Thyroidectomy is an operation with infrequent but potentially significant complications. This stu... more Thyroidectomy is an operation with infrequent but potentially significant complications. This study aimed to determine risk factors for complication after thyroidectomy in California. The California Office of Statewide Health Planning and Development database was retrospectively analyzed from 1995 to 2010. Main outcome measures were complications including death. Logistic regression identified risk factors for complications. There were 106,773 patients; 61% were women and 44% Caucasian; 16,287 (15%) thyroidectomies were performed at high-volume centers. Complication rates included voice change (.5%), vocal cord dysfunction (1.1%), hypocalcemia (4.5%), tracheostomy (1.62%), hematoma (1.75%), and death (.3%). There was significantly increased risk of complications for patients older than 65 compared with those younger than 40 years (odds ratio, 2.0; 95% confidence interval, 1.8 to 2.3; P < .01). High-volume hospitals were protective against complication (odds ratio, .8; 95% confide...
To our knowledge, long-term outcomes of open and endovascular (EVAR) repairs of abdominal aortic ... more To our knowledge, long-term outcomes of open and endovascular (EVAR) repairs of abdominal aortic aneurysms (AAAs) have not been studied on a population level outside a controlled trial setting. To determine long-term outcomes of EVAR vs open repair on a population level. Analysis of the longitudinally linked California Office of Statewide Health Planning and Development inpatient database from 2001 to 2009. Median follow-up was 3.3 years. Endovascular vs open repairs. Mortality and complications at 30 days, as well as long-term mortality and complications up to 9 years. In this observational study, a total of 23 670 patients were studied, with 52% receiving EVAR. Endovascular repair was associated with improved 30-day outcomes (all-cause mortality, readmission, surgical site infection, pneumonia, and sepsis), as well as significantly improved survival until 3 years postoperatively. After 3 years, mortality was higher for patients who underwent an EVAR repair. No significant differen...
Healthcare costs in the United States (U.S.) are rising. As outcomes improve, such as decreased l... more Healthcare costs in the United States (U.S.) are rising. As outcomes improve, such as decreased length of stay and decreased mortality, it is expected that costs should go down. The aim of this study is to analyze hospital charges, cost of care, and mortality in bariatric surgery over time. A retrospective analysis of the Nationwide Inpatient Sample (NIS) database was performed. Adults with morbid obesity who underwent gastric bypass or sleeve gastrectomy were identified by ICD-9 codes. Multivariate analyses identified independent predictors of changes in hospital charges and in-hospital mortality. Results were adjusted for age, race, gender, Charlson comorbidity index, surgical approach (open versus laparoscopic), hospital volume, and insurance status. In order to estimate baseline surgical inflation, changes in hospital charges over time were also calculated for appendectomy. From 1998 to 2011, 209,106 patients were identified who underwent bariatric surgery. Adjusted in-hospital ...
Improved outcomes have been associated with various methods of size matching between expanded cri... more Improved outcomes have been associated with various methods of size matching between expanded criteria (ECD) donors and recipients. A novel method for improved functional based matching was developed utilizing manipulation of Cockcroft-Gault estimated creatinine clearances for donor and recipient. We hypothesized that optimal clearance-based matches would have superior outcomes for both immediate graft function and long term graft survival. For the analysis, recipients of ECD kidneys in the Scientific Registry of Transplant Recipients (SRTR) transplanted between October 1, 1987 to August 31, 2011 were included. Univariate and multivariate analyses predicted the hazard ratio of graft failure and the odds ratio of requiring dialysis within the first week. 25,640 ECD kidney transplants were analyzed. On multivariate analysis, lower CCMR was associated with increased graft failure and odds of requiring dialysis within the first week (comparing highest ratio quintile versus lowest ratio ...
Most population-based studies lack long-term data, making the reporting of true mortality and out... more Most population-based studies lack long-term data, making the reporting of true mortality and outcome rates difficult. An accurate estimate of these rates in a high-risk population is critical for obtaining informed consent, especially for an elective procedure such as Roux-en-Y gastric bypass (RYGB). To examine the longitudinal outcomes of RYGB. The California Office of Statewide Health Planning and Development (OSHPD) longitudinal database. The OSHPD longitudinal database was queried for patients who underwent RYGB between 1995 and 2009. The primary outcome was mortality rates at 1, 5, and 10 years. Secondary outcomes were marginal ulcer and reoperation. The Cox hazard proportional analysis was used to determine adjusted survival and long-term outcomes for laparoscopic RYGB compared with open RYGB. The study included 129,432 RYGB patients. Rates of laparoscopy increased from 3% to 35% from 1995 to 2004 and then steeply increased to 80% in 2005 and to 93% in 2009. Overall mortality rate at 1, 5, and 10 years was 2.2%, 4.4%, and 8.1%, respectively; the rates of marginal ulcer were .3%, .7%, and 1%, respectively; and the reoperation rates were .3%, .8%, and 1.2%, respectively. Predictors of poor outcomes were male gender, age, smoking, alcohol, Medicare, Medi-Cal insurance, and Asian or Native American race. The laparoscopic approach was protective against death (hazard ratio [HR] 95% confidence interval [95%CI]: .63[.58-.69]) and long-term complications (HR .78[.72-.85]). This longitudinal population study showed high rates of mortality following RYGB, with improved long-term outcomes when the laparoscopic approach was used.
