Comparing remission and recurrence of hypertension after bariatric surgery: vertical sleeve gastrectomy versus Roux-en-Y gastric bypass.

BACKGROUND: Bariatric surgery results in rapid weight loss and resolution of many co-morbidities including hypertension. OBJECTIVES: To investigate the association of the 2 most common bariatric surgical procedures, vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB), with sustained remission from hypertension, and evaluate other independent predictors of sustained remission. SETTING: Privately insured patients with hypertension in the United States undergoing bariatric surgery. METHODS: A cohort of hypertensive bariatric patients was created using detailed inclusion and exclusion criteria. Remission was defined as no refill of antihypertensive medication for 30 days after patients' medication was expected to run out, and recurrence as medication refill after at least 90 days of remission. RESULTS: Of 7006 patients in our cohort, 5874 experienced remission of their hypertension (83.8%). 745 of the 5874 (12.7%) patients later experienced recurrence. The adjusted hazard ratio of remission for VSG compared with RYGB was 1.06 (95% confidence interval [CI]; 1.0, 1.11). The adjusted hazard ratio of recurrence for VSG compared with RYGB was .84 (95% CI; .71, .97). A higher number of medications at the time of surgery was associated with a decreased likelihood of remission and an increased risk of recurrence of hypertension. CONCLUSION: There was no difference in the likelihood of remission of hypertension between VSG and RYGB. The number of medications at the time of surgery was the most important predictor of remission and recurrence of hypertension after surgery.

The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank.

Maxillofacial trauma costs emergency departments approximately one billion dollars annually. Facial trauma has increased since 2000 and has been attributed to both increased use of computed tomography and interpersonal violence. Alcohol, male sex, and age 18-35 years are significant risk factors for interpersonal violence. This study is novel in using a large database to look at the effect of alcohol on clinical outcomes in facial trauma. A data analysis was performed in Stata/MP 14.2 using variables coded from the National Trauma Data Bank (NTDB); logistic regression was applied. A total 580,313 patient records were analyzed. Operations for facial fractures were performed in 20.19% of cases (n = 117,139). A positive alcohol test reduced the odds of requiring operative fixation in both the unadjusted (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.79-0.82, P < 0.001) and adjusted (OR 0.67, 95% CI 0.66-0.68, P < 0.001) models. Age and being struck (adjusted OR 1.99, 95% CI 1.91-2.07, P < 0.001) or shot (adjusted OR 1.95, 95% CI 1.84-2.06, P < 0.001) had a significant effect on operative fixation. Injury mechanisms related to interpersonal violence appeared to have higher operative fixation rates. This study did not find a correlation between acute intoxication and the need for an operative intervention. This further demonstrates the multifactorial nature of facial trauma and stresses the importance of injury and violence prevention on clinical outcomes.

Clinical outcomes following mechanical plus oral antibiotic bowel preparation versus oral antibiotics alone in patients undergoing colorectal surgery.

BACKGROUND: Despite growing evidence to support use of preoperative mechanical bowel preparation (MBP) plus oral antibiotic bowel preparation (OABP) compared with MBP alone or no bowel preparation before colorectal surgery, evidence supporting use of MBP plus OABP relative to OABP alone is lacking. This study aimed to investigate whether the addition of MBP to OABP was associated with improved clinical outcomes after colorectal surgery compared with outcomes following OABP alone. METHODS: Patients who underwent colorectal surgery and preoperative bowel preparation with either OABP alone or MBP plus OABP were identified using the American College of Surgeons' National Surgical Quality Improvement Program Colectomy Targeted Participant Use Data File for 2012-2015. Thirty-day postoperative outcomes were compared, estimating the average treatment effect with propensity score matching and inverse probability-weighted regression adjustment. RESULTS: In the final study population of 20 594 patients, 90·2 per cent received MBP plus OABP and 9·8 per cent received OABP alone. Patients who received MBP plus OABP had a lower incidence of superficial surgical-site infection (SSI), organ space SSI, any SSI, postoperative ileus, sepsis, unplanned reoperation and mortality, and a shorter length of hospital stay (all P < 0·050). After propensity score matching and inverse probability-weighted regression adjusted analysis, MBP plus OABP was associated with a reduction in superficial SSI, any SSI, postoperative ileus and unplanned reoperation (all P < 0·050). CONCLUSIONS: Use of MBP plus OABP before colectomy was associated with reduced SSI, postoperative ileus, sepsis and unplanned reoperations, and shorter length of hospital stay compared with OABP alone.

