Predictor Of Adverse Events Research Articles

P6491One-year clinical outcome and predictors of adverse events after percutaneous coronary intervention in elderly patients

P6491One-year clinical outcome and predictors of adverse events after percutaneous coronary intervention in elderly patients

The safety and feasibility of early discharge following ileostomy reversal: a National Surgical Quality Improvement Program analysis

BackgroundThis study aimed to compare 30-day clinical outcomes following routine ileostomy reversal between patients that underwent early discharge (<24 h) and standard discharge (postoperative day [POD] 2 or 3). MethodsA retrospective cohort analysis was conducted between 2005 and 2014 using the American College of Surgeons National Surgical Quality Improvement Program data set. All patients undergoing ileostomy reversal who were discharged on POD 0 or 1 (early discharge group [EDG]) versus POD 2 or 3 (standard discharge group [SDG]) were identified. The primary outcome was the 30-day adverse event rate. The secondary outcome was the 30-day readmission rate. A multivariate analysis was performed to determine the adjusted effect of early discharge as well as the predictors of adverse events and readmissions. ResultsThe study population consisted of 355 and 5805 patients in the EDG and SDG, respectively. There were 19 (5.4%) 30-day adverse events in the EDG and 341 (5.8%) in the SDG. The EDG had 17 (4.8%) 30-day readmissions and the SDG had 294 (5.1%). The adjusted odds ratio for 30-day adverse events in the EDG was 0.95 (P = 0.83), and for 30-day readmissions, it was 1.01 (P = 0.96). Higher BMI, longer operative time, ASA ≥3, chronic steroid use along with a history of bleeding disorder were significant predictors for adverse events and readmissions. ConclusionsSelect patients discharged within 24 h of ileostomy reversal did not have a significantly higher rate of adverse events or readmissions compared to patients discharged on POD 2 or 3 following uncomplicated surgery. Predictors of adverse events and readmissions can guide the selection of patients suitable for early discharge.

Full Metal Jacket With Drug-Eluting Stents for Coronary Chronic Total Occlusion

ObjectivesThe aim of this study was to evaluate the long-term outcomes and predictors of adverse events following successful “full metal jacket” (FMJ) (stent length ≥60 mm without gap) procedures using drug-eluting stents to treat coronary chronic total occlusions (CTOs). BackgroundThe FMJ stenting procedure is often required to treat CTOs, but its clinical efficacy and safety remain unknown. MethodsIn total, 1,126 successful CTO procedures (1,107 consecutive patients) performed between May 2003 and March 2015 were studied. The primary endpoint was target lesion failure, a composite of cardiac death, target vessel–related myocardial infarction, or target lesion revascularization or reocclusion. ResultsOverall, 406 patients (36.7%) underwent the FMJ procedure, increasing in frequency over time (28.5% from 2003 to 2006 and 41.7% after 2011). The mean stent length was 76.8 ± 14.6 mm (range 60 to 122 mm), and the average number of stent overlaps was 2.5 ± 0.6 (range 2 to 4). A total of 127 patients (31.3%) had persistent luminal narrowing at the distal reference segment after stenting. During the median follow-up period of 5.1 years, target lesion failure occurred in 16.0% of patients. There were 17 cases of total reocclusion and 5 cases of stent thrombosis. Multivariate analysis confirmed that the number of implanted stents (hazard ratio: 1.72; 95% confidence interval: 1.16 to 2.54; p = 0.006) and persistent distal luminal narrowing (hazard ratio: 2.73; 95% confidence interval: 1.66 to 4.47; p < 0.001) were predictors of increased risk for target lesion failure. ConclusionsThe FMJ procedure using drug-eluting stents for CTOs provides acceptable long-term clinical results. Persistent distal luminal narrowing increases the future likelihood of adverse events despite procedural success.

