk may be influenced jointly by flavonoid intake and genes involved in DNA repair, but our findings require confirmation.
    Cancer Causes and Control 11/2013; · 3.20 Impact Factor
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    ABSTRACT: To examine guideline-based use of prophylactic antibiotics in patients who underwent gynecologic surgery. We identified women who underwent gynecologic surgery between 2003 and 2010. Procedures were stratified as antibiotic-appropriate (abdominal, vaginal, or laparoscopically assisted vaginal hysterectomy) or antibiotic-inappropriate (oophorectomy, cystectomy, tubal ligation, dilation and curettage, myomectomy, and tubal ligation). Antibiotic use was examined using hierarchical regression models. Among 545,332 women who underwent procedures for which antibiotics were recommended, 87.1% received appropriate antibiotic prophylaxis, 2.3% received nonguideline-recommended antibiotics, and 10.6% received no prophylaxis. Use of antibiotics increased from 88.0% in 2003 to 90.7% in 2010 (P<.001). Among 491,071, who underwent operations for which antibiotics were not recommended, antibiotics were administered to 197,226 (40.2%) women. Use of nonguideline-based antibiotics also increased over time from 33.4% in 2003 to 43.7% in 2010 (P<.001). Year of diagnosis, surgeon and hospital procedural volume, and area of residence were the strongest predictors of guideline-based and nonguideline-based antibiotic use. Although use of antibiotics is high for women who should receive antibiotics, antibiotics are increasingly being administered to women for whom the drugs are of unproven benefit. LEVEL OF EVIDENCE:: III.
    Obstetrics and Gynecology 11/2013; · 4.37 Impact Factor
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    ABSTRACT: Suboptimal bowel preparation, present in over 20% of colonoscopies, can severely compromise the effectiveness of the colonoscopy procedure. We surveyed 93 primarily urban minority men and women who underwent asymptomatic 'screening' colonoscopy regarding their precolonoscopy bowel-preparation experience. Print materials alone (39.8%) and in-person verbal instructions alone (35.5%) were reportedly the most common modes of instruction from the gastroenterologists. Liquid-containing laxative (70.6%) was the most common laxative agent; a clear liquid diet (69.6%) the most common dietary restriction. Almost half of the participants mentioned 'getting the laxative down' as one of the hardest parts of the preparation; 40.9% mentioned dietary restrictions. The 24.7% who mentioned 'understanding the instructions' as one of the hardest parts were more likely to be non-US born and to have lower education and income. There was no relationship between difficulty in understanding instructions and mode of instruction or preparation protocol. One quarter suggested that a smaller volume and/or more palatable liquid would have made the preparation easier. Three quarters agreed that it would have been helpful to have someone to guide them through the preparation process. These findings suggest a variety of opportunities for both physician- and patient-directed educational interventions to promote higher rates of optimal colonoscopy bowel preparation.
    Therapeutic Advances in Gastroenterology 11/2013; 6(6):442-6.
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    ABSTRACT: Little is known about the use and toxicity of antiadhesion substances such as sodium hyaluronate-carboxymethylcellulose. We analyzed the patterns of use and safety of sodium hyaluronate-carboxymethylcellulose in patients undergoing colectomy and gynecologic surgery. This is a retrospective cohort study. This study covered hospitals nationwide. All patients in the Premier Perspective database who underwent colectomy or hysterectomy from 2000 to 2010 were included in the analyses. Hyaluronate-carboxymethylcellulose use was determined by billing codes. For the primary outcome, we used hierarchical mixed-effects logistic regression models to determine the factors associated with the use of hyaluronate-carboxymethylcellulose, whereas a propensity score-matched analysis was used to secondarily assess the association between hyaluronate-carboxymethylcellulose use and toxicity (abscess, bowel and wound complications, peritonitis). We identified 382,355 patients who underwent hysterectomy and 267,368 who underwent colectomy. For hysterectomy, hyaluronate-carboxymethylcellulose use was 5.0% overall, increasing from 1.1% in 2000 to 9.8% in 2010. Hyaluronate-carboxymethylcellulose was used in 8.1% of those who underwent colectomy and increased from 6.2% in 2000 to 12.4% in 2010. The year of diagnosis and procedure volume of the attending surgeon were the strongest predictors of hyaluronate-carboxymethylcellulose use. After matching and risk adjustment, hyaluronate-carboxymethylcellulose use was not associated with abscess formation (1.5% vs 1.5%) (relative risk = 0.97; 95% CI, 0.84-1.12) in those who underwent hysterectomy. A patient receiving hyaluronate-carboxymethylcellulose had a 13% increased risk of abscess (17.4% vs 15.0%) (relative risk = 1.13; 95% CI, 1.08-1.17) after colectomy. This was an observational study. Hyaluronate-carboxymethylcellulose use has increased over the past decade for colectomy and hysterectomy. Although there is no association between hyaluronate-carboxymethylcellulose use and abscess following hysterectomy, hyaluronate-carboxymethylcellulose use was associated with a small increased risk of abscess after colectomy.
