James X. Wu

Trends in the frequency and quality of parathyroid surgery: analysis of 17,082 cases over 10 years.

OBJECTIVE To examine trends in the frequency and quality of surgery for primary hyperparathyroidism (PHPT) in California during the period of 1999 to 2008. BACKGROUND The quality of surgery for PHPT can be measured by the complication rate and the success rate of surgery. A fraction of patients with failed initial surgery undergo reoperation. METHODS Data on patients undergoing parathyroidectomy (PTx) were obtained from the California Office of Statewide Health Planning and Development. Renal transplant recipients and dialysis patients were excluded. Hospitals were categorized by case volume: Very low: 1 to 4 operations annually; Low: 5 to 9; Medium, 10 to 19; High: 20 to 49; Very high: 50 or more. Complication rates and the percentage of cases requiring reoperation were analyzed. RESULTS A total of 17,082 cases were studied. Annual case volume grew from 990 to 2746 (177% increase) over the study period, corresponding to a 147% increase in the per capita PTx rate. The proportion of cases performed by very high-volume hospitals increased from 6.4% to 20.5% (P < 0.001). The overall complication rate declined from 8.7% to 3.8% (P < 0.001). Complication rates were inversely related to hospital volume (very high volume, 3.9% vs very low volume, 5.2%, P < 0.05). Reoperation was performed in 363 patients (2.1%). The reoperation rate increased from 0.91% to 2.73% during the study period (P < 0.01). The reoperation rate was inversely and nonlinearly related to hospital volume, as described by the equation % reoperation = 100/(total hospital case volume). CONCLUSIONS Surgery for PHPT has grown safer and more common over time. High-volume centers have lower rates of complication and reoperation.

Effect of malignancy rates on cost-effectiveness of routine gene expression classifier testing for indeterminate thyroid nodules

BACKGROUND The value of gene expression classifier (GEC) testing for cytologically indeterminate thyroid nodules lies in its negative predictive value, which is influenced by the prevalence of malignancy. We incorporated actual GEC test performance data from a tertiary referral center into a cost-effectiveness analysis of GEC testing. METHODS We evaluated consecutive patients who underwent GEC testing for Bethesda category III and IV nodules from 2012 to 2014. Routine GEC testing was compared with conventional management by the use of a decision tree model. Additional model variables were determined via literature review. A cost-effectiveness threshold of

Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial Allowing Outpatient Antibiotic Management

100,000 per quality-adjusted life-year (QALY) was used. RESULTS The prevalence of malignancy was 24.3% (52/214). Sensitivity and specificity of GEC testing were 96% and 60%. Conventional management cost

Cost effectiveness of nonoperative management versus laparoscopic appendectomy for acute uncomplicated appendicitis

11,119 and yielded 22.15 QALYs. Routine GEC testing was more effective and more costly, with an incremental cost-effectiveness ratio of

Reproductive Outcomes and Nononcologic Complications After Radioactive Iodine Ablation for Well-Differentiated Thyroid Cancer

119,700/QALY, making it not cost-effective. At malignancy rates of 15, 25, or 35%, routine GEC testing became cost-effective when the cost of GEC testing fell below

Clinical Factors Influencing the Performance of Gene Expression Classifier Testing in Indeterminate Thyroid Nodules

3,167,

Cost-Effectiveness of Long-Term Every Three-Year Versus Annual Postoperative Surveillance for Low-Risk Papillary Thyroid Cancer

2,595, or

Parathyroidectomy for asymptomatic primary hyperparathyroidism: A revised cost-effectiveness analysis incorporating fracture risk reduction

2,023. CONCLUSION The cost-effectiveness of routine GEC testing varies inversely with the underlying prevalence of malignancy in the tested population. The value of routine GEC testing should be assessed within the context of institution-specific malignancy rates.

The cost-effectiveness of nonoperative management versus laparoscopic appendectomy for the treatment of acute, uncomplicated appendicitis in children

Study objective Randomized trials suggest that nonoperative treatment of uncomplicated appendicitis with antibiotics‐first is safe. No trial has evaluated outpatient treatment and no US randomized trial has been conducted, to our knowledge. This pilot study assessed feasibility of a multicenter US study comparing antibiotics‐first, including outpatient management, with appendectomy. Methods Patients aged 5 years or older with uncomplicated appendicitis at 1 US hospital were randomized to appendectomy or intravenous ertapenem greater than or equal to 48 hours and oral cefdinir and metronidazole. Stable antibiotics‐first‐treated participants older than 13 years could be discharged after greater than or equal to 6‐hour emergency department (ED) observation with next‐day follow‐up. Outcomes included 1‐month major complication rate (primary) and hospital duration, pain, disability, quality of life, and hospital charges, and antibiotics‐first appendectomy rate. Results Of 48 eligible patients, 30 (62.5%) consented, of whom 16 (53.3%) were randomized to antibiotics‐first and 14 (46.7%) to appendectomy. Median age was 33 years (range 9 to 73 years), median WBC count was 15,000/&mgr;L (range 6,200 to 23,100/&mgr;L), and median computed tomography appendiceal diameter was 10 mm (range 7 to 18 mm). Of 15 antibiotic‐treated adults, 14 (93.3%) were discharged from the ED and all had symptom resolution. At 1 month, major complications occurred in 2 appendectomy participants (14.3%; 95% confidence interval [CI] 1.8% to 42.8%) and 1 antibiotics‐first participant (6.3%; 95% CI 0.2% to 30.2%). Antibiotics‐first participants had less total hospital time than appendectomy participants, 16.2 versus 42.1 hours, respectively. Antibiotics‐first‐treated participants had less pain and disability. During median 12‐month follow‐up, 2 of 15 antibiotics‐first‐treated participants (13.3%; 95% CI 3.7% to 37.9%) developed appendicitis and 1 was treated successfully with antibiotics; 1 had appendectomy. No more major complications occurred in either group. Conclusion A multicenter US trial comparing antibiotics‐first to appendectomy, including outpatient management, is feasible to evaluate efficacy and safety.

Down-regulation of pancreatic and duodenal homeobox-1 by somatostatin receptor subtype 5: a novel mechanism for inhibition of cellular proliferation and insulin secretion by somatostatin

BACKGROUND Appendectomy remains the gold standard in the treatment of acute, uncomplicated appendicitis in the United States. Nonetheless, there is growing evidence that nonoperative management is safe and efficacious. METHODS We constructed a decision tree to compare nonoperative management of appendicitis with laparoscopic appendectomy in otherwise healthy adults. Model variables were abstracted from a literature review, data from the Healthcare Cost and Utilization Project data, the Medicare Physician Fee schedule, and the American College of Surgeons Surgical Risk Calculator. Uncertainty surrounding parameters of the model was assessed via 1-way and probabilistic sensitivity analyses. RESULTS Operative management cost