Independent Predictor Of Complications Research Articles

Outcome and right ventricle remodelling after valve replacement for pulmonic stenosis

BackgroundComplications and need for reinterventions are frequent in patients with pulmonary valve stenosis (PVS). Pulmonary regurgitation is common, but no data are available on outcome after pulmonary valve replacement (PVR).MethodsWe...

Is Preoperative Serum Albumin Predictive of Adverse Surgical Outcomes in Maxillofacial Fracture Repair?

Malnutrition has been recognized as a predictor of postoperative adverse outcomes across many surgical subspecialties. The purpose of this study was to evaluate the relationship between serum albumin and adverse outcomes in patients undergoing operative repair of maxillofacial fractures. The authors utilized the 2011 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases to identify patients with facial fractures undergoing operative repair. The primary predictor variable was preoperative serum albumin level. Outcome variables included complications and other adverse outcomes occurring within 30 days of the index operation. Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between serum albumin and adverse outcomes. During the study period 1211 subjects underwent operative repair of a facial fracture and had a documented serum albumin level. Of these subjects, 1037 (85.6%) had normal albumin levels and 174 (14.4%) had hypoalbuminemia. A total of 90 subjects experienced a complication (7.43%), although albumin level was not associated with surgical complications or any complication. In bivariate analysis, subjects with hypoalbuminemia were significantly more likely to have an extended length of stay (P ≤ .001), adverse discharge disposition (P ≤ .001), and be readmitted (P=.002). In multivariate analysis, hypoalbuminemia was an independent predictor of an extended length of stay (P ≤ .001, 95% CI 2.50 to 7.62), adverse discharge disposition (P=.048, 95% CI 1.01 to 3.75), and readmission (P=.041, 95% CI 1.03 to 3.47). Serum albumin was not an independent predictor of complications after maxillofacial trauma repair. However, it was an independent predictor of other adverse outcomes including extended length of stay, adverse discharge disposition, and readmission. Targeted nutritional optimization may represent an opportunity to improve outcomes in this demographic.

Clinical Scenario and Long‐Term Outcome of Childhood Takayasu Arteritis Undergoing 121 Endovascular Interventions: A Large Cohort Over a Fifteen‐Year Period

Evidence-based studies on endovascular approaches for childhood Takayasu arteritis (TAK) are limited. Our objective was to present the largest current real-world scenario for patients with childhood TAK undergoing interventions and their postinterventional outcomes. Data were collected for patients with childhood TAK admitted from 2002 to 2017. Complication/reintervention-free survival was projected by Kaplan-Meier methods. Associated factors for intervention and predictors for postinterventional complications/reinterventions were assessed via regression models. Among 101 patients enrolled, 69 (68.3%) underwent 121 interventions (angioplasty 95, stenting 26) during a 3.1-year follow-up. Compared with the nonintervention group, the intervention group independently associated with a male population (odds ratio [OR] 0.27, P = 0.035) and type IV disease (OR 17.92, P = 0.001). Male sex also marginally indicated a risk for reintervention (hazard ratio [HR] 3.22, P = 0.05). Baseline retinopathy, delay in diagnosis, and descending thoracic aorta involvement were associated with stent insertion (P < 0.05). Hypertension secondary to renal artery stenosis (RAS; 59.4%) or mid-aorta stenosis (MAS; 14.5%), heart failure (21.7%), and claudication (21.7%) were leading clinical hints for interventions. The technical success rate was 96.7%. During a median 2.88-year of follow-up after intervention, 36 lesions occurred with complications in 28 patients, and 22 lesions in 17 patients, particularly on the renal artery or mid-aorta. The 5-year complication-free and reintervention-free survivals were 50.7% and 65.8%, respectively. Peri-interventional dual antiplatelet therapy (DAPT; HR 0.31), concurrent surgery (HR 26.5), and technical failure (HR 3.65) were independent predictors for complications (P < 0.05). Male sex (HR 2.52), retinopathy secondary to hypertension (HR 3.41), and pulmonary artery hypertension (PAH; HR 3.64) were baseline indicators for complications (P < 0.05). Over two-thirds of patients with childhood TAK require interventions, and the 5-year complication-free survival is 50.7%. Male sex, retinopathy, and PAH at baseline indicate the possibility of unfavorable outcomes. Interventions on MAS or RAS in childhood TAK raise specific concerns. DAPT peri-intervention appears to protect patients with childhood TAK from postinterventional complications.

