Difference In Risk Of Complications Research Articles

Persistent Racial Disparities in Morbidity Following Major Elective Operations.

Introduction: Despite considerable national attention, racial disparities in surgical outcomes persist. We sought to consider whether race-based inequities in outcomes following major elective surgery have improved in the contemporary era. Methods: All adult hospitalization records for elective coronary artery bypass grafting, abdominal aortic aneurysm repair, colectomy, and hip replacement were tabulated from the 2016-2020 National Inpatient Sample. Patients were stratified by Black or White race. To consider the evolution in outcomes, we included an interaction term between race and year. We designated centers in the top quartile of annual procedural volume as high-volume hospitals (HVH). Results: Of ∼2,838,485 patients, 245,405 (8.6%) were of Black race. Following risk-adjustment, Black race was linked with similar odds of in-hospital mortality, but increased likelihood of major complications (Adjusted Odds Ratio [AOR] 1.41, 95%Confidence Interval [CI] 1.36-1.47). From 2016-2020, overall risk-adjusted rates of major complications declined (patients of White race: 9.2% to 8.4%; patients of Black race 11.8% to 10.8%, both P < .001). Yet, the delta in risk of adverse outcomes between patients of White and Black race did not significantly change. Of the cohort, 158,060 (8.4%) were treated at HVH. Following adjustment, Black race remained associated with greater odds of morbidity (AOR 1.37, CI 1.23-1.52; Ref:White). The race-based difference in risk of complications at HVH did not significantly change from 2016 to 2020. Conclusion: While overall rates of complications following major elective procedures declined from 2016 to 2020, patients of Black race faced persistently greater risk of adverse outcomes. Novel interventions are needed to address persistent racial disparities and ensure acceptable outcomes for all patients.

Combined simultaneous transsphenoidal and transcranial regimen improves surgical outcomes in complex giant pituitary adenomas: A longitudinal retrospective cohort study.

Surgical treatment of complex giant pituitary adenomas (GPAs) presents significant challenges. The efficacy and safety of combining transsphenoidal and transcranial approaches for these tumors remain controversial. In this largest cohort of patients with complex GPAs, we compared the surgical outcomes between those undergoing a combined regimen and a non-combined regimen. We also examined the differences in risks of complications, costs, and logistics between the two groups, which might offer valuable information for the appropriate management of these patients. This was a multicenter retrospective cohort study conducted at 13 neurosurgical centers. Consecutive patients who received a combined or non-combined regimen for complex GPAs were enrolled. The primary outcome was gross total resection, while secondary outcomes included complications, surgical duration, and relapse. A propensity score-based weighting method was used to account for differences between the groups. Out of 647 patients (298 [46.1%] women, mean age: 48.5 ± 14.0 years) with complex GPAs, 91 were in the combined group and 556 were in the non-combined group. Compared with the non-combined regimen, the combined regimen was associated with a higher probability of gross total resection (50.5% vs. 40.6%, odds ratio [OR]: 2.18, 95% confidence interval [CI]: 1.30-3.63, P = 0.003). The proportion of patients with life-threatening complications was lower in the combined group than in the non-combined group (4.4% vs. 11.2%, OR: 0.25, 95% CI: 0.08-0.78, P = 0.017). No marked differences were found between the groups in terms of other surgical or endocrine-related complications. However, the combined regimen exhibited a longer average surgery duration of 1.3 h (P < 0.001) and higher surgical costs of 22,000 CNY (approximate 3,000 USD, P = 0.022) compared with the non-combined approach. The combined regimen offered increased rates of total resection and decreased incidence of life-threatening complications, which might be recommended as the first-line choice for these patients.

Applications Used to Increase the Accuracy Rate of Transthoracic Lung Biopsies Performed in Centers for Molecular Biological Diagnosis and Targeted Therapy for Oncology.