A retrospective cohort study of adverse events in patients undergoing orthopaedic surgery

BackgroundThis study’s objective was to identify adverse events following common orthopaedic procedures, and to estimate the incidence rates and risks of these events and their associations with age, sex, and comorbidities.MethodsThis retrospective cohort study manually reviewed and extracted electronic medical data on the incidence and predictors of adverse events that occurred within 90 days of the 50 most frequent orthopaedic surgeries at an academic hospital in 2010. We also extracted demographic data, baseline comorbidities, and duration of follow-up (≤90 days). Patients were scored on the Charlson Comorbidity Index (CCI) and the Functional Comorbidity Index (FCI). We estimated incidence rates and risks for all events and associations using regression methods. Prolonged pain 42-days post-surgery was treated as a separate outcome.ResultsWe included 1,552 patients; average age was 53.4 years, and 51.7% were female. A total of 1,148 adverse events were identified in 729 patients. The incidence rate of all adverse events was 10 events per 1,000 person-days at risk; 47% of all patients experienced at least one adverse event within 90 days. The most frequent events were prolonged pain (31% of all adverse events) and persistent swelling (7%). We found positive associations between both comorbidity scores and the incidence rate and 90-day risk of all adverse events, excluding pain, adjusting for age and sex (neither of which was associated with adverse events); the association was stronger for the FCI than for the CCI. For total hip arthroplasty (THA) and total knee arthroplasty (TKA), the incidence rate of all adverse events, excluding pain, was positively associated with both comorbidity scores and age; the 90-day risk was positively associate with the FCI score and male sex. The prevalence of prolonged pain at 42 days was greater in patients with higher FCI scores; for THA and TKA only, pain prevalence was greater in those with higher FCI scores and in men.ConclusionsAdverse events are frequent following common orthopaedic procedures. The incidence is greatest for patients with more functional comorbidities. For THA and TKA procedures, being male and being older are also associated with a greater incidence of adverse events.

Trends and Outcomes in the Operative Management of Traumatic Vascular Injuries: A Comparison of Open versus Endovascular Approaches

Controversy exists in vascular trauma regarding the best method of treatment-open versus endovascular techniques. Little has been published on this complex topic. Patients from 2005 to 2013 at a Level I trauma center with vascular injuries were identified via a prospectively trauma registry. Patient data, injury type/severity, treatment, and 30-day outcomes were obtained from the trauma registry and the chart review. Adverse events (limb loss, major disability, and death) were outcomes of interest. Univariate analysis and multivariate logistic regression were used to identify predictors of adverse events. In all, 346 patients were included (median age 34, range 1-93 years). Median Injury Severity Score (ISS) was 10 (1-59). Endovascular repairs (n = 52) increased from 0 per cent (2005) to 32 per cent (2013), and demonstrated equivalent outcomes to open approaches (P = 0.24). On multivariate analysis, higher ISS (P = 0.001), increasing age (P = 0.01), and lower extremity injuries (P = 0.001) were associated with adverse outcomes across the entire series. Endovascular approaches were most commonly used in vascular injuries of the chest/abdomen (39 of 52, 75% of all endovascular procedures in the series, P < 0.001), older patients (P = 0.003), blunt injury mechanism (P < 0.001), and patients with a higher ISS at presentation (P < 0.001). In conclusion, this large series, the use of endovascular procedures increased over time, and was associated with equivalent outcomes to open approaches, despite their higher usage in older patients, those with chest/abdominal injuries, and those with a higher ISS at presentation. Although these retrospective results are encouraging, further prospective study into the role of endovascular therapies in the treatment of vascular injuries.

Evolution of Left Ventricular Size in Late Survivors of Surgery for Hypoplastic Left Heart Syndrome

Aortic atresia and mitral atresia are predictors of adverse events in early life in patients with hypoplastic left heart syndrome, but it is unclear whether late outcomes are also affected, and whether this impact is related to a small hypertrophied left ventricle (LV) that impairs right ventricle (RV) function. Thirty patients with hypoplastic left heart syndrome surviving with a Fontan procedure were identified. Follow-up echocardiograms were available at birth, before the Fontan procedure, and several years after. Mean follow-up time was 10.9 ± 3.1 years. Measurements included interventricular septum thickness and ventricular length. The LV/RV length ratio at birth was calculated, and its impact on later LV and septal growth was examined. The primary endpoint was a composite of death, transplantation, or Fontan takedown. A cutoff LV/RV length ratio of 0.55 was identified: length ratio was 0.55 or less in group A (18patients) and more than 0.55 in group B (12 patients) The LV/RV length ratio and interventricular septum thickness decreased over time in group A while remaining static in group B. The LV length at birth did not affect late adverse outcomes (hazard ratio 2.7, 95% confidence interval: 0.31 to 23.4, p= 0.37), whereas aortic atresia and mitral atresia were the most potent predictors of death or transplantation or takedown (hazard ratio 8.5, 95% confidence interval: 1.2 to 57.7, p= 0.029). Patients with aortic atresia and mitral atresia have worse outcomes even after Fontan independently of a small, thick, hypertrophied LV. The most severely hypoplastic LVs do not grow proportionally as much as the RVs.

