207 S. Santa Anita St. Suite P-25
San Gabriel CA 91776
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Age- and sex-related incidence of surgically treated primary hyperparathyroidism. - World journal of surgery
Primary hyperparathyroidism (1 degrees HPT) is reported most often in women over the age of 50. Beyond that, little is known about the epidemiology of this condition, and no studies have specifically examined the age and gender distribution of patients with 1 degrees HPT.We analyzed patients from the Nationwide Inpatient Sample (NIS), a 20% random sample of all hospital stays from 2000-2004, and also from the University of Michigan endocrine surgery database from 1999-2005. Surgically treated 1 degrees HPT was used as a surrogate marker for 1 degrees HPT. An age- and sex-based frequency distribution was computed for each dataset.A total of 7,513 females and 2,677 males who underwent surgery for 1 degrees HPT in the 5-year period 2000 through 2004 were reported in the NIS. At the University of Michigan from 1999 through 2005, 790 females and 276 males underwent parathyroidectomy for 1 degrees HPT. In both datasets, the frequency of 1 degrees HPT began to rise slowly in both sexes at age 11 and increased more rapidly among females than males beginning at age 21-25 (NIS) and 26-30 (UM). Incidence curves for both women and men in both databases were similar in shape and unipolar in configuration. Peak incidence was at age 56-60 (NIS) and 61-65 (UM) in females and age 56-60 in males (both datasets). The female:male ratio was noted to rise steadily among the NIS patients until perimenopausal age, after which it became stable for the next 20 years before decreasing again. No change in the female:male ratio over time was seen among the UM patients.Primary HPT occurs more frequently in females than in males at all ages. The incidence increases steadily after age 25 in both sexes. The female:male ratio does not change during the peri- and postmenopausal years. This information should stimulate new hypotheses to explain the difference in the incidence of 1 degrees HPT between men and women.
Hospital volume and inpatient mortality outcomes of total hip arthroplasty in the United States. - The Journal of arthroplasty
The purpose of this study was to examine the effect of hospital volume on outcomes for primary and revision total hip arthroplasty (THA). The Nationwide Inpatient Sample database was used to identify our patient set. These data include a sample of non-Medicare and Medicare patients who are unique to this study, increasing external validity compared with other studies. Outcome variables examined included in-hospital mortality and prolonged length of stay (PLOS). Primary THA mortality was 0.16% in the highest volume quartile and 0.29% in the lowest volume quartile (P < .001). The rates of PLOS showed improved outcomes in the highest volume hospitals. Similar trends were found for revision THA, with an in-hospital mortality of 1.20% for lowest volume hospitals and 0.48% for highest volume hospitals (P < .001). Hospitals with higher volume had superior inpatient outcomes mortality, PLOS, and discharge disposition for THA and revision arthroplasty.
Changes in the utilization of spinal fusion in the United States. - Neurosurgery
Several reports suggest that spine surgery has experienced rapid growth in the past decade. Limited data exist, however, documenting the increase in spinal fusion. The objective of this work was to quantify and characterize the contemporary practice of spinal fusion in the United States.Clinical data were obtained from the Nationwide Inpatient Sample for the years from 1993 to 2003. All patients with International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes indicating cervical fusion, thoracolumbar fusion, lumbar or unspecified fusion were identified (n = 471,990). Primary ICD-9-CM diagnosis codes were used to determine the rationale for surgical fusion. Population-based utilization rates overall and for each procedure were calculated from United States census data. Rank order of spinal fusion compared with other inpatient procedures from the Nationwide Inpatient Sample was reported for the years 1997 to 2003.Overall utilization increased during the time period for cervical, thoracolumbar, and lumbar fusions by 89, 31, and 134%, respectively. Patients aged 40 to 59 years experienced the rapid rise in utilization for cervical fusions (60-110 per 100,000) and lumbar fusions (35-84 per 100,000). For patients 60 years and older, utilization also increased for cervical (30-67 per 100,000), thoracolumbar (4-9 per 100,000), and lumbar (42-108 per 100,000). Spinal fusion rose from the 41st most common inpatient procedure in 1997 to the 19th in 2003.Cervical, thoracolumbar, and lumbar spinal fusion have experienced a rapid increase in utilization in isolation and compared with other surgical procedures in contemporary practice. These changes are most pronounced for patients over 40 years of age, and degenerative disc disease seems to account for much of this increase.
