Practice Makes Perfect: A Volume-Outcome Study of Hospital Patients With HIV Disease

Cost-effectiveness of interventions for HIV/AIDS, malaria, syphilis, and tuberculosis in 128 countries: a meta-regression analysis

BACKGROUND

Cost-effectiveness analyses have been conducted for many interventions for HIV/AIDS, malaria, syphilis, and tuberculosis, but they have not been conducted for all interventions that are currently recommended in all countries. To support national decision makers in the effective allocation of resources, we conducted a meta-regression analysis of published incremental cost-effectiveness ratios (ICERs) for interventions for these causes, and predicted ICERs for 14 recommended interventions for Global Fund-eligible countries.

METHODS

In the meta-regression analysis, we used data from the Tufts University Center for the Evaluation of Value and Risk in Health (Boston, MA, USA) Cost-Effectiveness Registries (the CEA Registry beginning in 1976 and the Global Health CEA registry beginning in 1995) up to Jan 1, 2018. To create analysis files, we standardised and mapped the data, extracted additional data from published articles, and added variables from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD). Then we selected ratios for interventions with a minimum of two published articles and three published ICERs that mapped to one of five GBD causes (HIV/AIDS, malaria, syphilis, drug-susceptible tuberculosis, or multi-drug resistant tuberculosis), and to a GBD country; reported a currency year during or after 1990; and for which the comparator intervention was defined as no intervention, standard of care, or placebo. Our meta-regression analysis used all available data on 25 eligible interventions, and quantified the association between ICERs and factors at country level and intervention level. We used a five-stage statistical model that was developed to synthesise evidence on cost-effectiveness analyses, and we adapted it for smaller sample sizes by grouping interventions by cause and type (ie, prevention, diagnostics, and treatment). Using the meta-regression parameters we predicted country-specific median ICERs, IQRs, and 95% uncertainty intervals in 2019 US$ per disability-adjusted life-year (DALY) for 14 currently recommended interventions. We report ICERs in league tables with gross domestic product (GDP) per capita and country-specific thresholds.

FINDINGS

The sample for the analysis was 1273 ratios from 144 articles, of which we included 612 ICERs from 106 articles in our meta-regression analysis. We predicted ICERs for antiretroviral therapy for prevention for two age groups and pregnant women, pre-exposure prophylaxis against HIV for two risk groups, four malaria prevention interventions, antenatal syphilis screening, two tuberculosis prevention interventions, the Xpert tuberculosis test, and chemotherapy for drug-sensitive tuberculosis. At the country level, ranking of interventions and number of interventions with a predicted median ICER below the country-specific threshold varied greatly. For instance, median ICERs for six of 14 interventions were below the country-specific threshold in Sudan, whereas 12 of 14 were below the country-specific threshold in Peru. Antenatal syphilis screening had the lowest median ICER among all 14 interventions in 81 (63%) of 128 countries, ranging from $3 (IQR 2-4) per DALY averted in Equatorial Guinea to $3473 (2244-5222) in Ukraine. Pre-exposure prophylaxis for HIV/AIDS for men who have sex with men had the highest median ICER among all interventions in 116 (91%) countries, ranging from $2326 (1077-4567) per DALY averted in Lesotho to $53 559 (23 841-108 534) in Maldives.

INTERPRETATION

Country-specific league tables highlight the interventions that offer better value per DALY averted, and can support decision making at a country level that is more tailored to available resources than GDP per capita and country-specific thresholds. Meta-regression is a promising method to synthesise cost-effectiveness analysis results and transfer them across settings.

FUNDING

Bill & Melinda Gates Foundation.

Understanding the Influence of Hospital Volume on Inpatient Outcomes Following Hospitalization for Status Epilepticus

BACKGROUND

Prior studies show hospital admission volume to be associated with poor outcomes following elective procedures and inpatient medical hospitalizations. However, it is unknown whether hospital volume impacts Inpatient outcomes for status epilepticus (SE) hospitalizations. In this study, we aimed to assess the impact of hospital volume on the outcome of patients with SE and related inpatient medical complications.

METHODS

The 2005 to 2013 National Inpatient Sample database was queried using International Classification of Diseases 9th Edition diagnosis code 345.3 to identify patients undergoing acute hospitalization for SE. The National Inpatient Sample hospital identifier was used as a unique facility identifier to calculate the average volume of patients with SE seen in a year. The study cohort was divided into three groups: low volume (0-7 patients with SE per year), medium volume (8-22 patients with SE per year), and high volume (> 22 patients with SE per year). Multivariate logistic regression analyses were used to assess whether medium or high hospital volume had lower rates of inpatient medical complications compared with low-volume hospitals.