Adverse Effect of Post-Discharge Care Fragmentation on Outcomes after Readmissions after Liver Transplantation

Post-discharge surgical care fragmentation is defined as readmission to any hospital other than the hospital at which surgery was performed. The objective of this study was to assess the impact of fragmented readmissions within the first year after orthotopic liver transplantation (OLT). The Healthcare Cost and Utilization Project State Inpatient Databases for Florida and California from 2006 to 2011 were used to identify OLT patients. Post-discharge fragmentation was defined as any readmission to a non-index hospital, including readmitted patients transferred to the index hospital after 24 hours. Outcomes included adverse events, defined as 30-day mortality and 30-day readmission after a fragmented readmission. All statistical analyses considered a hierarchical data structure and were performed with multilevel, mixed-effects models. We analyzed 2,996 patients with 7,485 readmission encounters at 299 hospitals; 1,236 (16.5%) readmissions were fragmented. After adjustment for age, sex, readmission reason, index liver transplantation cost, readmission length of stay, number of previous readmissions, and time from transplantation, post-discharge fragmentation increased the odds of both 30-day mortality (odds ratio [OR]= 1.75; 95% CI 1.16 to 2.65) and 30-day readmission (OR= 2.14; 95% CI 1.83 to 2.49). Predictors of adverse events after a fragmented readmission included increased number of previous readmissions (OR= 1.07; 95% CI 1.01 to 1.14) and readmission within 90 days of OLT (OR= 2.19; 95% CI 1.61 to 2.98). Post-discharge fragmentation significantly increases the risk of both 30-day mortality and subsequent readmission after a readmission in the first year after OLT. More inpatient visits before a readmission and less time elapsed from index surgery increase the odds of an adverse event after discharge from a fragmented readmission. These parameters could guide transfer decisions for patients with post-discharge fragmentation.

Su1473 - Sedation During Endoscopy in Hospitalized Patients with Cirrhosis: Safety Profile and Predictors of Adverse Events

Su1473 - Sedation During Endoscopy in Hospitalized Patients with Cirrhosis: Safety Profile and Predictors of Adverse Events

Riser Pattern Is a Novel Predictor of Adverse Events in Heart Failure Patients With Preserved Ejection Fraction.

The cardiovascular prognosis of heart failure with preserved ejection fraction (HFpEF) has been shown to be similar to that of heart failure with reduced ejection fraction (HFrEF). It is unknown which factors predict cardiovascular outcome in HFpEF. We tested the hypothesis that the abnormal pattern of circadian blood pressure (BP) rhythm known as the riser BP pattern is associated with adverse outcomes in HFpEF.Methods and Results:We performed a prospective, observational cohort study of hospitalized HF patients who underwent ambulatory BP monitoring (ABPM). Five hundred and sixteen hospitalized HF patients (age, 69±13years; male, n=321 [62%]; female, n=195 [38%]) were followed up for a median 20.9months. The composite outcome consisting of all-cause mortality and cardiovascular events was observed in 220 patients. On Kaplan-Meier analysis, the riser BP pattern subgroup had a significantly higher incidence of the composite outcome than the other subgroups of HFpEF patients (HR, 3.01; 95% CI: 1.54-6.08, P<0.01), but not the HFrEF patients. The riser BP pattern was found to be a novel predictor of cardiovascular outcome in HFpEF patients.

