Composite Morbidity Research Articles

Perinatal outcomes of twin pregnancies affected by early twin-twin transfusion syndrome: A systematic review and meta-analysis.

Twin-to-twin transfusion syndrome (TTTS) is associated with a high risk of perinatal mortality and morbidity if not treated. However, the optimal timing and management in case of early (occurring < 18 weeks) TTTS has not been established yet. This is a systematic review and meta-analysis aiming at evaluating the outcomes of monochorionic diamniotic twin pregnancies complicated by early (ie before 18 weeks) TTTS according to different management options (expectant, laser therapy, amnioreduction or cord occlusion). The primary outcome was mortality, including single and double intrauterine, neonatal and perinatal death. Secondary outcomes were: composite morbidity, neuromorbidity, respiratory distress syndrome, admission to neonatal intensive care unit, intact survival (defined as survival free from neurological complications) and preterm birth < 32 weeks of gestation. All outcomes were reviewed according to the different management options (expectant, laser therapy, amnioreduction or cord occlusion) and reported FOR the overall population of twins, and for the donor and recipient separately. Subgroup analysis for TTTS occurring before 16 weeks of gestation was performed. Random-effect meta-analyses of proportions were used to analyse the data. Thirteen studies were included. Early TTTS occurred in 14.3% (95% confidence interval [CI] 11.9-17.0) of cases. The incidence of intrauterine death was 19.0% (95% CI 2.6-45.5) in twins managed expectantly, 32.4% (95% CI 16.5-50.7) in those who received laser treatment and 12.5% (95% CI 4.8-23.0) in those treated with amnioreduction. The incidence of neonatal death was 22.6% (95% CI 4.2-49.8) in twins managed expectantly, 24.7% (95% CI 0.5-80.3) in those who received laser and 20.2 (95% CI 5.8-43.4) in those who had amnioreduction; it was not possible to compute the incidence of these outcomes in twins undergoing cord occlusion because of insufficient sample and lack of reporting of most of the observed outcomes. Overall, the incidence of perinatal death was 43.9% (95% CI 5.9-87.7) in twins managed expectantly, 47.3% (95% CI 21.4-70.0) in those treated with laser and 28.5% in those who had amnioreduction. Twin pregnancies affected by early TTTS are at substantial risk of perinatal mortality and morbidity; however, the data come from very small studies with a high risk of selection bias.

Perinatal outcome of pregnancies complicated by placental chorioangioma: systematic review and meta-analysis.

To report the perinatal outcome of singleton pregnancies complicated by placental chorioangioma diagnosed on prenatal ultrasound. MEDLINE, EMBASE, CINAHL and ClinicalTrials.gov databases were searched for studies reporting the outcome of pregnancies complicated by placental chorioangioma. Inclusion criteria were singleton pregnancy diagnosed with placental chorioangioma on prenatal ultrasound, with no other associated structural anomaly. The primary outcome was perinatal mortality. Secondary outcomes included associated non-structural anomalies detected on prenatal ultrasound (including fetal hydrops, anemia, polyhydramnios, signs of hyperdynamic circulation and small-for-gestational-age (SGA) fetus), SGA at birth, composite neonatal morbidity and preterm birth. Outcome was assessed separately in pregnancies undergoing and those not undergoing fetal therapy. Subanalyses were performed according to the presence of hydrops and the size of the tumor in all pregnancies diagnosed with chorioangioma. Random-effects meta-analyses of proportions were used to analyze the data. Twenty-eight studies (161 pregnancies) were included. In pregnancies complicated by chorioangioma that did not undergo intervention, intrauterine death occurred in 8.2% (95% CI, 3.8-15.0%), while neonatal death and perinatal death occurred in 3.8% (95% CI, 1.0-8.1%) and 11.1% (95% CI, 5.0-19.4%), respectively. SGA at birth was present in 24.0% (95% CI, 13.5-36.5%) of cases, while preterm birth < 37 weeks complicated 34.1% (95% CI, 21.1-48.3%) of pregnancies. Composite neonatal morbidity occurred in 12.0% (95% CI, 4.5-22.3%) of cases. On ultrasound, signs of fetal hyperdynamic circulation were present in 21.0% (95% CI, 9.6-35.3%) of cases, while peak systolic velocity in the fetal middle cerebral artery was increased in 20.6% (95% CI, 10.9-32.3%). Subanalysis according to the size of chorioangioma, including both pregnancies that did and those that did not undergo intervention, showed a progressive increase in the occurrence of most of the outcomes explored with increasing size of the tumor. Furthermore, the prevalence of adverse perinatal outcome was high in pregnancies complicated by chorioangioma presenting with fetal hydrops. There was no randomized controlled trial comparing intervention vs expectant management in pregnancies complicated by chorioangioma with signs of fetal compromise (hydrops or hyperdynamic circulation). Overall, perinatal mortality occurred in 31.2% (95% CI, 18.1-46.1%) of fetuses undergoing in-utero therapy, and 57.3% (95% CI, 39.2-74.4%) had resolution of hydrops or hyperdynamic circulation after treatment. Placental chorioangioma is associated with adverse perinatal outcome. The size of the mass and presence of fetal hydrops are likely to be the main determinants of perinatal outcome in affected pregnancies. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Histologic chorioamnionitis concomitant placental abruption and its effects on pregnancy outcome

