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Purpose We determined if the USPSTF recommendation against prostate specific antigen screening was associated with a change in biopsy and cancer detection rates. Materials and Methods We conducted a time series analysis (October 2008 to June 2013) of prostate biopsies performed at University Health Network (Toronto). Biopsies for active surveillance or solely targeting magnetic resonance imaging detected lesions were excluded from study. Interventional ARIMA models with step functions were used to examine changes in the number of biopsies performed and cancers detected per month. Low risk prostate cancer was defined as no Gleason pattern 4 or greater, 3 or fewer cores involved, or 1/3 or less of the total number of cores involved, and no core with greater than 50% cancer involvement. Intermediate to high grade prostate cancer was defined as Gleason 7-10. Results A total of 3,408 biopsies were performed and 1,601 (47.0%) prostate cancers were detected (low risk prostate cancer 563 [16.5%], intermediate to high grade prostate cancer 914 [26.8%]). The median number of biopsies per month decreased from 58.0 (IQR 54.5–63.0) before the recommendations to 35.5 (IQR 27.0–41.0) afterward (p=0.003), while the median number of patients undergoing first-time biopsy decreased from 42.5 (IQR 37.5–45.5) to 24.0 (IQR 19.0–32.5, p=0.025). The median number of low risk prostate cancers detected per month decreased from 8.5 (IQR 6.5–10.5) to 5.5 (IQR 4.0–7.0, p=0.012), while the median number of intermediate to high grade prostate cancers per month decreased from 17.5 (IQR 14.5–21.5) to 10.0 (IQR 9.0–12.0, p <0.001). Conclusions After the USPSTF recommendation the number of biopsies performed (total and first-time), based on referrals from our catchment area, has decreased. This is likely due to decreased use of prostate specific antigen screening. Although it is encouraging that fewer low risk prostate cancers are being diagnosed, the sudden decrease in the detection rate of Gleason 7-10 prostate cancers is concerning. [ABSTRACT FROM AUTHOR]

Study Objective: To compare the overall characteristics and perioperative outcomes in morbidly obese and nonobese patients undergoing ambulatory surgery in the United States. Design: Retrospective, propensity-matched cohort study. Setting: Academic medical center. Measurements: The association between duration of surgical procedures, postoperative complications, and unplanned hospital admission was assessed in a propensity-matched cohort of morbidly obese and nonobese patients derived from the 2006 National Survey of Ambulatory Surgery. Main Results: Only 0.32% of the ambulatory procedures were performed on morbidly obese patients. The morbidly obese were significantly younger but had a higher burden of comorbidities, were more likely to undergo the procedure in hospital-based outpatient departments (HOPD; 80.1% vs 56.5%; P = 0.004), and had significantly shorter procedures than the nonobese (median [interquartile range], 28 [21-38] vs 42 [22-65]min; P b 0.0001). The incidences of postoperative hypertension, hypotension, hypoxia, cancellation of surgery, and unplanned hospital admissions did not differ significantly between groups. Similarly, adjusted rates of delayed dischargewere similar in morbidly obese and nonobese patients (odds ratio [OR], 0.46; 95%confidence interval [CI], 0.18 - 1.15; P = 0.09). In contrast, morbid obesity was associated with decreased odds of postoperative nausea and vomiting (OR, 0.27; CI, 0.09 - 0.84; P = 0.01). Conclusions: In 2006 in the U.S., the prevalence of ambulatory surgery in the morbidly obese was low, with most of the procedures being performed in the HOPD facilities, suggesting a conservative patient selection. The incidence of adverse postoperative outcomes and delayed discharge, as well as unplanned hospital admission after ambulatory surgery in the morbidly obese, was similar to that reported in the nonobese. [ABSTRACT FROM AUTHOR]

The article focuses on the state of the U.S. pharmaceutical industry and offers suggestions for active pharmaceutical ingredients (APIs) cost reduction. It hopes that the reduction or elimination of expenditures on drugs that are marginally better than the existing drugs will free up the funds that could be spent in developing better manufacturing processes. It points out that drug prices reflect the highest price to extend life and not set by competitive market forces. It suggests for the development and implementation of methods that will improve manufacturing while complying with the necessary regulations and in maximizing the profits.