    Diseases of the Colon & Rectum 10/2013; 56(10):1174-84. · 3.20 Impact Factor
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    ABSTRACT: Estimates of the proportion of estrogen receptor (ER) negative (-) and triple-negative (TRN) breast cancer from sub-Saharan Africa are variable and include high values. Large studies of receptor status conducted on non-archival tissue are lacking from this region. We identified 1218 consecutive women (91% black) diagnosed with invasive breast cancer from 2006--2012 at a public hospital in Soweto, South Africa. Immunohistochemistry based ER, progesterone receptor (PR) and human epidermal factor 2 (HER2) receptors were assessed at diagnosis on pre-treatment biopsy specimens. Mutually-adjusted associations of receptor status with stage, age, race and grade were examined using risk ratios (RRs). ER status was compared with age-stratified US Surveillance Epidemiology and End Results program (SEER) data. 35% (95% confidence interval (CI): 32--38) of tumors were ER-, 47% (45--52) PR-, 26% (23--29) HER2+ and 21% (18--23) TRN. Later stage tumors were more likely to be ER- and PR- (RRs 1.9 (1.1-2.9) and 2.0 (1.3-3.1) for stage III vs. I) but were not strongly associated with HER2 status. Age was not strongly associated with ER or PR status, but older women were less likely to have HER2+ tumors (RR 0.95 (0.92-0.99) per 5 years). During the study, stage III + IV tumors decreased from 66% to 46%. In black women the percentage of ER- (37% (34--40)) and PR- tumors (48% (45--52)) was significantly higher than in non-black patients (22% (14--31) and 34% (25--44), respectively with P = 0.004 and P = 0.02), which remained after age and stage adjustment. Age-specific ER- proportions in black South African women were similar to those of US black women, especially for women diagnosed over age 50. Although a greater proportion of black than non-black South African women had ER- or TRN breast cancer, in all racial groups in this study breast cancer was predominantly ER + and was being diagnosed at earlier stages over time. These observations provide initial indications that late-stage aggressive breast cancers may not be an inherent feature of the breast cancer burden across Africa.
    Breast cancer research: BCR 09/2013; 15(5):R84. · 5.88 Impact Factor
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    ABSTRACT: Objectives: Limited resection is commonly used for treating older, early stage non-small cell lung cancer (NSCLC) patients who cannot tolerate lobectomy. However, parenchymal-sparing procedures leave patients at increased risk of recurrence. The role of postoperative radiotherapy (PORT) and chemotherapy following limited resection is not established. Methods: We identified 1,929 stage I-II (≤5 cm in size) NSCLC patients who underwent limited resection (wedge or segmentectomy) from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. Using propensity score methods, we compared toxicity and survival of patients treated with limited resection alone, PORT, adjuvant chemotherapy, or PORT and chemotherapy. We conducted secondary analysis stratifying the sample by size (>2-5 cm), stage (IA vs. IB/IIA), and type of limited resection (wedge resection vs. segmentectomy). Results: Overall, 1656 (85.8%), 159 (8.3%), 74 (3.8%), and 40 (2.1%) patients were treated with limited resection alone, PORT, adjuvant chemotherapy or PORT and chemotherapy, respectively. Adjusted analysis using inverse probability weighting showed that PORT (hazard ratio [HR]: 1.57, 95% confidence interval [CI]: 1.45-1.69), adjuvant chemotherapy (HR: 1.48, 95% CI: 1.36-1.61), and PORT and chemotherapy (HR: 1.73, 95% CI: 1.61-1.86) were associated with worse survival compared with limited resection alone. Similar results were obtained in secondary analyses. Compared to limited resection alone, the adjusted odds ratio for toxicity were 1.97 (95% CI: 1.6-2.4), 3.15 (95% CI: 2.58-3.85), 2.59 (95% CI: 2.0-3.4) for PORT, chemotherapy, and PORT and chemotherapy, respectively. Conclusions: PORT and adjuvant chemotherapy are not beneficial and appear to be associated with increased toxicity and worse survival following limited resection in elderly patients with early stage NSCLC. Alternative strategies should be explored to improve local control.