Emergency department visits for attempted suicide and self harm in the USA: 2006-2013.

AIMS: To characterise and identify nationwide trends in suicide-related emergency department (ED) visits in the USA from 2006 to 2013. METHODS: We used data from the Nationwide Emergency Department Sample (NEDS) from 2006 to 2013. E-codes were used to identify ED visits related to suicide attempts and self-inflicted injury. Visits were characterised by factors such as age, sex, US census region, calendar month, as well as injury severity and mechanism. Injury severity and mechanism were compared between age groups and sex by chi-square tests and Wilcoxon rank-sum tests. Population-based rates were computed using US Census data. RESULTS: Between 2006 and 2013, a total of 3 567 084 suicide attempt-related ED visits were reported. The total number of visits was stable between 2006 and 2013, with a population-based rate ranging from 163.1 to 173.8 per 100 000 annually. The frequency of these visits peaks during ages 15-19 and plateaus during ages 35-45, with a mean age at presentation of 33.2 years. More visits were by females (57.4%) than by males (42.6%); however, the age patterns for males and females were similar. Visits peaked in late spring (8.9% of all visits occurred in May), with a smaller peak in the fall. The most common mechanism of injury was poisoning (66.5%), followed by cutting and piercing (22.1%). Males were 1.6 times more likely than females to use violent methods to attempt suicide (OR = 1.64; 95% CI = 1.60-1.68; p < 0.001). The vast majority of patients (82.7%) had a concurrent mental disorder. Mood disorders were the most common (42.1%), followed by substance-related disorders (12.1%), alcohol-related disorders (8.9%) and anxiety disorders (6.4%). CONCLUSIONS: The annual incidence of ED visits for attempted suicide and self-inflicted injury in the NEDS is comparable with figures previously reported from other national databases. We highlighted the value of the NEDS in allowing us to look in depth at age, sex, seasonal and mechanism patterns. Furthermore, using this large national database, we confirmed results from previous smaller studies, including a higher incidence of suicide attempts among women and individuals aged 15-19 years, a large seasonal peak in suicide attempts in the spring, a predominance of poisoning as the mechanism of injury for suicide attempts and a greater use of violent mechanisms in men, suggesting possible avenues for further research into strategies for prevention.

Risk factors for wound complications after abdominoperineal excision: analysis of the ACS NSQIP database.

AIM: The perineal wound following abdominoperineal excision (APR) is associated with a high complication rate. We aimed to evaluate the risk factors for wound complications and examine the effect of flap reconstruction on wound healing. METHOD: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was searched for patients who underwent APR for rectal adenocarcinoma. They were divided into two groups: primary closure of the perineal wound and flap reconstruction. A logistic regression analysis was performed to identify the risk factors for deep surgical site infection (SSI) and wound dehiscence. RESULTS: A total of 8449 (94%) patients from the database underwent primary closure and 550 (6%) underwent flap reconstruction. Patients who underwent flap reconstruction had a longer operation time, a higher incidence of deep SSI, wound dehiscence, more blood transfusion requirement and a higher rate of return to the operating room (all P < 0.001). Risk factors for deep SSI were African American race (OR 1.5, P = 0.02), American Society of Anesthesiologists (ASA) classification ≥ 4 (OR 3.2, P < 0.001), body mass index (BMI) ≥ 35 kg/m(2) (OR 1.7, P = 0.006), weight loss (OR 2, P < 0.001) and closure with a flap (OR 1.9, P < 0.001). Risk factors for wound dehiscence included ASA classification ≥ 4 (OR 2.2, P = 0.003), history of smoking (OR 2.2, P < 0.001), history of chronic obstructive pulmonary disease (OR 1.7, P = 0.03), BMI ≥ 35 kg/m(2) (OR 1.9, P = 0.001) and closure with a flap (OR 2.9, P < 0.001). CONCLUSION: Perineal wound complications are related to a patient's race, ASA classification, smoking, obesity and weight loss. Compared with primary closure, closure with a flap was associated with higher odds of wound infection and dehiscence and was not protective of wound complications in the presence of other risk factors. Therefore optimizing the patient's medical condition will lead to a better outcome irrespective of the technique used for perineal wound closure.

