Ronald G. Kaczmarek

Incidence and short-term outcomes of primary and revision hip replacement in the United States.

BACKGROUND The purpose of this study was to use 2003 nationwide United States data to determine the incidences of primary total hip replacement, partial hip replacement, and revision hip replacement and to assess the short-term patient outcomes and factors associated with the outcomes. METHODS We screened more than eight million hospital discharge abstracts from the 2003 Healthcare Cost and Utilization Project Nationwide Inpatient Sample and approximately nine million discharge abstracts from five state inpatient databases. Patients who had undergone total, partial, or revision hip replacement were identified with use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes. In-hospital mortality, perioperative complications, readmissions, and the association between these outcomes and certain patient and hospital variables were analyzed. RESULTS Approximately 200,000 total hip replacements, 100,000 partial hip replacements, and 36,000 revision hip replacements were performed in the United States in 2003. Approximately 60% of the patients were sixty-five years of age or older and at least 75% had one or more comorbid diseases. The in-hospital mortality rates associated with these three procedures were 0.33%, 3.04%, and 0.84%, respectively. The perioperative complication rates associated with the three procedures were 0.68%, 1.36%, and 1.08%, respectively, for deep vein thrombosis or pulmonary embolism; 0.28%, 1.88%, and 1.27% for decubitus ulcer; and 0.05%, 0.06%, and 0.25% for postoperative infection. The rates of readmission, for any cause, within thirty days were 4.91%, 12.15%, and 8.48%, respectively, and the rates of readmissions, within thirty days, that resulted in a surgical procedure on the affected hip were 0.79%, 0.91%, and 1.53%. The rates of readmission, for any cause, within ninety days were 8.94%, 21.14%, and 15.72%, and the rates of readmissions, within ninety days, that resulted in a surgical procedure on the affected hip were 2.15%, 1.61%, and 3.99%. Advanced age and comorbid diseases were associated with worse outcomes, while private insurance coverage and planned admissions were associated with better outcomes. No consistent association between outcomes and hospital characteristics, such as hip procedure volume, was identified. CONCLUSIONS Total hip replacement, partial hip replacement, and revision hip replacement are associated with different rates of postoperative complications and readmissions. Advanced age, comorbidities, and nonelective admissions are associated with inferior outcomes.

Mortality after aortic valve replacement: results from a nationally representative database

BACKGROUND Nationally representative estimates of in-hospital mortality after aortic valve replacement are needed to evaluate whether results from The Society of Thoracic Surgeons National Cardiac Surgery Database are applicable to other institutions in the United States performing these procedures. METHODS Data from the 1994 Nationwide Inpatient Sample were used to estimate the patient characteristics and in-hospital mortality rates associated with aortic valve replacements performed in nonfederal hospitals in the United States. Procedural and hospital characteristics were examined for possible associations with in-hospital mortality. RESULTS An estimated 46,397 aortic valve replacements were performed. In-hospital mortality occurred in 4.3% of first-time isolated aortic valve replacements and 6.4% overall. The highest quartile of procedure-specific hospital volume, compared with the lowest quartile, was associated with lower in-hospital mortality (adjusted odds ratio, 0.58; 95% confidence interval, 0.42 to 0.81). CONCLUSIONS The in-hospital mortality rates observed in this study are very similar to those reported from The Society of Thoracic Surgeons database. These data provide substantial evidence that results from The Society of Thoracic Surgeons database are representative of those achieved at other institutions. However, procedure-specific hospital volume must be considered in applying these results to individual institutions.

Multi-state investigation of the actual disinfection/sterilization of endoscopes in health care facilities

PURPOSE The purpose of this investigation was to observe and assess the actual disinfection or sterilization of endoscopes in health care facilities. MATERIALS AND METHODS A total of 22 hospitals and four ambulatory care centers in three states were studied. Facility protocols were reviewed, interviews conducted with relevant personnel, actual disinfection or sterilization procedures observed, and biologic tests performed to determine and assess disinfection/sterilization procedures. RESULTS Fundamental errors observed during the course of the investigation included respective failures to time the period of disinfection, to clean all channels, to flush all channels with disinfectant, to fully immerse the endoscope in the disinfectant solution, and to use a disinfectant. At 78% of the facilities, failure to sterilize all biopsy forceps was observed. A total of 23.9% of the bacterial cultures from the internal channels of 71 gastrointestinal endoscopes grew 100,000 colonies or more of bacteria. These cultures were obtained after the completion of all disinfection/sterilization procedures and the device was deemed ready for use in the next patient. CONCLUSIONS These data indicate that actual disinfection/sterilization procedures for endoscopes are not always optimal, and high-level disinfection of gastrointestinal endoscopes is not always achieved.