Purpose This study aims to assess the significance of imaging techniques and needle thickness employed in transthoracic core needle biopsy for determining the cancer type and subtypes, ultimately guiding the treatment of lung cancer. Material and methods Between 2018 and 2023, a cohort of 350 patients (69.7% male, 30.3% female) underwent CT-guided lung biopsy, predominantly utilizing core biopsies. Fine needle aspiration biopsies employed 18 or 20 G Chiba needles, while core needle biopsies utilized 16 or 18-gauge coaxial system semi-automatic needles. The preferred needle and biopsy sample size were 16 G in thickness and 2 cm in length. Pre-procedure positron emission tomography-computed tomography (PET-CT) images aided in identifying the most homogenous lesion with the highest SUV max value, guiding biopsy sample extraction. Post-procedure control CT evaluated complications according to the Society of Interventional Radiology (SIR) reporting standard. Results The average age of biopsied patients was 65.48 +/- 12.32 SD (range: 18-90). Tru-cut biopsy was predominant (69.7%), utilizing a larger number of 16G needles. Pathological diagnoses were mostly malignant (76.6%), with lesion sizes averaging 35.98 +/- 17.90 SD (range: 5-105 mm) and distances to pleura averaging 13.48 +/- 13.54 SD (range: 0-86 mm). Malignancy prevalence was higher in males (56.8%), tru-cut biopsies (72.7%), 16G needles used for tru-cut (47.7%), and PET-CT evaluation (59.1%). Complications were identified in 22% of cases, with distance to pleura significantly associated (p < 0.001). No significant differences in complication risk were observed between FNAB and tru-cut and between needle gauges (20 G-18 G and 16 G) (p: 0.734, p: 0.638, respectively). Conclusion The study underscores the paramount importance of biopsy sample size in diagnosing lung cancers and determining targeted therapy. Optimal biopsy localization, informed by pre-procedure imaging techniques, is crucial. Hence, the recommendation is to utilize the thickest needles and largest samples for lung biopsies.

Perioperative outcomes in minimally-invasive versus open surgery in infants undergoing repair of congenital anomalies

BackgroundThis study compared perioperative outcomes among infants undergoing repair of congenital anomalies using minimally invasive (MIS) versus open surgical approaches. MethodsThe ACS NSQIP Pediatric (2013–2018) was queried for patients undergoing repair of any of the following 9 congenital anomalies: congenital lung lesion (LL), mediastinal mass (MM), congenital malrotation (CM), anorectal malformation (ARM), Hirschsprung disease (HD), congenital diaphragmatic hernia (CDH), tracheoesophageal fistula (TEF), hepatobiliary anomalies (HB), and intestinal atresia (IA). Inverse probability of treatment weights (IPTW) derived from propensity scores were utilized to estimate risk-adjusted association between surgical approach and 30-day outcomes. Results12,871 patients undergoing congenital anomaly repair were included (10,343 open; 2528 MIS). After IPTW, MIS was associated with longer operative time (difference; 95% CI) (16 min; 9–23) and anesthesia time (13 min; 6–21), but less postoperative ventilation days (-1.0 days; -1.4- -0.6) and shorter postoperative length of stay (-1.4 days; -2.4- -0.3). MIS repairs had decreased risk of any surgical complication (risk difference: -6.6%; -9.2- -4.0), including hematologic complications (-7.3%; -8.9- -5.8). There was no significant difference in risk of complication when hematologic complications were excluded (RD -2.3% [-4.7%, 0.1%]). There were no significant differences in the risk of unplanned reoperation (0.4%; -1.5–2.2) or unplanned readmission (0.2%; -1.2–1.5). ConclusionsMIS repair of congenital anomalies is associated with improved perioperative outcomes when compared to open. Additional studies are needed to compare long-term functional and disease-specific outcomes. Mini-abstractIn this propensity-weighted multi-institutional analysis of nine congenital anomalies, minimally invasive surgical repair was associated with improved 30-day outcomes when compared to open surgical repair. Level of evidenceIII.

The Renaissance of Unicompartmental Knee Arthroplasty appears rational - A radiograph-based comparative Study on adverse Events and patient-reported Outcomes in 353 TKAs and 98 UKAs.