Proxy measures of vitamin D status - season and latitude - correlate with adverse outcomes after bariatric surgery in the Nationwide Inpatient Sample, 2001-2010: a retrospective cohort study.

OBJECTIVE: To investigate the association between adverse surgical outcomes following bariatric surgery and proxy measures of vitamin D (VitD) status (season and latitude) in the Nationwide Inpatient Sample (NIS). BACKGROUND: Obesity is an independent risk factor for VitD deficiency (25(OH)D < 20 ng ml-1). VitD deficiency compounds the chronic inflammation of obesity, increasing the risk of adverse outcomes following bariatric surgery. Epidemiology has long used season and latitude as proxies for group VitD, as VitD status is largely determined by sun exposure, which is greatest during summer and at the Equator. METHODS: We assessed proxy measures of group VitD status. We compared surgeries in VitD Summer (July to September), Winter (January to March), and Fall/Spring (October to December and April to June) and in the North (≥37°N) vs. the South (<37°N). RESULTS: We identified 932,091 bariatric surgeries; 81.2% were women and 74.4% were white. Sex was unequally distributed by season (p = 0.005). Median age was 43.0 years (all groups). Most surgeries occurred in the North (64.8%). Adverse outcome rates ranged from 0.01% (wound infections) to 39.4% [prolonged length of stay {LOS}]. Season was inversely associated with wound infection (p = 0.018) and dehiscence (p = 0.001). Extended LOS was inversely correlated with season (p < 0.001). These relationships held after adjustment. Prolonged LOS (p < 0.001) and any complication (p = 0.108) were more common in the North. CONCLUSIONS: We have demonstrated a graded relationship between seasonality and adverse outcomes following bariatric surgery. The association was strongest for dehiscence and prolonged LOS. These relationships held when using latitude. A prospective study measuring pre-operative 25(OH)D concentration would strengthen the case for causality in adverse surgical outcomes.

Validation of the WHO diagnostic algorithm and development of an alternative scoring system for the management of women presenting with vaginal discharge in Malawi.

OBJECTIVE: To evaluate the performance of the WHO algorithm for the detection of cervical infection in women presenting with vaginal discharge and modify the risk assessment score for optimum effectiveness in Malawi. METHODS: 550 consecutive women presenting with non-ulcerative genitourinary complaints were interviewed and examined. Cervical infection was defined as presence of Neisseria gonorrhoeae on culture and/or Chlamydia trachomatis by EIA. Other laboratory investigations included wet mount microscopy, serology for syphilis and HIV, LED testing of cervical and vaginal secretions, and pH testing of vaginal fluid. Sensitivity, specificity, and positive predictive values (PPV) of different algorithms were determined in the analysis. RESULTS: Cervical infection was identified in 19.5% of women (17.1% gonorrhoea, 3.7% chlamydial infection). The sensitivity/specificity/PPV of the WHO risk assessment were 43%/73%/28%, respectively by history and 62%/61%/27% with the addition of speculum examination. Using Malawi results to modify the risk assessment improved the performance to 61%/68%/31% respectively by history alone, which increased to 73%/64%/33% with bimanual examination and 72%/56%/29% with speculum examination. CONCLUSION: The sensitivity of the WHO risk assessment is low for the detection of cervical infection in Malawi. Although the Malawi risk assessment performed somewhat better on history alone, this study identified external and bimanual examination variables that improved the diagnostic performance of the algorithm in settings where speculum examination is not possible. Although the PPVs of the algorithms are low, country specific risk assessments can provide a framework for management until simple, affordable diagnostic tests for the definitive diagnosis of cervical infection are available.

Atherosclerotic disease in patients undergoing cataract extraction. A nationwide case-control study. The Cataract Patient Outcomes Research Team.