IntroductionTwo possible causative pathways have been suggested to participate in the development of placental abruption (PA), an acute inflammatory pathway and placental vascular derived, a chronic pathway. We aimed to study the impact of the inflammatory pathway on maternal and neonatal outcome. MethodsThe computerized medical files and placental reports of all pregnancies diagnosed with PA, between 11/2008-1/2019, at 24–42 weeks, were reviewed. Placental lesions were classified according to “Amsterdam” criteria into maternal and fetal vascular malperfusion lesions, acute inflammatory responses and chronic villitis. Composite neonatal morbidity included ≥1 of the following: seizures, intra-ventricular hemorrhage (IVH), hypoxic-ischemic encephalopathy, periventricular leukomalacia (PVL), blood transfusion, necrotizing enterocolitis (NEC), neonatal sepsis, respiratory distress syndrome, or neonatal death. Maternal and neonatal outcome were compared between PA with and without histologic chorioamnionitis (HC). ResultsAs compared to the PA without HC group (n = 267), the PA with HC group (n = 77) was characterized by lower gestational age (GA) at delivery (32.9 ± 5.5 vs. 35.6 ± 4.1 weeks, p < 0.001), higher rates of oligohydramnios (p < 0.001), bloody amniotic fluid at labor (p < 0.001), maternal postpartum fever (p < 0.001), longer maternal hospitalization (<0.001), and increased composite adverse neonatal morbidity (41.6% vs. 22.8%, p = 0.002). By multivariate analysis, GA and HC were found to be independently associated with adverse neonatal outcome, aOR 0.63 95% CI 0.43–0.78, p < 0.001, and aOR1.12, 95% CI 1.02–3.87, p = 0.04, respectively. DiscussionThe involvement of the inflammatory causative pathway in the development of placental abruption, is associated with increased maternal and neonatal morbidity.

Composite neonatal morbidity indicators using hospital discharge data: A systematic review.

Neonatal morbidity is associated with lifelong impairments, but the absence of a consensual definition and the need for large data sets limit research. To inform initiatives to define standard outcomes for research, we reviewed composite neonatal morbidity indicators derived from routine hospital discharge data. PubMed (updated on October 12, 2018). The search algorithm was based on three components: "morbidity," "neonatal," and "hospital discharge data." Studies investigating neonatal morbidity using a composite indicator based on hospital discharge data were included. Indicators defined for specific conditions (eg congenital anomalies, maternal addictions) were excluded. The target population, objectives, component morbidities, diagnosis and procedure codes, validation methods, and prevalence of morbidity were extracted. For each study, we assessed construct validity by describing the methods used to select the indicator components and evaluated whether the authors assessed internal and external validity. We also calculated confidence intervals for the prevalence of the morbidity composite. Seventeen studies fulfilled inclusion criteria. Indicators targeted all (n=4), low-/moderate-risk (n=9), and very preterm (VPT, n=4) infants. Components were similar for VPT infants, but domains and diagnosis codes within domains varied widely for all and low-/moderate-risk infants. Component selection was described for 8/17 indicators and some form of validation reported for 12/17. Neonatal morbidity prevalence ranged from 4.6% to 9.0% of all infants, 0.4% to 8.0% of low-/moderate-risk infants, and 17.8% to 61.0% of VPT infants. Multiple neonatal morbidity indicators based on hospital discharge data have been used for research, but their heterogeneity limits comparisons between studies. Standard neonatal outcome measures are needed for benchmarking and synthesis of research results.

