Indications, outcomes, and complications of neoumbilical reconstruction: A systematic review

BACKGROUND AND OBJECTIVES

Neoumbilicoplasty aims to reconstruct an aesthetically pleasing new umbilicus following agenesis, malignancy, anatomical distortion, or umbilicus loss. Despite the wide variety of surgical techniques described, literature is scarce when it comes to standardized categorization of these as well as the clear definition of patients' selections, specific indications, final outcomes, and possible complications. According to available literature, this work aims to evaluate different surgical approaches, and correlate them to specific surgical needs, to simplify the surgical choice and patient management.

METHODS

A systematic review was performed in December 2020 in PubMed, Web of Science, and MedLine Ovid databases according to the PRISMA guidelines.

RESULTS

A total of 41 studies and 588 patients were finally included. On the basis of the evidence of the literature collected, we divided the studies into four groups according to the neoumbilicoplasty techniques: single suture or purse-string suture, single flap, multiple flap, and skin graft. Patients' surgical comorbidities, neoumbilicoplasty indications, and aesthetic and surgical outcomes were investigated. Direct suture and single and multiple flap techniques assured overall, satisfactory cosmetic outcomes with a low rate of surgical complications. Whereas suture-only techniques were chosen mostly by general surgeons/urologists in laparoscopic surgery, the single flap was the preferred method to reconstruct the umbilicus in open abdominal surgery or combined abdominoplasty with herniorrhaphy. Multiple flap and skin grafts were adopted in abdominoplasty-related umbilicus reconstruction, although the latter option showed impactful aesthetic and surgical complications.

CONCLUSIONS

Umbilicoplasty can assure generally pleasant aesthetic outcomes with relatively low complication rates. Indications for specific techniques correspond to different patient populations and surgical scenarios.

Proof-of-concept and Randomized, Placebo-controlled Trials of an FcRn Inhibitor, Batoclimab, for Thyroid Eye Disease

CONTEXT

Inhibition of the neonatal fragment crystallizable receptor (FcRn) reduces pathogenic thyrotropin receptor antibodies (TSH-R-Ab) that drive pathology in thyroid eye disease (TED).

OBJECTIVE

We report the first clinical studies of an FcRn inhibitor, batoclimab, in TED.

DESIGN

Proof-of-concept (POC) and randomized, double-blind placebo-controlled trials.

SETTING

Multicenter.

PARTICIPANTS

Patients with moderate-to-severe, active TED.

INTERVENTION

In the POC trial, patients received weekly subcutaneous injections of batoclimab 680 mg for 2 weeks, followed by 340 mg for 4 weeks. In the double-blind trial, patients were randomized 2:2:1:2 to weekly batoclimab (680 mg, 340 mg, 255 mg) or placebo for 12 weeks.

MAIN OUTCOME

Change from baseline in serum anti-TSH-R-Ab and total IgG (POC); 12-week proptosis response (randomized trial).

RESULTS

The randomized trial was terminated because of an unanticipated increase in serum cholesterol; therefore, data from 65 of the planned 77 patients were analyzed. Both trials showed marked decreases in pathogenic anti-TSH-R-Ab and total IgG serum levels (P < .001) with batoclimab. In the randomized trial, there was no statistically significant difference with batoclimab vs placebo in proptosis response at 12 weeks, although significant differences were observed at several earlier timepoints. In addition, orbital muscle volume decreased (P < .03) at 12 weeks, whereas quality of life (appearance subscale) improved (P < .03) at 19 weeks in the 680-mg group. Batoclimab was generally well tolerated, with albumin reductions and increases in lipids that reversed upon discontinuation.

CONCLUSIONS

These results provide insight into the efficacy and safety of batoclimab and support its further investigation as a potential therapy for TED.

RF35 | PSAT269 Double-Blind, Randomized, Placebo-controlled, Multicenter, Phase 2b Study of Batoclimab in Active and Moderate-to-Severe Thyroid Eye Disease