OBJECTIVE: To evaluate the association between cataract extraction and atherosclerosis and its complications. DESIGN: A nationwide case-control study. SETTING AND PARTICIPANTS: Using a 5% random sample of all Medicare beneficiaries, we analyzed Medicare claims data on 60803 persons 65 years of age and older who underwent cataract extraction in 1986 or 1987 and a control group of 63765 persons matched to the cases for age, race, sex, ZIP code, and reason for Medicare entitlement. MAIN OUTCOME MEASURE: Atherosclerosis and atherosclerosis-related disease and procedures were defined by International Classification of Diseases, Ninth Revision, Clinical Modification, codes or by Health Care Financing Administration Common Procedure Classification System (Current Procedural Terminology) codes. The strength of evidence for atherosclerotic disease was categorized on the basis of the types of bills in the Medicare claims file. RESULTS: Odds of atherosclerosis-related morbidity and procedures were higher for cases than for controls. The association decreased with patient age and was strongest in beneficiaries aged 65 to 69 years (odds ratio, 1.30; 95% confidence interval, 1.13-1.48). CONCLUSION: Our findings suggest that there is a weak association between a visually significant cataract requiring surgery and atherosclerosis in the younger elderly.

Cervical abnormalities, human papillomavirus, and human immunodeficiency virus infections in women in Malawi.

Cervical lavage samples and Pap smears were obtained from 284 women in Malawi to evaluate the association between human papillomavirus (HPV) and human immunodeficiency virus (HIV) infections. Squamous intraepithelial lesions were present in 15% (17/16) of HIV-seropositive and 7% (11/152) of HIV-seronegative women (P=.05) and in 23% (19/83) of HPV polymerase chain reaction (PCR)-positive and 4% (6/156) of HPV PCR-negative women (P<.001). HPV DNA was detected in 23% of HIV-uninfected women but in 60% of HIV-infected women with <300 CD4 cells/mm(3) (P<.002). High-risk HPV types 16 and 18 constituted half of the identified types. HPV DNA in previously HPV-positive women was detected more often than in HIV-seropositive abnormal cervical cytology than uninfected ones and were more likely to have persistent HPV infections. Early detection of HPV and regular monitoring of HIV-related cervical lesions may be important in HIV-infected women.

Reported condom use is not associated with incidence of sexually transmitted diseases in Malawi.

OBJECTIVES: To establish frequency of reported condom use and validate reliability of self-reporting among urban women in Malawi. DESIGN: Cross-sectional survey in antenatal women in 1989 and 1993. Prospective study in cohort first surveyed in 1989. METHODS: A total of 6561 women in 1989 and 2460 women in 1993 answered questions about condom use and sexual activity, had a physical examination and were screened for HIV. A subset of women from the 1989 screening were administered a questionnaire and tested for syphilis, Neisseria gonorrhoeae and Trichomonas vaginalis infections every 6 months. RESULTS: Although between the two cross-sectional studies intermittent condom use increased from 6 to 15% (P < 0.001) with no difference according to HIV infection, consistent use was reported by less than 1%. In the prospective study, women reported a higher condom use at any visit than either group assessed cross-sectionally. Consistent condom use peaked at 62% in the first 6 months, but declined to as low as 8% in the second year of follow-up. Condom use at each visit, either intermittent or consistent, was higher in HIV-seropositive than HIV-seronegative women. Overall, the incidence of gonorrhea, trichomoniasis and syphilis did not decline in women reporting consistent condom use. CONCLUSIONS: In prospectively followed women reports of consistent condom use was substantially higher than in cross-sectional surveys, but rapidly decreased over time, irrespective of HIV status. The presence of new sexually transmitted diseases suggests that this population of urban women overreports condom use or underreports sexual activity, or both. Intensive and sustained education is needed to achieve consistent condom use. Biologic markers of sexual activity are useful in interpreting reported condom use.

PIP: To determine the frequency of reported condom use and validate the reliability of self-reporting among urban women in Malawi, 6561 women in 1989 and 2460 women in 1993 answered survey questions about condom use and sexual activity, had a physical examination, and were screened for HIV. A subset of women from the 1989 screening were administered a questionnaire and tested for syphilis, gonorrhea, and Trichomonas vaginalis infections every six months. The study populations consisted of consecutive women presenting for their first antenatal visit to Queen Elizabeth Hospital in Blantyre, Malawi. Intermittent condom use increased from 6% to 15% between the two cross-sectional studies, with no difference according to HIV infection; consistent condom use was reported by less than 1%. In the prospective study, women reported higher condom use at any visit than either group assessed cross-sectionally. Consistent condom use peaked at 62% in the first six months, but declined to as low as 8% during the second year of follow-up. Condom use at each visit, either intermittent or consistent, was higher among HIV-seropositive than HIV-seronegative women. Overall, the incidence of syphilis, gonorrhea, and trichomoniasis did not decline in women reporting consistent condom use. This incidence of new sexually transmitted diseases suggests that the studied population either overreports condom use or underreports sexual activity, or both.