Pre- and postnatal brain hemodynamics in pregnancies at term: correlation with Doppler ultrasound, birthweight, and adverse perinatal outcome

Purpose To elucidate the correlation between pre- and postnatal cerebral Doppler in pregnancies close to term and to explore whether they are associated with perinatal outcome. Materials and methods Prospective study on singleton pregnancies at 36–37 weeks of gestation. The primary outcome was a composite score of perinatal morbidity, while secondary outcomes were adverse intra-partum outcome and abnormal acid–base status. All pregnancies underwent ultrasound assessment of umbilical artery (UA), middle cerebral artery (MCA), uterine arteries (UtAs) pulsatility index (PI), and cerebroplacental ratio (CPR). At birth, neonatal MCA PI was measured 72 h from delivery and correlated with prenatal Doppler, primary and secondary outcomes. Fisher’s test and multivariate logistic regression analysis were used to analyze the data. Results One hundred and sixty-six fetuses with both pre- and postnatal Doppler assessment of the MCA were included in the study. The risk of composite perinatal morbidity was higher in fetuses (OR: 5.7, 95% CI 2.2–14.6) and newborns (OR: 4.1, 95% CI 1.8–9.6) with fetal MCA PI < 10th centile. Likewise, the incidence of abnormal acid–base status was higher both in fetuses (20 versus 4.2%, p = .026) and newborns (17.1 versus 3.2%, p = .001) with a low MCA PI before and at birth, respectively. At logistic regression analysis, fetal and neonatal MCAPI were independently associated with composite perinatal morbidity and abnormal acid–base status, but not with adverse intra-partum outcome. In small for gestational age (SGA) fetuses, the incidence of composite perinatal morbidity was higher in fetuses and new-borns presenting compared to those not presenting with an MCA PI < 10th centile (61.5 versus 20%, p = .003 and 52.6% versus 7.1%, p = .008, respectively), while such association was lost when considering non-SGA fetuses. Conclusion A low MCA PI is associated with adverse perinatal outcome in pregnancies at term and tends to persist after birth.

Risk Factors Associated With Cesarean Delivery After Induction of Labor in Women With Class III Obesity.

To assess the risk factors associated with cesarean delivery in women with class III obesity (body mass index [BMI, calculated as weight in kilograms divided by height in meters squared] 40 or higher) who are undergoing induction of labor. This was a retrospective cohort of obese women with a BMI of 40 or higher and singleton pregnancy of 34 weeks of gestation or longer who underwent induction of labor at two large teaching institutions from January 2013 to December 2015. The primary outcome was cesarean delivery. Secondary outcomes included maternal and neonatal composite morbidity. We then assessed the applicability of using a previously developed calculator to predict the risk of cesarean delivery. The area under the receiver operating characteristic (ROC) curve was used as a measure of the ability of the calculator to discriminate between women who underwent cesarean compared with vaginal delivery. There were 485 women with class III obesity who underwent induction during the study period. Of the 428 women who met inclusion criteria, 81.8% had a BMI of 40-50, 14.5% had a BMI of 50-60, and 3.7% had a BMI higher than 60. The overall cesarean delivery rate was 49.1% (46% with BMI 40-50, 63% with BMI 50-60, and 69% with BMI higher than 60, P=.012). Of the 428 women studied, 77.6% were black and 55% were nulliparous. Nulliparity, height, initial cervical dilation, and modified Bishop score were associated with a higher rate of cesarean delivery in multivariable models. Maternal and neonatal composite morbidity was higher in obese women who underwent cesarean delivery, compared with those who delivered vaginally. The performance of a previously developed induction calculator applied to this cohort had an area under the ROC curve of 75% (95% CI 0.70-0.79). In women with class III obesity who underwent labor induction, the cesarean delivery rate approaches 50%. Nulliparity, height, and unfavorable cervical examination were the most significant risk factors for cesarean delivery. This information can be used to augment counseling for the obese patient who is undergoing induction.