Clinical manifestations of thyroid eye disease (TED) are mainly caused by the binding of immunoglobulin G (IgG) thyrotropin receptors (TSHR) autoantibodies (TSHR-Ab) on orbital fibroblasts. Batoclimab (IMVT-1401) is an anti-neonatal Fc receptor (FcRn) human monoclonal antibody that prevents normal IgG recycling, leading to reduced levels of circulating IgG. Thus, batoclimab may provide benefit for patients with TED by reducing pathogenic anti-TSHR-Ab. In this Phase 2b, double-blind, randomized study (NCT03938545), subjects with active and moderate-to-severe TED received weekly subcutaneous (SC) injections of batoclimab (680mg, 340mg, 255mg) or placebo for 12-weeksSixty-five subjects were randomized and received batoclimab (680mg [n=18], 340mg [n=19], 255mg [n=10]) or placebo (n=18). Recruitment and treatment were stopped because of an unanticipated increase in LDL cholesterol levels, not included in subject informed consent. Hence, forty-five of 77 planned subjects completed the 12-week treatment period. Serum IgG and anti-TSHR-Ab were reduced from baseline to Week-12 with batoclimab (680mg [-77.9%; -65.5%], 340mg [-65.8%; -70.1%], 255mg [-56.6%; -42.1%]) versus placebo (-4.67%; -3.23%), respectively. Substantial reductions were also observed at Week-12 in stimulatory anti-TSHR-Ab. Fifty-one of 65 subjects had proptosis ≥ upper level of normal at baseline. At Week-12 (primary outcome), greater proportions of 680mg (30%; p=0.2197) and 340mg (30.8%; p=0.1311) subjects were proptosis responders (≥2mm reduction) versus placebo (8.3%). Absolute risk reduction (ARR [95% CI]) versus placebo was 21.4 (-11.3, 54.1) for 680mg and 24.2 (-4.8, 53.2) for 340mg at Week 12. Earlier proptosis responses were statistically different from placebo for 680mg at Weeks-four (35.7%; ARR [95% CI] 36.0 [10.9, 61.1]), five (42.9%; 43.0 [17.1, 68.9]), and 11 (41.7%; 34.5 [3.4, 65.6]) and for 340mg at Weeks-five (29.4%; 29.6 [7.9, 51.3]), nine(35.7%; 30.6 [3.0, 58.2]), and 11 (46.2%; 40.2 [10.2, 70.1]) (all p&lt;0.05). Changes in clinical activity at Week-12 were not significantly different from placebo.The proportion of subjects with an adverse event (AE) were similar across treatment groups; most were mild or moderate in severity. Two subjects reported serious AEs not related to treatment (optic neuropathy, autoimmune encephalitis [occurring after treatment period]). No subjects withdrew from the study due to an AE during the 12-week treatment period. There was a reversible dose-dependent reduction in serum albumin during the treatment period. Post-hoc lipid analysis demonstrated a reversible increase in mean serum LDL during treatment (680-mg: 58.7%; 340-mg: 30.8%; 255-mg: 19.0%) vs placebo (-3.9%),.In conclusion, batoclimab reduced circulating IgG and especially the pathogenic anti-TSHR-Ab. Although the proptosis response was not statistically significant at the primary endpoint, significance was seen at earlier time points. This is probably related to early study termination which reduced the numbers of patients available for efficacy assessment at the primary endpoint.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Monday, June 13, 2022 12:54 p.m. - 12:59 p.m.

A Randomized Controlled Trial of Animal-Assisted Therapy as an Adjunct to Intensive Family Preservation Services

METHOD

Families referred by Child Protective Services ( M _{child age} = 6 years ± 4; M _{parent age} = 32 years ± 8.26) were individually randomized to experimental ( n = 14) or control ( n = 14) intervention. Family functioning outcomes were measured using the North Carolina Family Assessment Scale for Reunification.

RESULTS

All four targeted family functioning outcomes were significantly increased for participants who received animal-assisted therapy as an adjunct to intensive family preservation services ( n = 14) with medium to large effect sizes. These improvements were sustained in two of the subscales through discharge. No significant differences were measured for the distal clinical outcome of disposition of children at discharge.

CONCLUSIONS

Findings suggest that adding animal-assisted therapy as an adjunct can improve evidence-based clinical interventions aimed at enhancing the caregiving contexts of children.

The relations among animal abuse, psychological disorders, and crime: Implications for forensic assessment

The confluence of developments in the assessment of animal abuse, the evolution of psychiatric nosology for the diagnosis of conduct disorder, legislative changes involving crimes against non-human animals, and the recent inclusion of crimes against animals in the FBI's National Incident-Based Reporting System, highlights the critical need for examining the forensic dimensions of animal abuse cases. We provide an overview of the research literature on these topics in the hope that forensic evaluators will have an evidence-based framework for assessing cases they encounter that include perpetration of violence against animals.