The effect of human immunodeficiency virus infection on birthweight, and infant and child mortality in urban Malawi.

BACKGROUND: Low birthweight, prematurity and intra-uterine growth retardation (IUGR) are major determinants of child survival. Therefore, it is important to assess excess mortality due to human immunodeficiency virus (HIV) infection in populations where low birthweight is common. METHODS: A prospective study was conducted on 1385 children born to seropositive and seronegative women in urban Malawi. Children were regularly examined and tested for HIV. RESULTS: The mortality rate of children of HIV seropositive mothers was substantially higher (223/1000 at 12 months, 317/1000 at 24 months and 360/1000 at 30 months) than that of children of seronegative mothers (68/1000 at 12 months, 106/1000 at 24 months and 118/1000 at 30 months). The incidence of prematurity and IUGR was also higher in infants of HIV seropositive mothers than in infants of seronegative mothers (12.7% versus 3.8%, P < 0.001 for premature and 7.7% versus 4.4%, P = 0.02 for IUGR infants). The mother-to-infant HIV-1 transmission rate was 35.1%. After 12 months of age, HIV infected children showed the highest mortality; however, uninfected children of HIV seropositive and children of HIV seronegative mothers had similar mortality. The mean birthweight of HIV infected and uninfected children was not significantly different. In HIV infected children the most frequent causes of death were diarrhoea, pneumonia and failure to thrive. Less common risk factors for child mortality included active maternal syphilis and cervicitis/vaginitis. CONCLUSION: The substantial difference in survival among children of HIV infected and uninfected mothers suggests that mortality could be reduced if HIV infection were not a risk factor. To decrease childhood mortality, a combination of interventions such as treatment of sexually transmitted infections during pregnancy and measures to reduce mother-to-infant transmission should be adopted.

PIP: Low birth weight, prematurity, and intra-uterine growth retardation (IUGR) are major determinants of child survival. Therefore, it is important to assess excess mortality due to human immunodeficiency virus (HIV) infection in populations where low birth weight is common. A prospective study was conducted on a total of 1385 children born to 679 HIV-seropositive and 687 seronegative women in urban Malawi. Children were regularly examined and tested for HIV. The mortality rate of children of HIV-seropositive mothers was substantiality higher (223/1000 at 12 months, 317/1000 at 24 months, and 360/1000 at 30 months, p 0.0001) than that of children of seronegative mothers (68/1000 at 12 months, 106/1000 at 24 months, and 118/1000 at 30 months). The incidence of prematurity and IUGR was also higher in infants of HIV-seropositive mothers than in infants of seronegative mothers (12.5% versus 3.8%, p 0.001 for premature and 7.7% versus 4.4%, p = 0.02 for IUGR infants). The mother-to-infant HIV-1 transmission rate was 35.1%. The overall incidence of low birth weight was 14.1%, but the incidence was 20.1% among children of seropositive mothers and 8.3% among those of seronegative mothers (p 0.001). After 12 months of age, HIV-infected children showed the highest mortality; however, uninfected children of HIV-seropositive and children of HIV-seronegative mothers had similar mortality. The mean birth weight of HIV-infected and uninfected children was not significantly different. In HIV-infected children the most frequent causes of death were diarrhea, pneumonia, and failure to thrive. Less common risk factors for child mortality included active maternal syphilis and cervicitis/vaginitis. A possible enrolment bias could have resulted in lower mortality estimates among babies of HIV-seronegative mothers. To decrease childhood mortality, a combination of interventions such as treatment of sexually transmitted infections during pregnancy and measures to reduce mother-to-infant transmission should be adopted.

Traditional vaginal agents: use and association with HIV infection in Malawian women.