Study Objective: We examined the association of body mass index (BMI) with hospital admission, same-day complications, and 30-day hospital readmission following day-case eligible joint arthroscopy.Design: Retrospective cohort study.Setting: Multi-institutional.Patients: Adult patients undergoing arthroscopy of the knee, hip or shoulder in the outpatient setting.Intervention: None.Measurements: Using the American College of Surgeons National Surgical Quality Improvement Program dataset from 2012 to 2016, we examined seven BMI ranges: normal BMI (≥20 kg/m2 and <25 kg/m2), underweight (<20 kg/m2), overweight (≥25 kg/m2 and <30 kg/m2), Class 1 and 2 obese (≥30 kg/m2 and <40 kg/m2, reference variable), and severe obesity, which we divided into the following BMI ranges: ≥40 kg/m2 and <50 kg/m2, ≥50 kg/m2 and <60 kg/m2, and ≥60 kg/m2. The primary outcome was hospital admission. Secondary outcomes included same-day postoperative complications and 30-day hospital readmission. We performed multivariable logistic regression and reported odds ratios (OR) and their associated 95% confidence interval (CI) and considered a p-value of <0.05 as statistically significant.Main Results: There were a total of 99,410 patients included in the final analysis, in which there was a 2.6% rate of hospital admission. When compared to class 3 obesity, only those with BMI ≥50 kg/m2(OR 1.55, 95% CI 1.18-2.01, p = 0.005) had increased odds of hospital admission. There were no differences in 30-day hospital readmission or same-day postoperative complications.Conclusion: We found that only patients with BMI ≥50 kg/m2 had increased odds for same-day hospital admission even when patient's comorbid conditions are optimized, suggesting that a BMI ≥50 kg/m2 may be used as a sole factor for patient selection in patients undergoing joint arthroscopy. For patients with BMI <50 kg/m2, we recommend that BMI alone should not be solely used to exclude patients from having joint arthroscopies performed in an outpatient setting, especially since this patient group makes up a significant proportion of joint arthroscopy. [ABSTRACT FROM AUTHOR]

The article presents an assessment of malignant hyperthermia (MH) and the predictors associated with in-hospital mortality in the U.S. between 2000 and 2005. It used an administrative national database representative of the country hospital charges, particularly data from the Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project. It reveals that incidence of MH in the country had increased and the overall mortality rate in patients with a diagnosis of MH was 11.7%. It suggests that based on the data, it should enable the identification of areas requiring increased focus in MH-related education.

Background: Major disparities in complications and mortality after appendectomy between countries with different income levels have not been well characterized, as comparative studies at patient level between countries are scant. This study aimed to investigate variations in postoperative complications, mortality, and failure to rescue after appendectomy between a high-income country and a low-to-middle-income country., Methods: Hospital discharges on adult patients who underwent appendectomy were extracted from administrative databases from Colombia and 2 states of the United States (Florida and New York). Outcomes included major postoperative complications, in-hospital mortality, and failure to rescue. Univariate analyses were conducted to compare outcomes between the 2 countries. Multivariable logistic regression analyses were conducted to examine the independent effect of country on outcomes after adjustment for patient age, sex, comorbidity index, severity of appendicitis, and appendectomy route (laparoscopic/open)., Results: A total of 62,338 cases from Colombia and 57,987 from the United States were included in the analysis. Patients in Colombia were significantly younger and healthier but had a higher incidence of peritonitis. Use of laparoscopy was significantly lower in Colombia (5.9% vs 89.4%; P < .0001). After adjustment for covariates, multivariable logistic regression analyses revealed that compared to the United States, Colombia had lower complication rates (2.8% vs 6.6%; odds ratio [OR], 0.41; 95% confidence interval [CI], 0.39-0.44; P < .0001) but higher mortality (0.44% vs 0.08%; OR, 8.92; 95% CI, 5.69-13.98; P < .0001) and failure to rescue (13.6% vs 1.0%; OR, 17.01; 95% CI, 10.66-27.16; P < .0001)., Conclusions: Despite lower rates of postoperative complications, in-hospital mortality after appendectomy was higher in Colombia than in the United States. This difference may be explained by higher rates of failure to rescue in the low-to-middle-income country (ie, decreased ability of Colombian hospitals to rescue patients from complications)., Competing Interests: Conflicts of Interests: See Disclosures at the end of the article., (Copyright © 2022 International Anesthesia Research Society.)