Complications of balloon pulmonary angioplasty for chronic thromboembolic pulmonary disease according to the classification proposed by the 6th world symposium on pulmonary hypertension

Abstract Introduction Balloon pulmonary angioplasty (BPA) is a complex procedure and not risk free. In an attempt to standardize reports of BPA complications in the several centers, a classification of complications was proposed by the task force on chronic thromboembolic hypertension (CTEPH) in the 6th World Symposium on Pulmonary Hypertension (WSPH). Purpose To determine the prevalence of BPA complications according to the classification of 6th WSPH and to identify its predictors. Methods Detailed procedural and technical aspects were collected for consecutive patients (pts) with inoperable, residual/recurrent chronic thromboembolic disease, undergoing BPA at a single institution from December/2017 to December/2020. Per procedure logistic regression analysis was used to evaluate the predictive variables for complications. Results A total of 76 BPA sessions in 15 pts were performed (mean age 63.2±14.0 years; 60.0% women; 86.7% CTEPH). Mean pulmonary artery pressure and pulmonary vascular resistance before the first BPA session were 33.1±13.3 mmHg and 4.8±3.2 woods unit, respectively (73.3% of pts under vasodilator therapy). Femoral access was used for all pts. Mean vessels treated per procedure were 4.3±1.9 (324 vessels in total). Webs, subtotal occlusions, ring-like stenosis and total occlusions were noted in 215 (66.4%), 58 (17.9%), 31 (9.6%) and 20 (6.2%) treated vessels, respectively. We performed 21 pressure-wire-guided sessions (27.6%). Intravascular imaging was used in 6 procedures (7.9%). Average time of fluoroscopy was 60.3±14.0 minutes and volume of contrast 273.0±73.0 mL per session. Procedure-related adverse events occurred in 25.0% of the interventions (27.6% in the first two years vs 16.7% in the last two). Pulmonary artery vascular injuries were noted in 6 BPA vessels (7.9% per procedure and 1.9% per treated vessel): haemoptysis in all, but perforation was only detected angiographically in 3 of them (balloon inflation was performed for 2 distal perforations, and 1 perforation sealed without any intervention). Vascular dissection in distal lesions occurred in 4 cases (5.3%) with no need of transcatheter or surgical procedures. We had 3 lung injuries, all grade 2. None of the pts required oral intubation or mechanical ventilation. Extra-pulmonary complications were illustrated in table. Importantly, there was no peri-procedural death. The occurrence of vascular or lung injuries was 0% in pressure-wire-guided BPA versus 14.5% in non-guided (p=0.098). Multivariate analysis revealed that age (OR 1.05; CI 1.01–1.10; p=0.030) was the only independent predictor of complications. Conclusions In our experience, BPA can be safely performed in inoperable, residual or recurrent CTEPH or CTED pts, with 25% minor procedural-related complications but no major adverse event. Age was the strongest factor related to the occurrence of complications. Funding Acknowledgement Type of funding sources: None.

Does the Modified Frailty Index (mFI-5) Predict Adverse Outcomes in Maxillofacial Fracture Repair?

Frailty has been recognized as a predictor of postoperative adverse outcomes in many surgical subspecialties. The purpose of this study was to evaluate the relationship between frailty and complications in patients undergoing operative repair of facial fractures. The authors utilized the 2011 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases to identify patients with facial fractures undergoing operative repair. The primary predictor variable was frailty as measured by the 5-Factor Modified Frailty Index (mFI-5). The primary outcome variable was the postoperative complication rate. Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between frailty and complications. During the study period, 4,290 subjects underwent operative repair of a facial fracture. Of these subjects, 4,086 (83.0%) were classified as nonfrail, 626 (12.7%) as moderately frail, and 208 (4.20%) as severely frail. A total of 237 subjects experienced a complication (4.82%), and the incidence of complications increased in a stepwise manner with increasing frailty (P ≤ .001). In multivariate regression, age (P = .050, 95% CI=1.00 to 1.02), Native Hawaiian/Pacific Islander race (P = .018, 95% CI=1.23 to 8.63), classification as moderately frail (P = .010, 95% CI=1.15 to 2.66), classification as severely frail (P = .032, 95% CI=1.06 to 3.70), mandibular fractures (P = .004, 95% CI=1.24 to 2.98), and wound classification as contaminated (P ≤ .001, 95% CI=1.53 to 4.57) or dirty/infected (P = .020, 95% CI=1.16 to 5.55) were independent predictors of complications. Severely frail subjects also had greater length of hospital admission (P ≤ .001) and higher 30-day readmission rates (P ≤ .001). Frailty is an independent predictor of complications following facial fracture repair and is associated with greater length of hospital admission and 30-day readmission rates.

