BackgroundProminent studies continue to measure the hospital volume-outcome relation using simple logistic or random-effects models. These regression models may not appropriately account for unobserved differences across hospitals (such as differences in organizational effectiveness) which could be mistaken for a volume outcome relation.ObjectiveTo explore alternative estimation methods for measuring the volume-outcome relation for six major cancer operations, and to determine which estimation method is most appropriate.MethodsWe analyzed patient-level hospital discharge data from three USA states and data from the American Hospital Association Annual Survey of Hospitals from 2000 to 2011. We studied six major cancer operations using three regression frameworks (logistic, fixed-effects, and random-effects) to determine the correlation between patient outcome (mortality) and hospital volume.ResultsFor our data, logistic and random-effects models suggest a non-zero volume effect, whereas fixed-effects models do not. Model-specification tests support the fixed-effects or random-effects model, depending on the surgical procedure; the basic logistic model is always rejected. Esophagectomy and rectal resection do not exhibit significant volume effects, whereas colectomy, pancreatic resection, pneumonectomy, and pulmonary lobectomy do.ConclusionsThe statistical significance of the hospital volume-outcome relation depends critically on the regression model. A simple logistic model cannot control for unobserved differences across hospitals that may be mistaken for a volume effect. Even when one applies panel-data methods, one must carefully choose between fixed- and random-effects models.Electronic supplementary materialThe online version of this article (doi:10.1007/s40258-016-0241-6) contains supplementary material, which is available to authorized users.

Distant metastases from papillary thyroid carcinoma (PTC) are rare and are associated with a poor prognosis. Here, we describe a patient with metastatic PTC who was treated with a tyrosine kinase inhibitor (TKI, sorafenib) for several months that was acutely exacerbated by discontinuation. A 43-year-old male was diagnosed with PTC in February 2004 and underwent total thyroidectomy followed by two courses of high-dose radioactive iodine (RAI) therapy. Despite two additional courses of high-dose RAI therapy, lung and muscle metastases were developed. Treatment with sorafenib was begun in September 2010. After 11 months treatment of sorafenib, newly developed metastatic lesions were found in mediastinal lymph nodes, liver, and bones. Considered as treatment failure, the administration of sorafenib was discontinued. Two weeks after sorafenib treatment was stopped, the disease progressed abruptly and caused death of the patient by respiratory failure. In our patient, PTC progressed rapidly after the cessation of sorafenib treatment. Patients with several other types of cancer have also experienced such rapid disease progression, termed "flare-ups." Physicians should be aware that flare-ups may occur in advanced PTC patients following the cessation of TKI therapy.

Recently, serotype K1 Klebsiella pneumoniae has been a major agent of an invasive syndrome characterized by liver abscess and its metastatic infection. Extrahepatic infection and its characteristics in patients with renal abscess caused by K. pneumoniae are poorly understood, and few cases of central nervous system infection have been reported. This is a report of 80-year-old woman with uncontrolled type 2 diabetes mellitus with renal abscess caused by serotype K1 K. pneumoniae, complicated with ventriculitis despite of appropriate use of antibiotics. Physicians need to be aware of possibility of metastatic infection in patients with serotype K1 K. pneumoniae infection, if they develop neurologic symptom and focus of infection is still present.

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