Incidence Of In-hospital Complications Research Articles

Revascularization and Digestive Tract Repair in Secondary Aortoenteric Fistula Using a Single-Center in Situ Revascularization Strategy

ObjectiveInformation regarding optimal revascularization and digestive tract repair in secondary aortoenteric fistula (sAEF) remains unclear. Thus, reporting treatment outcomes and presenting comprehensive patient details through a structured treatment approach are necessary to establish a treatment strategy for this rare, complex, and fatal condition. MethodsWe performed a single-center retrospective review of consecutive sAEF managed based on our in situ revascularization (ISR) and intestinal repair strategy. The primary endpoint of this study was all-cause mortality, and secondary endpoints were the incidence of in-hospital complications and midterm reinfections. ResultsBetween 2007 and 2020, 16 patients with sAEF, including 13 men (81%), underwent ISR and digestive tract repair. The median follow-up duration for all participants was 36 (interquartile range, 6–62) months. Among the participants, 81% (n = 13), 13% (n = 2), and 6% (n = 1) underwent aortic reconstruction with rifampin-soaked grafts, unsoaked Dacron grafts, and femoral veins, respectively. The duodenum was the most commonly involved site in enteric pathology (88%; n = 14), and 57% (n = 8) of duodenal breaks were repaired by a simple closure. Duodenum second part–jejunum anastomosis was performed in 43% of patients (n = 6), and perioperatively, 19% of the patients (n = 3) died. In-hospital complications occurred in 88% patients (n = 14), and the most frequent complication was gastrointestinal. Finally, 81% patients (n = 13) were discharged home. Oral antibiotics were administered for a median duration of 5.7 months postoperatively; subsequently, the participants were followed up carefully. Reinfection was detected in 6% of the patients (n = 1) who underwent reoperation without any complications. The 1- and 3-year overall survival rates of participants were 75% (n = 12) and 75% (n = 9), respectively, and no sAEF-related deaths occurred, except perioperative death. ConclusionsSurgical intervention with contemporary management based on our vascular strategy and digestive tract procedure may be a durable treatment for sAEF.

Protocol: dexmedetomidine on myocardial injury after noncardiac surgery—a multicenter, double-blind, controlled trial

AimsMyocardial injury after noncardiac surgery (MINS) is common in elderly patients and considered as an independent predictor of 30-day mortality after noncardiac surgery. Dexmedetomidine possesses cardiac-protective profile. Previous clinical studies have found that perioperative application of dexmedetomidine is associated with decreased 1-year mortality in patients undergoing cardiac surgery. The current study protocol aims to investigate the effects of dexmedetomidine on the incidence of MINS, complications, and 30-day mortality in elderly patients subjected to noncardiac surgery.MethodsA multicenter, randomized, controlled, double-blind, prospective trial is designed to explore cardiac protection of dexmedetomidine in the elderly patients undergoing noncardiac surgery. A total of 960 patients aged over 65 years will be recruited and randomly assigned to dexmedetomidine group (group Dex) and normal saline placebo group (group NS) in a ratio of 1:1. Patients in group Dex will receive a bolus dose of 0.5 μg/kg dexmedetomidine within 10 min before surgical incision, followed by a consistent infusion at the rate of 0.3–0.5 μg/kg/h throughout the operation. Group NS patients will receive the same volume of normal saline. The primary outcome is the incidence of MINS via detecting the hs-TnT level within 3 days after the operation. The secondary outcome includes myocardial ischemic symptoms, the incidence of major adverse cardiovascular events (MACE) in hospital, length of ICU and postoperative hospital stay, the incidence of inhospital complications, and 30-day all-cause mortality.DiscussionThe results of the current study will illustrate the effect of dexmedetomidine on myocardial injury for elderly patients undergoing major noncardiac surgery.Trial registrationThe trial was registered with Chinese Clinical Trial Registry (CHICTR) on Aug 24, 2021 (ChiCTR2100049946, http://www.chictr.org.cn/showproj.aspx?proj=131804).

Stroke Unit as an alternative to Intensive Care Unit for initial hospital admission of low-grade non-aneurysmal subarachnoid haemorrhage: A safety and cost-minimisation analysis.

