Minimally invasive pedicle screw fixation utilizing O-arm fluoroscopy with computer-assisted navigation: Feasibility, technique, and preliminary results.

BACKGROUND: Pedicle screw misplacement is relatively common, with reported rates ranging up to 42%. Although computer-assisted image guidance (CaIG) has been shown to improve accuracy in open spinal surgery, its use in minimally invasive procedures has not been as well evaluated. We present our technique and review the results from a cohort of patients who underwent minimally invasive lumbar pedicle screw placement utilizing the O-arm imaging unit in conjunction with the StealthStation Treon System. METHODS: A retrospective review of patients who underwent minimally invasive pedicle screw fixation with CaIG was performed. Eleven consecutive patients were identified and all were included. Nine patients underwent a single-level transforaminal lumbar interbody fusion. Two patients underwent multi-level fusion. Inaccurate pedicle screw placement was determined by postoperative computed tomography (CT) and graded as 0-2, 2-4, 4-6, or 6-8 mm. RESULTS: A total of 52 screws were placed. Forty screws were inserted in eight patients who had postoperative CT, and a misplacement rate of 7.5% was noted including one lateral and two medial breaches. All breaches were graded as 0-2 mm and were asymptomatic. In the remaining three patients, post-instrumentation O-arm imaging did not demonstrate pedicle screw misplacement. CONCLUSION: Although this initial study evaluates a relatively small number of patients, minimally invasive pedicle screw fixation utilizing the O-arm and StealthStation for CaIG appears to be safe and accurate.

Back and neck pain and psychopathology in rural sub-Saharan Africa: evidence from the Gilgel Gibe Growth and Development Study, Ethiopia.

STUDY DESIGN: Community-based cross-sectional analysis of the relation between symptoms of psychopathology and back pain (BP) or neck pain (NP) in rural southwest Ethiopia. OBJECTIVE: Using data from a community-based sample, we assessed the prevalence and psychopathologic correlates of BP or NP in rural sub-Saharan Africa. SUMMARY OF BACKGROUND DATA: BP and NP are among the most prevalent pain conditions. Psychopathology has been shown to be associated with both BP and NP in developed and urban developing contexts. Little is known about the relation between psychopathology and BP or NP in the rural, developing context. METHODS: Data on self-reported BP and NP, symptoms of depression, anxiety, and post-traumatic stress (PTS), gender, age, and socioeconomic status were collected from a representative cohort sample (N = 900) in rural southwest Ethiopia. We calculated univariate statistics to assess the prevalence of BP and NP. We used bivariate χ2 tests and multivariate logistic regression models to assess the relation between psychopathology and BP and NP. RESULTS: The prevalence of BP was 16.7%; that of NP was 5.0%. In χ2 analyses, symptoms of depression, anxiety, and PTS were significantly associated with increased risk for each outcome. In models adjusted for age, household assets, and gender, depression symptomatology was associated with increased risk for BP (OR = 3.44, 95% CI: 2.37-5.00) and NP (OR = 4.92, 95% CI: 2.49-9.74). Anxiety symptomatology was also associated with increased risk for BP (OR = 2.88, 95% CI: 1.98-4.20) and NP (OR = 2.67, 95% CI: 1.41-5.09). PTS symptomatology was associated with increased risk for BP (OR = 2.89, 95% CI: 1.78-4.69). CONCLUSION: In the first known study about the relation between psychopathologic symptomatology and BP and NP in a rural context in a developing country, the prevalence of BP and NP were comparable to published data in developed and developing countries. Symptoms of depression and anxiety were correlates of BP and NP, and symptoms of PTS were a correlate of BP. Comparative studies about the relation between psychopathology and chronic pain conditions between rural and urban contexts in the global south are needed.

Household food insecurity and symptoms of neurologic disorder in Ethiopia: an observational analysis.

