Secular Trends in the Incidence, Prevalence, and Medications for Epilepsy from 2007 to 2015 in Taiwan: A Nationwide Population-Based Study.

BACKGROUND: Patients with epilepsy have a higher mortality rate than the general population. Up-to-date estimates of epilepsy incidence, prevalence, and medication use are critical to assist policymaking. METHODS: Using the National Taiwan Insurance Research Database, the standardized incidence and prevalence of epilepsy were estimated in each calendar year from 2007 to 2015. We used the incident cases of epilepsy to analyze the change in prescribing patterns from 2007 to 2015. Joinpoint regression was used to estimate secular trends. RESULTS: From 2007 to 2015, the age- and sex-standardized incidence decreased from 0.72 (95% confidence interval [CI] 0.70-0.73) to 0.54 (95% CI 0.53-0.55) per 1,000 person-years, giving an annual percentage change (APC) of -2.73 (p < 0.05). Among patients younger than 20 years, the incidence did not change significantly. The age- and sex-standardized prevalence decreased from 6.94 (95% CI 6.90-6.98) to 6.86 (95% CI, 6.82-6.89) per 1,000 people, giving an APC of -0.31 (p < 0.05). However, the prevalence increased in the 35- to 49- and 50- to 64-year age-groups. The most common first-line anticonvulsant was phenytoin in 2007 and valproate in 2015. The use of levetiracetam, clobazam, and valproate increased during the study period, with APCs of 25.48% (95% CI 19.97-31.24), 6.41 (3.09-9.85), and 2.83 (1.51-4.16), respectively. The use of carbamazepine, phenytoin, and topiramate decreased; the APCs were -23.86% (95% CI -25.25 to -22.44), -6.61 (-8.40 to -4.79), and -4.29% (-7.87 to -0.57), respectively. CONCLUSIONS: The overall prevalence and incidence of epilepsy decreased slightly from 2007 to 2015. The prescribed first-line anticonvulsant also changed over time.

Temporal relationships between systemic lupus erythematosus and comorbidities.

OBJECTIVE: To examine the burden of comorbidities prior to and after the diagnosis of SLE and its impact on mortality. METHODS: We identified 1605 incident cases of SLE and 6284 matched controls from the UK primary care. The risks of comorbidities before (prevalence; odds ratios) and after SLE diagnosis (incidence; hazard ratios) and the impact of comorbidities at diagnosis on all-cause mortality were estimated. RESULTS: At diagnosis, SLE was associated with adjusted odds ratios (95% CI) of 2.25 (1.97-2.56), 3.37 (2.49-4.57) and 3.54 (1.89-6.63) for a Charlson comorbidity index of 1-2, 3-4 and ≥5, respectively. Following diagnosis, SLE also associated with increased risk of developing any comorbidity with an adjusted hazard ratio (95% CI) of 1.30 (95% CI, 1.13-1.49). At diagnosis, SLE was associated with a greater risk of cancer, cardiovascular, renal, liver, rheumatological and neurological diseases as well as depression, anaemia and psoriasis. Risks of developing incident comorbidity in the categories of neoplasm, cardiovascular, genitourinary, metabolic/endocrine, gastrointestinal and hepatic diseases, chronic pulmonary diseases, musculoskeletal/connective tissue and neurological diseases were higher in SLE patients. People with SLE had higher mortality risk compared with controls, with adjusted hazard ratio of 1.91 (95% CI, 1.62-2.26); after further adjusting for comorbidities this reduced to 1.64 (1.37-1.97). Comorbidities at SLE diagnosis accounted for 27.6% of the apparent difference in mortality between SLE patients and matched controls. CONCLUSION: People with SLE have increased risks of multiple comorbidities both prior to and after diagnosis and this contributes significantly to all-cause mortality.

Risk Factors for Undergoing Elective Abdominal Contouring Surgery Shortly After Hospitalization.