Cultured mononuclear phagocytes produce soluble factors that stimulate endothelial cells to relea... more Cultured mononuclear phagocytes produce soluble factors that stimulate endothelial cells to release GM-colony-stimulating activity (GM-CSA). One such factor was recently identified as interleukin 1 (IL 1). Studies were designed to determine which types of granulopoietic factors are released by IL 1-stimulated endothelial cells. Supernatants from endothelial cells cultured for 3 days in medium containing IL 1 alpha and beta were tested in both murine and human CFU-GM colony growth assays. The effect of conditioned media on differentiation of WEHI-3B myelomonocytic leukemic cells was also examined. Control media containing IL 1 alone or unstimulated endothelial cell-conditioned media contained no detectable CSA in any bioassay. Medium conditioned by IL 1-stimulated endothelial cells stimulated the clonal growth of both human and murine CFU-GM and induced macrophage differentiation of WEHI-3B cells. Treatment of these conditioned media with a highly specific neutralizing monoclonal G-C...
La r esection de la premi ere cô te et la scal enectomie est un traitement acceptable chez les ma... more La r esection de la premi ere cô te et la scal enectomie est un traitement acceptable chez les malades ayant une thrombose de la veine axillo-sous-clavi ere qui ont r epondu au traitement thrombolytique et d emontr e une perm eabilit e de la veine sous-clavi ere. Cependant, le traitement des malades se pr esentant avec une occlusion chronique de la veine sous-clavi ere est controvers e. Nous pr esentons quatre malades de ce type qui ont eu une r esection de la premi ere cô te et une scal enectomie et dont la veine sous-clavi ere s'est spontan ement recanalis ee dans l'ann ee suivant l'intervention, alors qu'ils etaient anticoagul es, ainsi que le protocole d'ultrasons utilis e dans notre institution pour identifier une telle recanalisation. L'â ge moyen de ces malades etait de 20 ans (extrê mes 17 et 23 ans). Trois etaient de sexe masculin et une de sexe f eminin. L'intervalle de temps moyen entre l'intervention et la thrombose etait de 25 semaines (extrê mes 12 et 34 semaines). Tous les malades etaient asymptomatiques et ont eu une r esection de la premi ere cô te et une scal enectomie par voie axillaire, en incisant le tendon du muscle sous-clavier. Tous ont eu un traitement post-op eratoire par warfarine et ont et e surveill es par echographie-Doppler. Chez chacun de ces quatre malades, la veine sous-clavi ere s'est recanalis ee par la suite apr es une moyenne de 7 mois (extrê mes deux et 11 mois) et l'anticoagulation a et e arrê t ee. La perm eabilit e de la veine sous-clavi ere qui en est r esult ee a et e corr el ee avec l'am elioration des symptô mes chez chacun des quatre malades. Tous les malades etaient asymptomatiques au cours de la p eriode de suivi post-op eratoire a une moyenne de 14 mois (extrê mes deux et 33 mois). En conclusion, certains malades ayant une occlusion de la veine sous-clavi ere peuvent ê tre trait es agressivement par r esection de la premi ere cô te et scal enectomie ainsi que par anticoagulation, entraînant la recanalisation et la r eouverture de la veine au cours du temps. Ce traitement est corr el e avec l'am elioration des symptô mes. La thrombose veineuse profonde d'effort du membre sup erieur, ou syndrome de Paget-Schroetter, a et e d ecrite pour la premi ere fois de façon ind ependante par Paget en 1875 1 et plus tard par Von Schroetter en France en 1884 2 . En 1949, Hughes 3 , dans une etude comportant 320 malades, a reconnu une entit e pathologique distincte et introduit le terme de syndrome de Paget-Schroetter. Celui-ci affecte fr equemment le membre sup erieur dominant de jeunes hommes actifs et en bonne sant e. L' ev enement pr edisposant est habituellement une sorte quelconque de mouvements r ep etitifs forc es. Une thrombose inattendue a et e rapport ee par Urschel et Razzuk 4 chez des malades ayant des activit es tr es diverses, depuis des halt erophiles et des joueurs de football jusqu' a des peintres et des esth eticiens. Des activit es laborieuses peuvent ê tre la cause de l esions de l'intima vasculaire, entraînant une augmentation de la pr edisposition a la thrombose. Si une compression extrins eque pr eexistante
Risk adjustment is an important component of quality assessment in surgical health care. However,... more Risk adjustment is an important component of quality assessment in surgical health care. However, data collection places an additional burden on physicians. There is also concern that outcomes can be gamed depending on the information recorded for each patient. To determine whether a number of machine-collected data elements could perform as well as a traditional full-risk adjustment model that includes other physician-assessed and physician-recorded data elements. All general surgery patients from the National Surgical Quality Improvement Program database from January 1, 2005, to December 31, 2010, were included. Separate multivariate logistic regressions were performed using either all 66 preoperative risk variables or only 25 objective variables. The area under the receiver operating characteristic curve (AUC) of each regression using objective preoperative risk variables was compared with its corresponding regression with all preoperative variables. Subset analyses were performe...
JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons, 2014
This study describes perioperative patient safety outcomes comparing laparoscopic appendectomy wi... more This study describes perioperative patient safety outcomes comparing laparoscopic appendectomy with open appendectomy in the elderly population (defined as age ≥65 years) during the diffusion of laparoscopic appendectomy into widespread clinical practice. We performed a cross-sectional analysis of patients undergoing open or laparoscopic appendectomy in the US Nationwide Inpatient Sample, a 20% sample of inpatient discharges from 1056 hospitals, from 1998 to 2009, and used weighted sampling to estimate national trends. Multivariate logistic regression modeling was used to examine the association of laparoscopy with perioperative outcomes. Patients who met the inclusion criteria totaled 257 484. Of these, 87 209 (34%) underwent laparoscopic appendectomy. These patients were younger (P < .001); had lower Charlson comorbidity scores (P < .001); were more likely to be white (P < .001), to be privately insured (P = .005), and to undergo surgery in urban hospitals (P < .001); ...
As the popularity of a laparoscopic Roux-en-Y Gastric Bypass (RYGB) surpassed that of an open app... more As the popularity of a laparoscopic Roux-en-Y Gastric Bypass (RYGB) surpassed that of an open approach, practice of concomitant cholecystectomy declined. Low rates of gallbladder disease following RYGB and high complication rates of concomitant cholecystectomy have been published, but these population-based studies have lacked long-term outcomes and survival data. The California Office of Statewide Health Planning and Development longitudinal database was queried for patients who underwent RYGB with or without cholecystectomy between 1995 and 2009. Additionally, patients who underwent cholecystectomy after RYGB were compared to all cholecystectomy patients. Primary outcome was survival; secondary long-term outcomes included cholangitis, common duct stones, dumping syndrome, metabolic derangements, ventral hernia, any hernia, marginal ulcers, and reoperation. Cox proportional hazard analysis was performed to determine adjusted survival and outcomes. Of 134,584 RYGB patients, 21,022 underwent concomitant cholecystectomy. Concomitant cholecystectomy improved both survival (HR[95 % CI] 0.51[.48-.54]) and long-term outcomes (HR 0.84[.77-.91]). Incidence of gallbladder disease following RYGB was 6.8 and 15.2 % at 1 and 5 years. In subsequent analysis of 829,333 cholecystectomy patients, 7,099 underwent prior RYGB with higher risk of conversion to open (HR 1.58[1.41-1.78]), post-operative complication (HR 1.47[1.36-1.6]) and death (HR 1.32[1.17-1.5]). Concomitant cholecystectomy is safe for RYGB patients. Given high rates of gallbladder disease and increased risk when cholecystectomy is performed following RYGB, cholecystectomy should be considered at the time of RYGB.
In response to high consumer demand, turkeys have been intensively selected for rapid growth rate... more In response to high consumer demand, turkeys have been intensively selected for rapid growth rate and breast muscle mass and conformation. The success in breeding selection has coincided with an increasing incidence of pale, soft, and exudative (PSE) meat defect, especially in response to heat stress. We hypothesized that the underlying mechanism responsible for the development of PSE meat arises from differences in expression of several critical genes. The objective of this study was to determine differential gene expression between normal and PSE turkey meat using a 6K turkey skeletal muscle long oligonucleotide microarray. Breast meat samples were collected from Randombred Control Line 2 turkeys at 22 wk of age, and classified as normal or PSE primarily based on marinade uptake (high = normal, low = PSE). Total RNA was isolated from meat samples with the highest (normal, n = 6) and the lowest (PSE, n = 6) marinade uptake. Microarray data confirmation was conducted using quantitative real-time PCR. Selection of differentially expressed genes for pathway analysis was performed using a combination of fold change (FC) ranking (FC &lt; -1.66, FC &gt;1.66) and false discovery rate (&lt;0.35) as criteria. The calcium signaling pathway was highlighted as the top canonical pathway associated with differential gene expression between normal and PSE turkey. Dramatic downregulation of fast-twitch myosin heavy chain coupled with upregulation of slow-twitch myosin and troponin C suggested a switch of skeletal muscle isoforms, which may alter muscle fiber arrangement and formation of actin-myosin complexes. Changes in expression of genes in the actin cytoskeleton signaling pathway also suggest altered structures of actin filaments that may affect cell motility as well as strength and flexibility of muscle cells. Substantial downregulation of pyruvate dehydrogenase kinase, isozyme 4 was observed in PSE samples, suggesting altered regulation of the aerobic metabolic pathway in the birds that developed PSE meat defect.