    Annals of the American Thoracic Society. 09/2013;
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    ABSTRACT: Drugs are approved on the basis of randomized trials conducted in selected populations. However, once approved, these treatments are usually expanded to patients ineligible for the trial. We used the SEER-Medicare database to identify subjects older than 65 years with metastatic breast, lung, and colon cancer, diagnosed between 2004 and 2007 and undergoing follow-up to 2009, who received bevacizumab. We defined a contraindication as having at least two billing claims before bevacizumab for thrombosis, cardiac disease, stroke, hemorrhage, hemoptysis, or GI perforation. We defined toxicity as first development of one of these conditions after therapy. Among 16,085 metastatic patients identified, 3,039 (18.9%) received bevacizumab. Receipt of bevacizumab was associated with white race, later year of diagnosis, tumor type, and decreased comorbid conditions. Of patients who received bevacizumab, 1,082 (35.5%) had a contraindication. In multivariate analysis, receipt of bevacizumab with a contraindication was associated with black race (odds ratio [OR] = 2.6; 95% CI, 1.4 to 4.9), increased age, comorbidity, later year of diagnosis, and lower socioeconomic status. Patients with lung (OR = 1.7; 95% CI, 1.1 to 2.4) and colon cancer (OR = 1.4; 95% CI, 1.1 to 1.9) were more likely to have a contraindication. In the group with no contraindication, 30% had a complication after bevacizumab; black patients were more likely to have a complication than were white patients (OR = 1.9; 95% CI, 1.21 to 2.93). Our study demonstrates widespread use of bevacizumab among patients who had contraindications. Black patients were less likely to receive the drug, but those who did were more likely to have a contraindication. Efforts to understand toxicity and efficacy in populations excluded from clinical trials are needed.
    Journal of Clinical Oncology 09/2013; · 17.88 Impact Factor
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    ABSTRACT: Although the prevalence of celiac disease in the USA approaches 1%, most cases are undiagnosed, in part, because of low adherence to the recommendation of submitting at least four specimens during duodenal biopsy. We aimed to determine whether physician and practice characteristics are associated with adherence to this recommendation. We used a large national pathology database to identify all adult patients who underwent duodenal biopsy during 2006-2009. Hierarchical modeling was used to determine whether procedure volume, the number of gastroenterologists per endoscopy suite, and the number of gastroenterologists per capita of the zip code of the practice were associated with adherence. We identified 92 580 patients (67% female, mean age 53.5 years) who met our inclusion/exclusion criteria. Specimens were submitted by 669 gastroenterologists from 200 endoscopy suites, located in 191 zip codes, with a mean of 3.4 gastroenterologists per suite. On multivariate analysis, a higher procedure volume was associated with a decreased adherence [odds ratio (OR) for each additional 100 procedures, 0.92; 95% confidence interval (CI), 0.88-0.97; P=0.002]. An increased adherence was reported for gastroenterologists working at suites with higher numbers of gastroenterologists (OR for each additional gastroenterologist, 1.08; 95% CI, 1.04-1.13; P<0.001) but not for a higher gastroenterologist density in the zip code of the practice (OR for each additional gastroenterologist per capita, 1.01; 95% CI, 0.99-1.03; P=0.21). High-volume physicians exhibit lower rates of adherence to biopsy guidelines, possibly because of the additional time required to submit at least four specimens. In contrast, a greater number of endoscopists working in an endoscopy suite are associated with an increased adherence, possibly because of peer education.
    European journal of gastroenterology & hepatology 08/2013; · 1.66 Impact Factor
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    ABSTRACT: Although a number of prohemostatic agents that are applied intraoperatively have been introduced to minimize bleeding, little is known about the patterns of use and the factors that influence use. We examined the use of hemostatic agents in patients undergoing major surgery. All patients who underwent major general, gynecologic, urologic, cardiothoracic, or orthopedic surgery from 2000-2010 who were recorded in the Perspective database were analyzed. Among 3,633,799 patients, hemostatic agents were used in 30.3% (n = 1,102,267). The use of hemostatic agents increased from 28.5% in 2000 to 35.2% in 2010. Over the same period, the rates of transfusion declined for pancreatectomy (-14.4%), liver resection (-15.0%), gastrectomy (-11.7%), prostatectomy (-6.6%), nephrectomy (-4.6%), hip arthroplasty (-10.4%), and knee arthroplasty (-6.6%). Over the same time period, the transfusion rate increased for colectomy (6.0%), hysterectomy (3.7%), coronary artery bypass graft (8.4%), valvuloplasty (4.2%), lung resection (1.9%), and spine surgery (1.6%). Transfusion remained relatively stable for thyroidectomy (0.2%). The use of hemostatic agents has increased rapidly even for surgeries associated with a small risk of transfusion and bleeding complications. In addition to patient characteristics, surgeon and hospital factors exerted substantial influence on the allocation of hemostatic agents.