Breech deliveries in OLVG, the Netherlands: A retrospective cohort study of seven years

BackgroundThe clinical dilemma on the preferred mode of delivery for breech position still exists. Elective caesarean delivery (CD) could be safer for neonates, whereas vaginal breech delivery (VBD) remains a safe option when conducted by an experienced person. Besides successful VBD is beneficial for mothers and subsequent pregnancies. ObjectivesTo evaluate breech deliveries on mode of delivery, maternal and neonatal outcomes. Study DesignA single center, retrospective, cohort study was performed of women who delivered a singleton fetus in breech position from 32 weeks’ gestation onwards from January 2011 to December 2017. Primary outcome measure was mode of delivery defined as an elective CD and planned VBD. Secondary outcome measures were neonatal and maternal outcome. For neonatal outcome, we used neonatal mortality and a composite measure neonatal morbidity. Maternal outcome included maternal mortality and maternal morbidity divided in severe and non-severe complications. We subcategorized for preterm (32 weeks to 37 weeks of gestation) and term pregnancies (from 37 weeks of gestation onwards). Results1.774 women delivered a child in breech position, 73 % opted for an elective CD. Of the 484 women that had a planned VBD (preterm 38 % (n = 59), term 26 % (n = 425)) 71 % were successful.Neonatal mortality occurred twice in the VBD cohort. Preterm neonatal morbidity occurred in the elective CD and VBD cohort equally (both 66 %), at term significantly more in the VBD cohort (12 % v 4%, OR 3.2, 95 % CI 2.1–4.8). For the total cohort, severe maternal postpartum complications occurred more often in the elective CD compared to successful VBD (2% v 0.3 %, OR 6.0, 95 % CI 0.80–44.3). ConclusionA high rate of successful VBD after opting for a planned VBD was found in our center. Nevertheless, compromised neonatal outcome at term was more frequent in the planned VBD group compared to the elective CD group. Severe maternal postpartum complications were more frequent in the elective CD group compared to the VBD group. Future research should focus alternations in the management of breech presentation.

Predictors of index admission mortality and morbidity in contemporary esophageal atresia patients

Background/PurposeThe Spitz classification for esophageal atresia with/without tracheoesophageal fistula (EA/TEF) predicts mortality. This study evaluates the contemporary relevance of the Spitz classification and investigates predictors of morbidity. MethodsEA/TEF patients born between 1995 and 2018 at two centers were retrospectively reviewed. Clinical variables including sex, prenatal diagnosis, birth weight, prematurity, major congenital heart disease (MCHD), and pre-operative mechanical ventilation (POMV) were collected. Index admission composite morbidity was considered positive if: length-of-stay >90th percentile (139 days), ventilation days >90th percentile (24 days), and/or gastrostomy was used for long-term feeding. Multivariable regression determined predictors of index admission mortality and composite morbidity. A composite morbidity predictive algorithm was created.ROC curves evaluated model discrimination. ResultsOf 253 patients, 13 (5.1%) experienced index admission mortality. Of the patients not suffering mortality, 74 (31.6%) experienced composite morbidity. Only MCHD predicted mortality (p = 0.001); birth weight did not (p = 0.173). There was no difference between the Spitz classification and MCHD alone in predicting mortality risk (p = 0.198); both demonstrated very good discrimination. Prenatal diagnosis, POMV, prematurity, and male sex predicted composite morbidity risk (p < 0.001; p = 0.008; p = 0.009; p = 0.05). An algorithm incorporating these predictors demonstrated good discrimination (AUC = 0.784; 95% CI: 0.724, 0.844). ConclusionsThe Spitz classification maintains contemporary relevance for mortality risk, though birth weight can be de-emphasized. A new morbidity risk algorithm is proposed for early postnatal counseling. Type of StudyPrognosis study. Level of EvidenceLevel IV.

Neonatal morbidity and small and large size for gestation: a comparison of birthweight centiles.

To compare rates of small- and large-for-gestational age (SGA and LGA) neonates using four different weight centiles, and to relate these classifications to neonatal morbidity. Neonates born at 33-40 weeks' gestation in a multiethnic population were classified as SGA or LGA by population reference (Fenton), population standard (INTERGROWTH), fetal growth curves (WHO), and customized (GROW) centiles. Likelihood of composite morbidity was determined compared with a common appropriate-for-gestational age referent group. Among 45,505 neonates, SGA and LGA rates varied up to threefold by different centiles. Those most likely to develop neonatal morbidity were SGA or LGA on both the population reference and an alternative centile. Customized centiles identified over twice as many at-risk SGA neonates. Customized centiles were most useful in identifying neonates at increased risk of morbidity, and those that were small on both customized and population reference centiles were at the highest risk.