BACKGROUND: Having posthospital syndrome (PHS) at the time of an elective surgery increases the risk of postoperative adverse outcomes. The purpose of this article was to identify incidence and risk factors for having PHS at the time of abdominal contouring surgeries. METHODS: Insurance claims from the Truven MarketScan Databases were used to identify patients who underwent outpatient abdominoplasty, liposuction, or panniculectomy between April 2010 and August 2015. Patients were presumed to have PHS if they were hospitalized within 90 d before surgery. Incidence rates of having PHS were calculated for patient groups defined by demographic data and comorbidities. Statistical inference based on adjusted odds ratios was used to evaluate the association of potential risk factors with PHS. A nonparametric regression method was used to demonstrate nonlinear effects of patient covariates on the risk of PHS. RESULTS: This study included 18,947 patients who underwent abdominal contouring; 77% were female, and the mean age was 48.7 y (SD = 14.7). Six percent (n = 1045) of patients had PHS at the time of surgery. A significantly stronger association with PHS (P < 0.001) was observed in patients with deep venous thrombosis (adjusted odds ratio = 3.56), Elixhauser score > 8 (3.28), and smokers (2.16). Age was found to have a piecewise linear effect on PHS, with odds increasing by 2.1% per year over the age of 45 y. CONCLUSIONS: Older patients have an increased risk of undergoing abdominal contouring surgery in a deconditioned state. Screening at-risk populations for PHS would help identify patients who need rehabilitation before operative intervention.

Pathology Evaluation of Reduction Mammaplasty Specimens and Subsequent Diagnosis of Malignant Breast Disease: A Claims-Based Analysis.

BACKGROUND: This study aimed to measure the use of pathology evaluation of breast specimens among patients undergoing reduction mammaplasty and assess rates of new diagnoses of breast disease and associated cost. METHODS: We analyzed the Truven MarketScan Databases from 2009 to 2015 to identify adult female patients undergoing reduction mammaplasty for macromastia. We recorded patient age, rates of obtaining pathology evaluation, new diagnoses of benign or malignant breast disease after pathology evaluation, and total cost for the surgery encounter. RESULTS: Among 17,738 macromastia patients undergoing reduction mammaplasty, 91.3% (n = 16,193) received pathology evaluation. Pathology evaluation rates were clinically similar across age groups <70 years (90.8-92.1%) and slightly lower for patients ≥70 (85.0%). Among 6987 patients less than 40 years who received pathology evaluation, 0.06% (n = 4) were subsequently diagnosed with malignant breast disease within 3 months, compared to 0.23% in the entire cohort (n = 37/16,193). Pathology claims resulted in an added $307 (SD 251) on average for the breast reduction surgery encounters. CONCLUSIONS: Breast tissue after reduction mammaplasty is routinely submitted for pathology evaluation, without consideration of age-based risk for breast cancer. Routine pathology evaluation of breast tissue in patients in lower risk age groups (less than 40 years) required an additional $536,000 on average to detect a single occult breast cancer compared to an added $85,600 to detect a new malignancy in patients 40 years and older. Clinicians and policy makers should consider whether routine pathology evaluation of breast tissue should be individualized based on risk factors for breast cancer.

The Impact of Pre-Referral Advanced Diagnostic Testing on Wait Time to See a Hand Surgeon for Common Upper-Extremity Conditions.

PURPOSE: We sought to evaluate the use of pre- and post-referral advanced diagnostic testing among patients with 3 common hand conditions, rates of subsequent tests, and differences in wait time to see a hand surgeon. METHODS: We analyzed a single academic tertiary care center administrative database of encounters from 2006 to 2015 to identify adult patients who were referred to a hand surgeon for 3 conditions (carpal tunnel syndrome [CTS], soft tissue masses [STM], and joint pain [JP]). We recorded patient characteristics, use and timing of diagnostic tests, and wait time for the initial hand surgeon evaluation. RESULTS: Among patients who received advanced diagnostic tests before the surgeon evaluation, CTS patients had the highest rate of receiving pre-referral advanced testing (53.4%) compared with JP (10.6% ) and STM patients (5.8%). The CTS patients had the highest rates of repeat testing (19.5%) compared with patients with JP (1.4%) and STM (0%). Across all 3 conditions, patients who received pre-referral advanced testing waited an additional 19 to 94 days to see a surgeon, compared with patients who received only post-referral testing or no testing. CONCLUSIONS: Use of pre-referral advanced diagnostic tests is associated with an increased time to see a hand surgeon for common hand conditions. CLINICAL RELEVANCE: Hand surgeons should have a role in identifying patients who do or do not benefit from advanced testing before referral to ensure that tests ordered before consultation are useful to both patients and treating surgeons.