Background: Upper airway surgery is an alternative treatment for patients with severe obstructive sleep apnea (OSA). However, there is controversy regarding selection criteria for outpatient versus inpatient settings for these surgical procedures. The aim of this retrospective study was to compare postoperative outcomes of patients undergoing airway surgery in outpatient and inpatient settings based on length of stay at the facility., Methods: The 2011-2017 American College of Surgeons National Surgical Quality Improvement databases were used to select adult patients with a diagnosis of OSA undergoing elective airway surgery procedures. Single-level (eg, uvulopalatopharyngoplasty [UPPP]) or multilevel surgery (eg, concomitant procedures on base of tongue, maxilla, palate, nose/turbinate, or tracheotomy) was identified using appropriate current procedural terminology (CPT) codes. Surgery setting was classified as outpatient (length of hospital stay = 0 days) or inpatient (length of stay ≥1 day). Propensity scores derived from logistic regression models were used to match inpatient to outpatient cases at a ratio of 1:1. Primary outcome was a composite of 30-day readmissions, reoperations, and/or postoperative complications. Outcomes between the matched groups were compared with McNemar's tests and generalized mixed linear regression analyses., Results: A total of 3208 cases were identified (1049 [32.7%] outpatient and 2159 [67.3%] inpatient). Inpatients were older, had more comorbidities, larger body mass index, and more multilevel procedures. UPPP was performed in about 96% of both inpatients and outpatients. The overall rate of composite of readmission, reoperations, and/or complications in the whole unmatched sample was 6.4% (6.8% and 5.5% in inpatients and outpatients, respectively). The propensity-matching algorithm produced a sample of 987 patients per surgical setting well balanced on available baseline characteristics. The incidence of the composite primary outcome was not significantly different between the groups (6.2% and 5.9% in inpatients and outpatients, respectively; odds ratio [OR] [95% confidence interval {CI}], 1.06 [0.73-1.53]; P = .77)., Conclusions: This retrospective study found that the complications and 30-day readmission rates after airway surgery for OSA are low. There were no significant differences in the composite outcome of 30-day readmissions, reoperations, or complications between inpatient and outpatient settings. Adequately designed prospective studies are necessary to confirm the retrospective observations of this study., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 International Anesthesia Research Society.)

Background: We aimed to examine whether safety-net burden is a significant predictor of failure-to-rescue (FTR) after major abdominal surgery controlling for patient and hospital characteristics, including surgical volume., Methods: Data were extracted from the 2007-2011 Nationwide Inpatient Sample. FTR was defined as mortality among patients experiencing major postoperative complications. Differences in rates of complications, mortality, and FTR across quartiles of safety-net burden were assessed with univariate analyses. Multilevel regression models were constructed to estimate the association between FTR and safety-net burden., Results: Among 238,645 patients, the incidence of perioperative complications, in-hospital mortality, and FTR were 33.7%, 4.4%, and 11.8%, respectively. All the outcomes significantly increased across the quartiles of safety-net burden. In the multilevel regression analyses, safety-net burden was a significant predictor of FTR after adjustment for patient and hospital characteristics, including hospital volume., Conclusion: Increasing hospital safety-net burden is associated with higher odds of FTR for major abdominal surgery., Competing Interests: Declarations of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The current opioid epidemic is perhaps the greatest public health crisis in the United States. Although multiple factors led to the rise of this epidemic, it is without question associated with the rise in opioid prescribing., Objectives: Better understanding of the opioid prescribing may provide insights into population-level trends contributing to this epidemic, and opportunities to decrease the magnitude of opioid overdose-related death. Therefore we assessed trends in opioid prescribing habits based on analysis of the Texas Prescription Drug Monitoring Program (PDMP) and geographic, ethnic, and income-related data from the US Census Bureau., Study Design: Multiple linear regression analysis of Texas PDMP and US Census Bureau data were performed to assess for correlations to opioid prescribing based on geographic, ethnic, income, and time-related variables., Setting: All controlled substances prescribed in the state of Texas from April 2015 to May 2018 were analyzed., Methods: We obtained data from the Texas PDMP for all controlled substances from April 2015 to May 2018. We performed multiple linear regression analysis of these data along with US Census Bureau data to assess for correlations based on geographic, ethnic, income, and time-related variables. We hypothesized that there would be substantial variability in opioid prescribing habits based on geographic, ethnic, and economic variables., Results: Approximately 200 million pills of controlled substances were prescribed per month over the studied time frame. Overall, high geographic variability was noted, and this strongly correlated to race and ethnicity. Opioid prescribing increased along with the proportion of white residents within a county, but a similar negative correlation was noted with increasing Hispanic population proportion. This correlation was noted throughout the study period, but up until 2017, lower income levels among higher white population had even higher correlation with increased opioid prescribing. Cumulative opioid prescriptions throughout the state fell beginning in 2017., Limitations: This analysis does not include opioids obtained illicitly or from prescriptions outside the state of Texas. The specificity of geographic data are limited to the county level due to irregular entry of zip code data by prescribing pharmacies., Conclusions: In the state of Texas over the studied time period, there was strong correlation for higher rates of opioid prescribing as white population increased despite overall decreased opioid prescribing starting in 2017. Until 2017, this correlation grew stronger as low-income white population increased., Key Words: Opioid, opioid epidemic, opioid utilization.