Outcomes after surgery for diverticulitis are of continued interest to improve quality of care. T... more Outcomes after surgery for diverticulitis are of continued interest to improve quality of care. The aim of this study was to assess variations in mortality, length of stay, and patient charges between geographic regions of the United States. A retrospective analysis of the Nationwide Inpatient Sample database was performed. Adults with diverticulitis who underwent laparoscopic or open segmental colectomy were identified using ICD-9 codes. Subset analyses were performed by state and then compared. Outcomes included mortality, length of stay (LOS), and total charges. Results were adjusted for age, race, gender, findings of peritonitis, stoma placement, Charlson comorbidity index, and insurance status on multivariate analysis. 148,874 patients underwent segmental colectomy for diverticulitis from 1998 to 2010. Using California as the comparison state and after adjusting for covariates, in-hospital mortality was significantly higher in the State of New York (OR 1.32; 95 % CI 1.13-1.55; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05) and Mississippi (OR 2.84; 95 % CI 1.24-6.51, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.02). Wisconsin had a significant lower mortality rate (OR 0.74; 95 % CI 0.59-0.94, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01). LOS was 1.4 days longer in New York and 0.54 days shorter in Wisconsin than in California (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01). Patients with age &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;40 years, findings of peritonitis, and without private insurance had higher in-hospital mortality and longer length of stay. Average hospital charges differed dramatically between the states in the observation period. The highest hospital charges occurred in California, Nebraska, and Nevada while lowest occurred in Maryland, Wisconsin and Utah. Patients who undergo surgical treatment for diverticulitis in the United States have high geographic variation in mortality, LOS, and hospital charges despite adjusting for demographic and socioeconomic factors. Further analysis should be performed to identify the causes of outlier regions, with the goal of improving and standardizing best practices.
To compare perioperative patient safety outcomes of minimally invasive cystectomy (MIC) with open... more To compare perioperative patient safety outcomes of minimally invasive cystectomy (MIC) with open cystectomy (OC) in a national cohort. Comparative outcomes data based on validated metrics are sparse for MIC, an emerging treatment for bladder cancer. We identified patients undergoing MIC and OC for bladder cancer from 2005 to 2010 using the US Nationwide Inpatient Sample. We compared perioperative outcomes using Patient Safety Indicators (PSIs), validated metrics developed by the Agency for Healthcare Research and Quality, and used multivariate regression analyses to generate adjusted odds ratios. Between 2005 and 2010, 42,919 patients underwent cystectomy. During this period, the prevalence of MIC increased from 0.8% to 10.3% of all cystectomies. Compared with OC, MIC patients were more likely to be male (P = .019) and treated at large teaching hospitals (P <.001). There were no significant differences in age, race, Charlson index, or region between groups. The median lengths of...
Bien que les lé sions du plexus brachial aient é té dé crites comme la complication la plus fré q... more Bien que les lé sions du plexus brachial aient é té dé crites comme la complication la plus fré quente aprè s intervention pour syndrome du dé filé thoraco-brachial (SDTB), et que des sé ries aient é té rapporté es, le taux d'incidence exact n'a pas é té rapporté . Nous avons ré alisé une analyse ré trospective de 5 ans (1999)(2000)(2001)(2002)(2003) de la base de donné es Nationwide Inpatient Sample. Les patients pré sentant un SDTB neurogè ne, les ré sections de cô te, les lé sions du plexus brachial, et les lé sions vasculaires sont identifié s par des codes de diagnostic CIM-9 ou des codes de procé dure. Un total de 2.016 opé rations pour SDTB ont é té identifié es dans cette base de donné es, allant de 317 à 468 par an. L'â ge moyen é tait 37,3 ans, avec 1409 (70,2%) femmes et 1270 (63%) de Caucasiens. Ces patients ont é té soigné s dans 392 hô pitaux, avec un volume moyen de 1,03 cas par hô pital par an (extrê mes 0 à 114 cas par hô pital par an). La duré e moyenne du sé jour à l'hô pital é tait de 2,51 jours (mé diane 2 jours), avec un coû t hospitalier total moyen de 16.160 $ en dollars de l'anné e 2005 ajusté s pour l'inflation (mé diane 11.824 $). La majorité (1421, ou 70,5%) a é té traité e dans un hô pital universitaire. Il y avait 12 lé sions du plexus brachial (0,60%), et 35 lé sions vasculaires (1,74%). Le taux de lé sions vasculaires é tait significativement moindre dans les hô pitaux universitaires (1,34% contre 2,69%, p ¼ 0,03) et chez les femmes (1,35% contre 2,67%, p ¼ 0,03). Les patients avec des lé sions vasculaires ont eu des duré es significativement plus longues de sé jour (7,7 jours contre 2,4 jours, p < 0,001) et des coû ts hospitaliers totaux plus é levé s (53.373 $ contre 15.507 $, p < 0,001), alors qu'on n'observait pas une telle diffé rence pour les patients ayant des lé sions du plexus brachial. A la sortie de l'hô pital, des lé sions du plexus brachial aprè s ré section de cô te pour SDTB se produisent dans moins de 1% des cas, alors que des lé sions vasculaires se produisent dans 1-2% des cas. Les faibles taux de complications suggè rent que l'intervention puisse ê tre effectué e sans risque chez tous les patients, particuliè rement dans les hô pitaux universitaires qui avaient des taux sensiblement moindres de lé sions vasculaires, des duré es plus courtes de sé jour à l'hô pital, et des coû ts hospitaliers moindres. Les faibles taux d'incidence de ces mesures cliniques traditionnelles des ré sultats chez les patients ayant un SDTB suggè rent que la mesure adapté e des ré sultats chez les patients ayant un SDTB soit la qualité de vie rapporté e par le patient ou les ré sultats fonctionnels.