The effect of secondary operations on mortality following abdominal aortic aneurysm repair in the United States: 1988-2001. - Vascular and endovascular surgery
Certain complications following open repair of abdominal aortic aneurysms (AAAs) require additional operations or invasive procedures. The purpose of this study was to determine the effect of secondary interventions on mortality rate following open repair of intact and ruptured AAAs in the United States. Clinical data on 98,193 patients treated from 1988 to 2001 with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) primary procedure code 38.44 (resection of the abdominal aorta with replacement) were analyzed. Demographic factors, types of secondary interventions, and in-hospital mortality rates were assessed by univariate and multivariate logistic regression analysis (SPSS Version 11.0, Chicago, IL). The database utilized in this study was The Nationwide Inpatient Sample (NIS). The mortality rate was 4.5% in the intact AAA group and 45.5% in the ruptured AAA group. The rate of secondary operations and procedures was much higher in the ruptured AAA group, especially related to renal failure (5.52% vs 1.49%, p <0.001); respiratory failure (3.67% vs 0.71%, p <0.001); postoperative bleeding (2.41% vs 0.81%, p <0.001); or colonic ischemia (2.38% vs 0.36%, p <0.001). Increased mortality following open repair of intact AAAs accompanied: peripheral artery angioplasty/stenting (OR, 1.25; 95% CI, 1.04-1.51; p = 0.018); coronary artery angioplasty/stenting (OR, 1.68; 95% CI, 1.05-2.70; p = 0.031); inferior vena cava (IVC) filter placement (OR, 2.02; 95% CI, 01.31-3.1; p = 0.001); vascular reconstruction or thromboembolectomy (OR, 2.05; 95% CI, 1.9-2.22; p <0.001); lower extremity amputation (OR, 4.09; 95% CI, 2.78-6.0; p <0.001); coronary artery bypass (OR, 6.71; 95% CI, 3.74-12.03; p <0.001); operations for postoperative bleeding (OR, 6.92; 95% CI, 5.71-8.4; p <0.001); initiation of hemodialysis (OR, 10.52; 95% CI, 9.22-12.01; p <0.001); tracheostomy (OR, 11.9; 95% CI, 9.86-14.37; p <0.001); and colectomy (OR, 16.22; 95% CI, 12.55-20.95; p <0.001). Increased risk of mortality following open repair of ruptured AAAs accompanied the following: operations for postoperative bleeding (OR, 1.5; 95% CI, 1.22-1.85; p <0.001); colectomy (OR, 1.63; 95% CI, 1.32-2.01; p <0.001); and initiation of hemodialysis (OR, 2.66; 95% CI, 2.30-3.08; p <0.001). The only independent variable in this group associated with decreased risk of in-hospital mortality was IVC filter placement (OR, 0.41; 95% CI, 0.27-0.64; p <0.001). This study confirms the perception that additional operations or invasive procedures following open repair of AAA entail significantly worse in-hospital mortality rates, especially when related to colonic ischemia, respiratory failure, and renal failure.
Hemiarthroplasty for femoral neck fracture in the elderly surgeon and hospital volume-related outcomes. - The Journal of arthroplasty
The elderly patient with a displaced femoral neck fracture is commonly treated via hemiarthroplasty. The objectives of this study were to: 1) determine the rates of in-hospital mortality, complications, and prolonged length of stay (LOS) in such patients; 2) elucidate the patient characteristics that predict these occurrences; and 3) investigate the influence of surgeon and hospital volumes on these outcomes. Using the Nationwide Inpatient Sample (NIS), 173,508 cases of hemiarthroplasty for femoral neck fracture were identified in patients > or =65 years of age. Univariate and multivariate analysis demonstrated that hospitals with low caseload volumes were associated with increased patient risk for prolonged LOS, pulmonary embolism, urinary tract infection, and pneumonia. Surgeons with low caseload volumes were associated with increased risk for mortality and prolonged LOS. Quality-improvement initiatives would benefit from consideration of these factors.