RESULTS

A total of 137,410 patients with SE were included in the analysis. Most patients (n = 50,939; 37%) were treated in a low-volume hospital, 31% (n = 42,724) were treated in a medium-volume facility, and 18% (n = 25,207) were treated in a high-volume hospital. Patients undergoing treatment at medium-volume hospitals (vs. low-volume hospitals) had higher odds of pulmonary complications (odds ratio [OR] 1.18 [95% confidence interval {CI} 1.12-1.25]; p < 0.001), sepsis (OR 1.24 [95% CI 1.08-1.43] p = 0.002), and length of stay (OR 1.13 [95% CI 1.0 -1.19] p < 0.001). High-volume hospitals had significantly higher odds of urinary tract infections (OR 1.21 [95% CI 1.11-1.33] p < 0.001), pulmonary complications (OR 1.19 [95% CI 1.10-1.28], p < 0.001), thrombosis (OR 2.13 [95% CI 1.44-3.14], p < 0.001), and renal complications (OR 1.21 [95% CI 1.07-1.37], p = 0.002). In addition, high-volume hospitals had lower odds of metabolic (OR 0.81 [95% CI 0.72-0.91], p < 0.001), neurological complications (OR 0.80 [95% CI 0.69-0.93], p = 0.004), and disposition to a facility (OR 0.89 [95% CI 0.82-0.96], p < 0.001) compared with lower-volume hospitals.

CONCLUSIONS

Our study demonstrates certain associations between hospital volume and outcomes for SE hospitalizations. Further studies using more granular data about the type, severity, and duration of SE and types of treatment are warranted to better understand how hospital volume may impact care and prognosis of patients.

Management of severe epithelial versus fibrous downgrowth following trabeculectomy: Case report and literature review

Purpose

To describe the presentation and management of a patient with epithelial versus fibrous downgrowth following trabeculectomy surgery and review relevant literature regarding this complication after intraocular surgery.

Observations

A 52-year-old monocular African-American woman was referred for management of presumed epithelial versus fibrous downgrowth following trabeculectomy surgery. The patient was initially treated with intracameral injections of 5-fluorouracil (x2) and bevacizumab (x1). Cataract extraction, membranectomy, and a third intracameral 5-fluorouracil injection were performed. Intraocular pressure (IOP) elevation was subsequently managed with a superotemporal Ahmed FP7 glaucoma drainage device in the sulcus, followed by an inferonasal Baerveldt 350 glaucoma drainage device in the sulcus. The downgrowth has not progressed and the intraocular pressure remains controlled at the most recent follow-up.

Conclusions

This case underscores the risk of this complication following trabeculectomy, the role of a combined medical and surgical approach to management, and the possible need for multiple surgical interventions to control IOP. A review of the literature regarding epithelial and fibrous downgrowth after intraocular surgery was conducted, which highlighted the aggressive nature of these conditions and the range of therapeutic approaches that have been described.

Larger is not necessarily better! Impact of HIV care unit characteristics on virological success: results from the French national representative ANRS-VESPA2 study

OBJECTIVES

To determine the impact of hospital caseload size on HIV virological success when taking into account individual patient characteristics.

METHODS

Data from the ANRS-VESPA2 survey representative of people living with HIV in France was used. Analyses were carried out on the 2612 (86.4% out of 3022) individuals receiving antiretroviral (ARV) treatment for at least one year. Outcomes correspond to two definitions of virological success (VS1 and VS2 respectively) and were analyzed under a multi-level modeling framework with a special focus on the effect of the caseload size on VS.

RESULTS

Structures with caseloads <1700 patients were more likely to have increased the proportion of patients achieving virological success (59% and 81% for VS1 and VS2, respectively) than structures whose caseloads numbered ≥1700 patients. Our results highlight that patients in the 11 largest care units in the sample were exposed to a context where their VS was potentially compromised by care unit characteristics, independently of both their individual characteristics and their own HIV treatment adherence behavior.

CONCLUSIONS

Our results suggest that - at least in the case of HIV care - in France large care units are not necessarily better. This result serves as an evidence-based warning to public authorities to ensure that health outcomes are guaranteed in an era when the French hospital sector is being substantially restructured.