Impact of tricuspid regurgitation with and without repair during aortic valve replacement

BackgroundLong-term outcomes of aortic valve replacement (AVR) are worse in patients with tricuspid regurgitation (TR), but the impact of concomitant tricuspid valve intervention remains unclear. The purpose of this study was to determine the effect of tricuspid intervention in patients with TR undergoing AVR. MethodsPatients undergoing AVR in a regional Society of Thoracic Surgeons database (2001-2017) were stratified by severity of TR and whether or not they underwent concomitant tricuspid intervention. Operative morbidity and mortality were compared between the 2 groups. Further analysis was performed using propensity score–matched pairs. ResultsAmong 17,483 patients undergoing AVR, 8984 (51%) had no TR, 7252 (41%) had mild TR, 1060 (6%) had moderate TR, and 187 (1%) had severe TR. Overall, more severe TR was associated with higher morbidity and mortality. Tricuspid intervention was performed in 104 patients (0.6%), including 0.2% of patients with mild TR, 2% of those with moderate TR, and 31% of those with severe TR. In the propensity score–matched analysis, there was not a statistically significant difference in operative mortality between the 2 groups (18% vs 9%; P = .16), but there was significantly higher composite major morbidity (51% vs 26%; P = .006) in the tricuspid intervention group compared with those without surgical TR correction. ConclusionsIncreasing severity of TR is associated with higher rates of morbidity and mortality after AVR. Correction of TR at the time of surgical AVR is not associated with increased operative mortality and has been shown to improve long-term outcomes.

Association of Geriatric-Specific Variables with 30-Day Hospital Readmission Risk of Elderly Surgical Patients: A NSQIP Analysis

Elderly patients (65 years of age and older) undergo an increasing number of operations performed annually in the US and they present with unique healthcare needs. Preventing postoperative readmission remains an important challenge to improving surgical care. This study examined whether geriatric-specific variables were independently associated with postoperative readmissions of elderly patients. The American College of Surgeons (ACS) Geriatric Surgery Research File (GSRF) was joined with the ACS NSQIP Participant Use Data Files for 2014 to 2016. This data set included 13 GSRF variables and 26 ACS NSQIP variables. Associations between clinically relevant variables and readmission were tested with multivariable logistic regression. The data represented 6,039 general surgery patients age 65 years and older. Fifty-eight percent of patients had colorectal operations, 19% pancreatic or hepatobiliary, 15% hernia, 4% thyroid or esophageal, and 3% had appendix operations. Twenty-four percent of patients experienced an NSQIP-defined 30-day postoperative complication and 3% died within 30 days after operation. Eleven percent of patients had unplanned 30-day readmission. Standard NSQIP variables, including 30-day composite morbidity (odds ratio [OR] 5.11; 95% CI, 4.24 to 6.16; p < 0.001), reoperation (OR 2.8; 95% CI, 2.07 to 3.79; p < 0.001), and steroid use (1.42; 95% CI, 1.03 to 1.96; p= 0.03) were associated with readmission. In addition, GSRF variables, including incompetent on admission (OR 1.63; 95% CI, 1.11 to 2.38; p= 0.01), fall risk at discharge (OR 1.42; 95% CI, 1.11 to 1.82; p= 0.005), use of mobility aid (OR 1.26; 95% CI, 1.02 to 1.56; p= 0.03), and discharged home with skilled care (OR, 1.22; 95% CI, 1.0 to 1.49; p= 0.04) were associated with readmission. Four GSRF and 3 current standard ACS NSQIP variables were important in the evaluation of postoperative readmission of elderly patients. Geriatric-specific variables contributed to the explanation of the relationship between clinical variables and readmissions in elderly surgical patients.