BACKGROUND: Food insecurity (FI) has been shown to be associated with poor health both in developing and developed countries. Little is known about the relation between FI and neurological disorder. We assessed the relation between FI and risk for neurologic symptoms in southwest Ethiopia. METHODS: Data about food security, gender, age, household assets, and self-reported neurologic symptoms were collected from a representative, community-based sample of adults (N = 900) in Jimma Zone, Ethiopia. We calculated univariate statistics and used bivariate chi-square tests and multivariate logistic regression models to assess the relation between FI and risk of neurologic symptoms including seizures, extremity weakness, extremity numbness, tremors/ataxia, aphasia, carpal tunnel syndrome, vision dysfunction, and spinal pain. RESULTS: In separate multivariate models by outcome and gender, adjusting for age and household socioeconomic status, severe FI was associated with higher odds of seizures, movement abnormalities, carpal tunnel, vision dysfunction, spinal pain, and comorbid disorders among women. Severe FI was associated with higher odds of seizures, extremity numbness, movement abnormalities, difficulty speaking, carpal tunnel, vision dysfunction, and comorbid disorders among men. CONCLUSION: We found that FI was associated with symptoms of neurologic disorder. Given the cross-sectional nature of our study, the directionality of these associations is unclear. Future research should assess causal mechanisms relating FI to neurologic symptoms in sub-Saharan Africa.

Firearms in major motion pictures, 1995-2004.

BACKGROUND: Firearms are a major cause of injury and death. We sought to determine (1) the prevalence of movie scenes that depicted firearms and verbal firearm safety messages; (2) the context and health outcomes in firearm scenes; and (3) the association between the Motion Picture Association of America ratings and firearm scene characteristics. METHODS: Ten top revenue-grossing motion pictures were selected for each year from 1995 to 2004 in descending order of gross revenues. Data on firearm scenes were collected by movie coders using dual-monitor computer workstations and real-time collection tools. RESULTS: Seventy of the 100 movies had scenes with firearms and the majority of movies with firearms were rated PG-13. Firearm scenes (N = 624) accounted for 17% of screen time in movies with firearms. Among firearm scenes, crime or illegal activity was involved in 45%, deaths occurred in 19%, and injuries occurred in 12%. A verbal reference to safety was made in 0.8%. CONCLUSIONS: Depictions of firearms in top revenue-grossing movies were common, but safety messages were exceedingly rare. Major motion pictures present an under-used opportunity for education about firearm safety.

Seatbelt and helmet depiction on the big screen blockbuster injury prevention messages?

BACKGROUND: Injuries from vehicle crashes are a major cause of death among American youth. Many of these injuries are worsened because of noncompliant safety practices. Messages delivered by mass media are omnipresent in young peoples' lives and influence their behavior patterns. In this investigation, we analyzed seat belt and helmet messages from a sample of top-grossing motion pictures with emphasis on scene context and character demographics. METHODS: Content analysis of 50 top-grossing motion pictures for years 2000 to 2004, with coding for seat belt and helmet usage by trained media coders. RESULTS: In 48 of 50 movies (53% PG-13; 33% R; 10% PG; 4% G) with vehicle scenes, 518 scenes (82% car/truck; 7% taxi/limo; 7% motorcycle; 4% bicycle/skateboard) were coded. Overall, seat belt and helmet usage rates were 15.4% and 33.3%, respectively, with verbal indications for seat belt or helmet use found in 1.0% of scenes. Safety compliance rates varied by character race (18.3% white; 6.5% black; p = 0.036). No differences in compliance rates were noted for high-speed or unsafe vehicle operation. The injury rate for noncompliant characters involved in crashes was 10.7%. A regression model demonstrated black character race and escape scenes most predictive of noncompliant safety behavior. CONCLUSIONS: Safety compliance messages and images are starkly absent in top-grossing motion pictures resulting in, at worst, a deleterious effect on vulnerable populations and public health initiatives, and, at minimum, a lost opportunity to prevent injury and death. Healthcare providers should call on the motion picture industry to improve safety compliance messages and images in their products delivered for mass consumption.

Informatics and the American College of Surgeons National Surgical Quality Improvement Program: automated processes could replace manual record review.

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) provides reliable, risk-adjusted outcomes data using standardized definitions and end points. Collection of the data is time consuming, and the surgical clinical nurse reviewers (SCNRs) can sample only a subset of all surgical cases. We sought to test the feasibility of using an informatics tool to automatically identify postoperative complications stored as free-text documents in our electronic medical record. STUDY DESIGN: We used a locally developed electronic medical record search engine (EMERSE) to build sets of terminology that could accurately identify postoperative complications of both myocardial infarction (MI) and pulmonary embolism (PE) as defined by the ACS-NSQIP. All complications had been previously identified by our SCNRs and these were considered the gold standard. We used 5,894 cases from 2001 to 2004 from our institution's ACS-NSQIP dataset for building the terminology and 4,898 cases from 2005 to 2006 for validation. False-positive cases were then further reviewed manually. RESULTS: We achieved sensitivities of 100.0% and 92.8% for identifying postoperative myocardial infarction and pulmonary embolism, respectively, with somewhat lower specificities of 93.0% and 95.9%, respectively. These results compared favorably with results from the SCNRs, especially because our manual review uncovered cases previously missed. CONCLUSIONS: Informatics has the potential to improve the efficiency and accuracy of chart abstraction by SCNRs for the ACS-NSQIP. Using such tools may eventually allow all cases at an institution to be reviewed rather than a small subset.