Thyroidectomy is an operation with infrequent but potentially significant complications. This stu... more Thyroidectomy is an operation with infrequent but potentially significant complications. This study aimed to determine risk factors for complication after thyroidectomy in California. The California Office of Statewide Health Planning and Development database was retrospectively analyzed from 1995 to 2010. Main outcome measures were complications including death. Logistic regression identified risk factors for complications. There were 106,773 patients; 61% were women and 44% Caucasian; 16,287 (15%) thyroidectomies were performed at high-volume centers. Complication rates included voice change (.5%), vocal cord dysfunction (1.1%), hypocalcemia (4.5%), tracheostomy (1.62%), hematoma (1.75%), and death (.3%). There was significantly increased risk of complications for patients older than 65 compared with those younger than 40 years (odds ratio, 2.0; 95% confidence interval, 1.8 to 2.3; P < .01). High-volume hospitals were protective against complication (odds ratio, .8; 95% confide...
To our knowledge, long-term outcomes of open and endovascular (EVAR) repairs of abdominal aortic ... more To our knowledge, long-term outcomes of open and endovascular (EVAR) repairs of abdominal aortic aneurysms (AAAs) have not been studied on a population level outside a controlled trial setting. To determine long-term outcomes of EVAR vs open repair on a population level. Analysis of the longitudinally linked California Office of Statewide Health Planning and Development inpatient database from 2001 to 2009. Median follow-up was 3.3 years. Endovascular vs open repairs. Mortality and complications at 30 days, as well as long-term mortality and complications up to 9 years. In this observational study, a total of 23 670 patients were studied, with 52% receiving EVAR. Endovascular repair was associated with improved 30-day outcomes (all-cause mortality, readmission, surgical site infection, pneumonia, and sepsis), as well as significantly improved survival until 3 years postoperatively. After 3 years, mortality was higher for patients who underwent an EVAR repair. No significant differen...
Healthcare costs in the United States (U.S.) are rising. As outcomes improve, such as decreased l... more Healthcare costs in the United States (U.S.) are rising. As outcomes improve, such as decreased length of stay and decreased mortality, it is expected that costs should go down. The aim of this study is to analyze hospital charges, cost of care, and mortality in bariatric surgery over time. A retrospective analysis of the Nationwide Inpatient Sample (NIS) database was performed. Adults with morbid obesity who underwent gastric bypass or sleeve gastrectomy were identified by ICD-9 codes. Multivariate analyses identified independent predictors of changes in hospital charges and in-hospital mortality. Results were adjusted for age, race, gender, Charlson comorbidity index, surgical approach (open versus laparoscopic), hospital volume, and insurance status. In order to estimate baseline surgical inflation, changes in hospital charges over time were also calculated for appendectomy. From 1998 to 2011, 209,106 patients were identified who underwent bariatric surgery. Adjusted in-hospital ...
Improved outcomes have been associated with various methods of size matching between expanded cri... more Improved outcomes have been associated with various methods of size matching between expanded criteria (ECD) donors and recipients. A novel method for improved functional based matching was developed utilizing manipulation of Cockcroft-Gault estimated creatinine clearances for donor and recipient. We hypothesized that optimal clearance-based matches would have superior outcomes for both immediate graft function and long term graft survival. For the analysis, recipients of ECD kidneys in the Scientific Registry of Transplant Recipients (SRTR) transplanted between October 1, 1987 to August 31, 2011 were included. Univariate and multivariate analyses predicted the hazard ratio of graft failure and the odds ratio of requiring dialysis within the first week. 25,640 ECD kidney transplants were analyzed. On multivariate analysis, lower CCMR was associated with increased graft failure and odds of requiring dialysis within the first week (comparing highest ratio quintile versus lowest ratio ...
Most population-based studies lack long-term data, making the reporting of true mortality and out... more Most population-based studies lack long-term data, making the reporting of true mortality and outcome rates difficult. An accurate estimate of these rates in a high-risk population is critical for obtaining informed consent, especially for an elective procedure such as Roux-en-Y gastric bypass (RYGB). To examine the longitudinal outcomes of RYGB. The California Office of Statewide Health Planning and Development (OSHPD) longitudinal database. The OSHPD longitudinal database was queried for patients who underwent RYGB between 1995 and 2009. The primary outcome was mortality rates at 1, 5, and 10 years. Secondary outcomes were marginal ulcer and reoperation. The Cox hazard proportional analysis was used to determine adjusted survival and long-term outcomes for laparoscopic RYGB compared with open RYGB. The study included 129,432 RYGB patients. Rates of laparoscopy increased from 3% to 35% from 1995 to 2004 and then steeply increased to 80% in 2005 and to 93% in 2009. Overall mortality rate at 1, 5, and 10 years was 2.2%, 4.4%, and 8.1%, respectively; the rates of marginal ulcer were .3%, .7%, and 1%, respectively; and the reoperation rates were .3%, .8%, and 1.2%, respectively. Predictors of poor outcomes were male gender, age, smoking, alcohol, Medicare, Medi-Cal insurance, and Asian or Native American race. The laparoscopic approach was protective against death (hazard ratio [HR] 95% confidence interval [95%CI]: .63[.58-.69]) and long-term complications (HR .78[.72-.85]). This longitudinal population study showed high rates of mortality following RYGB, with improved long-term outcomes when the laparoscopic approach was used.
