Bariatric surgery outcomes in Medicare beneficiaries.

BACKGROUND: The Medicare population is increasing while the prevalence of obesity remains high. Bariatric surgery is the most efficacious treatment of obesity and its comorbidities. The objective of this investigation was to assess trends in utilization, readmission, mortality, and cost of bariatric surgery in the Medicare population. METHODS: Utilizing the Medicare Provider Analysis and Review database, patients with clinically severe obesity undergoing laparoscopic Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB) from 2011-2015 were identified. Trends in procedure selection, readmissions, mortality, and cost were examined. A multivariable logistic regression analysis to evaluate factors associated with readmission and mortality was performed. RESULTS: Of the 73,718 patients identified, 53,949 (73%) of patients were enrolled in Medicare due to disability, 19,191 (26%) due to age, and 578 (<1%) due to end stage renal disease (ESRD). Utilization of SG increased (1% in 2011 to 61% in 2015), while utilization of RYGB (68% to 32%) and LAGB (31% to 1%) decreased. Length of stay (LOS) was highest after RYGB (2.54 days), and lowest after LAGB (1.32 days). LOS decreased from 2.23 days in 2011 to 2.12 days in 2015. Thirty-day readmissions were 8.24% for the disabled, 5.5% for the elderly, 12.8% with ESRD. Odds of readmission increased with black race, higher body mass index (BMI), and RYGB. Readmission decreased from 8% in 2011 to 7% in 2015. Thirty-day mortality was 0.22% in the disabled, and 0.28% in the elderly. Odds of 30-day mortality increased among men, those with higher BMI, some comorbidities, and those who underwent RYGB. Cost of SG decreased while cost of RYGB increased. CONCLUSIONS: Among the Medicare population, an increase in SG while a decrease in RYGB and LAGB utilization was noted from 2011-2015. Readmissions and cost have decreased, while mortality has remained low.

Photobiomodulation Alleviates Postoperative Discomfort After Mandibular Third Molar Surgery.

PURPOSE: Surgical removal of mandibular third molars is associated with some degree of postoperative pain, trismus, and facial swelling. The purpose of the study was to evaluate the effect of photobiomodulation in reducing these postoperative side effects after surgical removal of mandibular third molars. MATERIALS AND METHODS: This randomized, double-blinded, split-mouth pilot study was carried out in the Department of Oral and Maxillofacial Surgery, Post Graduate Institute of Dental Sciences, Rohtak, India, among patients with impacted mandibular third molars. In each patient, 1 side was treated by photobiomodulation and the other side received placebo. Photobiomodulation was performed by intraoral and extraoral application of an 830-nm and 30-mW laser at different time points. Pain, trismus, and facial swelling were evaluated at all time points. The number of analgesics taken also was recorded. The data were analyzed using descriptive, bivariate and multivariate statistics. RESULTS: The study was conducted in 25 patients (56% male patients) with a mean age of 22.16 ± 4.60 years. There were 50 sites divided equally into both groups. The sites treated with photobiomodulation showed a significant reduction in pain and swelling (P < .05) compared with the sites in the placebo group. Moreover, an increase in mouth opening was noted after photobiomodulation compared with that in the placebo group, but this was not statistically significant (P > .05). CONCLUSIONS: The results of this study suggest that photobiomodulation is effective in reducing pain and swelling after mandibular third molar surgery. Hence, it can be used as an alternative and effective modality after surgical removal of mandibular third molars, thereby improving the quality of life of the patients.

Effects of fluid absorption following percutaneous nephrolithotomy: Changes in blood cell indices and electrolytes.

BACKGROUND AND AIMS: Effects of fluid absorption on hematological profile in the immediate postoperative period in patients undergoing percutaneous nephrolithotomy (PCNL) have not been given due importance. Considering the limited number of studies available, we conducted this study to evaluate the changes in hemodynamics, complete blood count (CBC), and electrolytes in patients undergoing PCNL using normal saline for irrigation in the prone position. Furthermore, we evaluated the common factors known to affect the absorption. MATERIALS AND METHODS: Forty American Society of Anesthesiologist Class I or II patients aged 18-65 years were recruited who underwent PCNL under general anesthesia. Heart rate, blood pressure (BP), CBC, and serum electrolytes were recorded preoperatively and just before extubation and compared using the Student's t-test. Correlation of these changes with height and total volume of irrigating fluid, total time of irrigation, duration of operation, and total intravenous fluids administered intraoperatively were performed using the Pearson's correlation coefficient. RESULTS: There was a statistically significant fall in mean hemoglobin (12.5 g/dL to 11.5 g/dL), packed cell volume (38.6%-35.6%), platelet count (2.9 × 105 cells/µL to 2.5 × 105 cells/µL), and sodium ion concentration (Na+) (138.9 meq/L to 137.7 meq/L) in the immediate postoperative period as compared to that of the preoperative values. Rest of the blood indices and electrolytes did not show any significant change. There was a significant rise in postoperative heart rate and BP. Postoperative systolic BP showed a significant positive correlation with the total volume of irrigating fluid. No significant correlation was observed with height and total time of irrigation. CONCLUSION: This study reveals that there is a significant fall in hemoglobin and Na+ during PCNL in the immediate postoperative period. Only, total volume of irrigating fluid and total duration of surgery had a significant correlation with blood cell indices.

Purse String Suture Closure: A Useful Double-Layer Technique for Closure of an Oronasal Communication.

