Therapeutic study, level II-2 (prospective study). See the Guidelines for Authors for a complete description of levels of evidence.

Background-The role of valve surgery in left-sided infective endocarditis has not been evaluated in randomized controlled trials. We examined the association between valve surgery and all-cause 6-month mortality among patients with left-sided infective endocarditis. Methods and Results-A total of 546 consecutive patients with left-sided infective endocarditis were included. To minimize selection bias, propensity score to undergo valve surgery was used to match patients in the surgical and nonsurgical groups. To adjust for survivor bias, we matched the follow-up time so that each patient in the nonsurgical group survived at least as long as the time to surgery in the respective surgically-treated patient. We also used valve surgery as a time-dependent covariate in different Cox models. A total of 129 (23.6%) patients underwent surgery within 30 days of diagnosis. Death occurred in 99 of the 417 patients (23.7%) in the nonsurgical group versus 35 deaths among the 129 patients (27.1%) in the surgical group. Eighteen of 35 (51%) patients in the surgical group died within 7 days of valve surgery. In the subset of 186 cases (93 pairs of surgical versus nonsurgical cases) matched on the logit of their propensity score, diagnosis decade, and follow-up time, no significant association existed between surgery and mortality (adjusted hazard ratio, 1.3; 95% confidence interval, 0.5 to 3.1). With a Cox model that incorporated surgery as a time-dependent covariate, valve surgery was associated with an increase in the 6-month mortality with an adjusted hazard ratio of 1.9 (95% confidence interval, 1.1 to 3.2). Because the proportionality hazard assumption was violated in the time-dependent analysis, we performed a partitioning analysis. After adjustment for early (operative) mortality, surgery was not associated with a survival benefit (adjusted hazard ratio, 0.92; 95% confidence interval, 0.48 to 1.76). Conclusions-The results of our study suggest that valve surgery in left-sided infective endocarditis is not associated with a survival benefit and could be associated with increased 6-month mortality, even after adjustment for selection and survivor biases as well as confounders. Given the disparity between the results of our study and those of other observational studies, well-designed prospective studies are needed to further evaluate the role of valve surgery in endocarditis management.

HE REPRESENTATIVENESS HEUristic of the clinical features of infective endocarditis (IE) as described by Osler has undergone a significant change in developed countries. 1,2 Previously, IE was a disease that commonly affected patients with predisposing valvular abnormalities caused by rheumatic carditis, with viridans group streptococci the most common causative pathogens. 3 This presentation is currently seen in developing countries, where rheumatic heart disease is still prevalent. In developed countries, mitral valve prolapse (MVP) is now thought to be the most common predisposing cardiac condition in patients with IE. 2 Several recent studies from passively reported case series suggest that Staphylococcus aureus is now the most frequently identified causative pathogen. 1 These more recent clinical observations of IE characteristics, however, are based on data that come primarily from large, tertiary care centers 4,5 and may not reflect true changes in the epidemiology of IE but rather temporal changes in referral patterns. Thus, population-based investigations are needed to more accurately characterize IE in the United States. Olmsted County, Minnesota, is a setting uniquely qualified for the conduct of population-based studies of dis-See also pp 3012 and 3061.

IMPORTANCE Asymptomatic microscopic hematuria (AMH) is highly prevalent and may signal occult genitourinary (GU) malignant abnormality. Common diagnostic approaches differ in their costs and effectiveness in detecting cancer. Given the low prevalence of GU malignant abnormality among patients with AMH, it is important to quantify the cost implications of detecting cancer for each approach. OBJECTIVE To estimate the effectiveness, costs, and incremental cost per cancer detected (ICCD) for 4 common diagnostic approaches evaluating AMH. DESIGN, SETTING, AND PARTICIPANTS A decision-analytic model-based cost-effectiveness analysis using inputs from the medical literature. PubMed searches were performed to identify relevant literature for all key model inputs, each of which was derived from the clinical study with the most robust data and greatest applicability. Analysis included adult patients with AMH on routine urinalysis with subgroups of high-risk patients (males, smokers, age Ն50 years) seen in the primary care or urologic referral setting. INTERVENTIONS Four diagnostic approaches were evaluated relative to the reference case of no evaluation: (1) computed tomography (CT) alone; (2) cystoscopy alone; (3) CT and cystoscopy combined; and (4) renal ultrasound and cystoscopy combined. MAIN OUTCOMES AND MEASURES At termination of the diagnostic period, cancers detected, costs (payer perspective), and ICCD per 10 000 patients evaluated for AMH. RESULTS Of the 4 diagnostic approaches analyzed, CT alone was dominated by all other strategies, detecting 221 cancers at a cost of $9 300 000. Ultrasound and cystoscopy detected 245 cancers and was most cost-effective with an ICCD of $53 810. Replacing ultrasound with CT detected just 1 additional cancer at an ICCD of $6 480 484. Ultrasound and cystoscopy remained the most cost-effective approach in subgroup analysis. The model was not sensitive to any inputs within the proposed ranges. Using probabilistic sensitivity analysis, ultrasound and cystoscopy was the dominant strategy in 100% of simulations. CONCLUSIONS AND RELEVANCE The combination of renal ultrasound and cystoscopy is the most cost-effective among 4 diagnostic approaches for the initial evaluation of AMH. The use of ultrasound in lieu of CT as the first-line diagnostic strategy will optimize cancer detection and reduce costs associated with evaluation of AMH. Given our findings, we need to critically evaluate the appropriateness of our current clinical practices, and potentially alter our guidelines to reflect the most effective screening strategies for patients with AMH.