Cultured mononuclear phagocytes produce soluble factors that stimulate endothelial cells to relea... more Cultured mononuclear phagocytes produce soluble factors that stimulate endothelial cells to release GM-colony-stimulating activity (GM-CSA). One such factor was recently identified as interleukin 1 (IL 1). Studies were designed to determine which types of granulopoietic factors are released by IL 1-stimulated endothelial cells. Supernatants from endothelial cells cultured for 3 days in medium containing IL 1 alpha and beta were tested in both murine and human CFU-GM colony growth assays. The effect of conditioned media on differentiation of WEHI-3B myelomonocytic leukemic cells was also examined. Control media containing IL 1 alone or unstimulated endothelial cell-conditioned media contained no detectable CSA in any bioassay. Medium conditioned by IL 1-stimulated endothelial cells stimulated the clonal growth of both human and murine CFU-GM and induced macrophage differentiation of WEHI-3B cells. Treatment of these conditioned media with a highly specific neutralizing monoclonal G-C...
La r esection de la premi ere cô te et la scal enectomie est un traitement acceptable chez les ma... more La r esection de la premi ere cô te et la scal enectomie est un traitement acceptable chez les malades ayant une thrombose de la veine axillo-sous-clavi ere qui ont r epondu au traitement thrombolytique et d emontr e une perm eabilit e de la veine sous-clavi ere. Cependant, le traitement des malades se pr esentant avec une occlusion chronique de la veine sous-clavi ere est controvers e. Nous pr esentons quatre malades de ce type qui ont eu une r esection de la premi ere cô te et une scal enectomie et dont la veine sous-clavi ere s'est spontan ement recanalis ee dans l'ann ee suivant l'intervention, alors qu'ils etaient anticoagul es, ainsi que le protocole d'ultrasons utilis e dans notre institution pour identifier une telle recanalisation. L'â ge moyen de ces malades etait de 20 ans (extrê mes 17 et 23 ans). Trois etaient de sexe masculin et une de sexe f eminin. L'intervalle de temps moyen entre l'intervention et la thrombose etait de 25 semaines (extrê mes 12 et 34 semaines). Tous les malades etaient asymptomatiques et ont eu une r esection de la premi ere cô te et une scal enectomie par voie axillaire, en incisant le tendon du muscle sous-clavier. Tous ont eu un traitement post-op eratoire par warfarine et ont et e surveill es par echographie-Doppler. Chez chacun de ces quatre malades, la veine sous-clavi ere s'est recanalis ee par la suite apr es une moyenne de 7 mois (extrê mes deux et 11 mois) et l'anticoagulation a et e arrê t ee. La perm eabilit e de la veine sous-clavi ere qui en est r esult ee a et e corr el ee avec l'am elioration des symptô mes chez chacun des quatre malades. Tous les malades etaient asymptomatiques au cours de la p eriode de suivi post-op eratoire a une moyenne de 14 mois (extrê mes deux et 33 mois). En conclusion, certains malades ayant une occlusion de la veine sous-clavi ere peuvent ê tre trait es agressivement par r esection de la premi ere cô te et scal enectomie ainsi que par anticoagulation, entraînant la recanalisation et la r eouverture de la veine au cours du temps. Ce traitement est corr el e avec l'am elioration des symptô mes. La thrombose veineuse profonde d'effort du membre sup erieur, ou syndrome de Paget-Schroetter, a et e d ecrite pour la premi ere fois de façon ind ependante par Paget en 1875 1 et plus tard par Von Schroetter en France en 1884 2 . En 1949, Hughes 3 , dans une etude comportant 320 malades, a reconnu une entit e pathologique distincte et introduit le terme de syndrome de Paget-Schroetter. Celui-ci affecte fr equemment le membre sup erieur dominant de jeunes hommes actifs et en bonne sant e. L' ev enement pr edisposant est habituellement une sorte quelconque de mouvements r ep etitifs forc es. Une thrombose inattendue a et e rapport ee par Urschel et Razzuk 4 chez des malades ayant des activit es tr es diverses, depuis des halt erophiles et des joueurs de football jusqu' a des peintres et des esth eticiens. Des activit es laborieuses peuvent ê tre la cause de l esions de l'intima vasculaire, entraînant une augmentation de la pr edisposition a la thrombose. Si une compression extrins eque pr eexistante
Risk adjustment is an important component of quality assessment in surgical health care. However,... more Risk adjustment is an important component of quality assessment in surgical health care. However, data collection places an additional burden on physicians. There is also concern that outcomes can be gamed depending on the information recorded for each patient. To determine whether a number of machine-collected data elements could perform as well as a traditional full-risk adjustment model that includes other physician-assessed and physician-recorded data elements. All general surgery patients from the National Surgical Quality Improvement Program database from January 1, 2005, to December 31, 2010, were included. Separate multivariate logistic regressions were performed using either all 66 preoperative risk variables or only 25 objective variables. The area under the receiver operating characteristic curve (AUC) of each regression using objective preoperative risk variables was compared with its corresponding regression with all preoperative variables. Subset analyses were performe...