INTRODUCTION: Various treatment modalities are reported in the literature for the management of oronasal communication. Single-layer closure often leads to failure and persists a major concern to an operative surgeon. Therefore, double-layer closure is one of the keys to successful management of oronasal communication. METERIAL AND METHOD: A continuous intramucosal running purse string suture at submucosal depth was placed circumferentially around the defect margin with 3-0 round body polyglactin suture as a first layer. Pedicled palatal rotation axial flap based on greater palatine artery was used as the second layer of closure, above the first palatal submucosal layer. CONCLUSION: Intramucosal purse string suture technique provides adjacent local tissue for closure of oronasal communication. This technique is easy and can be used as an alternative option for double-layered closure of an oronasal communication, without donor site morbidity and minimal patient discomfort.

Orthopaedic Bone Tap: A 'Jugaad' for Zygomatic Bone Reduction.

INTRODUCTION: The use of the Carroll-Girard screw in the management of zygomatic complex fractures has been well documented. The instrument provides an excellent degree of control over the movements of the disrupted zygomatic bone. Often mentioned in textbooks and literature, they are not routinely available for the Indian maxillofacial surgeon. This often prevents the regular use of this approach. MATERIAL AND METHODS: We have used the 2.5-mm orthopaedic bone tap that is very commonly available and routinely used in orthopaedic surgeries for reduction of the malar bone. CONCLUSION: The orthopaedic bone tap is easy to use and functions as an excellent alternative to the traditional Carroll-Girard screw.

Drug use trends for arthritis and other rheumatic conditions and effect of patient's age on treatment choice.

BACKGROUND: Little is known about the influence of the patient's age on selection of treatment for arthritis and other rheumatic conditions (AORCs). The aim of the present study was to examine drug use trends in patients with AORCs in ambulatory care and to study age-specific drug use. METHODS: Data from the National Ambulatory Medical Care Survey and the outpatient department component of the National Hospital Ambulatory Medical Care Survey were used to examine ambulatory visits for AORCs during 2001-2005. Use of nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics (narcotics and nonnarcotics), steroids, and disease-modifying antirheumatoid drugs (DMARDs) was measured as the proportion of visits that resulted in a prescription. Age-specific drug use trends were determined separately for adult (19-64 years) and for elderly (> or = 65 years) patients. RESULTS: According to the national surveys, there were 208 million ambulatory visits for AORCs during the study period. Use of NSAIDs, analgesics, steroids, and DMARDs was found to be 33.3%, 23.5%, 15.7%, and 4.3%, respectively. Analgesic use increased from 18.3% in 2001 to 26.7% in 2005. DMARDs and NSAIDs were prescribed 1.2 times more to adult patients than to elderly patients. Steroids and analgesics were prescribed 1.3 and 1.2 times more, respectively, to elderly patients than to adult patients. LIMITATION: The findings do not translate to population-based prevalence measures, as the unit of analysis was the patient visit. CONCLUSIONS: NSAIDs remain the most frequently prescribed drug class for AORCs; however, there has been increased use of analgesics in recent years. The study findings suggest that the patient's age plays a role in the choice of drugs prescribed for AORCs.

Surgicel granuloma: unusual cause of "recurrent" mass lesion after laparoscopic nephron-sparing surgery for renal cell carcinoma.

We present the first clinical report of Surgicel granuloma after laparoscopic nephron-sparing surgery and present the characteristics of this radiological image mimicking local recurrence. A 47-year-old man underwent laparoscopic nephron-sparing surgery for left renal interpolar incidentaloma; Surgicel bolsters were used for hemostasis. Histological examination revealed conventional clear-cell renal cell carcinoma with negative surgical margins. Magnetic resonance imaging at 3 months revealed a 2.5-cm enhancing mass in the region of nephron-sparing surgery. Computed tomography-guided core biopsy revealed foreign-body granuloma. Serial magnetic resonance imaging showed a decrease in the size/enhancement of the lesion during 12 months. To conclude, Surgicel may invoke foreign-body reaction leading to formation of pseudotumor, which leads to diagnostic dilemma.

A novel technique of intracorporeal excisional tailoring of megaureter before laparoscopic ureteral reimplantation.

OBJECTIVES: To present our initial results of a novel technique of intracorporeal laparoscopic tailoring of megaureter (MGU) and nonrefluxing reimplantation. METHODS: Three young male patients presented with flank pain (3) and recurrent urinary tract infection (2). Investigations revealed refluxing MGU in 2 and obstructing MGU in 1. Laparoscopic tailoring and reimplantation was planned. Ureteral mobilization was carried out using a standard 3-port access. An additional 5 mm port was inserted under vision for "dynamic" traction on ureter using a vessel loop without disconnecting the ureter from hiatus. This maneuver led to a fixed anatomic orientation and a firm platform of ureter greatly facilitating excisional tailoring and resuturing. After this, a ureteral stent was inserted through one of the laparoscopic ports and reimplantation of ureter was carried out in nonrefluxing fashion using extravesical, suprahiatal technique. RESULTS: No immediate postoperative complications were observed. Stents were removed 6 weeks after surgery. Pain resolved in 2 and greatly improved in 1. None of the patients developed urinary tract infection during follow up. Follow up studies revealed complete resolution of reflux in 1 patient with grade V reflux and residual minimally symptomatic high-pressure (voiding) grade II reflux in another. Patient with obstructive MGU has grade I asymptomatic reflux. CONCLUSIONS: Our technique of intracorporeal laparoscopic excisional tailoring of MGU is feasible and reproducible.

Fabry's disease: An ultrastructural study of nerve biopsy.

Fabry's disease, an X linked recessive disorder caused by the deficiency of alpha-galactosidase A (alpha-gal A), leads to progressive accumulation of glycosphingolipids. We report this rare disease in a 19-year-old boy who presented with angiokeratomas, paresthesia and corneal opacities, and nerve biopsy revealed by electron microscopy lamellated inclusions in the smooth muscle, perineurial and endothelial cells characteristic of Fabry's disease.