Minimally invasive management versus open surgery in the treatment of penetrating bladder injuries: a retrospective cohort study

BackgroundWhile blunt extra-peritoneal bladder injury is typically treated non-operatively or with minimally invasive management, the treatment for penetrating bladder injury is generally open surgery. We identify a group of patients with penetrating bladder injury who were treated with minimally invasive management and compare the results with those who underwent traditional open surgical treatment.MethodsThis retrospective cohort study analyzes penetrating bladder injuries from a single trauma center from 2012 through 2019, and from the National Trauma Data Bank for 2016 and 2017. Mortality, complications, and length of stay were compared for minimally invasive management versus open surgery. We used Chi square to test significance for categorical variables, Mann–Whitney U test for ordinal variables, and T-test for continuous variables. Multivariate analysis was performed with multiple logistic, ordinal, and linear regression.ResultsLocal: 117 (0.63%) had a bladder injury; 30 (25.6%) were penetrating. 6 (20.0%) were successfully treated with minimally invasive management with no complication versus 24 complications in 11 patients (45.8%) for open surgery (p = 0.047). Open surgical management was not a significant independent predictor of mortality or hospital length of stay. National Trauma Data Bank: 5330 (0.27%) had a bladder injury; 963 (19.5%) were penetrating. 97 (10.1%) were treated with minimally invasive management. The minimally invasive management group had 12 complications in 5 patients (4.9%) versus 280 complications in 169 patients (19.7%) for open surgery (p = < 0.001). Open surgery was a significant independent predictor of complications (OR 1.57, p = 0.003) and longer hospital length of stay (B = 5.31, p < 0.001).ConclusionsMost penetrating bladder injury requires open surgery, however a small proportion can safely be managed with minimally invasive management. Minimally invasive management is associated with lower total complications and shorter hospital length of stay in select patients.

Adults With Tetralogy of Fallot: Early Postoperative Outcomes and Risk Factors for Complications

ObjectiveTo report the early postoperative outcomes in adults with tetralogy of Fallot (TOF) undergoing cardiac surgery and to identify patient factors associated with complications. Patients and MethodsWe performed a single-institution retrospective review of adults with TOF who underwent cardiac surgery from January 8, 2008, through June 21, 2018. Patients’ characteristics, preoperative imaging, surgical interventions, outcomes, and complications were analyzed. ResultsThere were 219 adults with TOF (mean age, 40 years; range, 18-83 years; 88 [40%] female) in the study. Surgical interventions included repair or replacement of the pulmonary valve (n=199 [91%]), tricuspid valve (n=70 [32%]), mitral valve (n=13 [5.9%]), and aortic valve (n=8 [3.7%]). Three patients (1.4%) underwent first-time TOF repair. The 30-day mortality rate was 1.4% (n=3). Early postoperative complications occurred in 66 (30%) and included arrhythmias requiring treatment, dialysis requirement, liver dysfunction, respiratory failure, infection, reoperation, cardiac arrest, mechanical circulatory support, and death. Multivariate analysis found older age at current surgery (odds ratio [OR], 1.04 per year; 95% CI, 1.01 to 1.06; P<.001), longer cardiopulmonary bypass time (OR, 1.01 per minute; 95% CI, 1.01 to 1.02; P<.001), right ventricular systolic dysfunction (OR, 1.31; 95%, CI 1.02 to 1.69; P=.03), diabetes mellitus (OR, 3.50; 95% CI, 1.20 to 10.2; P=.02), and history of initial palliative surgery (OR, 1.99; 95% CI, 1.01 to 3.91; P=.05) as independent predictors of complications. ConclusionSurgical interventions for adult patients with TOF can be performed with low early morbidity and mortality. Clinical characteristics and preoperative testing parameters can predict risk for complications in the postoperative period.