Abstract PR06: Functional prioritization of rare gene aberration drivers of cancer

Next generation sequencing (NGS) technologies are rapidly being incorporated into the clinic to facilitate decisions on cancer patient care. However, successful translation of NGS data requires knowledge on which DNA aberrations represent actionable events, either for development or re-positioning of approved agents to target their activated pathways. Recognizing this, large-scale tumor profiling efforts by consortia such as The Cancer Genome Atlas (TCGA) are cataloging genomic aberrations across major cancer lineages. These efforts have revealed an extraordinary level of genome complexity made up of not only key “driver” events critical to pathogenesis, but also numerous biologically-neutral “passengers” that accompany unstable tumor genomes. The challenge now is to find ways to identify functional driver aberrations, as targeting such events or their activated pathways has great potential for improving patient outcomes. To do this, we have developed high-throughput approaches to construct molecularly-barcoded versions of gene aberrations for functional screens. Specifically, we developed technologies that include (1) high-throughput, accurate modeling of somatic DNA mutations (somatic missense mutations and small insertions/deletions) using our robotics-driven platform of &gt;35,000 sequenced-verified open reading frame (ORF) clones, (2) a molecular barcoding strategy that permits rapid DNA tagging of wild-type and mutant ORFs, (3) multi-fragment recombineering methodologies allowing construction of cancer fusion genes, and (4) combining the use of these reagents for individual or pooled functional screens in vitro and in vivo using human and mouse systems. We are using these technologies, which are widely applicable to all cancer types, to identify the highest priority targets to enroll in deep mechanistic studies and drug discovery programs. We have scaled our pipelines to functionalize thousands of cancer gene aberrations. Importantly, we are now constructing entire somatically-mutated exomes from individual patients sequenced in the clinic. As an example of our “Personalized Functionalization” approach, we screened individual pancreatic ductal adenocarcinoma (PDAC) patient-derived aberration libraries for mutations capable of promoting tumorigenesis in vivo using a mouse xenograft model engineered with regulatable KRASG12D, an oncogene active in the majority of PDAC patient tumors. These studies revealed potent aberration drivers that are active as individual drivers as well as those that are contextual and are only active in the presence of KRASG12D. Based on these results, we have chosen NAD Kinase (NADK) for deep mechanistic studies and drug discovery programs. NADK catalyzes the conversion of cytoplasmic NAD+ to NADP+/NADPH and thus aids other modes of cellular NADPH production. Our validation studies indicate that the NADK mutation results in robust gain-of-function kinase activity leading to its hyper-phosphorylation of NAD+ accompanied by reduced accumulation or reactive oxygen species and increased tumor formation and growth. Interestingly, recent work by others report other mechanisms by which KRAS rewires PDAC tumors to maximize energy production and promote NADPH accumulation to maintain redox state and tumor growth. Even though NADK is mutated at low frequency in PDAC, its selection demonstrates that the discovery of rare, functional aberrations may intersect or otherwise lead us to important pathways and potential therapeutic liabilities. Our ultimate goal is to functionally annotate thousands of somatic aberrations in cancer, the vast majority of which have not been previously recognized or assayed for clinical relevance. These systems will reveal high priority edited targets to enroll in deep mechanistic biology studies, drug discovery and development programs ultimately leading to personalized treatment strategies.

Citation Format: Kenneth Scott, Yiu Huen Tsang, Turgut Dogruluk, Philip Tedeschi, Joseph Bertino, Gordon Mills. Functional prioritization of rare gene aberration drivers of cancer. [abstract]. In: Proceedings of the AACR Special Conference on Translation of the Cancer Genome; Feb 7-9, 2015; San Francisco, CA. Philadelphia (PA): AACR; Cancer Res 2015;75(22 Suppl 1):Abstract nr PR06.

Abstract 4208: The castrate resistant PC-3 cell line with neuroendocrine features is enriched in tumor initiating cells and is resistant to enzalutamide and abiraterone but sensitive to antimetabolites

BACKGROUND. Prostatic small cell carcinoma is increasing in frequency in patients resistant to all forms of androgen ablation. It is a high-grade malignant neoplasm with neuroendocrine features. There are no suitable cellular models to study this particular type of carcinoma. A recent study showed that the PC-3 cell line has neuroendocrine characteristics (1). This report prompted us to determine if this cell line is enriched in tumor initiating cells, and to use this cell line as a model to determine sensitivity to second generation anti androgen treatments and chemotherapeutic agents.

