Use of Various Glaucoma Surgeries and Procedures in Medicare Beneficiaries from 1994 to 2012.

PURPOSE: Determine how procedural treatments for glaucoma have changed between 1994-2012. DESIGN: Retrospective, observational analysis. PARTICIPANTS: Medicare Part B beneficiaries. METHODS: We analyzed Medicare fee-for-service paid claims data between 1994-2012 to determine the number of surgical/laser procedures performed for glaucoma in the Medicare population each year. MAIN OUTCOME MEASURES: Number of glaucoma-related procedures performed. RESULTS: Trabeculectomies in eyes without previous scarring decreased 52% from 54 224 in 1994 to 25 758 in 2003, and a further 52% to 12 279 in 2012. Trabeculectomies in eyes with scarring ranged from 9054 to 13 604 between 1994-2003, but then decreased 48% from 11 018 to 5728 between 2003-2012. Mini-shunts done via an external approach (including ExPRESS [Alcon Inc, Fort Worth, TX]) increased 116% from 2718 in 2009 to 5870 in 2012. The number of aqueous shunts to the extraocular reservoir increased 231% from 2356 in 1994 to 7788 in 2003, and a further 54% to 12 021 in 2012. Total cyclophotocoagulation procedures increased 253% from 2582 in 1994 to 9106 in 2003, and a further 54% to 13 996 in 2012. Transscleral cyclophotocoagulations decreased 45% from 5978 to 3268 between 2005-2012; over the same period, the number of endoscopic cyclophotocoagulations (ECPs) increased 99% from 5383 to 10 728. From 2001 to 2005, the number of trabeculoplasties more than doubled from 75 647 in 2001 to 176 476 in 2005, but since 2005 the number of trabeculoplasties decreased 19% to 142 682 in 2012. The number of laser iridotomies was fairly consistent between 1994-2012, increasing 9% over this period and ranging from 63 773 to 85 426. Canaloplasties increased 1407% from 161 in 2007 to 2426 in 2012. Between 1994-2012, despite a 9% increase in beneficiaries, the total number of glaucoma procedures and the number of glaucoma procedures other than laser procedures decreased 16% and 31%, respectively. CONCLUSIONS: Despite the increase in beneficiaries, the number of glaucoma procedures performed decreased. Glaucoma procedures demonstrating a significant increase in use include canaloplasty, mini-shunts (external approach), aqueous shunt to extraocular reservoir, and ECP. Trabeculectomy use continued its long-term downward trend. The continued movement away from trabeculectomy and toward alternative intraocular pressure-lowering procedures highlights the need for well-designed clinical trials comparing these procedures.

Emergence of hospital- and community-associated panton-valentine leukocidin-positive methicillin-resistant Staphylococcus aureus genotype ST772-MRSA-V in Ireland and detailed investigation of an ST772-MRSA-V cluster in a neonatal intensive care unit.

Sequence type 22 (ST22) methicillin-resistant Staphylococcus aureus (MRSA) harboring staphylococcal cassette chromosome mec (SCCmec) IV (ST22-MRSA-IV) has predominated in Irish hospitals since the late 1990s. Six distinct clones of community-associated MRSA (CA-MRSA) have also been identified in Ireland. A new strain of CA-MRSA, ST772-MRSA-V, has recently emerged and become widespread in India and has spread into hospitals. In the present study, highly similar MRSA isolates were recovered from seven colonized neonates in a neonatal intensive care unit (NICU) in a maternity hospital in Ireland during 2010 and 2011, two colonized NICU staff, one of their colonized children, and a NICU environmental site. The isolates exhibited multiantibiotic resistance, spa type t657, and were assigned to ST772-MRSA-V by DNA microarray profiling. All isolates encoded resistance to macrolides [msr(A) and mpb(BM)] and aminoglycosides (aacA-aphD and aphA3) and harbored the Panton-Valentine leukocidin toxin genes (lukF-PV and lukS-PV), enterotoxin genes (sea, sec, sel, and egc), and one of the immune evasion complex genes (scn). One of the NICU staff colonized by ST772-MRSA-V was identified as the probable index case, based on recent travel to India. Seven additional hospital and CA-ST772-MRSA-V isolates recovered from skin and soft tissue infections in Ireland between 2009 and 2011 exhibiting highly similar phenotypic and genotypic characteristics to the NICU isolates were also identified. The clinical details of four of these patients revealed connections with India through ethnic background or travel. Our study indicates that hospital-acquired and CA-ST772-MRSA-V is currently emerging in Ireland and may have been imported from India on several occasions.

Utilization of various glaucoma surgeries and procedures in Medicare beneficiaries from 1995 to 2004.