Objective: Increasing surgeon volume may improve outcomes for index operations. We hypothesized that there may be surrogate operative experiences that yield similar outcomes for surgeons with a low-volume experience with a specific index operation, such as esophagectomy., Background: The relationship between surgeon volume and outcomes has potential implications for credentialing of surgeons. Restrictions of privileges based on surgeon volume are only reasonable if there is no substitute for direct experience with the index operation. This study was aimed at determining whether there are valid surrogates for direct experience with a sample index operation-open esophagectomy., Methods: The Nationwide Inpatient Sample (2003-2009) was utilized. Surgeons were stratified into low and high-volume groups based on annual volume of esophagectomy. Surrogate volume was defined as the aggregate annual volume per surgeon of upper gastrointestinal operations including excision of esophageal diverticulum, gastrectomy, gastroduodenectomy, and repair of diaphragmatic hernia., Results: In all, 26,795 esophagectomies were performed nationwide (2003-2009), with a crude inhospital mortality rate of 5.2%. Inhospital mortality decreased with increasing volume of esophagectomies performed annually: 7.7% and 3.8% for low and high-volume surgeons, respectively (P < 0.0001). Among surgeons with a low-volume esophagectomy experience, increasing volume of surrogate operations improved the outcomes observed for esophagectomy: 9.7%, 7.1%, and 4.3% for low, medium, and high-surrogate-volume surgeons, respectively (P = 0.016)., Conclusions: Both operation-specific volume and surrogate volume are significant predictors of inhospital mortality for esophagectomy. Based on these observations, it would be premature to limit hospital privileges based solely on operation-specific surgeon volume criteria.