Population-based trends and risk factors of early- and late-onset preeclampsia in Taiwan 2001-2014.

BACKGROUND: Preeclampsia, a multisystem disorder in pregnancies complicates with maternal and fetal morbidity. Early- and late-onset preeclampsia, defined as preeclampsia developed before and after 34 weeks of gestation, respectively. The early-onset disease was less prevalent but associated with poorer outcomes. Moreover, the risk factors between early -and late- onset preeclampsia could be differed owing to the varied pathophysiology. In the study, we evaluated the incidences, trends, and risk factors of early- and late- onset preeclampsia in Taiwan. METHODS: This retrospective population-based cohort study included all ≧20 weeks singleton pregnancies resulting in live-born babies or stillbirths in Taiwan between January 1, 2001 and December 31, 2014 (n = 2,884,347). The data was collected electronically in Taiwanese Birth Register and National Health Insurance Research Database. The incidences and trends of early- and late-onset preeclampsia were assessed through Joinpoint analysis. Multivariate logistic regression was used to analyze the risk factors of both diseases. RESULTS: The age-adjusted overall preeclampsia rate was slightly increased from 1.1%(95%confidence interval [CI], 1.1-1.2) in 2001 to 1.3% (95%CI, 1.2-1.3) in 2012 with average annual percentage change (AAPC) 0.1%/year (95%CI, 0-0.2%). However, the incidence was remarkably increased from 1.3% (95%CI, 1.3-1.4) in 2012 to 1.7% (95%CI, 1.6-1.8) in 2014 with AAPC 1.3%/year (95%CI,0.3-2.5). Over the study period, the incidence trend in late-onset preeclampsia was steadily increasing from 0.7% (95%CI, 0.6-0.7) in 2001 to 0.9% (95%CI, 0.8-0.9) in 2014 with AAPC 0.2%/year (95%CI, 0.2-0.3) but in early-onset preeclampsia was predominantly increase from 0.5% (95%CI, 0.4-0.5) in 2012 to 0.8% (95%CI, 0.8-0.9) in 2014 with AAPC 2.3%/year (95%CI, 0.8-4.0). Advanced maternal age, primiparity, stroke, diabetes mellitus, chronic hypertension, and hyperthyroidism were risk factors of preeclampsia. Comparing early- and late-onset diseases, chronic hypertension (ratio of relative risk [RRR], 1.71; 95%CI, 1.55-1.88) and older age (RRR, 1.41; 95%CI 1.29-1.54) were more strongly associated with early-onset disease, whereas primiparity (RRR 0.71, 95%CI, 0.68-0.75) had stronger association with late-onset preeclampsia. CONCLUSIONS: The incidences of overall, and early- and late-onset preeclampsia were increasing in Taiwan from 2001 to 2014, predominantly for early-onset disease. Pregnant women with older age and chronic hypertension had significantly higher risk of early-onset preeclampsia.

Effect of Posthospital Syndrome on Health Care Utilization After Abdominal Contouring Surgery.

BACKGROUND: Posthospital syndrome (PHS) is a transient condition after acute hospitalizations when patients are physiologically deconditioned. The objective of this study was to determine if having PHS at the time of abdominal contouring surgery increased the incidence of postoperative adverse medical events. METHODS: We conducted a retrospective cohort study of patients enrolled in the MarketScan Databases who underwent outpatient functional or cosmetic abdominal contouring surgery (ie, abdominoplasty, liposuction, or panniculectomy) from April 2010 to August 2015. Patients were separated into 2 groups based upon PHS exposure, defined by hospitalization within 90 days before surgery. Differential health care utilization within 30 days after surgery was compared between cohorts. RESULTS: Among the 18,947 patients included in the final cohort, 1045 patients (6%) had PHS at the time of abdominal contouring surgery. Patients with PHS experienced more emergency department visits (0.16 vs 0.08 visits; adjusted odds ratio, 1.60; P < 0.001) and more episodes of hospitalization (0.11 vs 0.04 episodes; adjusted odds ratio, 1.70; P < 0.001) within 30 days postoperatively. The mean unadjusted health care utilization after abdominal contouring surgery for patients with PHS was US $7888 (SD, 17,659) versus US $2943 (SD, 9096) in patients without PHS. After controlling for confounders, such as comorbidity burden, PHS was associated with US $3944 greater cost than patients without PHS (P < 0.001). CONCLUSIONS: Among patients undergoing outpatient abdominal contouring surgery, having PHS increased the incidence of adverse medical events requiring medical attention in the 30-day postoperative period. These findings support the inclusion of PHS in preoperative evaluation and preparation for patients seeking abdominal contouring surgery.