PurposeTotal knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) are both considered suitable for antero-medial osteoarthritis and spontaneous osteonecrosis of the knee. National registry data are consistent in showing higher revision rates for UKA. Adequately adjusted, these findings may be challenged by differences in adverse events and patient-reported outcomes, as both can have serious long-term implications. Based on preoperative radiographs, the aim was to retrospectively compare the two principle surgeries in these respects.MethodsAll TKA procedures in 2016 in one Swedish county council were, according to certain radiograph-based consensus criteria, visually evaluated for medial UKA suitability. Then, using different regression models, they were compared with the corresponding medial UKAs performed in 2015–2017 regarding complications and patient-reported outcomes one year after surgery.ResultsThe UKA group showed an 82% reduced risk (OR 0.2; 95% CI 0.0–0.6) of any complications, whereas the 55% reduced risk of severe complication did not reach statistical significance (OR 0.5; 95% CI 0.1–2.1). These findings corresponded in high-volume surgeries to an absolute complication rate of 0% in the UKA group and 10% in the TKA group (p = 0.005) and to a severe complication rate of 0% and 5% respectively (p = 0.05). Though no differences were seen in any general patient-reported outcomes, the pain and function based OMERACT-OARSI responder criteria indicated in both around a 60% better chance of any response (OR 1.6 CI % 0.6–4.5) and a high response (OR 1.6; 95% CI 0.7–3.4) in the UKA group.ConclusionNo differences were shown in patient-reported outcomes but a clear difference in risk of complications, favoring the UKA procedure.

Ten-year risk of complication and mortality after total hip arthroplasty in morbidly obese patients: a population study

The relationship between morbid obesity and long-term patient outcomes after primary total hip arthroplasty (THA) has been understudied. The purpose of this study was to determine the association between morbid obesity and 10-year complications (revision surgery, reoperation, dislocation) and mortality in patients undergoing primary THA. We conducted a population-based cohort study of patients aged 45–74 years who underwent primary THA for osteoarthritis between 2002 and 2007 using Ontario administrative health care databases. Patients were followed for 10 years. We estimated risk ratios (RRs) of mortality, reoperation, revision and dislocation in patients with body mass index (BMI) greater than 45 kg/m2 (morbidly obese patients) compared with patients with a BMI of 45 kg/m2 or less (nonmorbidly obese patients). There were 22 251 patients in the study cohort, of whom 726 (3.3%) were morbidly obese. Morbid obesity was associated with higher 10-year risk of death (RR 1.38, 95% confidence interval [CI] 1.18–1.62). Risks of revision (RR 1.43, 95% CI 0.96–2.13) and dislocation (RR 2.38, 95% CI 1.38–4.10) were higher in morbidly obese men than in nonmorbidly obese men; there were no associations between obesity and revision or dislocation in women. Risk of reoperation was higher in morbidly obese women than in nonmorbidly obese women (RR 1.59, 95% CI 1.05–2.40); there was no association between obesity and reoperation in men. Morbidly obese patients undergoing primary THA are at higher risk of long-term mortality and complications. There were differences in complication risk by sex. The results of this study should inform perioperative counselling of patients considering THA.

Comparing the Risk of Complications for Second-Line Treatments of Immune Thrombocytopenia in Veterans: A U.S. National Study

Introduction: Chronic immune thrombocytopenia (cITP) is a common, acquired, autoimmune disorder resulting in abnormally low blood platelet counts (&amp;lt;100×109/L) that can lead to excessive bruising and bleeding. Management of cITP includes corticosteroids as first-line therapy. However, debate exists surrounding the clinically optimal nature and order of second- and third-line treatments, including rituximab, a clinically broadly-used off-label treatment, and thrombopoietin receptor agonists (TPO-RAs; only eltrombopag and romiplostim data were available), which are approved by the US Food and Drug Administration for the treatment of cITP. We compared the risks of long-term complications (i.e., infections, thromboembolic events, and cancer) as well as mortality with TPO-RAs versus rituximab among cITP-diagnosed US Veterans who had failed first-line corticosteroids. Methods: This historical cohort study used national US Veteran's Health Administration (VHA) datasets to identify cITP-diagnosed Veterans (ICD-9: 287.30, 287.31, 287.39; ICD-10: D69.3, D69.49) newly initiating either a TPO-RA or rituximab after prior corticosteroid use between 2011 and 2017. We controlled for selection bias and confounding by indication with inverse probability of treatment weights. Covariates included baseline demographics, platelet measures, comorbidities, and key concomitant medications. We used Cox proportional hazards regression models to calculate hazards ratios (HR) for incident complications and death associated with new users of TPO-RAs compared to new users of rituximab in the treatment-weighted population. Results: Of 31,501 Veterans with a diagnosis for cITP, 429 received TPO-RA (n=244) or rituximab (n=185) as their second treatment for cITP during the study period. The mean age was 67.9 (standard deviation 12.6), 93% were male, and 14% and 74% were Black and Caucasian, respectively. After weighting, standardized differences in proportions between the groups were less than 0.1 for all baseline characteristics, indicating no significant differences between the groups among all baseline characteristics. Table 1 shows the adjusted HRs for the differences in risks of complications and death for the TPO-RAs versus the rituximab group. Patients who received TPO-RAs were 27% less likely to have complications compared to those who received rituximab (HR 0.73; 95% CI 0.62, 0.85). However, there was no observed difference in the risk of death between the groups. Conclusions: Among cITP-diagnosed US Veterans, TPO-RA use was associated with lower risks of complications compared to rituximab. There was no observed difference in the risk of death between the groups. Disclosures Ruiz-Negron: Novartis Pharmaceuticals: Research Funding. Crook:Novartis Pharmaceuticals: Research Funding. Patwardhan:Novartis Pharmaceuticals: Employment. Said:Novartis Pharmaceuticals: Employment, Other: Restricted stocks in Novartis. Desai:Precision Xtract: Employment. LaFleur:Novartis Pharmaceuticals: Research Funding. Off Label Disclosure: On-label indications for TPO-RAs (including eltrombopag and romiplostim), but off-label use of rituximab; all medications were evaluated in the treatment of chronic immune thrombocytopenia.