The optimum conditions to collect X-ray data from very small samples.

A previous paper [Nave & Hill (2005). J. Synchrotron Rad. 12, 299-303] examined the possibility of reduced radiation damage for small crystals (10 microm and below in size) under conditions where the photoelectrons could escape from the sample. The conclusion of this paper was that higher-energy radiation (e.g. 40 keV) could offer an advantage as the photoelectron path length was greater and less energy would be deposited in the crystal. This paper refines these calculations further by including the effects of energy deposited owing to Compton scattering and the energy difference between the incident photon and the emitted photoelectron. An estimate is given for the optimum wavelength for collecting data from a protein crystal of a given size and composition. Another way of reducing radiation damage from a protein crystal is to collect data with a very short pulsed X-ray source where a single image can be obtained before subsequent radiation damage occurs. A comparison of this approach compared with the use of shorter wavelengths is made.

Use of endovascular coil embolization and surgical clip occlusion for cerebral artery aneurysms.

OBJECT: In recent years, endovascular treatment of cerebral artery aneurysms (CAAs) has received greater attention. The authors evaluated patient demographics, endovascular and surgical approaches, and basic outcomes in the treatment of CAAs in a nationally representative administrative database. METHODS: Using the Nationwide Inpatient Sample from 1998 to 2003, diagnosed CAA coded as either an unruptured or ruptured lesion and treated with surgical clip occlusion, wrapping combined with endovascular repair, or endovascular repair alone was included in the present study. RESULTS: Treatment of CAAs significantly increased for unruptured (from 4036 to 8334 cases, p = 0.002) but not ruptured (from 9330 to 11,269 cases, p = 0.231) lesions. Endovascular treatment of CAAs in particular also increased in patients with unruptured (from 11 to 43%, p < 0.001) and ruptured (from 5 to 31%, p < 0.001) lesions. In 2003, the mortality rate associated with unruptured CAAs treated using clip occlusion (1.36%) or endovascular repair (1.41%) was similar, whereas rate differences were noted between these treatments for ruptured CAAs (12.7% for clip occlusion compared with 16.6% for endovascular repair; p = 0.05). Endovascular treatment of unruptured CAAs was associated with a shorter length of stay (LOS) and higher rate of discharge to home compared with those for clip occlusion. The LOS was also shorter in patients with endovascularly treated ruptured CAAs. Aneurysm type (odds ratio [OR] 10.1, ruptured lesion), patient age (OR 1.28, each 10 years), comorbid conditions (OR 1.08, each condition), and hospital case volume (OR 0.97, each additional case) were significant predictors of death in the regression model. CONCLUSIONS: Endovascular techniques for the treatment of CAAs are being used increasingly in the US, although the majority of patients with this pathological entity still undergo surgical clip occlusion. In cases of unruptured CAAs, endovascular treatment is associated with a shorter LOS and higher discharge-to-home rate. Aneurysm status, patient age, comorbid conditions, and hospital case volume are significant predictors of death. Finally, demographic differences exist between the populations presenting with unruptured or ruptured CAAs.

Epidemiology of aortic aneurysm repair in the United States from 1993 to 2003.