METHODS. To determine the percentage of tumor initiating cells (TICs) marker expression comparing LNCaP with PC-3 cells, flow cytometry analysis was used. Functional assays such as migration, invasion, colony formation and sphere formation were used to determine metastatic potential. Secondary and tertiary spheroid assays were used to determine the self-renewal ability. The CellTiter 96® AQueous non-radioactive cell proliferation assay was used to identify response to hormone deprivation and chemotherapeutic drugs.

RESULTS. The growth rate of PC-3 was similar to LNCaP cells while the TIC marker CD44 was only expressed on PC-3 cells. Both LNCaP and PC-3 cells expressed α2β1 with the highest expression detected in PC-3 cells. No expression of CD133 was detected in either of the cell lines. PC-3, as compared to LNCaP cells, displayed an increase in 5-minute collagen-I attachment, cell migration, invasion, colony formation and sphere formation in an anchorage-independent environment. PC-3 cells were capable of self-renewal in the secondary and tertiary spheroid assays and expressed neuroendocrine markers such as chromogranin A and EMT marker, Twist. PC-3 cells were able to also grow in androgen-deprived media, and as compared to LNCaP cells, demonstrated resistance to anti-androgen drugs that included enzalutamide and abiraterone and chemotherapy drugs such as doxorubicin and taxotere. Surprisingly, PC-3 cells were more sensitive to methotrexate than LNCaP or DU145 cells. PC3 cells had lower levels of MTAP (methylthioadenosine phosphorylase) and hence may be the reason for their sensitivity to denovo purine synthesis inhibitors such as methotrexate.

CONCLUSIONS. The novel findings presented here provide evidence that castrate resistant PC-3 cells are CD44+/ α2β1+/CD24low/CD133_ and possess stem cell properties and may serve as a useful model to study the role of new treatments for prostate cancer with neuroendocrine features.

Reference:

1) Prostate. 2011 Nov; 71(15): 1668-79; PC3 is a cell line characteristic of prostatic small cell carcinoma; Tai S, Sun Y, Squires JM, Zhang H, Oh WK, Liang CZ, Huang J

Citation Format: Nitu Bansal, Lisa Wu, Nadine Johnson Farley, Philip Tedeschi, Joseph R. Bertino. The castrate resistant PC-3 cell line with neuroendocrine features is enriched in tumor initiating cells and is resistant to enzalutamide and abiraterone but sensitive to antimetabolites. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4208. doi:10.1158/1538-7445.AM2015-4208

Enhanced degradation of dihydrofolate reductase through inhibition of NAD kinase by nicotinamide analogs

Dihydrofolate reductase (DHFR), because of its essential role in DNA synthesis, has been targeted for the treatment of a wide variety of human diseases, including cancer, autoimmune diseases, and infectious diseases. Methotrexate (MTX), a tight binding inhibitor of DHFR, is one of the most widely used drugs in cancer treatment and is especially effective in the treatment of acute lymphocytic leukemia, non-Hodgkin's lymphoma, and osteosarcoma. Limitations to its use in cancer include natural resistance and acquired resistance due to decreased cellular uptake and decreased retention due to impaired polyglutamylate formation and toxicity at higher doses. Here, we describe a novel mechanism to induce DHFR degradation through cofactor depletion in neoplastic cells by inhibition of NAD kinase, the only enzyme responsible for generating NADP, which is rapidly converted to NADPH by dehydrogenases/reductases. We identified an inhibitor of NAD kinase, thionicotinamide adenine dinucleotide phosphate (NADPS), which led to accelerated degradation of DHFR and to inhibition of cancer cell growth. Of importance, combination treatment of NADPS with MTX displayed significant synergy in a metastatic colon cancer cell line and was effective in a MTX-transport resistant leukemic cell line. We suggest that NAD kinase is a valid target for further inhibitor development for cancer treatment.

Association of quarterly average achieved hematocrit with mortality in dialysis patients: a time-dependent comorbidity-adjusted model

BACKGROUND

Recent publications suggest that increased mortality is associated with high hematocrit targets in erythropoietin-stimulating agent-treated patients with chronic kidney disease. We aim to further inform the debate about optimal hematocrit targets, advancing the hypothesis that the current hematocrit target may not optimize the survival of patients with end-stage renal disease.

STUDY DESIGN

Cross-sectional observational study.

SETTING & PARTICIPANTS

Medicare dialysis patients from 2002 to 2004 (n = 393,967).

FACTORS

Quarterly average hematocrit and erythropoietin alfa (EPO) dose.

OUTCOMES

Mortality hazard ratios from time-dependent Cox proportional hazard models, adjusting for comorbidities.