Racial Differences in Complication Risk Following Emergency General Surgery: Who Your Surgeon Is May Matter

BackgroundUnderstanding the mechanisms that lead to health-care disparities is necessary to create robust solutions that ensure all patients receive the best possible care. Our objective was to quantify the influence of the individual surgeon on disparate outcomes for minority patients undergoing an emergency general surgery (EGS). Materials and methodsUsing the Florida State Inpatient Database, we analyzed patients who underwent one or more of seven EGS procedures from 2010 to 2014. The primary outcome was development of a major postoperative complication. To determine the individual surgeon effect on complications, we performed multilevel mixed effects modeling, adjusting for clinical and hospital factors, such as diagnosis, comorbidities, and hospital teaching status and volume. Results215,745 cases performed by 5816 surgeons at 198 hospitals were included. The overall unadjusted complication rate was 8.6%. Black patients had a higher adjusted risk of having a complication than white patients (odds ratio 1.12, 95% confidence interval 1.03-1.22). Surgeon random effects, when hospital fixed effects were held constant, accounted for 27.2% of the unexplained variation in complication risk among surgeons. This effect was modified by patient race; for white patients, surgeon random effects explained only 12.4% of the variability, compared to 52.5% of the variability in complications among black patients. ConclusionsThis multiinstitution analysis within a single large state demonstrates that not only do black patients have a higher risk of developing a complication after undergoing EGS than white patients but also surgeon-level effects account for a larger proportion of the between-surgeon variation. This suggests that the individual surgeon contributes to racial disparities in EGS.

Primary anastomosis or ostomy in necrotizing enterocolitis?

In neonates requiring operation for necrotizing enterocolitis (NEC), the complications due to enterostomy (ES) and the need for another operation to restore continuity have prompted several surgeons to employ primary anastomosis (PA) after resection as the operative strategy of choice. Our objective was to compare primary anastomosis to stoma formation in this population using systematic review and meta-analysis. Publications describing both interventions were identified by searching multiple databases. Appropriate studies that reported outcomes after PA and ES for NEC were included for analysis that was performed using the MedCalc3000 software. Results are reported as odds ratios (OR, 95% CI). No randomized trials were identified. Twelve studies were included for the final analysis. Neonates who underwent PA were associated with significantly less risk of mortality when compared to those who underwent ES (OR 0.34, 95% CI 0.17-0.68, p 0.002), possibly due to differences in severity of NEC. Although the types of complications in these groups were different, there was no significant difference in risk of complication (OR 0.86, 0.55-1.33, p 0.50). In neonates undergoing an operation for severe NEC, there is no significant difference in the risk of complications between primary anastomosis and enterostomy. A definitive suggestion cannot be made regarding the choice of one operative strategy over another.

Complications and Readmission After Cervical Spine Surgery in Elderly Patients: An Analysis of 1786 Patients.