OBJECTIVES: To assess the prevalence of traditional vaginal agent use in Malawian women and its association with HIV infection. METHODS: Consenting, consecutive antenatal women were administered a questionnaire and screened for sexually transmitted diseases (STD) including HIV. RESULTS: Of the 6603 consenting women, 886 (13%) reported using intravaginal agents for tightening and 2222 (34%) for self-treatment of vaginal discharge and itching. A higher proportion of HIV-infected than uninfected women (17% versus 14%) reported use of intravaginal agents for treatment (odds ratio, 1.29; 95% confidence interval, 1.05-1.57), but no difference in HIV status was found when these agents were used for tightening. In multivariate analysis, vaginal agent use for treatment was independently associated with HIV seropositivity. CONCLUSIONS: The association of HIV infection with vaginal agents for self-treatment, but not for tightening, suggests that STD may play a role or that vaginal agents are used differently for the two purposes. In addition to a small increased risk of HIV infection associated with vaginal agent use, these agents may interfere with condom effectiveness or acceptability of vaginal microbicides.

PIP: An exploratory study was conducted in Malawi to determine whether a correlation exists between human immunodeficiency virus (HIV) and traditional practices involving the intravaginal application of substances such as herbs and pulverized stone. Included in the survey were 6603 consecutive consenting volunteers who presented at the prenatal clinic of an urban hospital from October 1989-October 1990. The median age of study participants was 24 years. Although only 11% reported having had a sexually transmitted disease (STD) in the three years preceding the interview, laboratory analysis revealed the presence of such an infection in 46%. HIV infection was found in 1502 (23%). A total of 2953 (45%) of these pregnant women reported use of vaginal agents or vaginal incision, either for the treatment of discharge or itching or for the enhancement of sexual pleasure through vaginal tightening. Concerns have been raised that the placement of desiccants, irritants, and astringents in the vagina can induce certain physiological changes that increase the risk of HIV infection. Demonstrated in this survey was a slight association between HIV seropositivity and the use of vaginal agents for self-medication but not for vaginal tightening. In the univariate analysis, this finding persisted only for pregnant women without past or current STD infection. In the multivariate analysis, users of vaginal agents for treatment had a small increased risk of HIV in addition to--and independently of--the risk conferred by an STD history. It is possible, however, that the use of vaginal agents for self-medication is a marker for the presence of genital tract inflammation--a co-factor for HIV transmission. Given the extent of this traditional practice and its potential risk, more research is urged on the type of vaginal agents used and their effects on vaginal tissue.

An intervention to reduce the risk of mother-to-infant HIV transmission: results of a pilot toxicity study.

Although unproven, vaginal cleansing with antiseptics during labour could be a practical approach to reducing the rate of transmission of HIV infection from mother to infant. Before initiating a large scale clinical trial of the antiseptic chlorhexidine, we conducted a study to assess possible toxic effects as well as beneficial outcomes in 160 women volunteers: 40 non-pregnant chlorhexidine washed, 40 pregnant not washed, 40 pregnant saline washed, and 40 pregnant chlorhexidine washed. The wash was easily administered by the nurse-midwives. The participants generally felt better after the procedure, and had no complaints or adverse reactions in the subsequent 24 hours. Bacteriologically, the procedures lowered the carriage of Group B streptococcus and Staphylococcus aureus, but did not affect the frequency of T. vaginalis detection. No clinical problems were seen, and therefore the larger clinical trial of efficacy will proceed. Results of this trial are expected in late 1995.

Preventive eye care in people with diabetes is cost-saving to the federal government. Implications for health-care reform.

OBJECTIVE: Diabetic retinopathy, which leads to macular edema and retinal neovascularization, is the leading cause of blindness among working-age Americans. Previous research has demonstrated significant cost savings associated with detection of eye disease in Americans with type I diabetes. However, detection and treatment of eye disease among those with type II diabetes was previously thought not to be cost-saving. Our purpose was to estimate the current and potential federal savings resulting from the screening and treatment of retinopathy in patients with type II diabetes, based on recently available data concerning efficacy of treating both macular edema and neovascularization along with new data on federal budgetary costs of blindness. RESEARCH DESIGN AND METHODS: We used computer modeling, incorporating data from population-based epidemiological studies and multicenter clinical trials. Monte Carlo simulation was used, combined with sensitivity analysis and present value analysis of cost savings. RESULTS: Screening and treatment for eye disease in patients with type II diabetes generates annual savings of $247.9 million to the federal budget and 53,986 person-years of sight, even at current suboptimal (60%) levels of care. If all patients with type II diabetes receive recommended care, the predicted net savings (discounted at 5%) exceeds $472.1 million and 94,304 person-years of sight. Nearly all savings are associated with detection and treatment of diabetic macular edema. Enrolling each additional person with type II diabetes into currently recommended ophthalmological care results in an average net savings of $975/person, even if all costs of care are borne by the federal government. CONCLUSIONS: Our analysis indicates that prevention programs aimed at improving eye care for patients with diabetes not only reduce needless vision loss but also will provide a financial return on the investment of public funds.