Prevalence of latex-specific IgE antibodies in hospital personnel

BACKGROUND Rubber latex hypersensitivity is an important concern for health care workers. PURPOSE The Center for Devices and Radiological Health, in collaboration with the Consumer Product Safety Commission, conducted a multicenter study of the prevalence of latex-specific IgE antibodies among United States hospital personnel. MATERIALS AND METHODS Nine hospitals participated in the cross-sectional study. A total of 504 hospital personnel completed questionnaires that provided an array of demographic, occupational, and clinical information, including a history, if any, of allergies and the use of latex and nonlatex gloves. More than three-quarters (76.5%) of the participants were tested for total IgE and latex specific IgE. RESULTS A total of 21 (5.5%, 95% CI = 3%-7%) of the tested participants were positive for the presence of latex specific IgE antibodies, defined as a latex IgE level of > or = 0.6 ng/mL. Latex specific IgE antibodies were more prevalent in participants who reported tachycardia, palpitations, flushing, or wheezing associated with latex gloves (Odds Ratio = 10.2, 95% CI = 3.7-28.6). CONCLUSION The studys results suggest that the prevalence of latex-specific IgE antibodies among hospital personnel is appreciable and these personnel and their health care providers should be aware of this entity.

AN OVERVIEW OF OCCUPATIONAL HAZARDS AMONG VETERINARIANS, WITH PARTICULAR REFERENCE TO PREGNANT WOMEN

Veterinarians are challenged by an imposing group of occupational hazards, including exposure to ionizing radiation, injury, infectious agents, and chemicals. In this paper, the health hazards in the typical veterinary practice are inventoried, and the risks of each are assessed. During the past few decades, there has been a significant increase in women entering the veterinary profession. Information is presented concerning the impact of various occupational hazards on the health of female practitioners and paraprofessionals, particularly in regard to the reproductive system. Many of the occupational hazards are exclusively, or more significantly, detrimental to females (particularly when pregnant) and to their unborn. Women must be aware of and avoid these hazards in their clinical environment. The purpose of this review is to assist practitioners in identifying and assessing the hazards in their practice and determining what steps must be taken to eliminate or reduce them.

Sex and risk of hip implant failure: assessing total hip arthroplasty outcomes in the United States.

IMPORTANCE The role of sex in relationship to implant failure after total hip arthroplasty (THA) is important for patient management and device innovation. OBJECTIVE To evaluate the association of sex with short-term risk of THA revision after adjusting for patient, implant, surgery, surgeon, and hospital confounders. DESIGN AND SETTING A prospective cohort of patients enrolled in a total joint replacement registry from April 1, 2001, through December 31, 2010. PARTICIPANTS Patients undergoing primary, elective, unilateral THA. MAIN OUTCOME MEASURES Failure of THA, defined as revision procedure for (1) any reason, (2) septic reason, or (3) aseptic reason after the index procedure. RESULTS A total of 35,140 THAs with 3.0 years of median follow-up were identified. Women constituted 57.5% of the study sample, and the mean (SD) patient age was 65.7 (11.6) years. A higher proportion of women received 28-mm femoral heads (28.2% vs 13.1%) and had metal on highly cross-linked polyethylene-bearing surfaces (60.6% vs 53.7%) than men. Men had a higher proportion of 36-mm or larger heads (55.4% vs 32.8%) and metal on metal-bearing surfaces (19.4% vs 9.6%). At 5-year follow-up, implant survival was 97.4% (95% CI, 97.2%-97.6%). Device survival for men (97.7%; 95% CI, 97.4%-98.0%) vs women (97.1%; 95% CI, 96.8%-97.4%) was significantly different (P = .01). After adjustments, the hazards ratios for women were 1.29 (95% CI, 1.11-1.51) for all-cause revision, 1.32 (95% CI, 1.10-1.58) for aseptic revision, and 1.17 (95% CI, 0.81-1.68) for septic revision. CONCLUSIONS After considering patient-, surgery-, surgeon-, volume-, and implant-specific risk factors, women had a 29% higher risk of implant failure than men after THA in this community-based sample.

