Higher Rates Of Medical Complications Research Articles

The intra- and postoperative management of accidental durotomy in lumbar spine surgery: results of a German survey.

The intra- and postoperative management of accidental durotomy in operations of the lumbar spine is not standardized. It is the aim of our survey to obtain an overview on the current practice in neurosurgical departments in Germany. The used questionnaire consisted of three questions and could be answered within a few minutes by checking boxes. In September 2012, the questionnaire was sent to 149 German neurosurgical departments. In the following 4 weeks 109 replies (73.2 %) were received. Seventy-one neurosurgical departments (65.1 %) treat dural tears by a combination of methods, 28 (25.7 %) with suture alone, 7 (6.4 %) with fibrin-coated fleeces alone, 2 (1.8 %) with muscle patch alone and 1 (0.9 %) with fibrin glue alone. Sixty-six neurosurgical departments (60.5 %) decide on postoperative bed rest depending on the quality of the dural closure. Forty-three (39.5 %) neurosurgical departments do not rely on the quality of the dural closure for their postoperative management. In total, 72.5 % of the neurosurgical departments prescribe bed rest for 1-3 days, 1.8 % for more than 3 days, whereas 25.7 % allow immediate mobilization. Among German neurosurgeons, no consensus exists concerning the intra- and postoperative management of accidental durotomies in lumbar spine surgery. Despite not being proved to reduce the rate of cerebrospinal fluid fistulas, bed rest is frequently used. As bed rest prolongs the hospital stay with additional costs and has the potential of a higher rate of medical complications, a prospective multicenter trial is warranted.

Transfusions in Autologous Breast Reconstructions

Free tissue transfer requires lengthy operative times and can be associated with significant blood loss. The goal of our study was to determine independent risk factors for blood transfusions and transfusion-related complications and costs. We reviewed our prospectively maintained free flap database and identified all patients undergoing breast reconstruction receiving blood transfusions. These patients were compared with those not receiving a postoperative transfusion. We examined baseline patient comorbidities, preoperative and postoperative hemoglobin (HgB) levels, intraoperative and postoperative complications, and blood transfusions. Factors associated with transfusion were identified using univariate analyses, and multivariate logistic regression was used to determine independently associated factors. A total of 70 (8.2%) patients received postoperative blood transfusions. Multivariate analysis revealed associations between length of surgery (P=0.01), intraoperative arterial thrombosis [odds ratio (OR), 6.75; P=0.01], major surgical complications (OR, 25.9; P<0.001), medical complications (OR, 7.2; P=0.002), and postoperative HgB levels (OR, 0.2; P<0.001). Transfusions were independently associated with higher rates of medical complications (OR, 2.7; P=0.03). A significantly lower rate of medical complications was observed when a restrictive transfusion (HgB level, <7 g/dL) was administered (P=0.04). A cost analysis demonstrated that each blood transfusion was independently associated with an added $1,500 in total cost. Several key perioperative factors are associated with allogenic transfusion, including intraoperative complications, operative time, HgB level, and postoperative medical and surgical complications. Blood transfusions were independently associated with greater morbidity and added hospital costs. Overall, a restrictive transfusion strategy (HgB level, <7 g/dL or clinically symptomatic) may help minimize medical complications. Prognostic/risk category, level III.

Risk Versus Reward: Total Joint Arthroplasty Outcomes After Various Solid Organ Transplantations

Clinical outcomes were retrospectively reviewed for 76 primary total hip (THA) and total knee arthroplasties (TKA) performed after kidney, liver, cardiac, and lung transplantation with follow-up of 30.2 and 41.2months, respectively. For the THA and TKA cohorts, there were a high rate of medical complications (29% and 33%), increased hospital length of stay (4.2 and 3.7days), and more reoperations (7.2% and 9.1%). Only 1 (1.8%) periprosthetic infection was documented for THAs but 3 (14.2%) TKAs required two-stage revisions for infection. All transplant cohorts demonstrated significant increases (P<0.05) in HHS and KSS scores with majority of patients reporting overall good or excellent outcomes (82%–100%). These results suggest that various organ transplant patients may accept higher surgical risks for rewarding outcomes.