Cardiovascular disease risk in patients receiving organ transplantation: a national cohort study.

Although organ transplantation is the definitive treatment for end-stage organ failure, the post-transplant outcomes can be substantially influenced by cardiovascular complications. A national cohort study was performed to estimate risks of cardiovascular diseases in those with heart, lung, kidney, and liver transplantation. This cohort study consisted of 5978 solid organ transplantations identified using the Taiwan National Health Insurance Database. Cardiovascular and mortality risks in transplant recipients were evaluated using standardized incidence ratios, excess absolute risks, and standardized mortality ratios as compared to those in the general population. In heart, kidney, and liver recipients, the standardized incidence ratios of overall cardiovascular diseases were 9.41 (7.75-11.44), 3.32 (2.29-3.77), and 1.4 (1.15-1.7) and the overall standardized mortality ratios were 5.23 (4.54-6.03), 1.48 (1.34-1.63), and 3.95 (3.64-4.28), respectively. Except for heart organ recipients who were at highest risk for coronary artery disease with a standardized incidence ratio of 13.12 (10.57-16.29), kidney and liver organ recipients had a ninefold increased risk in developing deep vein thrombosis post-transplant. In conclusion, solid organ transplant patients are at risk of cardiovascular disease, in particular, deep vein thrombosis, which may warrant early identification of high-risk patients in addition to prompt and adequate thromboprophylaxis perioperatively.

The impact of hospital, surgeon, and patient characteristics on digit replantation decision: A national population study.

BACKGROUND: Traumatic finger amputations cause a substantial burden to health care system. The purpose of this study is to investigate the epidemiology of traumatic finger amputations, the incidence of replantation attempts and to examine the patient, surgeon, and hospital characteristics that were associated with replantation attempts. METHODS: We examined 49,469 patients with traumatic digit amputations from the National Health Insurance Research Database (NHIRD) of Taiwan. We used Chi-square, ANOVA tests, and regression analysis to determine the important factors in decision to replant. RESULTS: The replantation rate increased significantly with increased hospital volume (low-volume: 4.7%, medium-volume: 19.1 % and high-volume: 35.9 %). Regional hospitals were more likely to attempt replantation (odds ratio = 1.35). Low-volume hospitals had a replantation failure rate of 11.1 %, medium-volume 19.7 % and high-volume hospitals had 13.8 %. CONCLUSION: With the national health insurance coverage, hospital volume is a substantial factor to encourage microsurgical-trained staff to perform digit replantation when indicated. The findings from this study will support government initiatives to foster and reward regionalization centers with high to medium case volume of replants to manage this critical function restoring procedure.

Increased Risk of Dementia in Patients with Craniofacial Trauma: A Nationwide Population-Based Cohort Study.

OBJECTIVE: The role of maxillofacial trauma in dementia risk is not well established. The aim of this study was to evaluate the association between craniofacial trauma, including facial bone fracture and traumatic brain injury (TBI), and dementia. METHODS: Using Taiwan's National Health Insurance Research Database, we identified 501,889 adults who had had ≥1 medical record of craniofacial trauma between 2000 and 2010 and did not have a dementia diagnosis at baseline. Diagnoses of craniofacial trauma, including facial bone fracture and TBI, and dementia were made using International Classification of Diseases, Ninth Revision codes. The standardized incidence ratio was used to determine whether craniofacial trauma was associated with a greater risk of incident dementia compared with the general population. The Cox proportional hazards model was used to predict the risk of dementia among the trauma cohort by comparing the patients with and without comorbidities. RESULTS: A total of 501,889 patients with craniofacial trauma were included, of which 1.5% (n = 7804) developed dementia. Facial bone fracture (standardized incidence ratio, 1.58; 95% confidence interval, 1.25-2.00) was shown to be associated with an increased dementia risk compared with the general population. In addition, craniofacial trauma accompanied with postinjury comorbidities was associated with an increased risk of dementia during follow-up periods compared with the group without comorbidities. CONCLUSIONS: Craniofacial traumas, especially facial bone fracture, were associated with an increased risk of subsequent dementia. Maintaining a high index of suspicion for associated TBIs in all patients with facial trauma is crucial, even if no obvious initial signs and symptoms of brain injury are observed.