Stroke Units (SU) have been suggested as an alternative to Intensive Care units (ICU) for initial admission of low-grade non-aneurysmal spontaneous subarachnoid haemorrhage (naSAH). We hypothesised that the incidence of in-hospital complications and long-term clinical outcomes in low-grade naSAH patients would be comparable in both settings, and that a cost-minimisation analysis would favour the use of SU. Retrospective, single-centre study at a third-level stroke-referral hospital, including low-grade spontaneous naSAH patients with WFNS 1-2. Primary outcomes were death and functional status at 3 months. Secondary outcomes were incidence of in-hospital major neurological and systemic complications. Additionally, a cost-minimisation analysis was conducted to estimate the average cost savings that could be achieved with the most efficient approach. Out of 96 naSAH patients, 30 (31%) were initially admitted to ICU and 66 (69%) to SU. Both groups had similar demographic and radiological features except for a higher proportion of WFNS 2 in ICU subgroup. There were no statistically significant differences between ICU and SU-managed subgroups in death rate (2 (7%) and 1 (2%), respectively), functional outcome at 90 days (28 (93%) and 61 (92%) modified Rankin Scale 0-2) or neurological and systemic in-hospital complications. Cost-minimisation analysis demonstrated significant monetary savings favouring the SU strategy. Initial admission to the SU appears to be a safe and cost-effective alternative to the ICU for low-grade naSAH patients, with comparable clinical outcomes and a reduction of hospitalisation-related costs. Prospective multicenter randomised studies are encouraged to further evaluate this approach.

Current clinical practice of subcutaneous implantable cardioverter-defibrillator: Analysis using the JROAD-DPC database

Current evidence describing the characteristics of subcutaneous implantable cardioverter-defibrillator (S-ICD) therapy, its trend, and perioperative outcomes compared with transvenous implantable cardioverter-defibrillator (TV-ICD) based on a real-world, large-scale database is scarce. The purpose of this study was to identify the characteristics of current S-ICD therapy using a nationwide database. A retrospective analysis of ICD implantation was performed using a nationwide database obtained between 2016 and 2020. A total of 8690 patients implanted with ICD (median age 65 [52-72] year; 6902 men; 2021 S-ICD recipients) were analyzed. Younger patients were more prone to have S-ICD (P <.001). A history of ventricular fibrillation (VF) (odds ratio [OR] 2.45; 95% confidence interval [CI] 2.04-2.93), nonsustained ventricular tachycardia (VT) (OR 1.73; 95% CI 1.36-2.21), Brugada syndrome (BrS) (OR 3.14; 95% CI 2.48-4.00), and dialysis treatment (OR 2.02; 95% CI 1.44-2.82) were independent predictors of S-ICD selection on mixed-model logistic analysis. The proportion of S-ICD implantations has been increasing (P <.001), especially in patients with BrS (P <.001) and dialysis (P = .04). The proportion of combined complications after S-ICD implantation was low (1.3%) in the unmatched cohort and was comparable to TV-ICD in the 1:1 propensity-matched cohort of 3354 patients (1.5% vs 2.3%; OR 0.65; 95% CI 0.38-1.10). S-ICD was more likely to be implanted in younger patients and those with a history of VF, nonsustained VT, BrS, and dialysis treatment. The proportion of S-ICD implantation increased, especially in patients with BrS. The incidence of in-hospital complications was low in S-ICD recipients.

Features of the course of non-ST elevation myocardial infarction in patients with a history of COVID-19

Aim To study the clinical course of non-ST segment elevation myocardial infarction (NSTEMI) in hospitalized patients after COVID-19 and to evaluate the effect of baseline characteristics of patients on the risk of complications.Material and methods The study included 209 patients with NSTEMI; 104 of them had had COVID-19. The course of myocardial infarction (MI) was analyzed at the hospital stage, including evaluation of the incidence rate of complications (fatal outcome, recurrent MI, life-threatening arrhythmias and conduction disorders, pulmonary edema, cardiogenic shock, ischemic stroke, gastrointestinal bleeding).Results Mean age of patients after COVID-19 was 61.8±12.2 years vs. 69.0±13.0 in the comparison group (p&lt;0.0001). The groups were comparable by risk factors, clinical data, and severity of coronary damage. Among those who have had СOVID-19, there were fewer patients of the GRACE high risk group (55.8 % vs. 74.3 %; p&lt;0.05). Convalescent COVID-19 patients had higher levels of C-reactive protein and troponin I (p&lt;0.05). The groups did not significantly differ in the incidence of unfavorable NSTEMI course (p&gt;0.05). However, effects of individual factors (postinfarction cardiosclerosis, atrial fibrillation, decreased SpO2, red blood cell concentration, increased plasma glucose) on the risk of complications were significantly greater for patients after COVID-19 than for the control group (p&lt;0.05).Conclusion Patients with NSTEMI, despite differences in clinical history and laboratory data, are characterized by a similar risk of death at the hospital stage, regardless of the past COVID-19. Despite the absence of statistically significant differences in the incidence of in-hospital complications, in general, post-COVID-19 patients showed a higher risk of complicated course of NSTEMI compared to patients who had not have COVID-19. In addition, for this category of patients, new factors were identified that previously did not exert a clinically significant effect on the incidence of complications: female gender, concentration of IgG to SARS-CoV-2 ≥200.0 U/l, concentration of С-reactive protein ≥40.0 mg/l, total protein &lt;65 g/l. These results can be used for additional stratification of risk for cardiovascular complications in patients with MI and also for development of individual protocols for evaluation and management of NSTEMI patients with a history of COVID-19.