Complications After Surgery for Lumbar Stenosis in a Veteran Population

Secondary analysis of the prospectively collected Veterans Affairs National Surgical Quality Improvement Program database. Determine rates of major medical complications, wound complications, and mortality among patients undergoing surgery for lumbar stenosis and examine risk factors for these complications. Surgery for spinal stenosis is concentrated among older adults, in whom complications are more frequent than among middle-aged patients. Many studies have focused on infections or device complications, but fewer studies have focused on major cardiopulmonary complications, using prospectively collected data. We identified patients who underwent surgery for a primary diagnosis of lumbar stenosis between 1998 and 2009 from the Veterans Affairs National Surgical Quality Improvement Program database. We created a composite of major medical complications, including acute myocardial infarction, stroke, pulmonary embolism, pneumonia, systemic sepsis, coma, and cardiac arrest. Among 12,154 eligible patients, major medical complications occurred in 2.1%, wound complications in 3.2%, and 90-day mortality in 0.6%. Major medical complications, but not wound complications, were strongly associated with age. American Society of Anesthesiologists (ASA) class was a strong predictor of complications. Insulin use, long-term corticosteroid use, and preoperative functional status were also significant predictors. Fusion procedures were associated with higher complication rates than with decompression alone. In logistic regressions, ASA class and age were the strongest predictors of major medical complications (odds ratio for ASA class 4 vs. class 1 or 2: 2.97; 95% confidence interval, 1.68-5.25; P = 0.0002). After adjustment for comorbidity, age, and functional status, fusion procedures remained associated with higher medical complication rates than were decompressions alone (odds ratio = 2.85; 95% confidence interval, 2.14-3.78; P < 0.0001). ASA class, age, type of surgery, insulin or corticosteroid use, and functional status were independent risk factors for major medical complications. These factors may help in selecting patients and planning procedures, improving patient safety.

Medical Complications During Inpatient Rehabilitation Among Patients With Traumatic Disorders of Consciousness

ObjectiveTo assess the incidence of medical complications in patients with recent traumatic disorders of consciousness (DOCs). DesignData on adverse events in a placebo controlled trial of amantadine hydrochloride revealed no group difference, which allowed these events to be reanalyzed descriptively as medical complications experienced by the 2 groups collectively. SettingEleven clinical facilities in the United States, Denmark, and Germany with specialty rehabilitation programs for patients with DOCs. ParticipantsPatients (N=184) with nonpenetrating traumatic brain injury enrolled from acute inpatient rehabilitation programs between 4 and 16 weeks postinjury. InterventionsParticipants were randomized to receive 200 to 400mg of amantadine hydrochloride or placebo daily for 4 weeks, and followed for an additional 2 weeks. Adverse events were recorded and categorized with respect to their nature, timing, and severity. Main Outcome MeasureNumber, type, and severity of medical complications occurring during the 6-week study interval. ResultsA total of 468 medical complications were documented among the patients (.40 events per week per patient). More than 80% of patients experienced at least 1 medical complication, and 41 of these were defined as serious adverse events. New medical complications declined over time in rehabilitation and were not dependent on time since injury. Hypertonia, agitation/aggression, urinary tract infection, and sleep disturbance were the most commonly reported problems. Hydrocephalus, pneumonia, gastrointestinal problems, and paroxysmal sympathetic hyperactivity were the most likely to be severe. ConclusionsPatients with DOCs have a high rate of medical complications early after injury. Many of these complications require brain injury expertise for optimal management. Active medical management appears to contribute to the reduction in new complications. An optimal system of care for DOC patients must provide expert medical management in the early weeks after injury.