Surgery for Type A Aortic Dissection: 14-Year Contemporary Cohort Study

Type A aortic dissection is a fatal condition warranting emergency surgery to prevent complications and death. We reviewed the contemporary trends, characteristics, outcomes and predictors of this operation at our centre over a 14-year period. Consecutive patients undergoing type A aortic dissection surgery at Auckland City Hospital during March 2003-March 2017 were studied, and relevant characteristics and outcomes collected prospectively for statistical analyses. There were 327 patients included, and the number of operations each year remained similar from 2003-2010, and steadily increased thereafter. Median age was 60.6 years, with 124 (37.9%) females, 136 (41.6%) Maori or Pacific ethnicity, 319 (97.6%) emergency surgeries, 62 (19.0%) in a critical preoperative state and 154 (47.1%) having a malperfusion syndrome. Operative mortality occurred in 65 (19.9%), although this has decreased from 23.3% before 2014 to 14.0% since. Composite morbidity occurred in 212 (65.0%), predominantly acute kidney injury 134 (41.0%), ventilation >24 hours (129 (39.6%), return to theatre 94 (28.8%) and stroke 63 (19.3%). Survival at 1, 5 and 10 years was 79.0%, 71.7% and 57.8% respectively. Critical preoperative state and malperfusion syndrome were independent predictors of operative and long-term mortality and composite morbidity. Surgery for acute type A aortic dissection has been increasing since 2011 and continues to have high rates of operative mortality and morbidities, although the former has decreased since 2014. Critical preoperative state and malperfusion were the key predictors of adverse outcomes. After surviving the perioperative period, prognosis was good with low rates of late mortality.

Diagnostic Accuracy of Doppler Ultrasound in Predicting Perinatal Outcome in Appropriate for Gestational Age Fetuses: A Prospective Study.

To elucidate the role of Doppler ultrasound in predicting perinatal outcome in appropriate for gestational age (AGA) fetuses at term. Prospective study carried out in a dedicated research ultrasound clinic. The inclusion criterion was AGA fetuses, defined as those with an estimated fetal weight between the 10th and 90th percentile, at 36 + 0-37 + 6 weeks of gestation. The primary outcome was a composite score of adverse perinatal outcome including either adverse intrapartum events or abnormal acid-base status at birth. Secondary outcomes were the individual components of the primary outcome. The Doppler parameters explored were umbilical artery (UA) PI, middle cerebral artery (MCA) PI, uterine arteries (UtA) PI and cerebroplacental ratio (CPR). Attending clinicians were blinded to Doppler findings. Logistic regression and ROC curve analyses were used to analyze the data. 553 AGA fetuses were included. There was no difference in mean UA PI (p = 0.486), MCA PI (p = 0.621), CPR (p = 0.832) and UtA PI (p = 0.611) between pregnancies complicated by composite perinatal morbidity compared to those not complicated by composite perinatal morbidity. In pregnancies complicated by adverse intrapartum outcome, the mean MCA PI (1.47 ± 0.4 vs 1.61 ± 0.4, p = 0.0039) was lower compared to the control group, while there was no difference in UA PI (p = 0.758), CPR (p = 0.108), and UtA PI (p = 0.177). Finally, there was no difference in any of the Doppler parameters explored between AGA fetuses with abnormal acid-base status at birth compared to those without abnormal acid-base status at birth. In the logistic regression analysis, UA PI, MCA PI, CPR, UtA PI, EFW and AC percentiles were not independently associated with composite adverse outcome, adverse intrapartum outcome or abnormal acid-base status at birth in non-SGA fetuses. The diagnostic performance of all of these Doppler parameters for predicting composite adverse outcome, adverse intrapartum outcome and abnormal acid-base status was poor. Cerebroplacental and maternal Doppler is not associated with or predictive of adverse pregnancy outcome in AGA fetuses close to term.

Outcomes and Trends in Colorectal Surgery in U.S. Veterans: A 10-year Experience at a Tertiary Veterans Affairs Medical Center.