Background: The aim of the study was to assess the rate of 30-d hospital readmissions after ambulatory laparoscopic cholecystectomy., Materials and Methods: The 2009 to 2011 State Ambulatory Surgery and Services and State Inpatient Databases from California, Florida, and New York were analyzed to evaluate the incidence of 30-d readmissions after laparoscopic cholecystectomy performed in outpatient settings. Hospital transfers and the principal diagnoses of hospital readmission were analyzed as secondary outcomes. Multilevel generalized mixed linear regression analyses with fixed and random effects were used to evaluate variables associated with increased likelihood of readmissions., Results: A total of 230,745 encounters for ambulatory laparoscopic cholecystectomies performed in 890 ambulatory facilities between 2009 and 2011 in the three states were analyzed. The rate of 30-d readmission was 20.2 per 1000 discharges. The rate of direct transfers from the ambulatory surgery center to an acute care hospital was 0.6 per 1000 discharges. The most common diagnoses of readmission were surgical complications, postoperative pain, infection, and nausea or vomiting. After adjusting for comorbidities, increasing age, male sex, non-Hispanic white race/ethnicity, any nonprivate insurance type, diagnosis of acute cholecystitis, use of intraoperative cholangiography, and having the procedure performed on a weekend were significantly associated with increased odds of 30-d readmissions., Conclusions: This large-state data analysis reveals that the unplanned admission and readmission rates after laparoscopic cholecystectomy are very low. Some causes of readmission (e.g., pain, nausea, and vomiting) are modifiable by the intervention of surgeons and anesthesia providers., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Failure to rescue (FTR) is defined as the inability to rescue a patient from major perioperative complications, resulting in operative mortality. FTR is a known contributor to operative mortality after open abdominal aortic surgery. Understanding the causes of FTR is essential to designing interventions to improve perioperative outcomes. The objective of this study was to determine the relative contributions of hospital volume and safety-net burden (the proportion of uninsured and Medicaid-insured patients) to FTR., Methods: The Nationwide Inpatient Sample (2001-2011) was analyzed to investigate variables associated with FTR after elective open abdominal aortic operations in the United States. FTR was defined as in-hospital death following postoperative complications. Mixed multivariate regression models were used to assess independent predictors of FTR, taking into account the clustered structure of the data (patients nested into hospitals)., Results: A total of 47,233 elective open abdominal aortic operations were performed in 1777 hospitals during the study period. The overall incidences of postoperative complications, in-hospital mortality, and FTR in the whole cohort were 32.7%, 3.2%, and 8.6%, respectively. After adjusting for demographics, comorbidities, and hospital characteristics, safety-net burden was significantly associated with increased likelihood of FTR (highest vs lowest quartile of safety-net burden, odds ratio, 1.59; 95% confidence interval, 1.32-1.91; P < .0001). In contrast, after adjusting for safety-net burden, procedure-specific hospital volume was not significantly associated with FTR (P = .897)., Conclusions: After adjusting for patient- and hospital-level variables, including hospital volume, safety-net burden was an independent predictor of FTR after open aortic surgery. Future investigations should be aimed at better understanding the relationship between safety-net hospital burden and FTR to design interventions to improve outcomes after open abdominal aortic surgery., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Despite advances in pharmacologic options for the management of surgical pain, there appears to have been little or no overall improvement over the last two decades in the level of pain experienced by patients. The importance of adequate and effective surgical pain management, however, is clear, because inadequate pain control 1) has a wide range of undesirable physiologic and immunologic effects; 2) is associated with poor surgical outcomes; 3) has increased probability of readmission; and 4) adversely affects the overall cost of care as well as patient satisfaction. There is a clear unmet need for a national surgical pain management consensus task force to raise awareness and develop best practice guidelines for improving surgical pain management, patient safety, patient satisfaction, rapid postsurgical recovery, and health economic outcomes. To comprehensively address this need, the multidisciplinary Surgical Pain Congress™ has been established. The inaugural meeting of this Congress (March 8 to 10, 2013, Celebration, Florida) evaluated the current surgical pain management paradigm and identified key components of best practices.

Purpose: Significant controversy surrounds the management of blood glucose levels during labor and delivery. The American College of Obstetrics and Gynecology has recommended "tight" blood glucose control (<110 mg/dL). However, there is concern that tight control can increase the incidence of maternal hypoglycemia. Thus, there remains a lack of consensus regarding glycemic control during labor and delivery. To assess the current intrapartum glycemic management, we surveyed obstetrical residency programs in the United States., Methods: Questionnaires were distributed via email and if there was no response within 3 weeks, they were mailed to obstetrics/gynecology residency program directors., Results: Of the 117 questionnaires distributed, 49 responses (41.9%) were received, but one was excluded, as it was incomplete. Although 85% of responders reported having a written protocol in place regarding intrapartum BG management, there was significant variation in target blood glucose levels, maintenance of those levels, monitoring of glucose levels, and fluid management during labor and delivery., Conclusion: The key finding of our survey is that there is significant variation in blood glucose management during labor and delivery. This survey identifies areas for improvement as well as areas for future research. Given the sparse obstetrical literature, properly conducted trials are necessary to assess all aspects of optimal intrapartum glucose management.

NicOx is developing NCX-701, a nitric oxide-releasing derivative of paracetamol (acetaminophen), for the potential treatment of inflammation and pain. The compound is currently undergoing phase III clinical trials.