Epithelial Downgrowth after Intraocular Surgery Treated with Intracameral 5-Fluorouracil

Purpose. To present the clinical and histopathologic correlation of two cases of epithelial downgrowth (EDG) after prior intraocular surgery. Methods. Observational case reports. Results. We present two cases of EDG occurring after intraocular surgery. In both cases, after two anterior chamber injections of 5-fluorouracil (5FU), the area of EDG initially regressed. In Case 1, a limited area of EDG eventually recurred, and penetrating keratoplasty with cryotherapy was curative. In Case 2, subsequent corneal edema required Descemet-stripping automated endothelial keratoplasty, and the patient remained clinically free of EDG without further treatment. Conclusion. Intracameral 5FU may have a role in the treatment of EDG after intraocular surgery, though its precise utilization and impact remain to be defined.

Etiopathogenesis and therapy of epithelial ingrowth after Descemet's stripping automated endothelial keratoplasty

Descemet's stripping endothelial keratoplasty is an emerging technique finalized to treat endothelial dysfunction replacing only the pathological portion of cornea. The advent of any new technique puts us in front of new complications. The epithelial ingrowth is a well-known complication already studied in case of ocular trauma and more recently in refractive surgery. This job analyzed the potential etiopathogenesis of epithelial ingrowth after DSAEK, reviewing the cases described in literature, and suggests the potential therapy.

Histologically proven epithelial ingrowth in failed Descemet stripping automated endothelial keratoplasty (DSAEK) managed by repeat DSAEK

Purpose

To report a case of corneal graft failure due to epithelial ingrowth after an uneventful combined Descemet stripping automated endothelial keratoplasty (DSAEK) and phacoemulsification cataract surgery with intraocular lens implant treated successfully with a repeat DSAEK.

Methods

A 77-year-old male patient underwent combined DSAEK and phacoemulsification with intraocular lens implant implantation for Fuchs’ endothelial dystrophy plus cataract in the right eye. The donor cornea was cut on the Moria ALTK system and introduced using a suture pull-through technique. After an episode of endothelial rejection, the graft failed, with signs suggesting epithelial ingrowth. It was stripped from the host cornea using a Descemet’s membrane stripper, and a Simcoe irrigation-aspiration cannula was used to remove all traces of interface material. The excised lenticule was examined histologically using a hematoxylin and eosin stain.

Result

The patient regained and maintained excellent visual acuity with no sign of recurrence of epithelial ingrowth. Histopathological evaluation of the donor tissue of the first graft showed epithelial ingrowth on the stromal surface of the graft and very few endothelial cells, in keeping with the diagnosis of graft failure.

Conclusion

Epithelial ingrowth is a possible cause of endothelial graft failure, but histologically proven cases are rare. Surgical intervention can achieve successful clearance, with the potential for cure and an excellent outcome.

Surgeons' volume-outcome relationship for lobectomies and wedge resections for cancer using video-assisted thoracoscopic techniques

This study examined the effect of surgeons' volume on outcomes in lung surgery: lobectomies and wedge resections. Additionally, the effect of video-assisted thoracoscopic surgery (VATS) on cost, utilization, and adverse events was analyzed. The Premier Hospital Database was the data source for this analysis. Eligible patients were those of any age undergoing lobectomy or wedge resection using VATS for cancer treatment. Volume was represented by the aggregate experience level of the surgeon in a six-month window before each surgery. A positive volume-outcome relationship was found with some notable features. The relationship is stronger for cost and utilization outcomes than for adverse events; for thoracic surgeons as opposed to other surgeons; for VATS lobectomies rather than VATS wedge resections. While there was a reduction in cost and resource utilization with greater experience in VATS, these outcomes were not associated with greater experience in open procedures.

Descemet-stripping automated endothelial keratoplasty for vitrectomized cases with traumatic aniridia and aphakic bullous keratopathy

The surgical indication for Descemet-stripping automated endothelial keratoplasty (DSAEK) is largely limited to phakic or pseudophakic cases of endothelial dysfunction with normal pupils, because the endothelial lenticule is generally attached to the recipient cornea by use of gas tamponade into the anterior chamber. Although it may be desirable for vitrectomized cases with aniridia and aphakic bullous keratopathy without capsule support to undergo DSAEK, one of the major problems is lenticule detachment during surgery or in the postoperative period. To perform DSAEK in such cases, special surgical techniques are needed in order to facilitate adhesion of the lenticule. Herein, we describe a suture technique for attaching the endothelial lenticule in DSAEK for aniridic and aphakic cases that have undergone vitrectomy for traumatic vitreoretinal disease.