Maternal vitamin A deficiency and mother-to-child transmission of HIV-1.

Studies show that around 10-40% HIV-positive women will give birth to children who are also infected. However, the risk factors for transmission from mother to child are not well understood and the effects of maternal nutritional status are unknown. We conducted a study of vitamin A status in pregnant women as a risk factor for mother-to-child transmission of HIV in Malawi. Serum vitamin A, height, weight, CD4 T-cell counts, and duration of breastfeeding were measured in 338 HIV-positive mothers whose infant's HIV serostatus was known. Mother-to-child transmission of HIV was 21.9% among mothers whose infants survived to 12 months of age. Mean vitamin A concentration in 74 mothers who transmitted HIV to their infants was lower than that in 264 mothers who did not transmit HIV to their infants (0.86 [0.03] vs 1.07 [0.02], p < 0.0001). We divided HIV positive mothers to 4 groups, those with vitamin A concentrations of less than 0.70, between 0.70 and 1.05, between 1.05 and 1.40, and greater than or equal to 1.40 mumol/L. The mother-to-child transmission rates for each group were 32.4%, 26.2%, 16.0%, and 7.2%, respectively (p < 0.0001). Maternal CD4 cell counts, CD4%, and CD4/CD8 ratio were also associated with increased mother-to-child transmission of HIV. Maternal age, body-mass index, and breastfeeding practices were not significantly associated with higher mother-to-child transmission. Our study suggests that maternal vitamin A deficiency contributes to mother-to-child transmission of HIV.

Childhood malaria parasitaemia and human immunodeficiency virus infection in Malawi.

PIP: Malaria and human immunodeficiency virus (HIV) infection are major health problems in many areas in Sub-Saharan Africa. An interaction between malaria and HIV infection has been postulated, since both produce similar cellular immune responses, with a lowering of the CD4/CD8 lymphocyte ratio. The frequency of malaria parasitemia was examined in children born to HIV-seropositive and seronegative mothers attending regular postnatal visits. A prospective study on mother-to-infant transmission of HIV had been underway since 1989 in Queen Elizabeth Central Hospital, Blantyre, a major hospital in urban Malawi. Standard HIV serology was performed on pregnant women, after obtaining consent. To reduce the effect of selection bias and seasonality, HIV seropositive (case) and seronegative (control) mothers and their infants were enrolled at delivery. Children included in the study were 503 born to 494 HIV-seropositive mothers and 540 born to 536 HIV-seronegative mothers. At each 3-monthly postpartum visit a Giemsa-stained thick blood film from the child was examined for malaria parasites. Children born to HIV-seropositive mothers were tested for HIV antibodies at 12 and 18 months of age. Of the 353 children born to HIV-seropositive mothers, 82 children (23.2%) were found to be HIV seropositive by enzyme-linked immunosorbent assay and Western blotting at 12 and 18 months. No statistically significant difference was found in frequency of malaria parasitemia by maternal or infant HIV serostatus after controlling for child's age. There was, however, a significant trend of increase in high parasitemia with age, irrespective of the HIV serostatus of the mother or the child. The frequency of parasitemia was higher in the wet season than in the dry season. This study suggests that maternal or infant HIV infection does not alter susceptibility to, or the clinical course of, malaria in infants.^ieng

National outcomes of penetrating keratoplasty. Risks of endophthalmitis and retinal detachment.