Introduction: The past decade has witnessed numerous advances in colorectal surgery secondary to minimally invasive surgery, evidence-based enhanced recovery programs, and a growing emphasis on patient-centered outcomes. The purpose of this study is to benchmark outcomes and experiences of patients undergoing colorectal surgery at a tertiary Veterans Affairs Medical Center for a 10-year period. Materials and Methods: Veterans who underwent nonemergent colorectal procedures between 2008 and 2018 were identified using targeted Current Procedural Terminology (CPT) codes and the Computerized Patient Record System. Patient outcomes were captured using the Veterans Affairs Surgical Quality Improvement Program and focused on length of stay and aggregate postoperative morbidity profiles. SAS® Version 9.4 (SAS Institute Inc., Cary, NC) was used for all data analysis with P < .05 used to indicate significance. Results: In total, 327 patients underwent colon/rectal resection at our medical center. Of whom 95% of patients were male and the average age was 66 years. The median length of stay after surgery was 8 days. Within the 30-day postoperative period, the composite morbidity score was 24.1%: most notable being superficial surgical site infections (6.5%), wound dehiscence (4.6%), and pneumonia (3.1%). Over the course of the study period, the laparoscopic approach increased in utilization, with 22.2% of cases performed laparoscopically in 2008 that rose to 61.1% in 2018. Conclusion: Cataloging this decade of practice provides a foundation for future changes in the field of colorectal surgery and in the treatment of veterans. Understanding historical outcomes should help identify areas for ongoing process improvement and guide targeted approaches to quality metrics.

Impact of a Policy to Deliver at 39 Weeks for the Indication of Class III Obesity.

The aim of this study was to evaluate the effect of a policy to deliver at 39 weeks for class III obesity. This was a retrospective cohort study of women with class III obesity delivering at ≥ 37 weeks before (May 2012 to April 2014) and after the policy (September 2014 to August 2016). The primary outcome was the cesarean rate. Secondary outcomes included maternal morbidities and a neonatal morbidity composite. Modified Poisson regression was used to adjust for demographic differences between groups. The study included a total of 1,210 patients, 580 before the policy and 630 after the policy. Before and after the policy, cesarean rates were similar (41.6% vs. 47.1%; risk ratio [RR]: 1.13 [95% CI: 1.00-1.29]; adjusted RR [aRR]: 1.03 [95% CI: 0.92-1.14]). In adjusted comparisons of women undergoing labor induction, parous women had lower cesarean rates (aRR: 0.62; 95% CI: 0.41-0.94) but nulliparous women had higher cesarean rates (aRR: 1.32; 95% CI: 1.04-1.68) after the policy (P for interaction = 0.01). Rates of chorioamnionitis, endometritis, and cesarean wound infection were not different between groups. Composite neonatal morbidity was not different between pre- and postpolicy groups. A policy of delivery at 39 weeks for class III obesity did not affect overall cesarean rate or rates of maternal or neonatal morbidity. Further investigation should evaluate subsets of women who may have a higher cesarean rate with this policy.

Quantifying the Risks and Benefits of Continuing Labor Induction: Data for Shared Decision-Making

This study aimed to quantify the relative maternal and fetal risks and benefits of continuing labor induction. This retrospective cohort study included nulliparous women with nonanomalous, singleton, vertex, term pregnancies undergoing labor induction with intact membranes at a tertiary-care academic hospital from January 2015 to April 2017. The primary outcome was mode of delivery. Secondary outcomes included hemorrhage, transfusion, infection, and composite neonatal morbidity. The data were analyzed using chi-square and Fisher's exact tests. Multivariable regression was used to control for potential confounders. A total of 955 patients met the inclusion criteria. The median induction duration was 32.3 hours (interquartile range: 20.4-41 hours) and the vaginal delivery rate was 70.5% (n = 673). The chance of vaginal delivery at 12, 24, 36, 48, 60, and ≥60 hours was 76, 83, 77, 74, 72, and 48%, respectively. After controlling for confounders, there was a 20% decrease in chance of vaginal delivery with induction ≥ 24 hours compared with induction < 24 hours. The adjusted relative risks of hemorrhage, transfusion, and infection with induction ≥ 24 hours compared with induction < 24 hours were 1.9, 2.2, and 2.7, respectively (95% confidence interval [CI] of 1.4-2.5, 1.1-3.9, and 1.8-4.0, respectively). The relative risk for these outcomes remained stable or decreased at each subsequent time point. The increasing risks of hemorrhage and infection were primarily among patients who underwent cesarean delivery. There was no association between induction duration and neonatal morbidity. In this cohort, the chance of vaginal delivery remained nearly 50% even when induction extended beyond 60 hours. Risks of hemorrhage and maternal infection rose modestly over time, but primarily in patients who underwent cesarean delivery. There was no difference in the risk of transfusion beyond 24 hours and no association between induction duration and neonatal morbidity. These findings may be useful when engaging patients in shared decision-making during labor induction.