Perioperative Predictors of Unfavorable Outcome of Vascular Surgery

Concurrent cardiac failure is an universally accepted risk factor in surgical patients undergoiing cardiac or non-cardiac surgery. The aim of this study was to search for and identify factors or markers, which would permit to predict early (up to 30 days) or late (up to 1 year) adverse outcomes in patients with acute heart failure (AHF) in the vascular surgery. Materials and Methods. A randomized, multicenter, prospective — retrospective study was performed. 89 patients who had signed the Informed Consent Form were randomized. Throughout the four stages of the study, the cardiac index (CI) and the left ventricle ejection fraction (LVEF) values were recorded. At the same stages, blood was sampled to be tested for the NT-proBNP level. The TnT level was tested only at the 3rd stage of the study. The required stay in the intensive care unit (ICU) and in the in-patient hospital, the incidence of infarctions and strokes during the early postoperative period (up to 30 days), the 30&amp;day and one-year mortality rates were recorded. Results. Different AHF prevention methods were used in patients included into this study in the postoperative period. Predictors of adverse events were studied in a combined population. The incidence of acute myocardial infarction (AMI) was 12% and that of stroke was 2%. The in-hospital mortality rate in the combined group was 2%; the one-year mortality was 10%. Patients stayed in the intensive care unit for 3 (2—4) days; the hospital stay was 11 (10—13) days; the composite adverse outcome of the surgical treatment was registered in 15% of patients. As a result, the Troponin T level was the only significant prognostic factor during the first 24 hours of the postoperative period. A study of the prognostic significance of different parameters in relation to their effect on the one-year mortality rate demonstrated a similar result. Vasoactive Inotropes Score (VIS) turned out to be the most significant criterion for prediction of possible treatment duration. Conclusion. The study results confirmed the predictive value of early determination of TnT levels after reparative vascular surgeries in patients with decreased left ventricular ejection fraction. The diagnostic value of the VIS calculation needs further confirmation.

Incidence and predictors of adverse events and outcomes for adult critically ill patients transferred by paramedics to a tertiary care medical facility

Objective: The aim of this study was to determine the incidence of adverse events and patients' outcomes in inter-facility critical care transfers by paramedics. Methods: We conducted a retrospective cohort study of adults undergoing inter-facility transfer to a tertiary medical facility by paramedics. We included all patients transferred between 1st June, 2011 and 31st December, 2014. The primary outcome is in-transit adverse event and the secondary outcome is in-hospital mortality. Multiple logistic regression models were fitted to assess predictor variables for adverse events and in-hospital mortality. Results: The incidence of adverse events was 13.7% (31/227 patients had in-transit adverse event); the most common adverse events reported were desaturation and hypotension. A unit increase in risk score for transported patients (RSTP) significantly increased the occurrence of adverse events (adjusted odds ratio [OR]: 1.36, 95% confidence interval [CI]: 1.07–1.72 and adjusted P = 0.01). Compared to medical patients, cardiac patients were less likely to develop adverse events (adjusted OR: 0.117, 95% CI: 0.02–0.52 and adjusted P Conclusion: The incidence of adverse events was 13.7%. The most common observed adverse events were desaturation and hypotension. In-hospital mortality was 30.4% and 30-day survival was 68.1%.

Abstract 11413: Appearance of QRS Fragmentation Late After Atrial Switch Repair for d-Transposition of the Great Arteries is Associated With Adverse Clinical Outcome

Introduction: The extent of myocardial fibrosis on magnetic resonance imaging (MRI) in the systemic right ventricle (RV) of adults after atrial switch repair for d-transposition of the great arteries (d-TGA) correlates with outcome. However, MRI is costly and access is limited. Fragmented QRS (fQRS) on a 12-lead electrocardiogram (ECG) reflects inhomogeneous ventricular activation. It is considered to be a surrogate for fibrosis and related with outcome in ischemic cardiomyopathy. Hypothesis: Appearance of fQRS during follow-up is a predictor for adverse events in adults after atrial switch repair for d-TGA. Methods: Records of adults with atrial switch repair for d-TGA were retrospectively reviewed in the database of a tertiary care hospital. Exclusion criteria were systemic RV assist device or heart transplantation (HTx) before the age of 16 years, or fQRS already present at transfer from the pediatric department. One blinded reader analyzed all available ECGs to detect fQRS. fQRS, severe tricuspid regurgitation (TR), severe RV dysfunction and severe RV dilatation were modeled as time-dependent covariates. Cox regression was performed to assess the relationship between covariates and (1) the composite endpoint of cardiovascular mortality, HTx or systemic RV assist device, and (2) worsening RV function. Results: Records of 89 patients (34% female, 42% Mustard repair) were analyzed. Patients underwent atrial switch repair between Oct 1969 and Nov 1992. At latest follow-up, fQRS was noted in 26 patients (29%), most frequently inferior (92%). Over a median follow-up of 16.9 (IQR 12.6-22.9) years, the composite endpoint occurred in 9 patients (10%). In multivariate Cox analysis, appearance of fQRS (HR 14.11; 95% CI 1.42-140.12) and development of severe RV dysfunction (HR 11.36; 95% CI 2.08-62.17) were significantly associated with the composite endpoint. Moreover, appearance of fQRS was significantly associated with worsening RV function (HR 2.66; 95% CI 1.18-6.01), independently of development of severe TR. Conclusions: Appearance of fQRS is associated with adverse clinical outcome and worsening RV function in adults after atrial switch repair for d-TGA. It might become an easily implementable tool to identify patients at risk for adverse events.