JSLS : Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons, 2014
This study describes perioperative patient safety outcomes comparing laparoscopic appendectomy wi... more This study describes perioperative patient safety outcomes comparing laparoscopic appendectomy with open appendectomy in the elderly population (defined as age ≥65 years) during the diffusion of laparoscopic appendectomy into widespread clinical practice. We performed a cross-sectional analysis of patients undergoing open or laparoscopic appendectomy in the US Nationwide Inpatient Sample, a 20% sample of inpatient discharges from 1056 hospitals, from 1998 to 2009, and used weighted sampling to estimate national trends. Multivariate logistic regression modeling was used to examine the association of laparoscopy with perioperative outcomes. Patients who met the inclusion criteria totaled 257 484. Of these, 87 209 (34%) underwent laparoscopic appendectomy. These patients were younger (P < .001); had lower Charlson comorbidity scores (P < .001); were more likely to be white (P < .001), to be privately insured (P = .005), and to undergo surgery in urban hospitals (P < .001); ...
As the popularity of a laparoscopic Roux-en-Y Gastric Bypass (RYGB) surpassed that of an open app... more As the popularity of a laparoscopic Roux-en-Y Gastric Bypass (RYGB) surpassed that of an open approach, practice of concomitant cholecystectomy declined. Low rates of gallbladder disease following RYGB and high complication rates of concomitant cholecystectomy have been published, but these population-based studies have lacked long-term outcomes and survival data. The California Office of Statewide Health Planning and Development longitudinal database was queried for patients who underwent RYGB with or without cholecystectomy between 1995 and 2009. Additionally, patients who underwent cholecystectomy after RYGB were compared to all cholecystectomy patients. Primary outcome was survival; secondary long-term outcomes included cholangitis, common duct stones, dumping syndrome, metabolic derangements, ventral hernia, any hernia, marginal ulcers, and reoperation. Cox proportional hazard analysis was performed to determine adjusted survival and outcomes. Of 134,584 RYGB patients, 21,022 underwent concomitant cholecystectomy. Concomitant cholecystectomy improved both survival (HR[95 % CI] 0.51[.48-.54]) and long-term outcomes (HR 0.84[.77-.91]). Incidence of gallbladder disease following RYGB was 6.8 and 15.2 % at 1 and 5 years. In subsequent analysis of 829,333 cholecystectomy patients, 7,099 underwent prior RYGB with higher risk of conversion to open (HR 1.58[1.41-1.78]), post-operative complication (HR 1.47[1.36-1.6]) and death (HR 1.32[1.17-1.5]). Concomitant cholecystectomy is safe for RYGB patients. Given high rates of gallbladder disease and increased risk when cholecystectomy is performed following RYGB, cholecystectomy should be considered at the time of RYGB.
In response to high consumer demand, turkeys have been intensively selected for rapid growth rate... more In response to high consumer demand, turkeys have been intensively selected for rapid growth rate and breast muscle mass and conformation. The success in breeding selection has coincided with an increasing incidence of pale, soft, and exudative (PSE) meat defect, especially in response to heat stress. We hypothesized that the underlying mechanism responsible for the development of PSE meat arises from differences in expression of several critical genes. The objective of this study was to determine differential gene expression between normal and PSE turkey meat using a 6K turkey skeletal muscle long oligonucleotide microarray. Breast meat samples were collected from Randombred Control Line 2 turkeys at 22 wk of age, and classified as normal or PSE primarily based on marinade uptake (high = normal, low = PSE). Total RNA was isolated from meat samples with the highest (normal, n = 6) and the lowest (PSE, n = 6) marinade uptake. Microarray data confirmation was conducted using quantitative real-time PCR. Selection of differentially expressed genes for pathway analysis was performed using a combination of fold change (FC) ranking (FC &lt; -1.66, FC &gt;1.66) and false discovery rate (&lt;0.35) as criteria. The calcium signaling pathway was highlighted as the top canonical pathway associated with differential gene expression between normal and PSE turkey. Dramatic downregulation of fast-twitch myosin heavy chain coupled with upregulation of slow-twitch myosin and troponin C suggested a switch of skeletal muscle isoforms, which may alter muscle fiber arrangement and formation of actin-myosin complexes. Changes in expression of genes in the actin cytoskeleton signaling pathway also suggest altered structures of actin filaments that may affect cell motility as well as strength and flexibility of muscle cells. Substantial downregulation of pyruvate dehydrogenase kinase, isozyme 4 was observed in PSE samples, suggesting altered regulation of the aerobic metabolic pathway in the birds that developed PSE meat defect.