Glove use by health care workers: Results of a tristate investigation

The Center for Devices and Radiological Health, in collaboration with the state health departments of Iowa, Maryland, and Massachusetts, conducted a multi-state, multi-institutional investigation of glove use by health care workers (HCWs). Twenty-two hospitals and four ambulatory care centers were included in the investigation. All 26 health care facilities were found to have adopted universal precautions policies for glove use by HCWs, per Centers for Disease Control guidelines. Four hundred five observations were made of HCWs performing procedures that may involve contact with patient body fluids, particularly blood. The prevalence of glove use during selected procedures was as follows: arterial blood gas procedures, 92.3%; intravenous line initiation/maintenance, 77.6%; and phlebotomy, 70.6%. Glove use during phlebotomy (p less than 0.001) and intravenous line procedures (p less than 0.05) was significantly lower in the state with a prevalence of the acquired immunodeficiency syndrome (AIDS) below the national average than in the states with a higher AIDS prevalence. The investigation suggests that health care facilities have responded to the Centers for Disease Control and Occupational Safety and Health Administration campaign to adopt universal precaution policies for glove use by HCWs. Actual glove use by HCWs appears to be substantial but not universal. Glove use by HCWs is significantly related to statewide AIDS prevalence.

Occupational hazards to health care workers: Diverse, ill-defined, and not fully appreciated

Health care workers are challenged by an imposing group of occupational hazards. These hazards include exposure to ionizing radiation, stress, injury, infectious agents, and chemicals. The magnitude and diversity of these hazards are not fully appreciated. The acquired immunodeficiency syndrome epidemic has created additional occupational hazards and has focused attention on the problem of occupational hazards to health care workers. Concern over the nosocomial transmission of the human immunodeficiency virus has contributed to efforts to implement universal infection control precautions and to decrease needlestick injuries. Health care organizations and providers, who have prompted health and safety campaigns for the general public, should not overlook the dangers associated with the health care setting.

The Effects of Reprocessing Cuprophane and Polysulfone Dialyzers on β2-Microglobulin Removal From Hemodialysis Patients

To further define the relationship between dialyzer reuse and the removal of beta 2-microglobulin (beta 2M) during dialysis, 26 patients who received hemodialysis were studied. Thirteen patients were dialyzed with conventional cuprophane dialyzers, and thirteen patients were dialyzed with high-flux polysulfone dialyzers. Patients in each group were dialyzed with only new dialyzers during the primary-use phase of the study, and reprocessed dialyzers during the reuse phase. Dialyzers were used six times during the reuse phase. Serum beta 2M levels were measured both predialysis and postdialysis, and adjusted for fluid loss. Dialysis with conventional cuprophane new dialyzers during the primary-use phase of the study resulted in a 3.3% increase in serum beta 2M levels, and a 2.4% increase in serum beta 2M levels during the reuse phase. The difference in the change of the concentration of beta 2M between primary-use and reuse phases was not statistically significant. Dialysis with high-flux polysulfone new dialyzers during the primary-use phase was associated with a decrease of 59.5% in the mean postdialysis concentration of serum beta 2M compared with the predialysis level. A corresponding decrease of 62.6% in serum beta 2M levels was observed after dialysis with high-flux polysulfone reprocessed dialyzers during the reuse phase. These data show no evidence of an adverse effect on the clearance of beta 2M during dialysis from the reuse of dialyzers up to six times. The results confirm previous studies that have reported that high-flux dialysis with polysulfone dialyzers removes substantial amounts of beta 2M, and dialysis with conventional cuprophane dialyzers does not.

The Epidemiology of Cardiac Pacemakers in the Older US Population

OBJECTIVES: This study estimates the age distribution of older patients (>64 years) receiving implantable cardiac pacemakers in non‐federal US hospitals and determines major characteristics of this group using a massive, nationally representative sample of inpatient discharge records.