Objectives Medicaid and Uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes following major surgical operations in the United States is dependent on primary payer status. Methods From 2003 to 2007, 893,658 major surgical operations were evaluated using the Nationwide Inpatient Sample (NIS) database: lung resection, esophagectomy, colectomy, pancreatectomy, gastrectomy, abdominal aortic aneurysm repair, hip replacement, and coronary artery bypass. Patients were stratified by primary payer status: Medicare (n = 491,829), Medicaid (n = 40,259), Private Insurance (n = 337,535), and Uninsured (n = 24,035). Multivariate regression models were applied to assess outcomes. Results Unadjusted mortality for Medicare (4.4%; odds ratio [OR], 3.51), Medicaid (3.7%; OR, 2.86), and Uninsured (3.2%; OR, 2.51) patient groups were higher compared to Private Insurance groups (1.3%, P < 0.001). Mortality was lowest for Private Insurance patients independent of operation. After controlling for age, gender, income, geographic region, operation, and 30 comorbid conditions, Medicaid payer status was associated with the longest length of stay and highest total costs (P < 0.001). Medicaid (P < 0.001) and Uninsured (P < 0.001) payer status independently conferred the highest adjusted risks of mortality. Conclusions Medicaid and Uninsured payer status confers increased risk-adjusted mortality. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors or operation. These differences serve as an important proxy for larger socioeconomic and health system-related issues that could be targeted to improve surgical outcomes for US Patients.

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Chylothorax is a significant problem in pediatric cardiac surgery and is associated with increased mortality, cost, and length of stay. Strategies should be developed to improve prevention and treatment.

Bovine jugular grafts are associated with a significantly greater risk of late endocarditis but with lower reintervention rates compared with other valved conduits. The risk of endocarditis and durability must be balanced during conduit selection. Antibiotic prophylaxis and a high index of suspicion for endocarditis are warranted in patients with bovine jugular grafts.

CRAASBr is a potentially devastating consequence of RT for breast cancer, with poor LRFS, RFS, and OS rates. Patients with ecchymotic skin lesions require biopsy. Atypical vascular lesions require careful evaluation to rule out CRAASBr. If the diagnosis is confirmed, radical surgery encompassing both the breast parenchyma and the at-risk radiated skin should be performed.

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BACKGROUND: Radiotherapy (RT) has been a risk factor for development of soft tissue sarcomas (STS). The objective of the current study was to quantify the risk of STS after RT and surgery for breast cancer (BCa), assess time trends, and compare long‐term survival of patients with RT‐associated and non–RT‐associated angiosarcoma (AS) using the Surveillance, Epidemiology, and End Results (SEER) database. METHODS: Women with BCa reported to SEER in 1973 to 2003 were included. Kaplan‐Meier curves and proportional hazards models, reported as hazards ratios (HR) with 95% confidence intervals (95% CI), were used. Survival of patients who developed RT‐associated AS was compared with that of patients with primary AS of the thorax and upper extremities. RESULTS: The cohort of 563,155 BCa patients was divided into 2 groups: those who received RT (37%) and those who received no RT. RT use increased with time (P <. 0001). A total of 948 patients developed STS 1 to 29 years after BCa diagnosis. RT patients had a higher incidence of all STS (31 vs 22 per 100,000 person‐years; HR, 1.5 [95%CI, 1.3‐1.8]), AS (HR, 7.6; 95% CI, 4.9‐11.9), and malignant fibrous histiocytomas (MFH) (HR, 2.5; 95% CI, 1.6‐3.9). RT remained a significant predictor after adjustment for covariates (HR, 1.4; 95% CI, 1.2‐1.7). Partial mastectomies (HR, 7.1; 95% CI, 3.2‐16), RT (HR, 2.2; 95% CI, 1.1‐4.3), and lymph node dissections (HR, 2.6; 95% CI, 1.3‐5) were found to be independent risk factors for AS. The hazard of STS after RT peaked at 10 years, reaching the non‐RT hazard at approximately 23 years. The 5‐year survival for STS was 38%. There was no difference in survival noted between RT‐induced and non–RT‐induced AS. CONCLUSIONS: RT was found to increase the risk for STS, in particular AS and MFH. Patients who received RT for BCa should be followed closely for >20 years. Cancer 2009. © 2009 American Cancer Society.

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