ACUTE center for eating disorders

BACKGROUND

While patients with anorexia nervosa have a high mortality rate, more are living into adulthood. Patients with severe malnutrition secondary to anorexia nervosa often require hospitalization for medical stabilization prior to treatment in eating disorders programs.

METHODS

We developed the ACUTE Center at Denver Health Medical Center to medically stabilize adults with the medical complications of severe malnutrition due to an eating disorder. The first 2 years of patient characteristics and outcomes are reported.

RESULTS

From October 2008 through December 2010, the ACUTE unit had 76 admissions of which 62 were for medical stabilization, comprising 54 patients. Eighty-nine percent of patients were female. The mean age was 27 years old (range 17-65). The mean body mass index on admission was 12.9 kg/m(2) (standard deviation [SD] 2.0). At admission, patients were hyponatremic, anemic, and leukopenic, with low bone density, but had normal albumin levels. The mean body mass index on discharge was 13.1 ± 1.9 kg/m(2). Median length of stay was 16 days (interquartile range [IQR] 9-29 days). Eighteen percent were discharged to home and eighty-two percent were discharged to inpatient psychiatric eating disorder units. Inpatient mortality was zero.

DISCUSSION

Patients with this degree of severe malnutrition due to eating disorders are medically complex and relatively uncommon. Regionalized subspecialty centers of excellence, in which a multidisciplinary team is led by practitioners of hospital medicine who have developed expertise in a rare condition, may improve clinical outcomes, optimize healthcare resources, and provide unique professional and academic opportunities for the clinicians involved.

Intraoperative use of spectral-domain optical coherence tomography during Descemet's stripping automated endothelial keratoplasty

Purpose

To evaluate the intraoperative changes in the donor lenticule, recipient cornea, and the reduction of interface fluid thickness during Descemet’s stripping and automated endothelial keratoplasty with EndoGlide™ (Angiotech Pharmaceuticals Inc, Vancouver, Canada) donor insertion, using intraoperative spectral-domain optical coherence tomography.

Methods

Prospective observational case series of patients underwent Descemet’s stripping and automated endothelial keratoplasty using the EndoGlide inserter. Spectral-domain optical coherence tomography (iVue; Optovue Inc, Fremont, CA) with a handheld probe was used to image the cornea and anterior chamber. Standardized software was used to measure interface fluid gap, host cornea, and donor lenticule thicknesses during the following surgical stages of Descemet’s stripping and automated endothelial keratoplasty: (1) after donor insertion and immediately before full air tamponade; (2) after air tamponade and expression of fluid from venting incisions; (3) at 6 minutes of air tamponade; and (4) at 10 minutes of air tamponade.

Results

Ten patients with a mean age of 74.9 ± 11.8 years were recruited. Spectral-domain optical coherence tomography measurements of the interface fluid gap after fluid was expressed through the venting incisions (P < 0.001), at 6 minutes of air tamponade (P < 0.001) and at 10 minutes of air tamponade (P < 0.001 and P = 0.001, respectively), were significantly decreased compared to the measurements immediately before air tamponade. Donor thickness increased significantly at 6 minutes of air tamponade (P = 0.004) but reduced by 10 minutes compared to immediately before air tamponade.

Conclusion

Significant intraoperative changes in the donor, recipient cornea, and interface fluid thickness occurred following endothelial keratoplasty donor insertion.

Provider beliefs and practices relating to tobacco use in patients living with HIV/AIDS: a national survey

The entire online HIV Medical Association US registry was invited to complete a questionnaire regarding beliefs and practices related to smoking in persons living with HIV/AIDS (PLWHAs). 363/486 returned completed questionnaires. Respondents from 43 states reported caring for 76,570 PLWHAs. Only 22.9% had ever received formal tobacco treatment training. Respondents generally agreed that smoking is an important issue in PLWHAs, but reported low levels of cessation-promoting activities. Providers with larger patient panels, "primarily HIV" practices, and formal cessation training had higher questionnaire scores, indicating stronger beliefs in the harms of smoking, benefits of quitting, and effectiveness of cessation strategies.

Severe anorexia nervosa: outcomes from a medical stabilization unit

OBJECTIVE

We report data from the medical stabilization and refeeding of patients with severe anorexia nervosa admitted over a 15-month period.