Variation in the Treatment of Distal Radius Fractures in the United States: 2010 to 2015.

BACKGROUND: It remains unknown whether treatment trends for distal radius fracture have changed in light of value-based care initiatives during recent years. The authors aimed to characterize modern practice patterns for distal radius fracture management. METHODS: Truven MarketScan databases from 2009 to 2015 were used to extract demographic characteristics, geographic location, and comorbidities for patients receiving treatment for a distal radius fracture. Regression modeling and Joinpoint analysis were used to assess treatment trends and the association of patient factors with treatment provided. RESULTS: Among 499,766 eligible encounters, the rate of internal fixation fluctuated around 13 percent. Casting/splinting remained the most frequent treatment across all populations. Treatment trends varied by age; children and adolescents almost exclusively received closed treatment (mean, 97 percent), yet rates of internal fixation increased among adults and elderly patients. Patients aged 55 to 64 years were most likely to undergo internal fixation (OR, 1.89; 95 percent CI, 1.82 to 1.96). Higher median household income also significantly increased odds of receiving internal fixation (p < 0.001). Despite declining rates of external fixation and percutaneous pinning, regional variations among surgical modalities persist. CONCLUSIONS: The increased use of internal fixation for distal radius fractures may be slowing. Treatment type continues to differ widely across demographic groups, underscoring the need for standardization. In accordance with value-based care initiatives, treatment decisions should be made to combine patient needs with financial implications on the health system. Comparative effectiveness data to derive optimal management strategies are still warranted.

Impact of Economic Downturn on the Surgical Volumes of Common Hand Procedures.

BACKGROUND: Economic conditions affect surgical volumes, particularly for elective procedures. In this study, the authors aimed to identify the effects of the 2008 U.S. economic downturn on hand surgery volumes to guide surgeons and managers when facing future economic crises. METHODS: The authors used the California State Ambulatory Surgery and Services Database from January of 2005 to December of 2011, which includes the entire period of the Great Recession (December of 2007 to June of 2009). The authors abstracted the monthly volume of five common hand procedures using International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes. Pearson statistics were used to identify the correlation between unemployment rate and surgical volume for each procedure. RESULTS: The total number of operative cases was 345,583 during the 7-year study period. Most common elective hand procedures, such as carpal tunnel release and trigger finger release, had a negative correlation with unemployment rate, but the volume of distal radius fracture surgery did not show any correlation. Compared with carpal tunnel release (r = -0.88) or trigger finger release volumes (r = -0.85), thumb arthroplasty/arthrodesis volumes (r = -0.45) showed only a moderate correlation. CONCLUSIONS: The economic downturn decreased elective hand procedure surgical volumes. This may be detrimental to small surgical practices that rely on revenue from elective procedures. Taking advantage of the principle that increased volume reduces unit cost may mitigate the lost revenue from these elective procedures. In addition, consolidating hand surgery services at larger, regional centers may reduce the effect of the economic environment on individual hand surgeons.

Impact of urate-lowering drugs on the progression and recovery from chronic kidney disease among gout patients.

BACKGROUND: This study investigates the association between exposure to urate-lowering drugs (ULDs) and progression and recovery from chronic kidney disease (CKD). METHODS: We identified 5860 incident gout patients at Chang Gung Memorial Hospital from 2012 to 2015. Propensity score (PS)-weighted Cox proportional hazards model was used to estimate hazard ratios (HRs) for CKD progression and improvement. A separate analysis was conducted to assess the HR for CKD progression and CKD recovery among those with worsening CKD. RESULTS: The incidence of CKD progression among allopurinol, febuxostat and uricosuric agent users were 1.98, 1.88 and 1.64 per 1000 person-days. Compared with allopurinol users, the PS-weighted HR (95% confidence intervals [CIs]) was 1.77 (0.85-1.76) for febuxostat users and 1.37 (0.71-1.37) for uricosuric agent users for CKD progression and 1.43 (1.26-1.62) for febuxostat users and 1.00 (0.88-1.14) for uricosuric agent users for CKD improvement. Compared to allopurinol users, the HRs for CKD progression were 1.14 (0.80-1.66) for febuxostat users and 0.92 (0.67-1.31) for uricosuric agent users. Among 741 patients who had CKD progression, the incidence of CKD recovery was 1.33, 6.21 and 3.53 per 1000 person-days for allopurinol, febuxostat and uricosuric agent users. The HRs (95% CIs) for recovery in febuxostat and uricosuric agent users were 2.17 (1.40-3.47) and 1.80 (1.20-2.83) compared to allopurinol users. CONCLUSIONS: CKD progression and recovery are common in gout patients using ULDs. Febuxostat and benzbromarone were associated with a similar risk of CKD progression with allopurinol, which has a poorer recovery compared with other ULDs.