Percutaneous Coronary Intervention as Clinical Outcome Predictor for in-Hospital Adverse Events in STEMI patients

Background : Limited resources and the concurrent COVID19 pandemic hinders the appropriate time to achieve reperfusion in Infarct-related artery (IRA). The number of patients receiving late primary PCI (PPCI) and without revascularization are steadily increase within 2 years into the pandemic. The impact of PCI timing in this setting has not been fully elucidated. Objective : This study was conducted to evaluate the effect of early PPCI vs late PPCI vs non revascularization groups towards in-hospital mortality and complications. This study also aimed to determine whether PPCI is the main predictor for in-hospital adverse events in STEMI patients. Method : Data of STEMI patients registered in Saiful Anwar General Hospiital ACS registry were collected between 2018-2021 Patients were subdivided into early PPCI if receiving PCI within the recommended time of the 2017 ESC STEMI management guideline, late PPCI if receiving PCI outside the timeframe provided by the guideline, and optimal medical therapy group if not receiving any means of revascularization. Patients undergoing thrombolysis were excluded. Afterwards, the incidence of in-hospital adverse event were calculated as primary endpoints, development of immediate complications during hospitalizations were analyzed as secondary endpoints. Stratification of baseline characteristics and PCI categorizations were performed using multivariate analysis to determine the main predictor of in-hospital mortality between STEMI patients. Results : 568 STEMI patients were included in the study with 387 in early PPCI, 107 in late PPCI, and 74 in optimal medical therapy group. Incidence of in-hospital mortality were significantly higher in optimal medical therapy group and lowest in early PPCI group (32.4% and 7.5% respectively, P 0.00). Mortality odds ratio between early PPCI group and optimal medical therapy group were significantly lowest (OR 0.17, 95% CI 0.13 – 0.41). Complications between each treatment groups were significantly different with early PPCI had the lowest incidence of in-hospital complications of cardiogenic shock, cardiac arrest, and VT/VF. Stratification of baseline characteristics and PCI category reveals that timing PPCI is the main predictor for in-hospital adverse events (HR 4.506, 95% CI 2.487-6.662, P 0.00). Conclusion : Percutaneous coronary intervention is the main predictor for the incidence of in hospital mortality and complications in STEMI patients.

Comparison of variants of anesthesia for left atrial appendage occlusion in patients with atrial fbrillation

Objective: comparison of general anesthesia (GA) and intravenous conscious sedation during left atrial appendage occlusion (LAAO).Materials and Methods. The study included 120 patients from LAAO Register at the National Medical Research Center of Cardiology, who were divided into GA (n = 100) and intravenous sedation (n = 20) groups. In-hospital outcomes were assessed, as well as outcomes and data of transesophageal echocardiography (TEE) at 45 days and 6 months.Results. 3 patients required intraoperative conversion of the anesthetic method to GA. The duration of the procedure, the time of fluoroscopy, the amount of contrast medium, and the technical success did not differ signifcantly between the two groups. The incidence of in-hospital complications in the GA group was 10%, and 15% in the intravenous sedation group (p = 0.453). There were no statistically signifcant differences between the groups in long-term outcomes and TEE data after 45 days and 6 months.Conclusion. Combined intravenous sedation with local anesthesia is an effective and fairly safe method of anesthesiological support for implantation of the occluder of the left atrial auricle. It can be used in patients with a high risk of GA, with predictable difculties of tracheal intubation, as well as if the patient wishes accordingly. The limitations of the use of intravenous sedation in combination with local anesthesia are anatomical variants of SFM that are difcult for occluder implantation, as well as the patient's low tolerance to ECG in consciousness.