METHOD

Through chart review and computerized data collection, we evaluated demographic and clinical data from 25 consecutive patients admitted to our medical stabilization unit from October 2008 to January 2010.

RESULTS

In this adult-patient population with a median body mass index (BMI) of 13.1 kg/m(2) (interquartile range, 11.0-14.4), 44% developed hypoglycemia, 76% had abnormal liver function, 83% had abnormal bone density, 45% developed refeeding hypophosphatemia, and 92% were hypothermic. Severe liver function abnormality predicted the development of hypoglycemia (p = 0.02, OR 9.78, CI: 1.55-61.65). No clinical features predicted hypophosphatemia, including admission BMI (p = 0.19), serum glucose level (p = 0.21), elevated liver function tests (p = 0.39 for AST), or initial amount of kilocalories consumed (p = 0.06).

DISCUSSION

Patients with the most severe cases of anorexia nervosa have a high prevalence of serious medical complications during initial refeeding.

The association of hospital, clinic and provider volume with HIV/AIDS care and mortality: systematic review and meta-analysis

The objective of this systematic review and meta-analysis is to examine the association between hospital, clinic and provider patient volumes on HIV/AIDS patient outcomes including mortality, antiretroviral (ARV) use and proportion of patients on indicated opportunistic infection (OI) prophylaxis. We searched MEDLINE and nine other electronic databases from 1 January 1980 through 29 May 2009. Experimental and controlled observational studies of persons with HIV/AIDS were included. Studies examined the volume or concentration of patients with HIV/AIDS in hospitals, clinics or individual providers. Outcomes included mortality, ARV use and proportion of patients on indicated OI prophylaxis. We reviewed 22,692 titles and/or abstracts. Patient characteristics, study design, volume measures, medical outcomes and study confounders were abstracted. Data were extracted independently by two reviewers. Twenty-two studies were included in the final review. High volume hospital care was associated with lower in-hospital mortality (pooled odds ratio (OR) 0.71, 95% confidence interval [CI] 0.57-0.90 p = 0.004) and lower mortality 30 days from admission (pooled OR 0.62, 95% CI 0.47-0.81 p = 0.0004). Higher volume provider care was associated with significantly higher ARV use (pooled OR 4.41, 95% CI 2.70-7.18 p<0.00001). Differences in volume definitions and controlling for confounding variables did not appreciably alter the results. Higher volume hospitals, clinics and providers were associated with significantly decreased mortality for people living with HIV/AIDS and higher volume providers and clinics had higher ARV use. Heterogeneity of volume thresholds and absence of studies from resource-limited settings are major limitations.

Provider training and experience for people living with HIV/AIDS

BACKGROUND

The complexity of HIV/AIDS raises challenges for the effective delivery of care. It is important to ensure that the expertise and experience of care providers is of high quality. Training and experience of HIV/AIDS providers may impact not only individual patient outcomes but increasingly on health care costs as well.

OBJECTIVES

The objective of this review is to assess the effects of provider training and experience on people living with HIV/AIDS on the following outcomes: immunological (ie. viral load, CD4 count), medical (ie. mortality, proportion on antiretrovirals), psychosocial (ie. quality of life measures) and economic outcomes (ie health care costs).

SEARCH STRATEGY

We searched MEDLINE, EMBASE, Dissertation Abstracts International (DAI), CINAHL, HealthStar, PsycInfo, PsycLit, Social Sciences Abstracts, and Sociological Abstracts from January 1, 1980 through May 29, 2009.  Electronic searches were performed for abstracts from major international AIDS conferences. Reference lists from pertinent articles, books and review articles were retrieved and reviewed.

SELECTION CRITERIA

Randomized controlled trials (RCTs), controlled clinical trials, cohort, case control, cross-sectional studies and controlled before and after designs that examined the qualifications/training and patient volume of HIV/AIDS care of providers caring for persons known to be infected with HIV/AIDS were included.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed trial quality and extracted data. Study authors were contacted for further information as required. Assessment of confounding factors was undertaken independently by two reviewers.

MAIN RESULTS

A total of four studies (one randomized controlled trial, three non- randomized studies) involving 8488 people living with HIV/AIDS were included. The main findings of this review demonstrated a trend to improved outcomes when treated by a provider with more training/expertise in HIV/AIDS care in the outpatient (clinic) setting. Due to the heterogeneity of the included studies, we could not perform a meta-analysis. We present a descriptive review of the results.