The epidemiology of abdominal aortic aneurysm (AAA) disease has been well described over the preceding 50 years. This disease primarily affects elderly males with smoking, hypertension, and a positive family history contributing to an increased risk of aneurysm formation. The aging population as well as increased screening in high-risk populations has led some to suggest that the incidence of AAAs is increasing. The National Inpatient Sample (1993-2003), a national representative database, was used in this study to determine trends in mortality following AAA repair in the United States. In addition, the impact of the introduction of less invasive endovascular AAA repair was assessed. Overall rates of treated unruptured and ruptured AAAs remained stable (unruptured 12 to 15/100,000; ruptured 1 to 3/100,000). In 2003, 42.7% of unruptured and 8.8% of ruptured AAAs were repaired through an endovascular approach. Inhospital mortality following unruptured AAA repair continues to decline for open repair (5.3% to 4.7%, P = 0.007). Mortality after elective endovascular AAA repair also has statistically decreased (2.1% to 1.0%, P = 0.024) and remains lower than open repair. Mortality rates for ruptured AAAs following repair remain high (open: 46.5% to 40.7%, P = 0.01; endovascular: 40.0% to 35.3%, P = 0.823). These data suggest that the numbers of patients undergoing elective AAA repair have remained relatively stable despite the introduction of less invasive technology. A shift in the treatment paradigm is occurring with a higher percentage of patients subjected to elective endovascular AAA repair compared to open repair. This shift, at least in the short term, appears justified as the mortality in patients undergoing elective endovascular AAA repair is significantly reduced compared to patients undergoing open AAA repair.

Safety belt use by law enforcement officers on reality television: a missed opportunity for injury prevention?

BACKGROUND: Although safety belt usage rates are increasing nationwide, motor vehicle crashes (MVCs) remain a leading cause of death for young people and are emerging as a leading cause for police officers specifically. A content analysis was performed on the television show, COPS, to determine on-air safety belt usage rates. METHODS: A sample of 63 unique episodes of the reality-based television series, COPS, was viewed during a 4-month period (September 1, 2005 to January 1, 2006). Episodes had original airing dates ranging from 1990 to 2004. Safety belt usage status was determined per police officer per driving scene (N = 250). A driving scene represented a continuous trip (start to finish) with a total on-camera time exceeding 5 seconds. Scenes with indeterminate safety belt status were excluded. High-speed driving, officer gender, and officer race were also recorded. RESULTS: Of the 203 scenes included, 77 (38%) demonstrated safety belt usage. High-speed driving scenes had higher safety belt usage rates compared with low-speed (48% versus 29%, p = 0.005). More contemporary episodes (1999 to 2004) had higher safety belt usage rates as well (51% versus 28%, p = 0.001). Officer gender and race revealed no significant differences in safety belt usage rates (p = 0.930 and p = 0.900, respectively). CONCLUSIONS: In this popular, reality-based television series, safety belt usage by police officers is extremely low. These findings suggest the need to increase safety belt usage by police officers, especially those filmed for television.

Changes in the utilization of spinal fusion in the United States.

OBJECTIVE: Several reports suggest that spine surgery has experienced rapid growth in the past decade. Limited data exist, however, documenting the increase in spinal fusion. The objective of this work was to quantify and characterize the contemporary practice of spinal fusion in the United States. METHODS: Clinical data were obtained from the Nationwide Inpatient Sample for the years from 1993 to 2003. All patients with International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes indicating cervical fusion, thoracolumbar fusion, lumbar or unspecified fusion were identified (n = 471,990). Primary ICD-9-CM diagnosis codes were used to determine the rationale for surgical fusion. Population-based utilization rates overall and for each procedure were calculated from United States census data. Rank order of spinal fusion compared with other inpatient procedures from the Nationwide Inpatient Sample was reported for the years 1997 to 2003. RESULTS: Overall utilization increased during the time period for cervical, thoracolumbar, and lumbar fusions by 89, 31, and 134%, respectively. Patients aged 40 to 59 years experienced the rapid rise in utilization for cervical fusions (60-110 per 100,000) and lumbar fusions (35-84 per 100,000). For patients 60 years and older, utilization also increased for cervical (30-67 per 100,000), thoracolumbar (4-9 per 100,000), and lumbar (42-108 per 100,000). Spinal fusion rose from the 41st most common inpatient procedure in 1997 to the 19th in 2003. CONCLUSION: Cervical, thoracolumbar, and lumbar spinal fusion have experienced a rapid increase in utilization in isolation and compared with other surgical procedures in contemporary practice. These changes are most pronounced for patients over 40 years of age, and degenerative disc disease seems to account for much of this increase.

The effect of secondary operations on mortality following abdominal aortic aneurysm repair in the United States: 1988-2001.