Transfusion rates in emergency general surgery: high but modifiable

BackgroundTransfusion of red blood cells (RBC) increases morbidity and mortality, and emergency general surgery (EGS) cases have increased risk for transfusion and complication given case complexity and patient acuity. Transfusion...

The association of anaemia and its severity with composite morbidity after total hip arthroplasty.

Total hip arthroplasty (THA) is a common orthopaedic procedure and is expected to increase with an increasing elderly population. Many of these patients suffer from chronic diseases which might be associated with anaemia. Anaemia, by itself, increases the risk of morbidity. We aimed to delineate relationship between preoperative anaemia and postoperative composite morbidities in patients undergoing primary THA. A cohort study analysed the data from the American College of Surgeons National Surgical Quality Improvement Program 2008-2014 database. Adult patients who underwent unilateral primary THA were included and divided into 3 groups: no anaemia, mild anaemia, and moderate-to-severe anaemia. Thirty-day mortality and morbidity were recorded as adverse events. The associations between anaemia, baseline characteristics, and adverse events were analysed after adjusting for confounders. Moderate-to-severe anaemia patients were at increased risk for composite morbidity (adjusted odds ratio, 1.43 [1.17-1.74]) when compared to non-anaemics. The stratification revealed a significant effect of younger age, male gender, white race, obesity, general anaesthesia, and mean operative time >120 minutes in patients with moderate-to-severe anaemia. These patients were also at a higher risk of developing several specific morbidities. Moderate-to-severe anaemia increases the risk for composite morbidities, but not mortality in patients undergoing primary THA. Further studies are needed to assess whether preoperative management of moderate-to-severe anaemia would improve outcomes in patients undergoing THA.

Dialysis in Pregnancy: Role of the Underlying Cause of Renal Failure on Peripartum Outcomes.

Pregnancy on dialysis is rare and few studies in this population exist. Currently, pregnancy outcomes are thought to be related to dialysis intensity. We hypothesize women requiring dialysis due to diabetes or lupus will have worse pregnancy outcomes compared with other indications for dialysis. All women receiving dialysis during pregnancy from 2012 to 2016 in a single health system were identified. Differences in perinatal outcomes among those with renal failure caused by diabetes or lupus and with other causes were evaluated. Sixteen women were identified, seven with diabetes or lupus causing renal failure; the remaining nine women had hypertension, focal segmental glomerular sclerosis, polycystic kidney disease, congenital hypoplastic kidneys, or neurogenic bladder. The rates of composite maternal morbidity were similar among the two groups. Composite neonatal morbidity was higher in those with renal failure caused by diabetes or lupus compared with other causes (100% vs. 29%, p = 0.028). Despite similar dialysis intensity, the composite neonatal morbidity was higher in women with renal failure caused by diabetes or lupus compared with other etiologies. Our findings suggest that pregnancy outcome in women receiving dialysis is dependent on both the intensity of dialysis as well as the etiology of renal failure.

Clinical Utility of Weekly Laboratory Testing in the Outpatient Management of Preeclampsia and Gestational Hypertension.

Objective To investigate the utility of obtaining weekly laboratory testing in patients managed as an outpatient for gestational hypertension and preeclampsia without severe features. Study Design A multisite retrospective cohort study was performed evaluating preterm women diagnosed with gestational hypertension/preeclampsia managed in an outpatient setting between gestational ages of 23 0/7 and 36 6/7 . Patients were divided into two groups: weekly laboratory evaluation (laboratories group) and a no laboratories group. The primary study outcome was composite maternal morbidity including more than one of the following: development of severe features, HELLP syndrome, eclampsia, placental abruption, maternal intensive care unit admission, or maternal death. Results A total of 204 patients were included in this study, laboratories group ( n = 120) and no laboratories group ( n = 84). The laboratories group was older (28.8 vs. 26.6 years, p = 0.02), had a higher rate of chronic hypertension (44 [36.7%] vs. 17 [20.2%], p = 0.01), and more often experienced the primary composite outcome (53 [44.2%] vs. 24 [28.5%], p = 0.02). No patients in our cohort were delivered for abnormal laboratory values. Conclusion This study found that weekly laboratory testing may have minimal clinical utility in the outpatient management protocol in monitoring patients with mild gestational hypertension or preeclampsia. Delivery was guided by other clinical factors.