RESULTS

N = 2,712,197 patient-facility quarters. During the study, 100,086 deaths were identified. Percentages of patient quarters within each hematocrit category: hematocrit less than 27% (2.0%), 27% to 28.49% (1.7%), 28.5% to 29.9% (2.9%), 30% to 31.49% (5.2%), 31.5% to 32.99% (9.0%), 33% to 34.49% (14.9%), 34.5% to 35.99% (19.2%), 36% to 37.49% (18.0%), 37.5% to 38.99% (12.0%), 39% to 40.49% (6.4%), 40.5% to 41.99% (3.0%), and 42% or greater (3.1%). Mortality hazard ratios from the fully adjusted model: hematocrit less than 27% (3.11), 27% to 28.49% (2.60), 28.5% to 29.9% (2.14), 30% to 31.49% (1.80), 31.5% to 32.99% (1.44), 33% to 34.49% (1.17), 34.5% to 35.99% (reference), 36% to 37.49% (0.98), 37.5% to 38.99% (1.01), 39% to 40.49% (1.13), 40.5% to 41.99% (1.32), and 42% or greater (1.57).

LIMITATIONS

First, potential confounding by indication related to associations between underlying illness and mortality, anemia, and EPO responsiveness. Second, Medicare claims data reflect a range of conditions and degrees of severity not easily translated into the clinical context. Third, for Medicare claims, EPO reporting is not required if EPO is not billed. Greater than 95% of "missing hematocrit" quarters are "EPO = 0" patient quarters. Interpretation of results for the missing hematocrit and EPO = 0 use categories is complicated by data source limitations.

CONCLUSIONS

We show an association between mortality and low hematocrit in dialysis patients, in part reflecting the presence of comorbidities. We also show an association between increased mortality and high hematocrit. Additional interventional trials should be undertaken to better define the optimal target for anemia management in patients with end-stage renal disease, with careful prospective identification of underlying comorbidities and clinical factors contributing to high erythropoietin-stimulating agent requirement.

Case-mix adjustment for an expanded renal prospective payment system

Medicare is considering an expansion of the bundle of dialysis-related services to be paid on a prospective basis. Exploratory models were developed to assess the potential limitations of case-mix adjustment for such an expansion. A broad set of patient characteristics explained 11.8% of the variation in Medicare allowable charges per dialysis session. Although adding recent hematocrit values or prior health care utilization to the model did increase explanatory power, it could also create adverse incentives. Projected gains or losses relative to prevailing fee-for-service payments, assuming no change in practice patterns, were significant for some individual providers. However, systematic gains or losses for different classes of providers were modest.

Understanding the basic case-mix adjustment for the composite rate

In April 2005, Medicare began adjusting payments to dialysis providers for composite-rate services for a limited set of patient characteristics, including age, body surface area, and low body mass index. We present analyses intended to help the end-stage renal disease community understand the empirical reasons behind the new composite-rate basic case-mix adjustment. The U-shaped relationship between age and composite-rate cost that is reflected in the basic case-mix adjustment has generated significant discussion within the end-stage renal disease community. Whereas greater costs among older patients are consistent with conventional wisdom, greater costs among younger patients are caused in part by more skipped sessions and a greater incidence of certain costly comorbidities. Longer treatment times for patients with a greater body surface area combined with the largely fixed cost structure of dialysis facilities explains much of the greater cost for larger patients. The basic case-mix adjustment reflects an initial and partial adjustment for the cost of providing composite-rate services.

Racial and gender variation in use of diagnostic colonic procedures in the Michigan Medicare population

BACKGROUND

There is accumulating evidence that screening programs can alter the natural history of colorectal cancer, a significant cause of mortality and morbidity in the US. Understanding how the technology to diagnose colonic diseases is utilized in the population provides insight into both the access and processes of care.

METHOD

Using Medicare Part B billing files from the state of Michigan from 1986 to 1989 we identified all procedures used to diagnose colorectal disease. We utilized the Medicare Beneficiary File and the Area Resource File to identify beneficiary-specific and community-sociodemographic characteristics. The beneficiary and sociodemographic characteristics were, then, used in multiple regression analyses to identify their association with procedure utilization.

RESULTS

Sigmoidoscopic use declined dramatically with the increasing age cohorts of Medicare beneficiaries. Urban areas and communities with higher education levels had more sigmoidoscopic use. Among procedures used to examine the entire colon, isolated barium enema was used more frequently in African Americans, the elderly, and females. The combination of barium enema and sigmoidoscopy was used more frequently among females and the newest technology, colonoscopy, was used most frequently among White males.