Neonatal morbidity in singleton late preterm infants compared with full‐term infants

The aim of this study was to test the hypothesis that singleton late preterm infants (34 0/7 to 36 6/7 weeks of gestation) compared with full-term infants have a higher incidence of short-term morbidity and stay longer in hospital. In this retrospective, multicentre study, electronic data of children born at five hospitals in Switzerland were recorded. Short-term outcome of late preterm infants was compared with a control group of full-term infants (39 0/7 to 40 6/7 weeks of gestation). Multiple gestations, pregnancies complicated by foetal malformations, maternal consumption of illicit drugs and infants with incomplete documentation were excluded. The results were corrected for gender imbalance. Data from 530 late preterm and 1686 full-term infants were analysed. Compared with full-term infants, late preterm infants had a significant higher morbidity: respiratory distress (34.7% vs. 4.6%), hyperbilirubinaemia (47.7% vs. 3.4%), hypoglycaemia (14.3% vs. 0.6%), hypothermia (2.5% vs. 0.6%) and duration of hospitalization (mean, 9.9 days vs. 5.2 days). The risk to develop at least one complication was 7.6 (95% CI: 6.2-9.6) times higher among late preterm infants (70.8%) than among full-term infants (9.3%). Singleton late preterm infants show considerably higher rate of medical complications and prolonged hospital stay compared with matched full-term infants and therefore need more medical and financial resources.

Assessing the Economic Costs of Serious Mental Illness

Assessing the Economic Costs of Serious Mental Illness

Scapula osteocutaneous free flap reconstruction of the head and neck: Impact of flap choice on surgical and medical complications

The scapula osteocutaneous free flap is frequently used to reconstruct complex head and neck defects given its tissue versatility. Because of minimal atherosclerotic changes in its vascular pedicle, this flap also may be used as a second choice when other osseous flaps are not available because of vascular disease at a preferred donor site. We performed a retrospective chart review evaluating flap outcome as well as surgical and medical complications based upon the flap choice. The flap survival rate was 97%. The surgical complication rate was similar for the 21 first-choice flaps (57.1%) and the 12 second-choice flaps (41.7%; p = .481). However, patients having second-choice flaps had a higher rate of medical complications (66.7%) than those with first-choice flaps (28.6%; p = .066). Age and the presence of comorbidities were associated with increased medical complications. All patients with comorbidities that had a second-choice flap experienced medical complications, with most being severe. The scapula osteocutaneous free flap has a high success rate in head and neck reconstruction. Surgical complications occur frequently regardless of whether the flap is used as a first or second choice. However, medical complications are more frequent and severe in patients undergoing second-choice flaps.

Stroke patients with atrial fibrillation have a worse prognosis than patients without: data from the Austrian Stroke registry.

Stroke patients with atrial fibrillation (AF) have a poorer neurological outcome than stroke patients without AF. Whether stroke patients with AF also have a higher rate of medical complications is unknown. The aim of the study was to compare the in-hospital course of acute stroke patients with and without AF. The Austrian Stroke registry was a prospective multi-centre study involving 57 medical departments documenting the hospital course of consecutive stroke patients from June 1999 to October 2000. AF was diagnosed in 304 (31%) of 992 patients. Patients with AF were older (79 versus 75 years, p < 0.0004) than no-AF patients. There were more cases of pneumonia (23% versus 9%, p < 0.0004), pulmonary oedema (12% versus 6%, p < 0.0004) and symptomatic intracerebral haemorrhage (8% versus 2%, p < 0.0004) in AF compared to no-AF. In-hospital mortality was higher in AF (25% versus 14%, p < 0.0004), and neurological outcome was poorer (65 versus 90 Barthel index, p < 0.0004). On multivariable logistic regression analysis, however, AF was no predictor for mortality, but a Barthel index of zero (odds ratio 5.30, 95% CI 3.10-9.08, p < 0.0001), a National Institutes of Health Stroke Scale > 21 or comatose (odds ratio 3.13, 95% CI 2.26-4.32, p < 0.0001), age > 75 years (odds ratio 3.15, 95% CI 1.85-5.37, p < 0.0001), heart rate > 100 min(-1) (odds ratio 2.15, 95% CI 1.26-3.66, p = 0.0049), obstructive pulmonary disease (odds ratio 2.58, 95% CI 1.03-6.48, p = 0.0442) and creatinine > 125 micromol/l (odds ratio 1.84, 95% CI 1.00-3.37, p = 0.0479). Stroke in AF is associated with a poor prognosis, an increased rate of medical and neurological complications and a higher in-hospital mortality than in no-AF.