To investigate risk factors and complications of cervical spine surgery in elderly patients. A retrospective study was performed using data from the American College of Surgeons National Surgical Quality Improvement Program. Patients ≥65 years old who underwent cervical spine surgery from 2005 to 2013 were identified using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and Current Procedural Terminology codes. Outcome data were classified as major complication, minor complication, readmission, or mortality. Of 1786 patients ≥65 years old undergoing cervical spine surgery identified, 175 (9.80%) patients experienced at least 1 complication or death. Patients ≥75 years old were at higher risk of developing a complication or death (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.13-2.61). Patients with increased operative times (OR3.54, 95% CI 2.27-5.53), patients who were partially or totally dependent (OR 3.01, 95% CI 1.79-5.07), and patients listed as American Society of Anesthesiologists class III/IV/V (OR 1.87, 95% CI 1.20-2.94) had increased risks of perioperative complications. Patients 70-74 years old (OR 1.94, 95% CI 1.03-3.65) and patients with at least 1 postoperative complication (OR 9.59, 95% CI 5.17-17.80) had increased risks of unplanned readmissions. Patients ≥75 years old undergoing a laminectomy/laminotomy were at higher risk of complications (OR 3.20, 95% CI 1.33-7.70), whereas there was no difference in risk of complications based on age for elderly patients undergoing a fusion. Patient comorbidities and clinical factors, such as longer operating time and emergency cases, impact risk of adverse events. Patients 70-74 years old and patients with at least 1 postoperative complication had an increased risk of unplanned readmission.

Trends and Complications in Bilateral Salpingectomy and Hysterectomy for Benign Disease in the United States [7G

INTRODUCTION: Recent literature has shown that bilateral salpingectomy (BS) may reduce the risk of ovarian cancer. However, little evidence exists in the United States on the rates and risks of complications associated with this procedure. We sought to examine current rates and common medical and surgical complications associated with BS with hysterectomy for benign indications in the United States. METHODS: We conducted a retrospective cohort study from the National Inpatient Sample (NIS) database. Patients undergoing hysterectomy for benign gynecological disease during 1998–2012 were identified. First, rates of BS were tested for trends over time. Second, risks of complications with BS were identified. Finally, surgical approaches for hysterectomy with BS were compared based on complications. RESULTS: During the study period 7,009,330 hysterectomies were performed for benign indications. Of these 103,966 had BS with an increase in rate from 1.0% to 5.1% between 1998 and 2012. BS procedures were associated with a significant increased risk of complications (aOR 1.063, P=.01). An abdominal approach had the greatest risk of complications (aOR 1.585, P<.001). There was no difference in risk of complications between a laparoscopic or vaginal approach (aOR 1.093, P=.244). CONCLUSION: Opportunistic BS completed with hysterectomies for benign indications are increasing; yet overall rates are still very low. There is a small statistically significant increase in risk of complications with BS as opposed to hysterectomy alone in benign cases. There is not a significantly increased risk of complications between the vaginal and laparoscopic approach.

Complications of Intravenous Sedation Versus General Anesthesia for Adolescent Patients Receiving Third-Molar Extraction

The American Association of Oral and Maxillofacial Surgeons (AAOMS) established the Oral and Maxillofacial Surgery Outcomes System (OMSOS) with the goal of “tracking national practice trends, estimating risk-adjusted outcomes of care, and determining associations between alternative processes of care and outcomes of care.” While previous literature has focused on reporting anesthesia practices of oral surgeons in the ambulatory setting, studies are yet to risk-stratify adverse anesthesia complications for adolescent patients. Therefore, the purpose of this study was to examine the complications resulting from intravenous sedation versus deep sedation/general anesthesia for adolescent patients receiving third-molar extraction, and whether any differences in complication risk exist between the two methods of anesthesia. Our aims were to 1) document the type and frequency of anesthetics use, 2) calculate the anesthesia complication rate, and 3) model the risk of adverse complication for each of the methods of anesthesia.

Warfarin treatment quality is consistently high in both anticoagulation clinics and primary care setting in Sweden

