Failure in glaucoma surgery and its management

Surgical management of glaucoma may include many different procedures, but filtering surgery is the most frequent. The subject of operative failure following glaucoma surgery is extremely important to every ophthalmo-logist who does glaucoma surgery. More over, it is most distressing; that what initially appears to he a clinical success eventually proves to be a failure. If we can analyse the patients operated for glaucoma where satisfactory control is not achieved, we can choose a safer and more successful procedure

Severe Thyroid Eye Disease in the US: A National Perspective

Background: Thyroid eye disease (TED) is an unpredictable autoimmune inflammatory disease which can be sight-threatening, debilitating, and disfiguring. The majority of patients have mild, self-limited TED, 20-30% of patients experience moderate/severe disease, and 3-5% may develop sight-threatening disease, such as CON or exposure keratopathy. Surgical intervention is commonly necessary for patients with moderate/severe stable disease or sight-threatening disease, however, there is little data on the prevalence of TED requiring surgical interventions. Objective: To document the number of surgical procedures for thyroid eye disease in the US and evaluate the associated costs of these interventions. Methods: National Ambulatory Surgery Sample (NASS) is the largest ambulatory surgery database, representing approximately 14 million ambulatory surgeries performed annually in a hospital setting in the US. Data from 2,699 hospital-owned facilities located in 31 States and the District of Columbia, approximating a 63-percent stratified sample of U.S. hospital-owned facilities performing selected ambulatory surgeries are available for analyses. Data on clinical procedures and diagnoses, disposition of the patient, expected source of payment, and total charges, as well as geographic, hospital-owned facility, and patient characteristics are collected. For the purposes of this study, TED was identified by concomitantly occurring ICD 10 codes of thyroid disease and ICD-10 codes for eye manifestations of thyroid eye disease. CPT codes were used to identify eye surgeries performed in these patients. The coding algorithms were developed by consensus of three ophthalmic surgeons. Results: In 2018, a total of 1,991 patients with TED required eye surgery, with a national prevalence of 0.6 per 100,000 population. Mean age at surgery was 56.2 years (95% Confidence Interval (CI) 55.3-57.2). Women comprised 73% (1455 women and 536 men) of TED patients who underwent surgery. The average charges for each surgical encounter were $21,875 (95$19,066-$24,684). Total charges for TED surgery in the US totaled over 43.5 million annually. While many patients had private insurance (49.7%), Medicare (31%) and Medicaid (13%) were also significant sources of reimbursement. Of all TED-related surgeries, 93% were conducted in teaching hospitals. Only 0.2% of surgeries were conducted in non-urban rural settings. Conclusion: In the US, severe TED requiring surgery, although uncommon, has significant economic impact. Further research is warranted to better understand the natural history of TED that may inform treatment pathways which may prevent complications needing surgery

Concurrent conditions in patients with chronic constipation: a population-based study.

BACKGROUND: Chronic constipation (CC) is a common condition but its concurrent conditions are not well characterized. We measured the prevalence and risk of developing 15 pre-specified concurrent conditions in patients with CC. METHODS: Retrospective cohort study using the Medicaid database of California, utilizing ICD-9 codes for detection of cases (CC), controls (patients with GERD) and concurrent conditions. Study period was 01/01/1995 to 06/30/2005. Index date was the date 3 months before the first physician visit for CC. Pre-index time (12 months) was compared to post-index time (12 months) to assess the association of every concurrent condition within each cohort. To account for ascertainment bias, an adjusted odds ratio was calculated by comparing the odds ratio for every concurrent condition in the CC cohort to that in the GERD cohort. RESULTS: 147,595 patients with CC (mean age 54.2 years; 69.7% women; 36.2% white) and 142,086 patients with GERD (mean age 56.3 years; 65.3% women; 41.6% white) were evaluated. The most prevalent concurrent conditions with CC were hemorrhoids (7.6%), diverticular disease (5.9%), ano-rectal hemorrhage (4.7%), irritable bowel syndrome (3.5%) and fecal impaction (2%). When adjusted for ascertainment bias, the most notable associations with CC were Hirschsprung's disease, fecal impaction and ano-rectal conditions such as fissure, fistula, hemorrhage and ulcers. CONCLUSION: Chronic constipation is associated with several concurrent conditions of variable risk and prevalence. To reduce the overall burden of CC, these concurrent conditions need to be addressed

Affordable Care Act and healthcare delivery: A comparison of California and Florida hospitals and emergency departments