Impact of frailty on elderly patients with infective endocarditis

Abstract Introduction Frailty studies focused on patients with infective endocarditis (IE) are scarce and its potential impact on patient outcomes is not well known. The aim of this study is to describe the clinical profile and prognosis of elderly patients with IE, comparing patients who met the frailty criteria versus those who did not. Methods A total of 121 cases of confirmed IE were consecutively collected in three tertiary hospitals between 2017 and 2019. The patients were classified into two groups: Group I (n=49), patients with IE who met the Frail criteria for frailty, and Group II (n=72), those patients without frailty by this scale. Results The median age of our cohort was 77 years (69–82), and 62.8% were men. Frail patients were older than those in Group II, as shown in Table 1. Regarding comorbidity, chronic anemia (40.8% vs 25%; p&amp;lt;0.060) was more common in Group I, as well as rheumatic manifestations at admission (12.2% vs 1.4%; p=0.014). The most frequently isolated microorganisms were S. aureus (n=25), coagulase negative staphylococci (n=25), viridans group streptococci (n=14), and enterococci (n=14). Enterococci (16.3% vs 8.3%, p=0.177) and non-viridans streptococci (10.2% vs 2.8%); p=0.086) were more frequent in frail patients. Vegetation (79.6% vs 80.6%; p=0.896) and periannular complications (24.5% vs 29.2%; p=0.571) were similar in both groups. No significant differences were found regarding the location of the infection. The incidence of in-hospital complications was similar between both groups. Frail patients underwent surgery less frequently than those in Group II, and had higher predicted mortality on surgical risk scale scores. However, the percentage of patients who met the surgical criteria and were considered inoperable was similar (33.3% vs 26.2%; p=0.415). In-hospital mortality was similar in both groups. When analyzing in-hospital mortality according to the therapeutic strategy in Group I, a mortality of 34.5% was observed in frail patients with conservative medical treatment, compared to 47.1% in those patients who underwent surgery in the same group. One third of our patients received outpatient antibiotic treatment, being significantly more frequent in Group I (39.6% vs 29.0%; p=0.232). Conclusions The elderly patients with IE and frailty criteria were older and more frequently had rheumatic symptoms at admission. Enterococci and non-viridans streptococci were isolated more frequently than in non-frailty patients. Surgery was less performed among frail patients, who had a higher predicted surgical risk. Although complications and in-hospital mortality were similar between both groups, in the group of frail patients, those with conservative management showed lower mortality compared to surgery. Funding Acknowledgement Type of funding sources: None.

The risk factors and outcomes of preoperative hepatic dysfunction in patients who receive surgical repair for acute type A aortic dissection.

BackgroundHepatic dysfunction (HD) is a common complication that can occur after surgical repair of acute type A aortic dissection (ATAAD) and is associated with poor prognosis. However, the incidence of early preoperative HD and the associated risk factors in patients with ATAAD have not been fully elucidated.MethodsA total of 984 ATAAD patients who received surgical repair within 48 hours of symptom onset at our department from January 2014 to December 2019 were retrospectively analyzed. Patients were divided into the non-HD group and the HD groups according to the Model of End-Stage Liver Disease (MELD) score before surgery. The clinical parameters and clinical outcomes of the 2 groups were collected and compared.ResultsPreoperative HD was detected in 268 patients (27.2%). The incidence of in-hospital complications, including the need for dialysis (34.0% vs. 9.2%; P<0.001), was significantly higher in patients with HD compared to patients without HD (69.8% vs. 51.0%; P<0.001). Patients with HD had a higher 30-day mortality rate compared to patients without HD (20.1% vs. 8.4%; P<0.001). Multivariate analysis demonstrated that preoperative cardiac tamponade, preoperative serum creatinine levels, and serum troponin T levels upon admission were independent predictors for preoperative HD in patients with ATAAD. Interestingly, even though preoperative HD was associated with an increased 30-day mortality rate, it did not significantly affect the long-term mortality rate (log-rank P=0.259).ConclusionsEarly HD before surgery was commonly observed in patients with ATAAD and was associated with increased in-hospital complications after surgery, but did not significantly affect long-term survival.