Outcomes after surgery for diverticulitis are of continued interest to improve quality of care. T... more Outcomes after surgery for diverticulitis are of continued interest to improve quality of care. The aim of this study was to assess variations in mortality, length of stay, and patient charges between geographic regions of the United States. A retrospective analysis of the Nationwide Inpatient Sample database was performed. Adults with diverticulitis who underwent laparoscopic or open segmental colectomy were identified using ICD-9 codes. Subset analyses were performed by state and then compared. Outcomes included mortality, length of stay (LOS), and total charges. Results were adjusted for age, race, gender, findings of peritonitis, stoma placement, Charlson comorbidity index, and insurance status on multivariate analysis. 148,874 patients underwent segmental colectomy for diverticulitis from 1998 to 2010. Using California as the comparison state and after adjusting for covariates, in-hospital mortality was significantly higher in the State of New York (OR 1.32; 95 % CI 1.13-1.55; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05) and Mississippi (OR 2.84; 95 % CI 1.24-6.51, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.02). Wisconsin had a significant lower mortality rate (OR 0.74; 95 % CI 0.59-0.94, P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01). LOS was 1.4 days longer in New York and 0.54 days shorter in Wisconsin than in California (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01). Patients with age &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;40 years, findings of peritonitis, and without private insurance had higher in-hospital mortality and longer length of stay. Average hospital charges differed dramatically between the states in the observation period. The highest hospital charges occurred in California, Nebraska, and Nevada while lowest occurred in Maryland, Wisconsin and Utah. Patients who undergo surgical treatment for diverticulitis in the United States have high geographic variation in mortality, LOS, and hospital charges despite adjusting for demographic and socioeconomic factors. Further analysis should be performed to identify the causes of outlier regions, with the goal of improving and standardizing best practices.
To compare perioperative patient safety outcomes of minimally invasive cystectomy (MIC) with open... more To compare perioperative patient safety outcomes of minimally invasive cystectomy (MIC) with open cystectomy (OC) in a national cohort. Comparative outcomes data based on validated metrics are sparse for MIC, an emerging treatment for bladder cancer. We identified patients undergoing MIC and OC for bladder cancer from 2005 to 2010 using the US Nationwide Inpatient Sample. We compared perioperative outcomes using Patient Safety Indicators (PSIs), validated metrics developed by the Agency for Healthcare Research and Quality, and used multivariate regression analyses to generate adjusted odds ratios. Between 2005 and 2010, 42,919 patients underwent cystectomy. During this period, the prevalence of MIC increased from 0.8% to 10.3% of all cystectomies. Compared with OC, MIC patients were more likely to be male (P = .019) and treated at large teaching hospitals (P <.001). There were no significant differences in age, race, Charlson index, or region between groups. The median lengths of...
Bien que les lé sions du plexus brachial aient é té dé crites comme la complication la plus fré q... more Bien que les lé sions du plexus brachial aient é té dé crites comme la complication la plus fré quente aprè s intervention pour syndrome du dé filé thoraco-brachial (SDTB), et que des sé ries aient é té rapporté es, le taux d'incidence exact n'a pas é té rapporté . Nous avons ré alisé une analyse ré trospective de 5 ans (1999)(2000)(2001)(2002)(2003) de la base de donné es Nationwide Inpatient Sample. Les patients pré sentant un SDTB neurogè ne, les ré sections de cô te, les lé sions du plexus brachial, et les lé sions vasculaires sont identifié s par des codes de diagnostic CIM-9 ou des codes de procé dure. Un total de 2.016 opé rations pour SDTB ont é té identifié es dans cette base de donné es, allant de 317 à 468 par an. L'â ge moyen é tait 37,3 ans, avec 1409 (70,2%) femmes et 1270 (63%) de Caucasiens. Ces patients ont é té soigné s dans 392 hô pitaux, avec un volume moyen de 1,03 cas par hô pital par an (extrê mes 0 à 114 cas par hô pital par an). La duré e moyenne du sé jour à l'hô pital é tait de 2,51 jours (mé diane 2 jours), avec un coû t hospitalier total moyen de 16.160 $ en dollars de l'anné e 2005 ajusté s pour l'inflation (mé diane 11.824 $). La majorité (1421, ou 70,5%) a é té traité e dans un hô pital universitaire. Il y avait 12 lé sions du plexus brachial (0,60%), et 35 lé sions vasculaires (1,74%). Le taux de lé sions vasculaires é tait significativement moindre dans les hô pitaux universitaires (1,34% contre 2,69%, p ¼ 0,03) et chez les femmes (1,35% contre 2,67%, p ¼ 0,03). Les patients avec des lé sions vasculaires ont eu des duré es significativement plus longues de sé jour (7,7 jours contre 2,4 jours, p < 0,001) et des coû ts hospitaliers totaux plus é levé s (53.373 $ contre 15.507 $, p < 0,001), alors qu'on n'observait pas une telle diffé rence pour les patients ayant des lé sions du plexus brachial. A la sortie de l'hô pital, des lé sions du plexus brachial aprè s ré section de cô te pour SDTB se produisent dans moins de 1% des cas, alors que des lé sions vasculaires se produisent dans 1-2% des cas. Les faibles taux de complications suggè rent que l'intervention puisse ê tre effectué e sans risque chez tous les patients, particuliè rement dans les hô pitaux universitaires qui avaient des taux sensiblement moindres de lé sions vasculaires, des duré es plus courtes de sé jour à l'hô pital, et des coû ts hospitaliers moindres. Les faibles taux d'incidence de ces mesures cliniques traditionnelles des ré sultats chez les patients ayant un SDTB suggè rent que la mesure adapté e des ré sultats chez les patients ayant un SDTB soit la qualité de vie rapporté e par le patient ou les ré sultats fonctionnels.
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