Should pre-operative left atrial volume receive more consideration in patients with degenerative mitral valve disease undergoing mitral valve surgery?

BackgroundSevere primary mitral regurgitation (MR) carries a significant incidence of mortality and morbidity. Though a number of prognostic factors have been identified, the best timing for mitral valve repair is still debated. We assessed the role of Left Atrial Volume Indexed (LAVI) as predictor of adverse events after mitral valve surgery. Methods134 patients with severe MR were studied with a follow-up of 42±16months. Endpoints were Post-Operative Atrial Fibrillation (POAF), atrial and ventricular remodeling (LARR/LVRR) and correlation with outcome. POAF was defined as AF occurring within 2weeks and late AF (LAF) more than 2weeks after surgery. LARR was defined as LAVI reduction ≥15% and LVRR as any reduction of ventricular mass after surgery. ResultsForty-one patients experienced POAF, 26 had LAF. Pre-operative LAVI was an independent risk factor for POAF (OR 1.03, CI [1.00–1.06], p=0.01), LAF (OR 1.03, CI [1.00–1.06], p=0.02), LARR and LVRR (OR 1.04, CI [1.01–1.07], p=0.002, respectively). LARR was found in 75 patients, while LVRR in 111. Patients with heart remodeling had less incidence of LAF and cardiac adverse events, better diastolic function and improved their NYHA class after surgery. ConclusionsLAVI should be given more weight into decision making for patients with MR as it predicts POAF and LAF and reverse atrial and ventricular remodeling, both associated to long-term outcome.

Associations of Preimplant Red Blood Cell Distribution Width with Clinical Outcomes Among Individuals with Left Ventricular Assist Devices.

Left ventricular assist devices (LVADs) are increasingly used for end-stage heart failure. However, post-LVAD complications are potentially devastating and remain unpredictable. The red blood cell distribution width (RDW) is a predictor of adverse events in patients with heart failure but has not been studied in the LVAD population. We reviewed laboratory results and clinical outcomes for all continuous flow LVADs implanted from 2004 to June 2014 (N = 188). Cox proportional hazards models adjusted for demographic, cardiovascular, and laboratory variables were used to assess association of preimplant RDW tertiles with mortality, gastrointestinal bleed, infection, pump thrombosis, and stroke more than 1 year of follow-up. Compared with the lowest tertile (RDW < 15.7%), the higher two tertiles (RDW 15.7-18% and RDW >18.1%) had significantly higher risks of mortality (hazard ratio (HR) 6.95 [confidence interval: 2.67-18.10] and HR 4.61 [1.74-12.21], respectively) after full adjustment. Preimplant RDW was not statistically associated with our secondary outcomes. In conclusion, higher preimplant RDW is independently associated with an increased risk of postimplant mortality and infection. Future studies are needed to understand the prognostic ability of RDW and to understand the biologic mechanism underlying this association.

TCT-282 Risk Factors Associated with Adverse Events during Chronic Total Occlusion Percutaneous Coronary Interventions: A sub-Analysis of the OPEN-CTO Study

Coronary chronic total occlusions (CTOs) are prevalent and the development of the hybrid approach to CTO PCI has been associated with increased technical success rates. However, the incidence and predictors of adverse events (AEs) during CTO PCI remains poorly defined. We analyzed baseline patient

Cytomegalovirus Serostatus as Predictor for Adverse Events After Cardiac Surgery: A Prospective Observational Study