    Journal of Surgical Research 08/2013; · 2.12 Impact Factor
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    ABSTRACT: There is growing recognition that, in addition to occurrence of perioperative complications, the treatment of these complications influences outcome. We examined complications, failure to rescue (death after a complication), and mortality in women who underwent abdominal hysterectomy. Women who underwent abdominal hysterectomy from 1998-2010 and were recorded in the Nationwide Inpatient Sample (NIS) were identified. Hospitals were stratified based on risk-adjusted mortality into five quintiles and rates of complications and failure to rescue were examined. A total of 664,229 women treated at 741 hospitals were identified. The overall morality rate for the cohort was 0.17%. The risk-adjusted, hospital-level mortality rate ranged from 0% to 1.12%. The complication rate was 6.5% at the lowest mortality hospitals, 9.9% at the second quintile hospitals, 9.5% at both the third and fourth quintile hospitals and 7.9% at the highest mortality hospitals. In contrast to complications, the failure to rescue rate increased with each successive risk-adjusted mortality quintile. The failure to rescue rate was 0% at the lowest mortality hospitals and then increased with each successive quintile to 1.1%, 2.1%, 2.7% and 4.4% in the highest mortality hospitals (P<0.0001). For women undergoing abdominal hysterectomy, hospital complication rates correlate poorly with mortality while failure to rescue is strongly associated with in-hospital mortality. The treatment of complications, not the actual development of a complication, is the most important factor predicting mortality after major gynecologic surgery.
    American journal of obstetrics and gynecology 08/2013; · 3.97 Impact Factor
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    ABSTRACT: Celiac disease (CD) is associated with an increased risk for lymphoproliferative malignancy (LPM). Whether this risk is affected by the results of follow-up intestinal biopsy, performed to document mucosal healing, is unknown. To examine the association between mucosal healing in CD and subsequent LPM. Population-based cohort study. 28 pathology departments in Sweden. 7625 patients with CD who had follow-up biopsy after initial diagnosis. The risk for LPM was compared with that of the general population by using expected rates. The rate of LPM in patients with persistent villous atrophy was compared with that of those with mucosal healing by using Cox regression. Among 7625 patients with CD and follow-up biopsy, 3308 (43%) had persistent villous atrophy. The overall risk for LPM was higher than that in the general population (standardized incidence ratio [SIR], 2.81 [95% CI, 2.10 to 3.67]) and was greater among patients with persistent villous atrophy (SIR, 3.78 [CI, 2.71 to 5.12]) than among those with mucosal healing (SIR, 1.50 [CI, 0.77 to 2.62]). Persistent villous atrophy compared with mucosal healing was associated with an increased risk for LPM (hazard ratio [HR], 2.26 [CI, 1.18 to 4.34]). The risk for T-cell lymphoma was increased (HR, 3.51 [CI, 0.75 to 16.34]) but not for B-cell lymphoma (HR, 0.97 [CI, 0.21 to 4.49]). No data on dietary adherence. Increased risk for LPM in CD is associated with the follow-up biopsy results, with a higher risk among patients with persistent villous atrophy. Follow-up biopsy may effectively stratify patients with CD by risk for subsequent LPM. National Institutes of Health, The American-Scandinavian Foundation, Celiac Sprue Association, Örebro University Hospital, Karolinska Institutet, Swedish Society of Medicine, Swedish Research Council, and Swedish Celiac Society.Chinese translation.
    Annals of internal medicine 08/2013; 159(3):169-75. · 16.10 Impact Factor
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    ABSTRACT: Using Surveillance, Epidemiology, and End Results database we identified 43,882 (97.0%) women with endometrioid adenocarcinomas and 1,374 (3.0%) with mucinous adenocarcinomas. Women with mucinous tumors were older (P < .0001), more often white (P = .04), and more often to present at advanced stage (P = .001). Survival was similar for both histologies; the hazard ratio for cancer-specific survival for mucinous compared to endometrioid tumors was 0.90 (95% CI, 0.74-1.09) while the hazard ratio for overall survival was 0.95 (95% CI, 0.85-1.07). Five-year survival for stage I mucinous tumors was 89.9% (95% CI, 87.6-91.9%) compared to 89.0% (95% CI, 88.6-89.4%) for endometrioid tumors.