Characterisation of in-hospital complications associated with COVID-19 using the ISARIC WHO Clinical Characterisation Protocol UK: a prospective, multicentre cohort study

SummaryBackgroundCOVID-19 is a multisystem disease and patients who survive might have in-hospital complications. These complications are likely to have important short-term and long-term consequences for patients, health-care utilisation, health-care system preparedness, and society amidst the ongoing COVID-19 pandemic. Our aim was to characterise the extent and effect of COVID-19 complications, particularly in those who survive, using the International Severe Acute Respiratory and Emerging Infections Consortium WHO Clinical Characterisation Protocol UK.MethodsWe did a prospective, multicentre cohort study in 302 UK health-care facilities. Adult patients aged 19 years or older, with confirmed or highly suspected SARS-CoV-2 infection leading to COVID-19 were included in the study. The primary outcome of this study was the incidence of in-hospital complications, defined as organ-specific diagnoses occurring alone or in addition to any hallmarks of COVID-19 illness. We used multilevel logistic regression and survival models to explore associations between these outcomes and in-hospital complications, age, and pre-existing comorbidities.FindingsBetween Jan 17 and Aug 4, 2020, 80 388 patients were included in the study. Of the patients admitted to hospital for management of COVID-19, 49·7% (36 367 of 73 197) had at least one complication. The mean age of our cohort was 71·1 years (SD 18·7), with 56·0% (41 025 of 73 197) being male and 81·0% (59 289 of 73 197) having at least one comorbidity. Males and those aged older than 60 years were most likely to have a complication (aged ≥60 years: 54·5% [16 579 of 30 416] in males and 48·2% [11 707 of 24 288] in females; aged <60 years: 48·8% [5179 of 10 609] in males and 36·6% [2814 of 7689] in females). Renal (24·3%, 17 752 of 73 197), complex respiratory (18·4%, 13 486 of 73 197), and systemic (16·3%, 11 895 of 73 197) complications were the most frequent. Cardiovascular (12·3%, 8973 of 73 197), neurological (4·3%, 3115 of 73 197), and gastrointestinal or liver (0·8%, 7901 of 73 197) complications were also reported.InterpretationComplications and worse functional outcomes in patients admitted to hospital with COVID-19 are high, even in young, previously healthy individuals. Acute complications are associated with reduced ability to self-care at discharge, with neurological complications being associated with the worst functional outcomes. COVID-19 complications are likely to cause a substantial strain on health and social care in the coming years. These data will help in the design and provision of services aimed at the post-hospitalisation care of patients with COVID-19.FundingNational Institute for Health Research and the UK Medical Research Council.

Abstract 16794: Characteristics, Trends, Outcomes, and Costs of Stimulant-Related Acute Heart Failure Hospitalizations in the United States

Introduction: Heart failure hospitalizations remains significant burden on the health care system. Simulants including cocaine and methamphetamine are amongst the most used illegal substances in the United States. The information regarding stimulant related heart failure hospitalizations is scarce. Hypothesis: We sought to evaluate the characteristics and trends of stimulants-related heart failure hospitalizations in the United States and their associated outcomes and resource utilization. Methods: Using the National Inpatient Sample (NIS), we identified patients with a primary diagnosis of heart failure hospitalization. These hospitalizations were further divided into those with and without a concomitant diagnosis of stimulant (cocaine or amphetamine) dependence or abuse. Survey specific techniques were employed to compare trends in baseline characteristics, complications, procedures, outcomes and resource utilization between the two cohorts. Results: We identified 9,932,753 hospitalizations (weighted) with a primary diagnosis of heart failure, of those 138,438 (1.39%) had a diagnosis of active stimulant use. The proportion of stimulant related ACHF hospitalization is on the rise (1.1% to 1.9%) as the mean age of these stimulant related ACHF hospitalizations (from 49.9 to 52 years). Stimulant related ACHF hospitalization mostly affects African Americans and the proportion of ACHF is highest amongst the age group of 30-39 years. It is associated with increased incidence of in-hospital complications but lower mortality and length of stay. These patients have more than 7-fold higher discharge against medical advice. Conclusions: Stimulant related heart failure hospitalizations have been increasing. Evaluation of in-hospital outcomes is limited by a high proportion of patients leaving against medical advice.