Severe chronic venous insufficiency: magnitude of the problem and consequences. - Annals of vascular surgery
The aim of this study was to characterize patients requiring hospitalization for severe chronic venous insufficiency (CVI) at the local and national levels and to analyze factors related to primary amputation. An administrative database (Nationwide Inpatient Sample, 1988-2000) and a single institution (1992-2000) were reviewed using the International Classification of Diseases, 9th ed., Clinical Modification, codes for CVI, excluding phlegmasia and concomitant peripheral vascular occlusive disease codes. Demographics, clinical course, and outcomes were assessed. Descriptive, univariate, and multivariate statistical analyses were used; p < 0.05 was considered significant. Nationally, CVI occurred with a mean incidence of 92/100,000 admissions, of which 55% were women, having a mean age of 65 years and a median length of stay of 7 days. Mean hospital charges were $13,900 and did not change significantly over time. Acute deep vein thrombosis affected 1.3%, amputation was performed in 1.2%, and in-hospital mortality was 1.6% The local cohort included 67 patients with a mean age of 51 years; a majority were men (60%), and 85% were C6 (of Clinical-Etiologic-Anatomic-Pathophysiology [CEAP]). Patients averaged 23 clinic visits and a median of one hospitalization for CVI care over a 44-month follow-up. Twelve patients (18%) underwent a CVI-related amputation (one transmetatarsal amputation, nine below-knee amputations, and two above-knee amputations). They had fourfold more CVI-related hospitalizations, greater preoperative chronic narcotic use than nonamputee patients (85% vs. 58%), but less ongoing wound care needs (25% vs. 89%) (all p values < 0.05). However, no significant difference in long-term mortality, number of clinic visits, duration of symptoms, antibiotic courses, or prior venous-related surgeries was found. In those with amputation, ambulatory status was maintained in 75% at 15-month follow-up. The physiological and economic costs of severe CVI are significant and have not decreased over more than a decade. Amputation for CVI-related nonhealing wounds has a reasonable outcome. Future therapy must focus on prevention of CVI sequelae.
Osteomyelitis of the foot and toe in adults is a surgical disease: conservative management worsens lower extremity salvage. - Annals of surgery
To characterize the national epidemiology of adult osteomyelitis (OM) and, using a single institutions' experience, test the hypothesis that early surgical therapy as compared with antibiotics alone results in an improved chance of wound healing and limb salvage.Foot and digit OM is a very common problem for which management is variable and for which few guidelines exist.The Nationwide Inpatient Sample (NIS) and a single institution review from 1993 to 2000 form the basis of this study, using ICD-9CM codes for lower extremity foot and digit OM. Demographics, risk factors, and treatments were analyzed against the outcomes of a healed wound, limb salvage, and death.The NIS included 51,875 patients (incidence = 9/10,000 patients per year) with a mean age of 60 years, and 59% were men. The median length of stay decreased from 9 to 6 days (P < 0.001), but the average admission charge of 19,000 dollars did not significantly decrease over 7 years. Of these patients, 23% underwent a digit amputation and 8.5% suffered proximal limb loss. Single-institution analysis of 237 consecutive patients with OM confirmed a similar mean age (58 years), gender (67% men), and most presented with a foot or digit ulcer (56%). Wound healing was achieved in 56% and overall limb salvage was 80%. Decreased wound healing was associated with peripheral vascular occlusive disease (odds ratio, 0.4; 95% confidence interval, 0.2-0.8, P = 0.006) and preadmission antibiotic use (odds ratio, 0.2; 95% confidence interval, 0.05-1.1, P=0.07), while surgical debridement (odds ratio, 2.2; 95% confidence interval, 1.2-4.2, P = 0.02) was associated with increased healing. Limb salvage was improved with an arterial bypass (odds ratio, 3.9; 95% confidence interval, 1.1-14, P = 0.04), while preadmission solid organ transplant (odds ratio, 0.37; 95% confidence interval, 0.14-0.96, P = 0.04), peripheral vascular occlusive disease (odds ratio, 0.25; 95% confidence interval, 0.12-0.5, P = 0.001), and preadmission antibiotic use (odds ratio, 0.34; 95% confidence interval, 0.15-0.77, P = 0.009) were associated with greater limb loss.Digit OM is an expensive and morbid disease. Aggressive surgical debridement/digit amputation and selected use of arterial bypass should improve wound healing and limb salvage, respectively. In contrast, antibiotic therapy alone is associated with decreased wound healing and limb salvage.