AUTHORS' CONCLUSIONS

The results demonstrate improved medical outcomes when treated by a provider with more training/expertise in HIV/AIDS care in the outpatient (clinic) setting. Since all of these studies were conducted in North America, this does not address any issues regarding the level of training/expertise required by providers working in countries with more limited resources. Practitioners who do not consider themselves 'experts' in HIV/AIDS care and care for few of these patients need to seriously consider this review which demonstrates a trend towards worse patient outcomes when receiving care by those with low caseloads/training in HIV/AIDS care.

Influences on place of death in Botswana

OBJECTIVE

There is an emerging body of research aimed at understanding the determinants of place of death, as where people die may influence the quality of their death. However, little is known about place of death for people of Southern Africa. This study describes place of death (home or hospital) and potential influencing factors (cause of death, age, gender, occupation, and district of residence).

METHOD

We collected the death records for years 2005 and 2006 for all adult non-traumatic deaths that occurred in Botswana, described them, and looked for associations using bivariate and multivariate analyses.

RESULTS

The evaluable sample consisted of 18,869 death records. Home deaths accounted for 36% of all deaths, and were predominantly listed with "unknown" cause (82.3%). Causes of death for hospital deaths were HIV/AIDS (49.7%), cardiovascular disease (13.8%), and cancer (6.6%). The mean age at the time of all deaths was 53.2 years (SD = 20.9); with 61 years (SD = 22.5) for home deaths and 48.8 years (SD = 18.6) for hospital deaths (p < .001). Logistic regression analysis revealed the following independent predictors of dying at home: unknown cause of death; female gender; >80 years of age; and residing in a city or rural area (p < .05).

SIGNIFICANCE OF RESULTS

A major limitation of this study was documentation of cause of death; the majority of people who died at home were listed with an unknown cause of death. This finding impeded the ability of the study to determine whether cause of death influenced dying at home. Future study is needed to determine whether verbal autopsies would increase death-certificate listings of causes of home deaths. These data would help direct end-of-life care for patients in the home.

Visually significant and nonsignificant complications arising from Descemet stripping automated endothelial keratoplasty

PURPOSE

To examine the complications encountered after Descemet stripping automated endothelial keratoplasty (DSAEK) at one institution.

DESIGN

Retrospective case review.

METHODS

The first 126 consecutive DSAEKs done at the New York Eye and Ear Infirmary from March 1, 2006 to March 1, 2008 were reviewed. A total of 126 eyes of 113 patients underwent DSAEK. All cases were included regardless of outcome. All complications intraoperatively and postoperatively were recorded.

RESULTS

Graft detachment was the most common complication, occurring in 22 eyes (17.5%); 17 of these (77%) were successfully repositioned. Idiopathic graft failure occurred in 15 eyes (6%). Other visually significant complications included graft rejection (2 eyes), choroidal effusion (2 eyes), epithelial ingrowth (2 eyes), endophthalmitis (1 eye), pupillary block (1 eye), and suture abscess (1 eye). Twenty-four eyes had non-visually significant complications including decentered lenticles, interface fibers, partial peripheral detachments, retained Descemet membrane, and eccentric trephination.

CONCLUSIONS

While DSAEK is a viable alternative to penetrating keratoplasty, serious complications may still occur postoperatively. While certain rare complications like endophthalmitis, epithelial ingrowth, and suture abscess may affect vision, more common complications such as decentered lenticles and partial peripheral detachments are less likely to affect visual outcome.

Failed descemet-stripping automated endothelial keratoplasty grafts: a clinicopathologic analysis

PURPOSE

To describe the clinicopathologic findings in failed Descemet-stripping automated endothelial keratoplasty (DSAEK) grafts.

DESIGN

Retrospective, interventional case series.

METHODS

SETTING

New York Eye and Ear Infirmary.

STUDY POPULATION

Twenty-one patients with 22 failed DSAEK grafts treated between March 1, 2006 and February 1, 2008.

INTERVENTION

Repeat DSAEK or penetrating keratoplasty were performed in the eyes with failed grafts. All failed grafts were examined histopathologically.

MAIN OUTCOME MEASURES

Histopathologic parameters studied in failed DSAEK grafts included endothelial cell count, interface characteristics, retrocorneal membrane formation, inflammation, and immunoreactivity for herpes simplex virus type 1 (HSV-1) antigen.