Safety and feasibility of same-day discharge after elective percutaneous balloon mitral valvotomy: a prospective, single-center registry in India

Background Percutaneous mitral balloon valvotomy (PBMV) is an alternative to surgery for patients with severe mitral valve (MV) stenosis. However, the safety and feasibility of same-day discharge (SDD) in patients undergoing elective PBMV for severe MV stenosis is yet to be investigated. This study aimed to assess safety and feasibility of SDD in patients undergoing elective PBMV because of severe MV stenosis in a tertiary-care hospital in India. Methods From January 2018 to November 2018, patients with a diagnosis of severe MV stenosis were treated with PBMV at our institution. Among these patients, those suitable for SDD were prospectively included in this registry. Vascular access was achieved in forearm arteries and femoral veins. Clinical, echocardiographic and hemodynamic features were collected before and after PBMV. The primary outcome was 30-day mortality. The secondary outcome was incidence of in-hospital complications. Other outcomes of interest were arterial spasm and forearm haematoma. Results A total of 98 patients scheduled for SDD after elective PBMV were included in the registry. Mean MV area increased from 0.8 ± 0.1 to 1.6 ± 0.2 cm2 (p < .001). Severe MV regurgitation after PBMV occurred in 3 patients, and 1 patient developed pericardial tamponade. Severe arterial spasm occurred in 2 patients. None of the included patients developed a clinically relevant haematoma of forearm. A total of 94 (96%) were discharged on the same day. No patient died up to 30-day follow-up. Conclusion PBMV from the venous access site can reduce the hospital stay of patients to less than a day with less local site complications.

PC170. Impact of National Adoption of Endovascular Revascularization on a Regional Referral Center Specializing in Management of Chronic Mesenteric Ischemia

A dramatic increase in the national rates of endovascular revascularization (ER) for chronic mesenteric ischemia (CMI) has occurred; however, the incidence of open mesenteric bypass (OMB) has remained largely unchanged. The impact of ER adoption on referral hospitals specializing in CMI management that may be disproportionately affected by features precluding ability to use ER remains poorly defined. The purpose of this analysis was to determine the temporal variation in management and outcomes within a center with regional specialization for CMI management. A single, large tertiary academic referral institution’s prospectively collected database was queried retrospectively to identify all patients treated for CMI (2002-2018). The primary end point was temporal change in revascularization strategy (ER vs OMB; eras for analysis: 2002-2007, 2008-2013, 2014-2018). Secondary end points included temporal change in complications, reintervention, and survival. Life tables were used to estimate end points. The incidence of organ dysfunction (hepatic, renal, pulmonary, coagulopathy) was examined, and its relationship to outcomes was determined. There were 189 patients identified (OMB, n = 109 [antegrade, 91%; retrograde, 8%]; ER, n = 80 [mesenteric stent, 91%; angioplasty alone, 9%]. There was a significant difference in use of ER and OMB (most recent era, 84% OMB; P < .0001). For either ER or OMB, incidence of in-hospital complications or 30-day mortality was similar over time. OMB patients were significantly younger (66 ± 11 years vs ER, 71 ± 11 years; P = .006) and more likely to have undergone prior ER (OMB, 36%; ER, 17%; P = .005). No significant difference in presenting symptoms (postprandial pain > unintentional weight loss) or comorbidities was present. Major complications were more frequent with OMB (OMB, 54%; ER, 20%; P < .0001); however, 30-day mortality was similar (OMB, 6% [n = 6]; ER, 1% [n = 1]; P = .012). ER had a negligible incidence of postoperative organ dysfunction, whereas OMB was associated with a 75% incidence (threefold or higher transaminitis, 72%; thrombocytopenia [platelet count <40,000], 35%; renal injury, 9%; respiratory failure, 13%). Two-year symptom resolution overall was 69%; however, there was greater frequency of restenosis or recurrent symptoms after ER (50% vs OMB, 9%; P < .0001). Five-year freedom from reintervention or restenosis was significantly higher for OMB (77% ± 7% vs ER, 33% ± 6%; log-rank, P < .0001). There was a nonsignificant trend toward improved 5-year survival after OMB (70% ± 5% vs ER, 60% ± 6%; Cox model, P = .06; Fig). Centers focused on CMI management may not reflect national trends in revascularization strategies as evidenced by the increasing use of OMB. This selection pressure is predominantly due to a significant proportion of prior mesenteric revascularization failures or nonanatomic suitability for ER. Despite specialization and a high-volume referral pattern, complication rates, including frequency of postoperative organ dysfunction, remained similar over time, probably reflecting a cohort of complex patients with significant comorbidities. These findings highlight the significant challenges and resource utilization faced by regional referral centers and provide contemporary benchmarks for outcomes, especially when elective OMB occurs.