To clarify whether reactivated cytomegalovirus (CMV) infections in critically ill patients lead to worse outcome or just identify more severely ill patients. If CMV has a pathogenic role, latently infected (CMV-seropositive) patients should have worse outcome than seronegative patients because only seropositive patients can experience a CMV reactivation. Post-hoc analysis of a prospective observational study. Single university hospital. The study comprised 983 consecutive patients scheduled for on-pump surgery. None. CMV antibodies were analyzed in preoperative plasma samples. Postoperative adverse events (reintubation, low cardiac output or reinfarction, dialysis, stroke) and 30-day and 1-year mortality were evaluated prospectively. The plasma of reintubated patients and matched control patients was tested for CMV deoxyribonucleic acid, and 618 patients were found to be seropositive for CMV (63%). Among these, the risk for reintubation was increased (10% v 4%, p = 0.001). This increase remained significant after correction for confounding factors (odds ratio 2.70, p = 0.003) and was detectable from the third postoperative day throughout the whole postoperative period. Other outcome parameters were not different. Reintubated seropositive patients were more frequently CMV deoxyribonucleic acid-positive than were matched control patients (40% v 8%, p<0.001). CMV-seropositive patients had an increased risk of reintubation after cardiac surgery, which was associated with reactivations of their CMV infections. Additional studies should determine whether this complication may be prevented by monitoring of latently infected patients and administering antiviral treatment for reactivated CMV infections.

Predictors of adverse events in patients with ischemic chronic heart failure with reduced ejection fraction and renal dysfunction

Chronic heart failure (CHF) is one of the most significant health, economic and social problems of the XXI century. Aim. To identify predictors of adverse events in patients with ischemic chronic heart failure with reduced ejection fraction and renal dysfunction taking into account the results of three years observation. Materials and methods. In order to reveal prognostic factors of adverse events, 140 patients (81.4% men, mean age 60 (54.5–68) years) with ischemic chronic heart failure with reduced ejection fraction and renal dysfunction were investigated. For determination of dependent and independent prognostic factors of adverse events ROC-analysis, univariate and multivariate Cox proportional hazard regression analyses were done. Results . In order to determine independent predictors of major adverse cardiovascular events 18 hazards indicators were analyzed using Cox proportional. By results of multivariate regression analysis Cox proportional hazards found that the optimal cut-off point in excess distribution age>65 years, the risk of cumulative endpoint in patients with ischemic heart failure significantly increased in 2.75 times (95% CI 1.67–4.50; p=0.001), heart rate>79 beats minute – in 2.26 times (95% CI 1.32–3.87, p=0.002) and the presence of lower than optimal point distribution values SAP≤140 mmHg – the risk is increased 1.83-fold (95% CI 1.02–3.64, p=0.03), eGFR≤70.27 ml/min/1,73m 2 – at 1.73 times (95% CI 1.09–2.75; p=0.02), EF≤34,23% – to 1.94 times (95% CI 1.21–3.11, p=0.005), HDL≤0.86 mmol/l – 1.83 times (95% CI 1.12–2.99, p=0.01). Conclusion. It was revealed that in patients with ischemic chronic heart failure with reduced ejection fraction and renal dysfunction within three years of observation there are such independent predictors of adverse cardiovascular events as age, heart rate, systolic blood pressure, glomerular filtration rate, left ventricular ejection fraction and HDL levels.

Insulin pump-associated adverse events are common, but not associated with glycemic control, socio-economic status, or pump/infusion set type.

While there have been many outcome-focussed studies examining insulin pump therapy, only a few have looked at potential adverse events (AEs), with none examining the relationship between AEs and pump/infusion set type, ethnicity or socio-economic status. In addition, current data on the incidence and characteristics of pump-associated AEs are confined to one paediatric centre. We aimed to describe the incidence, characteristics and potential predictors of insulin pump-associated AEs in New Zealand adults and children with T1DM. We approached adults and families of children with T1DM on insulin pumps in four main New Zealand centres. Participants completed a questionnaire examining pump-related issues they had experienced in the preceding 12 months. Response rate was 64% with 174 of 270 eligible people participating in the study. 84% of subjects reported one or more AEs, with an overall AE incidence of 3.42 per person/year (95% CI 3.14, 3.73). An event serious enough to require a hospital presentation occurred in 9.8%, all but one reporting high ketones or diabetic ketoacidosis (DKA). Set/site problems were the AE most commonly reported (by 53% of respondents), followed by cutaneous complications (43%) and pump malfunction (38%). Few predictors of AEs (of any type) were found; however, a negative binomial regression model found that a longer duration of pumping (p=0.018) and age <18years (p=0.043) were both associated with fewer AEs (all types combined). Insulin pump-associated AEs are very common. However, few variables are predictive of them with no relationships seen with glycaemic control, socio-economic status, pump manufacturer or infusion set type. Based on these findings, AEs should be anticipated in both adults and children, with anticipatory patient education and training recommended for their successful and safe use.