124. Cervical deformity score: a composite alignment tool to optimize outcomes while mitigating complications

<h3>BACKGROUND CONTEXT</h3> Cervical alignment and cervical deformity surgery are complex topics. Recently, a score inspired by work on thoracolumbar alignment was developed for cervical alignment (cervical deformity score, CDS). While this score was designed to predict early mechanical failures, its association with patient reported outcomes (PROM) remains unclear. <h3>PURPOSE</h3> Investigate the association between PROM, complications, and a newly described cervical deformity score. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of prospective multicenter database. <h3>PATIENT SAMPLE</h3> A total of 102 adult cervical deformity (CD) patients with at least 1 year follow-up. <h3>OUTCOME MEASURES</h3> NDI, neck pain, EQ5D, complication rates. <h3>Methods</h3> CD patients with baseline and 1-year follow-up were included. Postoperative CDS was constructed using offset from age-adjusted values: SVA [(age -55)*2+25], T1 Slope [(age -55)/4 + 28.7], and TS minus CL [cst: between 26.5 and 14.5°]. Points were assigned based on the offset from alignment targets and the CDS was the sum of the three individual scores. Association with patient-reported outcomes was investigated using Pearson's correlations. Comparison of CDS between patients with and without complication within 1-year was conducted. Logistical regression controlling for demographic and comorbidities was conducted to identify if CDS was an independent predictor of complications. <h3>Results</h3> A total of 102 patients met inclusion criteria (61.7yo±10, 66.7% F); 37.6% of them had a history of previous cervical surgery (16.7% previous ACDF, 11.7% previous posterior fusion). Preoperatively, they had elevated disability (NDI: 47.1±18.1), pain (NSR Neck: 6.6±2.5), myelopathy (mJOA: 13.6±2.7) and lower general health (EQ5D: 0.74±0.07). They also presented with an overall cervical kyphotic alignment (C2-C7: -6.3°±20.9), a moderate cervical anterior alignment (cSVA: 39mm±20; TS-CL: 37.9°±19.4) and a posterior global thoracolumbar alignment (SVA: -3mm±68). The median of number of levels fused was 7 [4-9], with 49% treated with a posterior approach and 30.4% with a combined approach; 83.2% received an osteotomy, 44.6% some posterior osteotomy, 16.8% grade 6 or 7. The mean operative time was 368min±208, median EBL was 525cc [200 1025], and LOS was 5 days [4 8]. At 1 year, patients improved significantly in terms of disability (NDI: 36.2±20.7, 60.8% reached MCID), pain (NSR: 4.1±2.9) and general health (EQ5D: 0.79±0.08) (all p<0.001). The cervical alignment significantly changed (C2-C7: 7.8±14.5m; cSVA: 34mm±15; TS-CL: 28.9°±12.6 all p <0.002), with a 1-year CDS of 1.68±2.46 (prctl [0 3.25]). There was a significant association between increased CDS and increased disability (r=0.273), pain (r=0.336) and lower general health (r=-0.283). Patient with a lower disability level (NDI<20) had a significantly lower CDS (0.71±2.3 vs 2.16±2.4 p<0.004). Patients without any complications before 1 year had a lower CDS (0.78±2.33 vs 2.18±2.40 p=0.005), as did patients without major complications (1.36±2.27 vs 2.50±.78 p=0.037). Deeper analysis revealed significant differences in terms of CDS for patients experiencing cardiopulmonary, instrumentation and radiographic complications (p<0.05). Multivariate analysis, controlling for age and comorbidities, show 1-year CDS to be a significant predictor of complication (p=0.002, OR=1.409). <h3>Conclusions</h3> With better outcomes and lower complication rate, maintaining a proportionate alignment postoperatively can result in superior outcomes following CD surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Prediction of Readmission and Complications After Pituitary Adenoma Resection via the National Surgical Quality Improvement Program (NSQIP) Database.