Certain complications following open repair of abdominal aortic aneurysms (AAAs) require additional operations or invasive procedures. The purpose of this study was to determine the effect of secondary interventions on mortality rate following open repair of intact and ruptured AAAs in the United States. Clinical data on 98,193 patients treated from 1988 to 2001 with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) primary procedure code 38.44 (resection of the abdominal aorta with replacement) were analyzed. Demographic factors, types of secondary interventions, and in-hospital mortality rates were assessed by univariate and multivariate logistic regression analysis (SPSS Version 11.0, Chicago, IL). The database utilized in this study was The Nationwide Inpatient Sample (NIS). The mortality rate was 4.5% in the intact AAA group and 45.5% in the ruptured AAA group. The rate of secondary operations and procedures was much higher in the ruptured AAA group, especially related to renal failure (5.52% vs 1.49%, p <0.001); respiratory failure (3.67% vs 0.71%, p <0.001); postoperative bleeding (2.41% vs 0.81%, p <0.001); or colonic ischemia (2.38% vs 0.36%, p <0.001). Increased mortality following open repair of intact AAAs accompanied: peripheral artery angioplasty/stenting (OR, 1.25; 95% CI, 1.04-1.51; p = 0.018); coronary artery angioplasty/stenting (OR, 1.68; 95% CI, 1.05-2.70; p = 0.031); inferior vena cava (IVC) filter placement (OR, 2.02; 95% CI, 01.31-3.1; p = 0.001); vascular reconstruction or thromboembolectomy (OR, 2.05; 95% CI, 1.9-2.22; p <0.001); lower extremity amputation (OR, 4.09; 95% CI, 2.78-6.0; p <0.001); coronary artery bypass (OR, 6.71; 95% CI, 3.74-12.03; p <0.001); operations for postoperative bleeding (OR, 6.92; 95% CI, 5.71-8.4; p <0.001); initiation of hemodialysis (OR, 10.52; 95% CI, 9.22-12.01; p <0.001); tracheostomy (OR, 11.9; 95% CI, 9.86-14.37; p <0.001); and colectomy (OR, 16.22; 95% CI, 12.55-20.95; p <0.001). Increased risk of mortality following open repair of ruptured AAAs accompanied the following: operations for postoperative bleeding (OR, 1.5; 95% CI, 1.22-1.85; p <0.001); colectomy (OR, 1.63; 95% CI, 1.32-2.01; p <0.001); and initiation of hemodialysis (OR, 2.66; 95% CI, 2.30-3.08; p <0.001). The only independent variable in this group associated with decreased risk of in-hospital mortality was IVC filter placement (OR, 0.41; 95% CI, 0.27-0.64; p <0.001). This study confirms the perception that additional operations or invasive procedures following open repair of AAA entail significantly worse in-hospital mortality rates, especially when related to colonic ischemia, respiratory failure, and renal failure.

Variable-temperature neutron diffraction studies of the short, strong hydrogen bonds in the crystal structure of pyridine-3,5-dicarboxylic acid.

Pyridine-3,5-dicarboxylic acid has been studied by single-crystal neutron diffraction at 15 and 296 K. Pyridine-3,5-dicarboxylic acid, in which the carboxylic acid protons have been replaced by deuterons, has also been studied at 15, 150 and 296 K. The protonated structure contains a short N...H...O hydrogen bond [N...O 2.523 (2) Angstrom at 15 K]. Temperature-dependent proton migration occurs where the N--H distance in the hydrogen bond changes from 1.213 (4) Angstrom at 15 K to 1.308 (6) Angstrom at 300 K. In the deuterated structure the overall hydrogen-bond length increased [N...O 2.538 (3) Angstrom at 15 K] and the magnitude of the migration increased so that the N--D distance changes from 1.151 (3) Angstrom at 15 K to 1.457 (4) Angstrom at 300 K.

Surgical reversal of prolonged blindness from a metastatic neuroblastoma.

BACKGROUND: Reports of tumor-related anterior visual pathway blindness that have resolved after surgical decompression are rare. The longest reported duration of tumor-related blindness completely reversed by optic nerve decompression is 3 days. We describe a pediatric patient with 7 days of no light perception who experienced reversal of blindness following tumor resection and optic nerve decompression. CASE DESCRIPTION: A 33-month-old boy presented with a 4-day history of no light perception. Magnetic resonance imaging revealed a mass involving the sphenoid sinus, sella turcica, and clivus with significant optic nerve involvement. Loss of light perception and complete absence of a pupillary light reflex were documented for the next 72 h. A sluggish pupillary light reflex was regained 24 h after instituting intravenous steroids. An urgent bi-frontal craniotomy and optic nerve decompression were performed 7 days after the onset of blindness. Surgical pathology revealed metastatic neuroblastoma. Eleven days after optic nerve decompression, the child was able to count fingers and recognize faces and printed book characters. CONCLUSION: Prolonged blindness secondary to tumor-related optic nerve compression may be reversible up to 1 week from onset in children presenting with no light perception.