Evaluation of the effect of the child protection act on serious child physical abuse in Taiwan.

BACKGROUND: Few studies have examined the effects of the Child Protection Act on child maltreatment in Taiwan. OBJECTIVE: This study estimated the secular trends in the incidence rate of physical abuse of children requiring hospitalization between 1996 and 2013, and the subsequent in-hospital death proportion before and after implementation of the Act in 2003. PARTICIPANTS AND SETTING: The cases were children younger than 12 years old who were hospitalized due to child abuse, shaken-baby syndrome, neglect, or homicide between 1996 and 2013. A comparison group consisted of children requiring hospitalization for other reasons. We used the National Health Insurance database to identify patients. METHODS: The Joinpoint Regression Program was used to estimate temporal trends in the standardized incidence rates. RESULTS: Between 1996 and 2013, 2050 children required hospitalization for physical abuse. Before 2005, the annual percent change increased by 9.40 [95% confidence interval (CI), 4.98-14.00] per year, and after 2005 the annual percent change was -4.80 (95% CI, -9.53-0.17) per year. Among the 2050 physically abused children requiring hospitalization, 83 (4%) died in hospital. The in-hospital death proportion was 2.62% before 2003 and 4.90% after 2003, and the ratio of these two proportions was 1.43 (95% CI, 0.80-2.58). CONCLUSIONS: The trend in the incidence of hospitalization of children due to physical-abuse-related injuries started to decline 2 years after implementation of the Child Protection Act. However, the proportion of children who died in hospital as a result of physical abuse requiring hospitalization did not change.

Unplanned Emergency Department Visits within 30 Days of Mastectomy and Breast Reconstruction.

BACKGROUND: Unplanned emergency department visits are often overlooked as an indicator of care quality. The authors' objectives were to (1) determine the rate of 30-day emergency department visits following mastectomy with or without immediate reconstruction, (2) perform a risk analysis of potential factors associated with emergency department return, and (3) assess for potentially preventable visits with a focus on returns for pain. METHODS: Using the Healthcare Cost and Utilization Project data, the authors identified adult women who underwent mastectomy with or without reconstruction. Multivariable logistic regression was performed to evaluate risk of unplanned emergency department visits. The authors identified and sorted diagnostic codes to investigate why patients were seeking emergency department care. In addition, the authors performed a subgroup analysis on patients returning with a pain-related diagnosis to evaluate risk. RESULTS: Of 159,275 cases of mastectomy with or without immediate reconstruction, 4917 (3.1 percent) experienced an unplanned return to the emergency department within 30 days of operation. A substantial proportion of those who returned (23 percent) presented with a pain-related diagnosis. Only 0.9 percent of cases with a 30-day emergency department return were readmitted. CONCLUSIONS: Numerous patients return to the emergency department within 30 days of mastectomy with or without immediate reconstruction. There is a need for policy makers and physicians to implement strategies to reduce discretionary emergency department use, specifically among younger or publicly insured patients. Combining unplanned emergency department visits with readmission rates as a care quality indicator warrants consideration. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Effect of Impactful Articles on Clinical Practice in the United States: Corticosteroid Injection for Patients with Lateral Epicondylitis.