<div><p>Importance</p><p>The Affordable Care Act (ACA) has expanded access to health insurance for millions of Americans, but the impact of Medicaid expansion on healthcare delivery and utilization remains uncertain.</p><p>Objective</p><p>To determine the early impact of the Medicaid expansion component of ACA on hospital and ED utilization in California, a state that implemented the Medicaid expansion component of ACA and Florida, a state that did not.</p><p>Design</p><p>Analyze all ED encounters and hospitalizations in California and Florida from 2009 to 2014 and evaluate trends by payer and diagnostic category. Data were collected from State Inpatient Databases, State Emergency Department Databases and the California Office of Statewide Health Planning and Development.</p><p>Setting</p><p>Hospital and ED encounters.</p><p>Participants</p><p>Population-based study of California and Florida state residents.</p><p>Exposure</p><p>Implementation of Medicaid expansion component of ACA in California in 2014.</p><p>Main outcomes or measures</p><p>Changes in ED visits and hospitalizations by payer, percentage of patients hospitalized after an ED encounter, top diagnostic categories for ED and hospital encounters.</p><p>Results</p><p>In California, Medicaid ED visits increased 33% after Medicaid expansion implementation and self-pay visits decreased by 25% compared with a 5.7% increase in the rate of Medicaid patient ED visits and a 5.1% decrease in rate of self-pay patient visits in Florida. In addition, California experienced a 15.4% increase in Medicaid inpatient stays and a 25% decrease in self pay stays. Trends in the percentage of patients admitted to the hospital from the ED were notable; a 5.4% decrease in hospital admissions originating from the ED in California, and a 2.1% decrease in Florida from 2013 to 2014.</p><p>Conclusions and relevance</p><p>We observed a significant shift in payer for ED visits and hospitalizations after Medicaid expansion in California without a significant change in top diagnoses or overall rate of these ED visits and hospitalizations. There appears to be a shift in reimbursement burden from patients and hospitals to the government without a dramatic shift in patterns of ED or hospital utilization.</p></div

Impact of preoperative imaging on surgical approach for primary hyperparathyroidism: Data from single institution in India

Context: Preoperative localization of parathyroid adenoma is essential in deciding the surgical approach of parathyroidectomy. Aim: To describe clinical and biochemical profile, evaluate preoperative imaging modalities and surgical approach in patients with primary hyperparathyroidism (PHPT). Methodology: This was a retrospective study conducted at the single institution. All patients who underwent evaluation and surgery for PHPT from 2011 to 2015 were included in the study. Results: A total of 100 patients underwent surgery for PHPT. Mean (standard deviation) age was 51.6 (15.9) years with female to male ratio of 1.7:1. Forty patients had severe symptoms, and sixty had mild to moderate symptoms. The sensitivity of technetium-99m hexakis (2-methoxyisobutylisonitrile) (MIBI) scan and ultrasonography (USG) neck in identifying abnormal parathyroid gland was 93% (93/100) and 98% (98/100), respectively. The MIBI scan results of 90/93 (96.7%) patients corresponded with their surgical findings whereas preoperative USG findings of 96/98 patients (98%) showed correlation with operative findings. Intraoperative intact parathyroid hormone (IOPTH) levels at 10 min postexcision were measured in forty patients (minimally invasive parathyroidectomy = 38, bilateral neck exploration = 1, and unilateral neck exploration = 1). All patients except two had <50% fall in IOPTH. Adenoma weight was positively correlated with preoperative intact PTH. Conclusion: We found that USG has higher sensitivity (98%) than MIBI scan (93%) in localizing abnormal parathyroid gland. Moreover, USG had a higher preoperative localization accuracy (93%) than MIBI scan (90%), allowing to choose an appropriate surgical approach. A higher proportion of patients (60%) had mild/asymptomatic form of PHPT

Ectopic undescended left parathyroid adenoma: Diagnosed on ultrasound

We report here a case of left ectopic undescended parathyroid nodule located high in the neck, at the angle of jaw which was diagnosed primarily on high-resolution color Doppler ultrasound imaging at our institution, followed by Sestamibi and computed tomography-single photon emission computed tomography (CT-SPECT) and surgery. A 41-year-old female having endometrial hyperplasia and planned for TAH + BSO. Her routine preoperative investigations showed serum calcium to be 13.0 mg/dL. Serum parathyroid hormone (PTH) was 914.6 pg/mL and 25–OH Vitamin D 8.0 g/mL. Ultrasound neck with color Doppler localized an ectopic undescended left parathyroid adenoma located high in the neck just adjacent to the left submandibular gland. Sestamibi was suggestive of the left ectopic undescended parathyroid adenoma (below the pole of the left submandibular gland), confirmed further on CT-SPECT. The patient was operated and a 30 mm × 23 mm × 10 mm sized parathyroid adenoma was removed and confirmed on histopathology. A dedicated high-resolution color Doppler ultrasound has a great potential to localize the parathyroid nodules in all cases of raised serum PTH and must be utilized in all cases along with other imaging modalities

Total population, racial/ethnic.

<p>Total population, racial/ethnic.</p

Affordable Care Act and healthcare delivery: A comparison of California and Florida hospitals and emergency departments - Fig 2

<p><b>(A)</b> Predicted vs. Actual Emergency Department visits in Medicaid enrollees in California (per 100 state residents). In 2014, the actual rate was 32.2% higher than predicted based on 2009–2013 data (p<0.0001). <b>(B)</b> Florida Medicaid ED visit rates did not differ from those predicted based on 2009–2013 data.</p

Emergency department utilization in California (A) and Florida (B) between 2009 and 2014 by payer, expressed as annual visits per 100 state residents. Hospital utilization in California (C) and Florida (D) between 2009 and 2014 by payer, expressed as annual hospitalizations per 100 state residents.

<p>See <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0182346#pone.0182346.s001" target="_blank">S1 Table</a> for corresponding data tables.</p