IntroductionPituitary adenomas are common intracranial tumors (incidence 4:100,000 people) with good surgical outcomes; however, a subset of patients show higher rates of perioperative morbidity. Our goal was to identify risk factors for postoperative complications or readmission after pituitary adenoma resection.MethodsWe undertook a retrospective cohort study of patients who underwent surgery for pituitary adenoma in 2006-2018 by using the National Surgical Quality Improvement Program database. The main outcome measures were patient complications and the 30-day readmission rate.ResultsAmong the 2,292 patients (mean age 53.3±15.9 years), there were 491 complications in 188 patients (8.2%). Complications and 30-day readmission have remained stable over time rather than declined. Unplanned readmission was seen in 141 patients (6.2%). Multivariable analysis demonstrated that hypertension (OR=1.6; 95% CI= 1.1, 2.1; p=0.005) and high white blood cell count (OR=1.08; 95% CI=1.03, 1.1; p=0.0001) were independent predictors of complications. Return to the operating room (OR=5.9, 95% CI=1.7, 20.2, p=0.0005); complications (OR=4.1, 95% CI=1.6, 10.6, p=0.004); and blood urea nitrogen (OR=1.08, 95% CI=1.02, 1.2, p=0.02) were independent predictors of 30-day readmission.ConclusionUsing one of the largest datasets of pituitary adenoma patients, we identified perioperative factors most critical for patient outcome. One strength of this study is adjusting for cofactors that predict outcomes, which has not been done previously. Several patient biomarkers, namely white blood cell count and blood urea nitrogen, may serve as preoperative markers that might identify patients at higher risk. Control of blood pressure and renal disease may be perioperative management strategies that can impact the outcome.

ENDOVASCULAR INTERVENTIONS FOR CHILDHOOD TAKAYASU ARTERITIS: A 16-YEAR REVIEW

Objective: Evidence-based studies on endovascular approaches for childhood Takayasu arteritis(c-TA) are limited. This study presented the real-world scenario of largest cohort up-to-date for c-TA patients undergoing interventions and their post-interventional outcomes. Design and method: Patients with c-TA satisfying the 1990 ACR or 2010 EULAR/PRINTO/PReS criteria were recruited from January 2002 to December 2017. Data on clinical, laboratory, imaging features, treatment and post-interventional outcomes were collected. Statistical analysis was performed based on data distribution. Complication-free survival and Re-intervention-free survival were projected by Kaplan-Meier methods and compared by Log-rank tests. Associated factors for intervention (or stenting) and predictors for post-interventional complications (or re-interventions) were assessed via Logistic regression and COX regression models, respectively. Results: Among 101 patients enrolled, 69(68.3%) underwent 121 interventions (Angioplasty 95; Stenting 26) during a median 3.1 years of follow-up. Compared with the medical treatment group, the intervention group appeared with fewer male population(18.8% vs 39.3%, OR = 0.2, p = 0.017) and more type IV disease(47.8% vs. 17.9%, OR = 10.60, p = 0.002). Male sex also indicated the risk for re-intervention(HR = 4.72, p = 0.016). Retinopathy(OR = 4.8, p = 0.027), time of delay in diagnosis per year(OR = 1.76, p = 0.016) and descending thoracic aorta involvement(OR = 10.19, p = 0.003) associated with stent insertion. Hypertension secondary to renal artery(59.4%) or mid-aorta(14.5%) stenosis, heart failure(21.7%), claudication(21.7%) served as leading clinical hints for interventions. Anti-inflammatory and anti-platelet therapies covered 89.9% and 91.3% patients, respectively. The technical success rate was 96.7%. Over median 2.88 years since intervention, 36 lesions occurred complications in 28 patients and 22 lesions in 17 patients, majorly on renal artery or mid-aorta. The 5-year complication-free and re-intervention survivals were 50.7% and 65.8%, separately. Dual antiplatelet therapy(HR = 0.28, p = 0.011), concurrent surgery(HR = 14.84, p = 0.002), retinopathy secondary to hypertension(HR = 3.54, p = 0.004), and pulmonary artery hypertension(HR = 3.0, p = 0.024) were independent predictors for complications. Conclusions: Over two-thirds c-TA patients require interventions and the 5-year complication-free survival is 50.7%. Male sex, retinopathy, and pulmonary artery hypertension alert unfavorable outcomes. Dual anti-platelet therapy appears to protect c-TA patients from post-interventional complications. Endovascular approaches can be a choice for mid-aorta and/or renal artery lesions caused by c-TA.