BackgroundWarfarin treatment in Sweden holds a high standard with time in therapeutic range (TTR) over 75%. Internationally, specialized anticoagulation clinics (ACC) have shown higher TTR compared to primary health care centres (PHCC). ObjectivesTo compare warfarin treatment quality in Sweden for ACC versus PHCC, thereby clarifying whether centralization is for the better. Patients/methodsIn total 77.058 patients corresponding to 217.058 treatment years with warfarin in the Swedish national quality register AuriculA from 1. Jan 2006 to 31. Dec 2011. Information regarding TTR was calculated from AuriculA, while patient characteristics and complications were retrieved from the Swedish National Patient Register. ResultsOf the 100.554 treatment periods examined, 78.7% were monitored at ACC. Mean TTR for INR 2-3 for all patients irrespective of intended target range was 76.5% with an annual risk of bleeding or thrombotic events of 2.24% and 2.66%, respectively. TTR was significantly higher in PHCC compared to ACC (79.6% vs. 75.7%, p<0.001), with no significant difference in overall risk of complications. Treatment periods for atrial fibrillation, except intended direct current conversion, showed similar results between ACC and PHCC without significant difference in annual risk of bleeding (2.50% vs. 2.51%) or thrombosis (3.09% vs. 3.16%). After propensity score matching there was still no significant difference in complication risk found. ConclusionsWarfarin treatment quality is consistently high in both ACC and PHCC when monitored through AuriculA in Sweden, both measured as TTR and as risk of complications. In this setting, centralized warfarin monitoring is not likely to improve the results.

Use of lumbar laminoplasty vs. laminotomy for transection of the filum terminale does not affect early complication rates or postoperative course.

Various techniques are used for spinal cord untethering. The purpose of this study was to compare patient characteristics, postoperative course, and early complications after laminotomy vs. laminoplasty for transection of the filum terminale for tethered cord release. Retrospective analysis of clinical and magnetic resonance imaging data was undertaken for all patients (<18 years) who underwent tethered cord release by transection of the filum terminale at Oregon Health & Science University, Doernbecher Children's Hospital, from 2000 to 2011. Data from two hundred and forty-eight patients were analyzed. Mean age was 5.2 years (range 0.3 to 16.8 years). Access to the thecal space during surgery was achieved using laminotomy or laminoplasty in 82 (33.1 %) and 166 (66.9 %) patients, respectively. Laminoplasty patients were significantly younger than laminotomy patients (3.2 vs. 9.3 years, p<0.0001); other clinical and radiographic characteristics were similar between the groups. Nine patients (3.6 %) experienced early complications, including cerebrospinal fluid leak (n=2), suprafascial infection requiring surgical management and intravenous (IV) antibiotics (n=3) or IV antibiotics alone (n=1), a small area of peri-incisional cutaneous necrosis (n=1), perioperative seizures (n=1), and mild, transient malignant hyperthermia (n=1). There was no difference in the number of early complications between the two groups. Univariate and multivariate analyses revealed no significant risk factor for postoperative complication associated with technique. As judged by caregivers, independent of surgical technique, 97 % of patients improved after surgery. There was no difference in complication risk when performing transection of the filum terminale for tethered cord release using laminotomy or laminoplasty.

Postabortion Hemorrhage and Risk of Other Complications in Women With Second-Trimester Fetal Demise

INTRODUCTION: Dilation and evacuation for intrauterine fetal demise has been associated with higher rates of morbidity and mortality compared with dilation and evacuation for abortion. To date, this risk has not been well studied, and no clear recommendations exist for perioperative management. This study examines the complication rates after dilation and evacuation for each indication. METHODS: We conducted a matched, retrospective, double-cohort study of patients seen at San Francisco General Hospital Women's Options Center between 2009 and 2013. We abstracted data on patient characteristics and complications such as hemorrhage (estimated blood loss greater than 500 cc) and disseminated intravascular coagulopathy from charts. We also abstracted data for a gestational age-matched comparison group comprised of dilation and evacuations among women without intrauterine fetal demise. Unadjusted analyses were performed using Student's t test or Wilcoxon rank-sum test for continuous variables and Fisher's exact or χ2 test for categorical variables. RESULTS: During the study period, 97 dilation and evacuations were done for patients with intrauterine fetal demise. To date, we have abstracted data on 50 (52%) intrauterine fetal demise cases and 50 matched, nonintrauterine fetal demise cases. Preliminary analyses indicate that estimated blood loss and complications did not differ between the two groups. Two intrauterine fetal demise cases experienced hemorrhage; one was diagnosed with disseminated intravascular coagulopathy and required transfusion. One nonintrauterine fetal demise case experienced hemorrhage without transfusion. We will complete data abstraction and analysis before presentation. CONCLUSIONS: Preliminary results indicate that dilation and evacuations for intrauterine fetal demise and nonintrauterine fetal demise cases may have no difference in complication risk. Final results are forthcoming and may help to inform perioperative management.