OBJECTIVE: To observe how the treatment of glaucoma has changed over the last decade. DESIGN: Retrospective, observational, population-based analysis. PARTICIPANTS: Medicare beneficiaries between 1995 and 2004. METHODS: Medicare fee-for-service data claims between 1995 and 2004 were analyzed to determine the number of penetrating surgeries and laser procedures performed for glaucoma in the decade spanning 1995 and 2004. MAIN OUTCOME MEASURE: Number of Medicare beneficiaries receiving glaucoma-related laser procedures or surgery. RESULTS: Trabeculectomies in eyes without previous surgery or trauma decreased 53% over the study period, from 51,690 in 1995 to 24,178 in 2004, although trabeculectomy in eyes with scarring increased 9%. The number of aqueous shunting devices placed rose 184%, from 2728 in 1995 to 7744 in 2004. Cyclophotocoagulation procedures rose 248% over the study period, from 3264 procedures in 1995 to 11,356 procedures in 2004. Between 1995 and 2001, the number of laser trabeculoplasties decreased 57%, from a high of 151,244 in 1995 to a low of 75,647 in 2001. From 2001 to 2004, the number of trabeculoplasties more than doubled, with 157,490 performed in 2004. The number of laser iridotomies showed little fluctuation, increasing 18% over the study period and ranging from 63,773 to 85,286 every year. Over the study period, surgical iridectomies, including peripheral and sector iridectomies, decreased 66%, from a total of 4842 in 1995 to 1654 in 2004. Fistulization procedures other than trabeculectomy (including the Scheie and Holt procedures and iridencleisis) dropped 83% over the study period, decreasing from 2833 in 1995 to 478 in 2004. CONCLUSIONS: Medicare recipients with glaucoma are more likely to be treated with aqueous shunting procedures or cyclophotocoagulation and less likely to be treated with trabeculectomy, compared with past years. After a decline in use between 1995 and 2001, laser trabeculoplasty increased substantially from 2001 to 2004. Fistulization procedures other than trabeculectomy and surgical iridectomy have become very uncommon.

Symptomatic primary Cytomegalovirus infection in a HIV-positive pregnant woman.

We describe a case of symptomatic primary Cytomegalovirus infection in a HIV-positive pregnant woman on antiretroviral treatment with a CD4 count >200 × 10(6)/l requiring intravenous ganciclovir. No adverse consequences from ganciclovir or evidence of congenital Cytomegalovirus infection were found.

Surgical site infection after cesarean section: implementing 3 changes to improve the quality of patient care.

BACKGROUND: Surgical site infection (SSI) is an important complication of cesarean section (CS) delivery and a key quality indicator of patient care. METHODS: A baseline assessment was undertaken to determine SSI rates, and subsequently a quality improvement program was introduced, followed by repeat surveillance. Data were collected during in-hospital stays and for up to 30 days after CS during both periods. Interventions in the quality improvement program included the use of nonabsorbable sutures for skin closure, use of clippers instead of razors, and use of 2% ChloraPrep for skin disinfection before incision. RESULTS: A total of 710 patients were surveyed before the interventions, and 824 patients were surveyed after the interventions. Of these, 114 (16%) had an SSI before the interventions, and 40 (4.9%) had an SSI after the interventions (P < .001; odds ratio, 0.27), with 90% and 83%, respectively, detected after hospital discharge. In multivariate analysis, obesity (P = .002) and the use of absorbable suture materials for skin closure (P = .008) were significantly associated with a higher SSI rate before the interventions; however, only obesity was associated with a higher SSI rate after the quality program. CONCLUSION: Surveillance of SSI rates after CS followed by 3 interventions contributed to a significant reduction in SSI rate and improved patient care.

Use of retinal procedures in medicare beneficiaries from 1997 to 2007.

OBJECTIVE: To observe how the treatment of retinal conditions changed over the preceding decade. METHODS: Medicare fee-for-service data claims filed between 1997 and 2007 were analyzed. RESULTS: Fewer than 5000 intravitreal injections of a pharmacological agent were performed annually between 1997 and 2001. Thereafter, the annual number of intravitreal injections more than doubled every year through 2006, reaching a high of 812,413 in 2007. Photodynamic therapy procedures decreased 83% from a peak of 133,565 procedures in 2004 to 22,675 procedures in 2007, while laser treatment of choroidal lesions or neovascularization decreased 83% from a peak of 82,089 in 1999 to a minimum of 13,821 in 2007. Vitrectomies for primary retinal detachment (with or without scleral buckling) increased 72% over the study period from 11,212 in 1997 to 19,923 in 2007, while scleral buckles performed without vitrectomy decreased 69% from 8691 to 2660. Substantial volume increases were also observed for vitrectomy with retinal membrane stripping (90% increase from 29,426 in 1997 to 56,051 in 2007) or endolaser panretinal photocoagulation (86% increase from 10,319 in 1997 to 19,154 in 2007). Volumes of pneumatic retinopexy, laser prophylaxis for retinal detachment, laser treatment for retinal edema, and laser treatment for retinopathy all changed less than 25% from 1997 and 2007. CONCLUSIONS: Marked changes in the use of several retinal procedures occurred between 1997 and 2007, particularly in the treatment of macular degeneration and retinal detachment. These changes point to greater acceptance and incorporation of vitrectomy and intravitreal injection as treatment modalities.