Bariatric Surgery in Patients with Systolic and Diastolic Heart Failure: Insights from the Nationwide Inpatient Sample

Purpose Obesity is an established risk factor for the development of heart failure (HF). Weight loss after bariatric surgery may have a positive impact in long-term HF outcomes; however, there is scarcity of data exploring the safety of bariatric surgery in this population. Methods Using the 2010-2015 Nationwide Inpatient Sample database, we identified the overall demographic characteristics and incidence of in-hospital complications in HF patients after bariatric procedures. Multivariate logistic regression was used to determine the relationship between HF and in-hospital outcomes. Results A total of 963,603 patients underwent bariatric procedures. Of these, 3,427 (0.36%) had systolic HF (sHF) and 6,327 (0.66%) had diastolic HF (dHF). Patients with HF were older and had a higher burden of comorbidities as appraised by Charlson Comorbidity Index (Table 1). HF patients had greater length of stay; this was consistent across sHF (4 vs 18 days; p Conclusion HF patients who underwent bariatric surgery in this national cohort had an increased risk of in-hospital complications when compared to patients without HF. Further studies are needed to better select candidates and balance the risk of short-term complications against potential long-term benefits.

Predictors and in-hospital outcomes of preoperative acute kidney injury in patients with type A acute aortic dissection.

BackgroundAcute kidney injury (AKI) is common after surgery for acute aortic dissection (AAD) and increases in-hospital and long-term mortality. However, few data exist on the clinical and prognostic relevance of early preoperative AKI in patients with type A AAD. We aimed to determine the incidence and predictors of preoperative AKI and the impact of AKI on in-hospital outcomes in patients with type A AAD.MethodsFrom May 2009 to June 2014, we retrospectively enrolled 178 patients admitted to our hospital within 48 h from symptom onset and receiving open surgery for type A AAD. The patients were divided into no AKI and AKI groups and staged with AKI severity according to the KDIGO criteria before surgery.ResultsAKI occurred in 41 patients (23.0%). The incidence of in-hospital complications was significantly higher in patients with preoperative AKI compared to no AKI (41.5% vs. 9.5%, P < 0.001), including renal infarction (7.3% vs. 0, P = 0.012), and it increased with AKI severity (Ptrend < 0.001). Patients with AKI had higher in-hospital mortality compared with patients without AKI, although no significant difference was found (14.6% vs. 5.1%, P = 0.079). Multivariate analysis indicated that male gender, diastolic blood pressure on admission and bilateral renal artery involvement were independent predictors of preoperative AKI in patients with type A AAD.ConclusionsEarly AKI before surgery was common in patients with type A AAD, and was associated with increased in-hospital complications. Male gender, diastolic blood pressure on admission and bilateral renal artery involvement were major predictors for preoperative AKI.

Impact of Alcohol on Outcomes in Hospitalized Major Trauma Patients: A Literature Review.

To critically appraise available studies investigating the impact of alcohol outcomes in hospitalized patients after major trauma. Outcomes included injury severity, mortality, complications, and hospital/intensive care length of stay. Data were sourced from MEDLINE, CINAHL, and SCOPUS databases. Abstracts were screened for inclusion/exclusion criteria with 15 articles appraised and analyzed based on in-hospital outcomes. Although alcohol intoxication is associated with a marginal increase in the incidence of in-hospital complications (sepsis and multiorgan failure), overall studies suggest it is not associated with longer intensive care or in-hospital length of stay. This literature review also demonstrated decreased mortality and injury severity in patients with traumatic brain injury. Further research is required to determine the reasons for these associations.

Risk profile and in-hospital prognosis in elderly patients presenting for acute ST-elevation myocardial infarction in the Tunisian context