Renal Cryoablation Versus Robot-Assisted Partial Nephrectomy: Washington University Long-Term Experience

American Urological Association guidelines endorse partial nephrectomy as the preferred treatment for patients with small renal masses, while considering patients with significant comorbidities potential candidates for ablative therapy. We compared perioperative, renal functional, and oncologic outcomes of renal cryoablation and robot-assisted partial nephrectomy (RAPN) based on our long-term institutional experience. A retrospective review evaluated 267 patients who underwent laparoscopic or percutaneous cryoablation (July 2000-June 2011) and 233 patients who underwent RAPN (June 2007-September 2012) for enhancing renal masses at Washington University. The perioperative complication rate was 8.6% in the cryoablation group vs 9.4% in the RAPN group (P = 0.75). There was no significant difference in complication risk between the two treatment modalities on multivariate analysis. Estimated glomerular filtration rate (eGFR) at last follow-up was 6% lower than preoperative eGFR in the cryoablation group and 13% lower in the RAPN group (P<0.01). The advantage of cryoablation in preserving renal function persisted on multivariate analysis (P = 0.02). In patients with pathologically proven renal-cell carcinoma, 5-year Kaplan-Meier disease-free survival (DFS), cancer-specific survival (CSS), and overall survival was 83.1%, 96.4%, and 77.1% in the cryoablation cohort vs 100%, 100%, and 91.7% in the RAPN group. Mean time to recurrence was 16.2 months (range 0.03-42.0 mos). Cryoablation was associated with increased recurrence risk (hazard ratio [HR] = 11.4, P = 0.01) on multivariate analysis. Cryoablation and RAPN are safe alternatives for managing renal masses amenable to nephron-sparing interventions, offering acceptable morbidity and excellent renal preservation. While RAPN offers improved DFS, for those willing to undergo close postoperative monitoring and accept the potential need for re-treatment of recurrent disease, cryoablation offers excellent long-term CSS.

Obstetric outcomes of booked teenage pregnancies at University of Calabar Teaching Hospital, Nigeria

BackgroundTeenage pregnancy is high-risk and associated with complications due to adverse physiological, anatomical, and socioeconomic factors. The purpose of this study was to determine the patterns and obstetric outcomes of booked teenage pregnancies at the University of Calabar Teaching Hospital (UCTH) in Nigeria.MethodsA retrospective comparative analysis of teenage pregnancies and mature mothers at UCTH was carried out from January 2011 to December 2011. A total of 82 teenage pregnancies and 72 mature pregnancies were compared.ResultsThere were 145 teenage deliveries from a total of 2313 deliveries, ie, 6.3% of total deliveries. There was no statistically significant difference in the mode of delivery (cesarean section, spontaneous vaginal delivery, instrumental delivery) between the groups of mothers. There was also no difference in risk of complications, including obstructed labor, retained placenta, uterine atony, pre-eclampsia/eclampsia, and antepartum hemorrhage. However, teenage mothers had more perineal lacerations (P = 0.02) and more preterm labor (P = 0.05), and delivered more low-birth-weight babies (P = 0.02).ConclusionSupervised teenage pregnancy may not be as hazardous as previously thought.

Effect of Glycemic Exposure on the Risk of Microvascular Complications in the Diabetes Control and Complications Trial—Revisited

The Diabetes Control and Complications Trial (Diabetes 44:968-983, 1995) presented statistical models suggesting that subjects with similar A1C levels had a higher risk of retinopathy progression in the conventional treatment group than in the intensive treatment group. That analysis has been cited to support the hypothesis that specific patterns of glucose variation, in particular postprandial hyperglycemia, contribute uniquely to an increased risk of microvascular complications above and beyond that explained by the A1C level. We performed statistical evaluations of these models and additional analyses to assess whether the original analyses were flawed. Statistically, we show that the original results are an artifact of the assumptions of the statistical model used. Additional analyses show that virtually all (96%) of the beneficial effect of intensive versus conventional therapy on progression of retinopathy is explained by the reductions in the mean A1C levels, similarly for other outcomes. Furthermore, subjects within the intensive and conventional treatment groups with similar A1C levels over time have similar risks of retinopathy progression, especially after adjusting for factors in which they differ. A1C explains virtually all of the difference in risk of complications between the intensive and conventional groups, and a given A1C level has similar effects within the two treatment groups. While other components of hyperglycemia, such as glucose variation, may contribute to the risk of complications, such factors can only explain a small part of the differences in risk between intensive and conventional therapy over time.