RESULTS

DSAEK failure was strongly associated with postoperative lenticle dislocation. Graft failure was primary in 19 DSAEKs and secondary to rejection, eccentric trephination with epithelial ingrowth, or bacterial infection in the remaining 3. All failed grafts demonstrated endothelial hypocellularity and stromal edema. Additional findings included stromal inflammation (68%), interface fibrosis (50%), retrocorneal membrane (36%), unplanned retention of Descemet membrane (14%), immunoreactivity for HSV-1 (14%), paucicellular stroma (14%), and uneven trephination with epithelial ingrowth (5%).

CONCLUSIONS

Most DSAEK failures are secondary to endothelial cell loss. Other contributing factors include interface fibrosis, retrocorneal membrane formation, retained host Descemet membrane, uneven trephination, epithelial ingrowth, graft rejection, and infection.

Determinants of length of stay for psychiatric inpatients: analysis of a national database covering the entire Korean elderly population

OBJECTIVE

In a rapidly aging society, inappropriately long geropsychiatric inpatient hospitalization is a challenging concern for mental health policy-makers and researchers. This study aimed to investigate patient and institutional factors affecting geropsychiatric inpatient length of stay (LOS), providing an overview of current geropsychiatric health care system in South Korea.

METHODS

This retrospective, population-based, cross-sectional study analysed nationwide reimbursement claim databases covering the entire elderly population of Korea between January 2005 and June 2006. Given the nested structure of the data, a multivariate multilevel regression analysis was performed.

RESULTS

The average LOS was 128 days. Males, patients with schizophrenia, and those enrolled in a National Medical Care Aid program tended to have longer hospital stays. Patient age was negatively related to LOS. Institutional variables related to longer hospitalizations included a psychiatric hospital, a higher number of beds, fewer human resource employees, a higher proportion of male, oldest old, and patients with dementia.

CONCLUSIONS

Our results suggest that policies targeting geropsychiatric patients diagnosed with schizophrenia, enrolled in National Medical Care Aid programs, and admitted to psychiatric hospitals could reduce LOS. Additionally, the impact of the patient composition of a medical institution on LOS needs to be closely investigated.

Descemet's stripping endothelial keratoplasty: safety and outcomes: a report by the American Academy of Ophthalmology

OBJECTIVE

To review the published literature on safety and outcomes of Descemet's stripping endothelial keratoplasty (DSEK) for the surgical treatment of endothelial diseases of the cornea.

DESIGN

Peer-reviewed literature searches were conducted in PubMed and the Cochrane Library with the most recent search in February 2009. The searches yielded 2118 citations in English-language journals. The abstracts of these articles were reviewed and 131 articles were selected for possible clinical relevance, of which 34 were determined to be relevant to the assessment objectives.

RESULTS

The most common complications from DSEK among reviewed reports included posterior graft dislocations (mean, 14%; range, 0%-82%), followed by endothelial graft rejection (mean, 10%; range, 0%-45%), primary graft failure (mean, 5%; range, 0%-29%), and iatrogenic glaucoma (mean, 3%; range, 0%-15%). Average endothelial cell loss as measured by specular microscopy ranged from 25% to 54%, with an average cell loss of 37% at 6 months, and from 24% to 61%, with an average cell loss of 42% at 12 months. The average best-corrected Snellen visual acuity (mean, 9 months; range, 3-21 months) ranged from 20/34 to 20/66. A review of postoperative refractive results found induced hyperopia ranging from 0.7 to 1.5 diopters (D; mean, 1.1 D), with minimal induced astigmatism ranging from -0.4 to 0.6 D and a mean refractive shift of 0.11 D. A review of graft survival found that clear grafts at 1 year ranged from 55% to 100% (mean, 94%).

CONCLUSIONS

The evidence reviewed is supportive of DSEK being a safe and effective treatment for endothelial diseases of the cornea. In terms of surgical risks, complication rates, graft survival (clarity), visual acuity, and endothelial cell loss, DSEK appears similar to penetrating keratoplasty (PK). It seems to be superior to PK in terms of earlier visual recovery, refractive stability, postoperative refractive outcomes, wound and suture-related complications, and intraoperative and late suprachoroidal hemorrhage risk. The most common complications of DSEK do not appear to be detrimental to the ultimate vision recovery in most cases. Long-term endothelial cell survival and the risk of late endothelial rejection are beyond the scope of this assessment.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.