The syndrome of hydrocephalus in young and middle-aged adults (SHYMA).

OBJECTIVES: Currently, headache, nausea/vomiting, visual changes, and altered mental status are accepted as indications for the evaluation of hydrocephalus in children; while dementia, gait apraxia, and urinary incontinence remain indications in the elderly. The clinical presentation of hydrocephalus in young and middle-aged adults remains poorly described. Hence, middle-aged patients with mild gait, cognitive, or urinary symptoms unaccompanied by clear exam findings often remain undiagnosed and untreated. METHODS: We report the clinical presentation, treatment, and outcomes of 46 adults (ages 16-55 years) presenting with congenital, acquired, or idiopathic hydrocephalus with imaging-documented ventriculomegaly and elevated CSF pressure. RESULTS: Primary symptoms were related to gait (70%), cognition (70%), urinary urgency (48%), and headaches (56%). Eighty-four percent complained of impaired job performance. The exam findings were subtle or absent (no gait apraxia, minor gait changes in 42.9%, mildly abnormal Mini Mental State exams in only 14.3%, and incontinence in only 3.6%). Twenty-nine patients underwent ventriculoperitoneal (VP) shunting, and 11 endoscopic third ventriculostomy, of whom six subsequently required a VP shunt. Symptomatic improvement was observed in 93% of patients 16+/- 11 months after shunting (56% complete resolution, 37% partial resolution). Patients had been followed for their symptoms an average of 6 years (range, 1-30) prior to diagnosis. DISCUSSION: We propose that there exists a clinically distinct syndrome of hydrocephalus in young and middle-aged adults (SHYMA) that comprises hydrocephalus of all etiologies. SHYMA is characterized by complaints of impaired gait, cognition, bladder control, and headaches, with a discrepancy between the prominence of symptoms and the subtlety of clinical signs. Despite the subtlety of clinical signs, CSF diversion treatment is effective at resolving symptomatology.

Single-crystal neutron-diffraction study of 3.4% Zn-doped (ND4)2[Cu(D2O)6](SO4)2 at 20 K.

Doping the perdeuterated ammonium copper Tutton salt (ND4)2[Cu(D2O)6](SO4)2 [perdeuterated diammonium hexaaquacopper(II) bis(sulfate)] with Zn leads to a change in the structure from dimorph A (low density) to dimorph B (high density). This change, which accompanies a switch in the direction of the Jahn-Teller distortion, had previously been observed to occur with substitution of Zn2+ at the Cu2+ site of between 1.3 (A) and 3.4% (B). In this study, the single-crystal neutron-diffraction analysis of (ND4)2[(Cu/Zn)(D2O)6](SO4)2 at 20 K, with 3.4% Zn doping and a deuterium substitution of 85% on the H-atom sites, reveals that the structure is entirely of type B, with the Cu/Zn site at an inversion centre and with no evidence of disorder or unusual atomic displacement parameters that might occur near a phase transition boundary.

Variation in outcomes after percutaneous coronary intervention in the United States and predictors of periprocedural mortality.

The objective of this study was to characterize variation in mortality rates across hospitals performing percutaneous coronary intervention (PCI) in the United States. For this purpose, data (n = 735,022) from the Nationwide Inpatient Sample from 1996 to 2001 were analyzed. The primary outcome for the analysis was postprocedural in-hospital mortality. Mortality rates were calculated by race, gender, geographic region, comorbid status and hospital volume. There were significant variations in mortality across gender groups, comorbid status, regions and by hospital volume status. Independent predictors of mortality in this large cohort were older age, female gender, lower income and lower hospital volume. The data suggests targets for quality improvement initiatives for patients undergoing PCI particularly in the elderly, females, lower income patients and low volume hospitals. Even in the contemporary era of adjunctive pharmacological therapies and ubiquitous use of stents, hospital volume remains a significant independent predictor of in-hospital mortality.