Venous thromboembolism: regional differences in the nationwide inpatient sample, 1993 to 2000. - Vascular
Venous thromboembolism (VTE) is a costly complication of hospitalization. The sequelae make it a concern for public health planners. The Nationwide Inpatient Sample (NIS) contains data for hospital discharges in the United States. These data were reviewed to determine their suitability for health policy planning. International Classification of Diseases, Ninth Revision, Clinical Modification codes for VTE were applied to the NIS data. The sample was queried for demographic information, mortality, length of hospital stay, diagnosis, and treatment. The rates were standardized for geographic region and disease acuity. Statistical analysis included descriptive reporting of means and event rates; analysis of variance and logistic regression were used for regional effects and modeling of mortality. Between 1993 and 2000, 636,814 discharges involved VTE (1.2%). This rate was consistent over time and within regions. Regional differences existed in the acceptance of new technology and hospital charges. Mortality varied from 6.3% (Midwest) to 7.9% (Northeast) and was associated with admission type, comorbidities, pulmonary embolism, and discharge from the Northeast region. White race, chronic venous insufficiency, and female gender were protective variables. The NIS data report a consistent mortality rate despite improved therapy. Regional diagnostic, treatment, and economic differences exist. The data are useful for the purposes of public health care planning and stimulating clinical trial questions.
Variation in outcomes after percutaneous coronary intervention in the United States and predictors of periprocedural mortality. - Cardiology
The objective of this study was to characterize variation in mortality rates across hospitals performing percutaneous coronary intervention (PCI) in the United States. For this purpose, data (n = 735,022) from the Nationwide Inpatient Sample from 1996 to 2001 were analyzed. The primary outcome for the analysis was postprocedural in-hospital mortality. Mortality rates were calculated by race, gender, geographic region, comorbid status and hospital volume. There were significant variations in mortality across gender groups, comorbid status, regions and by hospital volume status. Independent predictors of mortality in this large cohort were older age, female gender, lower income and lower hospital volume. The data suggests targets for quality improvement initiatives for patients undergoing PCI particularly in the elderly, females, lower income patients and low volume hospitals. Even in the contemporary era of adjunctive pharmacological therapies and ubiquitous use of stents, hospital volume remains a significant independent predictor of in-hospital mortality.Copyright 2005 S. Karger AG, Basel.
Epidemiology of surgically treated abdominal aortic aneurysms in the United States, 1988 to 2000. - Vascular
Abdominal aortic aneurysm (AAA) repair is a complex procedure about which little information exists regarding trends in surgical practice in the United States. This study was undertaken to define benchmark data regarding performance and outcomes of conventional AAA repair that might be used in comparisons with endovascular AAA repair data. Patients undergoing repair of intact (n = 87,728) or ruptured (n = 16,295) AAAs in the Nationwide Inpatient Sample (NIS) for 1988 to 2000 were studied. The NIS represents a 20% stratified random sample of all discharges from US hospitals. Unadjusted and case mix-adjusted analyses of in-hospital mortality and length of stay were performed. The overall frequency of intact AAA repair remained relatively stable during the study period, ranging from 18.1 to 16.3 operations/100,000 adults between 1988 and 2000, respectively. The operative mortality rate for intact AAA repair decreased significantly (p < .001) from 6.5% in 1988 to 4.3% in 2000. Length of stay following intact AAA repair also declined significantly (p < .001) from a median of 11 days in 1988 (interquartile range [IQR] 9-15 days) to 7 days in 2000 (IQR 5-10 days). The incidence of ruptured AAA repair decreased significantly (p < .001) from 4.2 to 2.6 operations/100,000 adults between 1988 and 2000, respectively. Mortality for ruptured AAA repair, averaging 45.6%, did not decrease significantly during the study period. Intact AAA repair by conventional means has become increasingly safe, with decreased operative mortality and shorter hospital stays. Ruptured AAA repair by conventional means has not become safer but has decreased in incidence, suggesting possible reductions in risk factors contributing to rupture, coupled with more timely intact AAA repairs.
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207 S. Santa Anita St. Suite P-25 San Gabriel, CA 91776
1381 E Las Junas Dr Suite #8
529 E Valley Blvd Ste 288A