The impact of complications on outcomes after resection for esophageal and gastroesophageal junction carcinoma.

Efforts to improve surgical outcomes have traditionally focused on improving preoperative patient selection and reducing the risk of postoperative medical complications. Strategies to optimize surgical technique have been less well studied. We sought to assess the relation between complications related to surgical technique and outcomes after esophagogastrectomy for cancer. Medical records of 510 consecutive patients undergoing esophagogastrectomy for invasive squamous cell carcinoma or adenocarcinoma at Memorial Sloan-Kettering Cancer Center from 1996 to 2001 were reviewed. Data on diagnosis, stage of disease, therapies received, surgical approach, patient comorbidities, technical complications, and postoperative medical complications and outcomes including length of stay and overall survival were determined by one reviewer of the medical records. The primary predictor was surgical complications and the primary outcome was survival. Of the 150 patients studied 138 (27%) had complications directly attributable to surgical technique, such as an anastomotic leak, a paralyzed vocal cord, or chylothorax. At 3 years 43 of 138 patients (31%) with technical complications were alive, whereas 179 of 372 patients (48%) without technical complications were alive. Technical complications were associated with increased length of stay (median 23 days versus 11 days, p < 0.001), increased in-hospital mortality (12.3% versus 3.8%, p < 0.001), and a higher rate of medical complications (77.5% versus 47.3%, p < 0.001). After controlling for age, medical comorbidities, use of induction therapy, tumor stage, histology, and location, and completeness of resection the presence of a technical complication was highly predictive of poorer overall survival; the multivariable hazard ratio was 1.41 (1.22 to 1.63, p = 0.008). Technical complications have a large negative impact on survival after esophagogastrectomy for cancer. Strategies to optimize surgical technique and minimize complications should improve outcomes in this cancer operation.

Anterior Screw Fixation in Type II Odontoid Fractures: Is There a Difference in Outcome between Age Groups?

Optimal treatment of elderly patients with Type II odontoid fractures is controversial. Suggestions vary between conservative management and different types of early surgery. Recent data confirm that early surgery may be warranted because conservative treatment has a high rate of failure in the elderly. We performed a case-control study of 27 patients with Type II odontoid fracture who were treated with anterior odontoid double-screw fixation at our institution. The aim of the study was to determine whether patients aged 70 years or older have a less favorable outcome than younger patients with this operative technique. Cases were defined as patients with Type II odontoid fracture aged 70 years or older. All patients younger than 70 years served as controls. There were 15 patients aged 70 years or older (Group 1) and 12 patients younger than 70 years of age (Group 2). Mean follow-up was 16.6 months. Mean interval between fracture and surgery was 10 days. All patients were treated with anterior odontoid screw fixation by use of two compression screws. Fusion rates were 73% in Group 1 and 75% in Group 2. Additional dorsal stabilization was performed in 13% of cases in Group 1 and 17% of cases in Group 2. Complications occurred in 20% of cases in Group 1 and 8% of cases in Group 2. The only death occurred in Group 1, leading to 7% mortality in this group. Neurological status at admission and after treatment was similar in both groups. Statistical analysis did not reveal significant differences between groups for the factors studied. Outcome after anterior odontoid screw fixation is not affected by patient age. Slightly higher rates of medical complications did not reach statistical significance. Because conservative management of odontoid fractures in the elderly has a high rate of failure, anterior stabilization for Type II odontoid fractures can be recommended.

Anterior Screw Fixation in Type II Odontoid Fractures: Is There a Difference in Outcome between Age Groups?