    Cancer Investigation 08/2013; 31(7):500-4. · 2.24 Impact Factor
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    ABSTRACT: To examine the use of inpatient hysterectomy and explore changes in the use of various routes of hysterectomy and patterns of referral. The Nationwide Inpatient Sample was used to identify all women aged 18 years or older who underwent inpatient hysterectomy between 1998 and 2010. Weighted estimates of national trends were calculated and the number of procedures performed estimated. Trends in hospital volume and across hospital characteristics were examined. After weighting, we identified a total 7,438,452 women who underwent inpatient hysterectomy between 1998 and 2010. The number of hysterectomies performed annually rose from 543,812 in 1998 to a peak of 681,234 in 2002; it then declined consistently annually and reached 433,621 cases in 2010. Overall, 247,973 (36.4%) fewer hysterectomies were performed in 2010 compared with 2002. From 2002 to 2010 the number of hysterectomies performed for each of the following indications declined: leiomyoma (-47.6%), abnormal bleeding (-28.9%), benign ovarian mass (-63.1%), endometriosis (-65.3%), and pelvic organ prolapse (-39.4%). The median hospital case volume decreased from 83 procedures per year in 2002 to 50 cases per year in 2010 (P<.001). The number of inpatient hysterectomies performed in the United States has declined substantially over the past decade. The median number of hysterectomies per hospital has declined likewise by more than 40%. : III.
    Obstetrics and Gynecology 08/2013; 122(2 Pt 1):233-41. · 4.37 Impact Factor

Publication Stats

12k Citations
3,206.31 Total Impact Points


  • 2014
    • Georgetown University
      Washington, Washington, D.C., United States
  • 1993–2014
    • CUNY Graduate Center
      New York City, New York, United States
    • New York State
      New York City, New York, United States
  • 1988–2014
    • Gracie Square Hospital, New York, NY
      New York City, New York, United States
    • Columbia University
      • • Department of Urology
      • • Herbert Irving Comprehensive Cancer Center
      • • Department of Environmental Health Sciences
      • • Department of Epidemiology
      • • Department of Medicine
      • • Department of Biomedical Informatics
      • • College of Physicians and Surgeons
      New York City, New York, United States
  • 2013
    • University of the Witwatersrand
      Johannesburg, Gauteng, South Africa
    • University of Rochester
      Rochester, New York, United States
  • 2012–2013
    • William Paterson University
      • Department of Public Health
      Wayne, New Jersey, United States
    • Tongji Medical University
      Shanghai, Shanghai Shi, China
    • Devry College of New York, USA
      New York City, New York, United States
  • 2010–2013
    • Kaiser Permanente
      Oakland, California, United States
  • 2004–2013
    • University of North Carolina at Chapel Hill
      • • Department of Nutrition
      • • Department of Epidemiology
      • • Department of Medicine
      Chapel Hill, NC, United States
    • Case Western Reserve University
      • Division of Gastroenterology and Liver Disease
      Cleveland, OH, United States
  • 1995–2013
    • New York Presbyterian Hospital
      • Department of Pain Medicine
      New York City, New York, United States
    • Icahn School of Medicine at Mount Sinai
      • Department of Preventive Medicine
      Manhattan, New York, United States
    • Saint Luke's Hospital (NY, USA)
      New York City, New York, United States
    • Carmel Medical Center
      H̱efa, Haifa District, Israel
  • 2011
    • Stellenbosch University
      • Division of Radiation Oncology
      Stellenbosch, Province of the Western Cape, South Africa
    • Johns Hopkins Medicine
      • Department of Medicine
      Baltimore, MD, United States
  • 2006–2009
    • Long Island University
      • Department of Psychology (Post)
      New York City, NY, United States
    • Mayo Clinic - Scottsdale
      Scottsdale, Arizona, United States
    • New York Eye and Ear Infirmary
      New York City, New York, United States
    • National Institutes of Health
      • Branch of Epidemiology (EPI)
      Bethesda, MD, United States
    • Samuel Lunenfeld Research Institute
      Toronto, Ontario, Canada
  • 2004–2006
    • Roswell Park Cancer Institute
      • Department of Epidemiology
      Buffalo, New York, United States
  • 2002–2003
    • Queen Elizabeth Dental Services Inc.
      Montréal, Quebec, Canada
  • 1996–2002
    • Lenox Hill Hospital
      New York City, New York, United States
  • 1997
    • New York Medical College
      • Department of Medicine
      New York City, New York, United States
    • New York University
      • Department of Medicine
      New York City, NY, United States
  • 1989–1996
    • Rambam Medical Center
      • Northern Israel Oncology Center
      H̱efa, Haifa District, Israel
  • 1992–1995
    • Technion - Israel Institute of Technology
      • Rambam Medical Center
      H̱efa, Haifa District, Israel