We studied rehospitalization for endophthalmitis or retinal detachment (RD) in 40,351 Medicare beneficiaries who were admitted to US hospitals for penetrating keratoplasty (PK) between 1984 and 1987. This cohort represents 56.5% of all PKs performed during this period for recipients of age to receive Medicare benefits. Penetrating keratoplasty was combined with intracapsular cataract extraction in 1188 patients (2.9%) and with extracapsular cataract extraction in 7038 patients (17.4%). Anterior vitrectomy was performed in 8428 patients (20.9%). The risk of rehospitalization for endophthalmitis within 6 months of PK was 0.77%. Concurrent anterior vitrectomy increased this risk to 1.03% (P = .004). The risk of rehospitalization for RD within 2 years of PK was 1.85%. Concurrent anterior vitrectomy increased this risk to 2.49% (P = .0001). Combined PK and intracapsular cataract extraction demonstrated a 3.9-fold increased rate of RD compared with PK and extracapsular cataract extraction (P = .0001). Anterior vitrectomy with PK and extracapsular cataract extraction increased the risk of RD 4.3-fold compared with PK and extracapsular cataract extraction alone (P = .007). Men were at a 68% higher risk of RD than women (P = .0001). The risk of rehospitalization for endophthalmitis following PK is five times higher and the risk of RD two times higher than that reported following cataract surgery. Anterior vitrectomy, however, results in similar risk increases following either surgery.

National outcomes of cataract extraction. Increased risk of retinal complications associated with Nd:YAG laser capsulotomy. The Cataract Patient Outcomes Research Team.

PURPOSE: The authors studied 57,103 randomly selected Medicare beneficiaries who underwent extracapsular cataract extraction in 1986 or 1987 to determine the possible association between performance of neodymium (Nd):YAG laser capsulotomy and the risk of subsequent retinal break or detachment. METHODS: Cases of cataract surgery were identified from Medicare claims submitted in 1986 and 1987 and were followed through the end of 1988. Episodes of cataract surgery, posterior capsulotomy, and retinal complications were ascertained based on procedure and diagnosis codes listed in physician bills and hospital discharge records. Lifetable and Cox's proportional hazards models were used to analyze the risk of retinal detachment or break in patients undergoing and not undergoing capsulotomy during the period of observation. RESULTS: Of the 57,103 persons identified as having undergone extracapsular cataract extraction in 1986 or 1987, 13,709 subsequently underwent Nd:YAG laser capsulotomy between 1986 and 1988. A total of 337 persons had aphakic or pseudophakic retinal detachments between 1986 and 1988 and an additional 194 underwent repair of a retinal break. Proportional hazards modeling shows a 3.9-fold increase in the risk of retinal break or detachment among those who underwent capsulotomy (95% confidence interval: 2.89 to 5.25). Younger patient age, male sex, and white race also were associated with increased risk of retinal complications after extracapsular cataract extraction. CONCLUSION: The authors conclude that there is a statistically significant increase in the risk of retinal detachment or break in those patients who undergo capsulotomy after cataract extraction. Therefore, capsulotomy should be deferred until the patient's impairment caused by capsular opacification warrants the increased risk of retinal complications associated with performance of capsulotomy.

National outcomes of cataract extraction. III. Corneal edema and transplant following inpatient surgery.

We analyzed the likelihood of rehospitalization for corneal edema or corneal transplantation in all 338,141 Medicare beneficiaries older than 65 years who were admitted to US hospitals for cataract extraction in 1984. The rate of rehospitalization for corneal edema or transplant within 4 years of intracapsular cataract extraction was 1.4%, almost twice the rate associated with extracapsular extraction (0.63%) or phacoemulsification (0.62%; P less than .0001). No significant difference in the rate of corneal transplantation was detected between those undergoing extracapsular cataract extraction and those undergoing phacoemulsification. Among patients who had intracapsular cataract extraction, those who underwent concurrent intraocular lens implantation surgery had a higher rate of rehospitalization for corneal edema or transplantation than those who did not (1.11% vs 0.86%; P = .0003). However, this difference is only manifest starting at about 3 years after surgery. Among patients who underwent extracapsular cataract extraction and phacoemulsification, however, those who underwent intraocular lens implantation during surgery had a lower rate of corneal edema or transplantation than those who did not (0.47% vs 0.74%; P less than .0001). This difference was seen almost immediately after surgery. Cataract surgery accompanied by anterior vitrectomy was associated with a threefold increase in the 4-year rate of corneal edema or transplantation compared with cataract surgery alone (2.42% vs 0.87%; P less than .0001).