AbstractOBJECTIVEOptimal treatment of elderly patients with Type II odontoid fractures is controversial. Suggestions vary between conservative management and different types of early surgery. Recent data confirm that early surgery may be warranted because conservative treatment has a high rate of failure in the elderly.METHODSWe performed a case-control study of 27 patients with Type II odontoid fracture who were treated with anterior odontoid double-screw fixation at our institution. The aim of the study was to determine whether patients aged 70 years or older have a less favorable outcome than younger patients with this operative technique. Cases were defined as patients with Type II odontoid fracture aged 70 years or older. All patients younger than 70 years served as controls.RESULTSThere were 15 patients aged 70 years or older (Group 1) and 12 patients younger than 70 years of age (Group 2). Mean follow-up was 16.6 months. Mean interval between fracture and surgery was 10 days. All patients were treated with anterior odontoid screw fixation by use of two compression screws. Fusion rates were 73% in Group 1 and 75% in Group 2. Additional dorsal stabilization was performed in 13% of cases in Group 1 and 17% of cases in Group 2. Complications occurred in 20% of cases in Group 1 and 8% of cases in Group 2. The only death occurred in Group 1, leading to 7% mortality in this group. Neurological status at admission and after treatment was similar in both groups. Statistical analysis did not reveal significant differences between groups for the factors studied.CONCLUSIONOutcome after anterior odontoid screw fixation is not affected by patient age. Slightly higher rates of medical complications did not reach statistical significance. Because conservative management of odontoid fractures in the elderly has a high rate of failure, anterior stabilization for Type II odontoid fractures can be recommended.

Effect of very advanced maternal age on pregnancy outcome and rate of cesarean delivery

Objective: To determine outcomes of pregnancies in women at least 44 years of age and to determine factors predicting cesarean delivery in these patients. Methods: Between January 1988 and December 1995, 109 women at least 44 years old delivered in our medical center. These women were matched to a group of 309 women 20–29 years of age. Multiple logistic regression analysis was used to evaluate the association between maternal age and outcome variables, controlling for possible confounding factors. Based on the logistic regression, a predictive model was calculated for cesarean delivery and validated prospectively in a separate group of 30 consecutive women at least 44 years old, who delivered during the first 8 months of 1996. Results: Very advanced maternal age, compared with younger age, was associated with a significantly higher rate of medical complications (hypertensive disorder and diabetes) (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.5, 4.1; P < .001), instrument-assisted vaginal delivery (OR 7.5; 95% CI 2.2, 25.0; P < .004), and cesarean delivery (OR 7.3; 95% CI 2.2, 16.7; P < .001). The incidences of preterm labor, premature rupture of membranes, emergency cesarean delivery, meconium-stained amniotic fluid, small for gestational age newborns, and 5-minute Apgar scores of 7 or lower were not influenced by maternal age. The regression model showed an increased risk for cesarean delivery associated with age of at least 44 years (OR 7.3; 95% CI 2.2, 16.7), primiparity (OR 3.5; 95% CI 1.3, 9.8), infertility treatment (OR 3.6; 95% CI 1.5, 8.8), and egg donation (OR 19.5; 95% CI 6.1, 62.2), with positive and negative predictive values of 94 and 86%, respectively. Conclusion: Maternal age of at least 44 years is associated with medical complications in pregnancy and more interventions during labor. However, overall pregnancy outcomes are favorable. Cesarean delivery can be predicted accurately based on maternal age, parity, and infertility treatment.

Traumatic Brain Injury in Elderly Individuals

Elderly individuals are second only to young adults among those most likely to sustain traumatic brain injury. Falls, pedestrian accidents, and low-speed motor vehicle accidents are the most common causes of traumatic brain injury in the elderly and often result in focal contusions or subdural or intraparenchymal hematomas. Individuals with coma lasting less than 6 hours, a supportive social network, and absence of substance abuse are likely to have good outcomes, whereas those living alone and with prolonged coma and chronic alcohol use often have poor outcomes. Slower recovery, a higher rate of medical complications, and payer limitations make necessary careful assessment and imaginative use of home and other settings for treatment. Intensive rehabilitation can be effective with selected elderly individuals.