Outcomes in Moderate Mixed Aortic Valve Disease: Is it Time for a Paradigm Shift?

BackgroundA direct comparison of outcomes between moderate mixed aortic valve disease (MAVD) and isolated aortic stenosis (AS) or aortic regurgitation (AR) has not been performed, making evidence-based recommendations difficult in patients with MAVD. ObjectivesThis study sought to determine adverse event (AE) occurrence (the primary endpoint), defined as New York Heart Association functional class III/IV symptoms, aortic valve replacement, or cardiac death, and to compare AE rates between MAVD and isolated AS or AR. MethodsAsymptomatic patients were identified with moderate MAVD and an ejection fraction ≥50% and were followed at Mayo Clinic from 1994 to 2013. Moderate MAVD was defined as a combination of moderate AS and moderate AR. Age- and sex-matched control groups were selected with isolated moderate AR (n = 117), moderate AS (n = 117), or severe AS (n = 117). ResultsAt 9.1 ± 4.2 years of follow-up, patients with moderate MAVD (n = 251) had a mean age of 63 ± 11 years, 73% were male, and 38% had bicuspid valve. AE occurred in 193 (77%) patients in this group, including symptom development (69%), aortic valve replacement (67%), and cardiac death (4%). Predictors of AE were older age (hazard ratio [HR]: 1.71 per decade; 95% confidence interval [CI]: 1.38 to 1.97 per decade; p = 0.001), and relative wall thickness >0.42 (HR: 2.01; 95% CI: 1.86 to 2.33; p = 0.002). AE rates were similar in the MAVD and severe AS group (71% vs. 68% at 5 years; p = 0.49), but were significantly higher compared with the moderate AS and AR groups. ConclusionsMAVD patients had outcomes comparable to those with severe AS, and preserved ejection fraction and should be monitored closely for symptoms.

Simplified Frailty Index as a Predictor of Adverse Outcomes in Total Hip and Knee Arthroplasty

BackgroundThe modified frailty index (mFI) has been shown to predict adverse outcomes in multiple nonorthopedic surgical specialties. This study aimed to assess whether mFI is a predictor of adverse events in patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). MethodsPatients who underwent THA and TKA from 2005-2012 were identified in the National Surgical Quality Improvement Program database. mFI was calculated for each patient using 15 variables found in National Surgical Quality Improvement Program. Bivariate and multivariate analyses of postoperative adverse events, including Clavien-Dindo grade IV complications, were performed. ResultsA total of 14,583 THA and 25,223 TKA patients were included for analysis. The mean (standard deviation, range) mFIs were 0.083 (0.080, 0-0.55) for THA and 0.097 (0.080, 0-0.64) for TKA cohorts. On bivariate analyses, incidence of Clavien-Dindo grade IV complications (cardiac arrest, myocardial infarction, septic shock, pulmonary embolism, postoperative dialysis, reintubation, and prolonged ventilator requirement), hospital-acquired conditions (surgical site infection, venous thromboembolism, and urinary tract infection), any complications, and mortality increased significantly with increase in mFI (P < .0001 for all). Adjusting for demographics, age ≥ 75, body mass index ≥40, American Society of Anesthesiologists class ≥4, and nonclean wound status, mFI ≥0.45 was shown to be the strongest independent predictor of Clavien-Dindo grade IV complications for both THA and TKA cohorts with odds ratios of 5.140 and 4.183, respectively. ConclusionmFI ≥0.45 is an independent predictor of Clavien-Dindo grade IV complications in TKA/THA patients with greater odds ratios than age >75, body mass index ≥40, American Society of Anesthesiologists class ≥4. mFI should be considered for risk stratifying joint arthroplasty patients preoperatively and perhaps determining immediate postoperative destination.