CONCLUSION

The existence of race, gender, and socioeconomic disparities in the use of colorectal technologies in a group of patients with near-universal insurance coverage demonstrates the necessity of understanding the reason(s) for these observed differences to improve access to appropriate technologies to all segments in our society.

Hospitalization for gastrointestinal and liver diseases: the effect of socioeconomic and medical supply factors

A growing body of research has documented significant variation in health care use between communities. As the health care system is transformed, providers and payers should understand the interaction between a community, its sociodemographic characteristics, and its use of health resources. We describe the association between a population's demographic, socioeconomic, and medical resources and hospital use related to gastrointestinal and liver diseases. We used an all-payer hospital discharge database for Michigan from 1986 to 1988. We identified all medical and surgical hospital admissions during this period from two of the Diagnostic Related Group, Major Diagnostic Categories: No. 6, Diseases and Disorders of the Digestive System; and No. 7, Diseases and Disorders of the Hepatobiliary System and Pancreas. We analyzed age- and sex-specific use rates. Finally, we analyzed the influence of sociodemographic variables from the Area Resource File at the county level, on hospital use, using a Poisson regression model. We noted a significant association between increased hospitalizations and increased age in a community. Hospital beds per capita did not influence admission rates overall, although more hospital beds were associated with more medical admissions. Overall, the total physician supply was associated with more admissions. Finally, the most important socioeconomic variable was education. As the level of education of a county increased, hospital admissions decreased dramatically. The transformation of the health care delivery system presents opportunities and challenges. Understanding the underlying epidemiology of disease and how it interacts with a community's socioeconomic and medical resources or medical supply characteristics will be necessary to meet the community's health needs and to ensure the financial viability of providers. This is especially true when payers use a standard payment in a region, such as Medicare's managed care payment, without adjustments for the underlying population characteristics known to influence use.

Regional variation of nonrural pediatric ambulance transport rates: an ecological study

STUDY OBJECTIVE

To determine the relationship of pediatric transport rates per hundred thousand pediatric population (RATE) to socioeconomic status (SES) factors and also mortality in Emergency Medical Services (EMS) systems.

DESIGN

Retrospective ecological study.

SETTING

Four EMS Medical Control Authorities (MCAs) in Michigan.

PARTICIPANTS

Patients (3,792), 0-19 years of age, responded to as a nonscheduled emergency response and transported to a hospital by ambulance.

METHODS AND MEASUREMENTS

RATE, economic status (INCOME), private transportation status (VEHICLE), educational status (EDUC), primary care physician availability (PHYS), and EMS disease death rate (EMSDD) were determined for each MCA and analyzed using Spearman rank correlation.

RESULTS

RATE between MCAs varied from 325 to 750. RATE was highest in the most urban MCA: its 0-4 RATE was fourfold larger than any other MCA. INCOME, EDUC, and VEHICLE were inversely correlated with transport rate: -1.00, -1.00, -1.00; P < 0.001. Rate was positively correlated with EMSDD: 1.00; P < 0.001.

CONCLUSIONS

Substantial variation in RATE between MCAs may be primarily due to the high 0-4 transport rate in the most urban MCA. This study also suggests that higher pediatric EMS system utilization rates may be correlated to higher mortality and also to unavailability of personal transportation.

Community correlates of hospital use

This article demonstrates that the variation among communities in hospital use, measured by the total patient-day rate, is overwhelmingly associated with the variation in discharge rates. In particular, this variation is primarily attributable to the variation in nonsurgical discharge rates. While there is residual variance associated with variance in length of stay and interaction effects, more than two-thirds of the variance in the patient-day rates is attributable to variance in discharge rates. Further, little variation is demonstrated across communities in total average length of stay. High use communities have high discharge rates which are not explicable in terms of several need-determining characteristics of the community populations. Discharge-rate variation is demonstrated to be strongly associated with differences in the supply of medical care resources--in particular, acute care beds, surgeons, and nonsurgical specialists.

Classification of hospital patients as "surgical." Implications of the shift to ICD-9-CM

Using a nearly complete set of hospital discharge abstracts for Michigan in 1980, the authors offer evidence that the shifts in diagnostic and procedure coding (from HICDA-2 to ICD-9-CM) and associated class definitions may have affected both estimates of surgical/nonsurgical use rates and expected lengths of stay of operated versus nonoperated patients as defined using Commission on Professional and Hospital Activities length-of-stay texts.