Younger patients had greater expectations of total shoulder arthroplasty, which may have implications for outcome and implant longevity.

Background Surgeons strive to set patient expectations for recovery following total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, some patients report dissatisfaction after surgery due to unmet expectations. Purpose We compared patients' and surgeon's recovery expectations prior to primary THA and TKA. Methods Sixty eight patients scheduled to undergo primary total hip replacement (THR) or total knee replacement (TKR) surgery were enrolled. Before surgery, patients filled out a validated recovery expectations questionnaire that quantified expectations of postoperative pain relief, function, and well-being with a value from 0 to 100 (higher being more optimistic). The surgeon independently completed the same questionnaire for each patient. Overall score and itemspecific comparisons were conducted. Correlations were explored between agreement level, demographics, patient-reported health status measures, and patients' assessments of the risk of complications associated with surgery. Results Most patients undergoing THR or TKR had higher expectations for recovery than their surgeon. Applying the clinically meaningful difference in expectations (≥7 points), 52.5% of the TKA patients' expectations exceeded those of the surgeon, while 22.5% expected less than their surgeon and 60.7% of THA patients' expectations exceeded those of the surgeon, while 21.4% expected less than their surgeon. THA patients with either lower or higher expectations than their surgeon had lower physical and mental health status scores. TKA patients with lower expectations compared to their surgeon had a higher expectation of complications. Conclusions More than 50% of the patients had higher expectations than their surgeon and this was driven by expectations of high-level activities and extreme range of motion. Further investigations are needed to understand these differences so as to enhance patient preoperative education.

No abstract

Background The multiple-ligament-injured knee represents a special challenge, being an uncommon injury that is both severe and complicated to treat. Many studies have evaluated patients treated for this injury, but most are limited in their scope. The evaluation of this injury and its treatment using an administrative database might provide a different perspective.Questions/purposes Using a large administrative database, we determined (1) the number of multiligament knee reconstructions in New York State, (2) the rate of 90-day hospital readmission, and (3) the frequency of subsequent knee surgery. We examined the rates of these outcomes as a function of diagnosis, admission type, discharge status, comorbidity burden, and patient demographic factors. Methods We used the New York Department of Health Statewide Planning and Research Cooperative System (SPARCS), a database with information on patient characteristics, diagnoses, and treatments, to identify patients who underwent a multiligament procedure in a nonfederal facility from 1997 to 2005 using ICD-9-CM and Current Procedural Terminology codes. SPARCS collects data from all nonfederal acute care facilities, with an estimated reporting completeness of almost 99% for the years in this study. We evaluated data on patient age, sex, admission type, discharge status, and comorbidity burden (using Elixhauser comorbidities) and developed a multivariable logistic regression model to assess the influence of confounding variables. Results We identified 1032 patients in this database who underwent multiligament knee reconstruction in New York State from 1997 to 2005. The frequency of readmission within 90 days was 4.8% (n = 49). Readmission was more likely for patients who underwent inpatient multiligament reconstruction (odds ratio [OR] = 2.3; 95% CI: 1.2-4.4; p = 0.014), had a diagnosis of dislocation (OR = 2.2; 95% CI: 1.2-3.9; p = 0.011), or had various Elixhauser comorbidities, including chronic lung disease (OR = 6.4; 95% CI: 1.5-27.2; p = 0.013), fluid and electrolyte disorders (OR = 19.7; 95% CI: 2.5-155.7; p = 0.005), and anemia deficiency (OR = 5.6; 95% CI: 1.05-29.4; p = 0.044). Two hundred eighty-seven patients (28%) underwent subsequent knee surgery between their index