BACKGROUND: Following publication of high-level evidence demonstrating that it is not an effective treatment for lateral epicondylitis, a reduction in the corticosteroid injection rate would be expected. The authors aimed to clarify current clinical practice pattern for lateral epicondylitis and identify factors that influence the introduction of evidence into clinical practice. METHODS: In this administrative claims analysis, the authors used 2009 to 2015 Truven MarketScan data to extract claims for corticosteroid injection, physical therapy, platelet-rich plasma injection, and surgery for lateral epicondylitis. The authors performed multivariable analysis using a generalized estimating equation model to identify the variables that potentially affect the odds of receiving a given treatment. RESULTS: Among 711,726 claims, the authors found that the odds of receiving a corticosteroid injection increased slightly after publication of contradictory evidence (OR, 1.7; 95 percent CI, 1.04 to 1.11 in 2015). Being male (OR, 1.21; 95 percent CI, 1.19 to 1.23), older (OR, 1.16; 95 percent CI, 1.13 to 1.19), and having managed care insurance (OR, 1.15; 95 percent CI, 1.13 to 1.18) significantly contributed to increased odds of receiving corticosteroid injections. Patients seen at facilities in the South (OR, 1.33; 95 percent CI, 1.30 to 1.36 compared with the Northeast) and by plastic/orthopedic surgeons (OR, 2.48; 95 percent CI, 2.43 to 2.52) also had increased odds of receiving corticosteroid injection. CONCLUSIONS: Corticosteroid injection use did not decrease after publication of impactful articles, regardless of provider specialty or other patient-related factors. This finding emphasizes that there are various barriers for even high-level evidence to overcome the inertia of current practice.

Graft outcomes following immunosuppressive therapy with different combinations in kidney transplant recipients: a nationwide cohort study.

BACKGROUND: Immunosuppression plays an essential role to overcome immune-related allograft rejection, but it also causes some nephrotoxicity. This study aimed to investigate how the immunosuppressant combinations affect graft outcomes in kidney transplant recipients. METHODS: A nationwide population-based cohort study using the Taiwan National Health Insurance Database was conducted. A total of 3,441 kidney transplant recipients who underwent kidney transplantation during the targeted period were included. The effects on graft outcomes contributed by conventional immunosuppressants, including corticosteroid, calcineurin inhibitors, antimetabolite purine antagonists, and mammalian target of rapamycin inhibitors, were compared. RESULTS: A total of 423 graft failures developed after the index date. Therapy regimens incorporated with purine antagonists had a comparable reduction of graft failure among four main drug groups regardless of whether they were given as monotherapy or in combination (adjusted hazard ratio: 0.52, 95% confidence interval: 0.42-0.63). Corticosteroid was found to have inferior effects among four groups (adjusted hazard ratio: 1.67, 95% confidence interval: 1.28-2.21). Furthermore, all 15 arrangements of mutually exclusive treatment combinations were analyzed by referencing with corticosteroid monotherapy. As referenced with steroid-based treatment, regimens incorporated with purine antagonists all have superior advantage on graft survival regardless of whether given in monotherapy (65% of graft failure reduced), dual therapy (48%-67% reduced), or quadruple therapy (43% reduced). In all triple therapies, only corticosteroid combined with calcineurin inhibitor and purine antagonist demonstrated superior protection on graft survival (52% of graft failure reduced). CONCLUSION: The results may recommend several superior regimens for contributing to graft survival, and for supporting a steroid-minimizing strategy in immunosuppression maintenance.

Postoperative Ketorolac in Breast and Body Contouring Procedures: A Nationwide Claims Analysis.

BACKGROUND: Nonsteroidal antiinflammatory drugs are useful alternatives to narcotics for analgesia. However, concerns remain regarding their safety. The authors evaluated ketorolac use and complications. We hypothesized that no association between ketorolac and morbidity exists in patients undergoing body contouring. METHODS: Truven MarketScan claims database was analyzed for patients undergoing breast and body contouring surgery. Patients selected received ketorolac and were enrolled a minimum of 90 days. The authors performed a multivariable logistic regression to calculate risk of morbidity, adjusting for clinical and sociodemographic factors. RESULTS: Among the 106,279 patients enrolled, 4924 (4.6 percent) received postoperative ketorolac. In multivariable regression analysis, ketorolac was not associated with hematoma (OR, 1.20; 95 percent CI, 0.99 to 1.46; p > 0.05). There was an increased rate of reoperation within 72 hours (OR, 1.22; 95 percent CI, 1.00 to 1.49; p < 0.05; number needed to harm, 262 patients). Ketorolac was associated with fewer readmissions (OR, 0.76; 95 percent CI, 0.62 to 0.93; p < 0.05; number needed to treat, 87 patients), with a reduction in the rate of pain as a readmission diagnosis (0.6 percent versus 4.3 percent; p = 0.021). Ketorolac was associated with seroma, but this association may not be causal (OR, 1.28; 95 percent CI, 1.05 to 1.57; p < 0.05; number needed to harm, 247 patients). Ketorolac provided an estimated savings of $157 per patient. CONCLUSIONS: The benefits of ketorolac likely outweigh the risks after surgery. Absolute differences in reoperation rates were low, and improved rates of hospital admission impact cost savings. The authors advocate postoperative ketorolac once the wound is hemostatic. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Antibiotic Prophylaxis after Immediate Breast Reconstruction: The Reality of Its Efficacy.