ObjectivesLittle is known about the risk profile and in-hospital prognosis of elderly patients presenting for ST-elevation myocardial infarction (STEMI) in Tunisia. We sought to determine in-hospital prognosis of elderly patients with STEMI in a Tunisian center. MethodsThe study was carried out on a retrospective registry enrolling 1403 patients presenting with STEMI in a Tunisian center between January 1998 and January 2013. Patients ≥75 years old were considered elderly. Risk factors and in-hospital prognosis were compared between elderly and younger patients, and then predictive factors of in-hospital death were determined in elderly patients. ResultsOut of the overall population, 211 (15%) were part of the elderly group. Compared to younger patients, elderly patients were more likely to have arterial hypertension but less likely to be smokers and obese. Thrombolysis was significantly less utilized in the elderly group (22.3% vs. 36.6% in the younger group, p<0.001), whereas the use primary percutaneous coronary intervention was comparable between the two sub-groups (24.2% vs. 28.8%, p=0.17). The incidence of in-hospital complications was higher in the elderly group, and so was the in-hospital mortality rate (14.2% vs. 8.1%, p=0.005). Heart failure on-admission, renal failure on-admission, and inotropic agents use were independently associated to in-hospital death in the elderly group. ConclusionsIn the Tunisian context, elderly patients presenting with STEMI have higher prevalence of risk factors and a worse in-hospital course in comparison to younger patients. Clinical presentation on-admission has a strong impact on in-hospital prognosis.

Opioid-Based Analgesia: Impact on Total Joint Arthroplasty

The objective of this study was to characterize the impact of opioid-based analgesia in total joint arthroplasty. The primary outcomes were incidence of in-hospital complications, length of stay, and discharge destination. Six hundred and seventy-three primary total hip and knee arthroplasties were retrospectively reviewed. The incidence of opioid-related adverse drug events was 8.5%, which accounted for 58.2% of all postoperative complications. Age, anesthesia technique, ASA score, and surgery type were significant risk factors for complications. After adjusting for these confounders, opioid-related adverse drug events were significantly associated with increased length of stay (P < 0.001) and discharge to extended care facilities (P = 0.014).

Impact of right ventricular involvement on the prognosis of takotsubo cardiomyopathy.

Previous studies showed that patients with takotsubo cardiomyopathy had a higher long-term mortality rate than the general population and the incidence of in-hospital complications was higher in takotsubo cardiomyopathy with than without right ventricular (RV) involvement. This study was performed to investigate the long-term prognostic impact of RV involvement in takotsubo cardiomyopathy. The clinical data of 113 patients (72.7 ± 11.4 years old, 84 females) with takotsubo cardiomyopathy were studied retrospectively. The patients were divided into two groups according to the presence (biventricular group, n = 21, 18.6%) or absence (classical group, n = 92, 81.4%) of RV involvement assessed by initial echocardiography. The end point was a composite of all-cause death, re-hospitalization due to heart failure, and recurrence of takotsubo cardiomyopathy. The in-hospital mortality rate was significantly higher in the biventricular group than the classical group (14.3 vs. 1.1%, respectively, P = 0.02). Kaplan-Meier analysis indicated a significantly lower event-free survival rate in the biventricular group than the classical group (log-rank, P < 0.001). On multivariate analysis, RV involvement was the only independent predictor of the end point (HR: 2.73, P = 0.026). The rates of in-hospital and long-term events were significantly higher in takotsubo cardiomyopathy with than without RV involvement, and RV involvement was the independent predictor of the poor prognosis.

Relation of in-hospital serum creatinine change patterns and outcomes among ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention.

The worsening of serum creatinine (sCr) level is a frequent finding among ST-segment elevation MI (STEMI) patients undergoing primary percutaneous coronary intervention (PCI), associated with adverse short-term and long-term outcomes. No information is present, however, regarding the incidence and prognostic implications associated with an improvement in sCr levels throughout hospitalization, as compared with admission levels. Reversible renal impairment prior to PCI is not associated with adverse outcomes. We retrospectively studied 1260 STEMI patients undergoing primary PCI. The incidence of in-hospital complications and long-term mortality was compared between patients having stable, worsened (>0.3 mg/dL increase), or improved (>0.3 mg/dL decrease) sCr levels throughout hospitalization. Overall, 127 patients (10%) had worsening in sCr levels, whereas 44 (3.5%) had an improvement of sCr compared with admission levels. Patients with worsening sCR had more complications during hospitalization, higher 30-day (13% vs 1%; P < 0.001) and up to 5-year all-cause mortality (28% vs 5%; P < 0.001) compared with those with stable sCR. No significant difference was found regarding complications and mortality between patients having an improvement in sCr and stable sCr. Compared with patients with stable sCr, the adjusted hazard ratio for all-cause mortality in patients with worsened sCr was 6.68 (95% confidence interval: 2.1-21.6, P = 0.002). In STEMI patients undergoing primary PCI, renal impairment prior to PCI is a frequent finding. In contrast to post-PCI sCr worsening, this entity is not associated with adverse short-term and long-term outcomes.