BACKGROUND: Numerous techniques are used to prevent infection after immediate implant-based breast reconstruction. Postoperative antibiotic prophylaxis is commonly prescribed to decrease the risk of reconstructive failure, despite conflicting evidence regarding its effectiveness. The authors studied whether postoperative antibiotic prophylaxis decreases the risk of infection-related explantation in the setting of immediate prosthesis-based breast reconstruction. METHODS: Using Truven MarketScan databases, the authors identified all patients who underwent immediate implant reconstruction between January of 2010 and June of 2014 with at least 6 months of follow-up. Postoperative antibiotic prophylaxis was defined as any oral antibiotic course to be taken postoperatively based on prescriptions filled within 14 days preoperatively through 24 hours after discharge. Reconstructive failure, defined as explantation because of infection, was the primary outcome. Secondary outcomes of interest included wound complications, infection, and readmission for infection. Multivariable regression analyses controlled for demographic variables/comorbidities. RESULTS: Of the 7443 patients, 6049 (81 percent) filled prescriptions for postoperative antibiotic prophylaxis. These patients were equally likely to develop a wound complication (OR, 0.93; 95 percent CI, 0.71 to 1.23) or infection (OR, 0.89; 95 percent CI, 0.70 to 1.14), undergo explantation because of infection (OR, 0.82; 95 percent CI, 0.57 to 1.18), or require readmission for infection (OR, 1.21; 95 percent CI, 0.82 to 1.78) compared with those who did not receive antibiotics. There was no significant difference in the risk of infection-related outcomes based on postoperative antibiotic prophylaxis duration. CONCLUSIONS: Postoperative antibiotic prophylaxis was not associated with a reduced risk of infection or explantation following prosthesis-based breast reconstruction. Given rising rates of antibiotic resistance, focusing instead on technical considerations and the management of comorbid conditions may more effectively enhance the safety of breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Nationwide cohort study on the epidemiology and survival outcomes of thyroid cancer.

In the past three decades, the thyroid cancer incidence has surged globally. Herein, the Taiwan National Health Insurance database was used to identify thyroid cancer patients and to estimate the prevalence and incidence of thyroid cancer during 1997-2012. The Taiwan Cancer Registry and the National Death Registry databases were crosslinked to obtain information on the histological subtypes and survival rates. Joinpoint regression analysis was used for estimating the average annual percentage changes (APCs) in prevalence, incidence, and survival. The age-standardized incidence of thyroid cancer increased from 5.66 per 100,000 person-years in 1997 to 12.30 per 100,000 person-years in 2012, with an average APC of 5.1 (6.9 in males, 4.6 in females). Thyroid cancer was more prevalent in patients with high socioeconomic status and in urban areas. Papillary carcinoma was the most abundant subtype, with a 2.9-fold increase of incident cases noted during 1998-2012 (from 80.6% to 89.8% of all cases). Among the different treatments, partial thyroidectomy increased the most (average APC, 17.3). The overall survival rates by sex and subtype remained stable over time, with 5-year survival rates of 90.2% in 1997 and 92.4% in 2010. In conclusion, 2.2- and 4.2-fold increases in the incidence and prevalence of thyroid cancer, respectively, were observed during 1997-2012 in Taiwan. The surging incidence of thyroid cancer but stable survival rates, and mainly increased in the papillary subtype, altogether imply enhanced detection of subclinical lesions. A true increase due to environmental carcinogens might also be responsible, but warrant further investigations.