Safety and complications of catheter ablation for atrial fibrillation: Predictors of complications from an updated analysis the National Inpatient Database

Catheter ablation is increasingly employed in the management of atrial fibrillation (AF). Data regarding safety of ablation of AF is largely derived from controlled clinical trials. The aim of this study was to analyze safety and complications of AF ablation performed in a "real world" setting outside of clinical trials, and obtain insights on predictors of complications. We utilized the National Inpatient Sample database, to identify all patients who underwent AF ablations between 2015 and 2017 using International Classification of Disease-Tenth revision codes. Complications were defined as per the Agency for Health Care Research and Quality Guidelines. Statistical tests including multivariate logistic regression were performed to determine predictors of complications. Among 14,875 cases of AF ablation between 2015 and 2017, a total of 1884 complications were identified among 1080 (7.2%) patients. Patients with complications were likely to be older and female with a higher burden of comorbidities. A 27% increase in complications was observed from 2015 to 2017, driven by an increase in pericardial complications. Multivariate regression analysis revealed that pulmonary hypertension (adjusted odds ratio [aOR]: 1.99, p = .041) and chronic kidney disease (CKD; aOR: 1.67, p = .024), were independent predictors of complications. Centers with higher procedural volumes were associated with lower complication rates. Complication rates related to AF ablations remain substantially high. Presence of pulmonary hypertension and CKD are predictive of higher procedural complications. Furthermore, hospital procedure volume is an important factor that correlates with complication rates.

The Impact of Hepatitis C and Liver Disease on Risk of Complications After Total Hip and Knee Arthroplasty: Analysis of Administrative Data From Louisiana and Texas.

BackgroundMillions of Americans have hepatitis C and other liver diseases, many of whom have end-stage osteoarthritis requiring total joint arthroplasty (TJA). This study aimed to determine the extent to which hepatitis C and other liver diseases are independent risk factors for complications, including readmission and reoperation, in patients undergoing TJA.MethodsRetrospective study of a REACHnet data set containing demographics, International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes, and clinical and laboratory data for patients who underwent primary total knee or hip replacement from 2013 to 2017 at 3 hospital systems in Louisiana and Texas. Multivariable logistic regression analyses examined predictors of complications. Any complication was defined as a 90-day medical complication or readmission or reoperation within 1 year.ResultsAmong 13,673 patients who met inclusion criteria, 14.9% (2044/13,673) had any complication, 11.7% (1600/13,673) were readmitted within 90 days, and 3.6% (497/13,673) had a reoperation within 1 year. Liver disease increased the odds for any complication (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.08-1.18), 90-day medical complication (OR, 1.13; 95% CI, 1.04-1.22), and 90-day readmission (OR, 1.11; 95% CI, 1.06-1.17). Hepatitis C was not, by itself, associated with an increase in any type of complication but was usually associated with liver disease. Comorbidity severity was the strongest predictor of all types of complications after TJA.ConclusionPatients in Louisiana and Texas with liver disease were at increased risk for complications after TJA, corroborating findings of previous studies. Hepatitis C was not an independent predictor of complications because of its high association with liver disease.

Patient Risk Factors Associated With Postoperative Complications After Common Hand Procedures.

Carpal tunnel syndrome (CTS), trigger finger (TF), and De Quervain tenosynovitis (DQ) are 3 common pathologies of the hand often treated with relatively simple surgical procedures. However, outcomes from these procedures can be compromised by postoperative complications. The aim of this study was to evaluate the association between diabetes, tobacco use, and obesity and the incidence of postoperative complications. We reviewed 597 patients treated surgically for CTS, TF, or DQ from 2010 to 2015. We used bivariate and multivariate analyses to assess independent associations between diabetes, tobacco use, obesity, and surgical complications and compared the incidences with healthier patients without these comorbidities. We also looked at patients with overlapping diagnoses of these comorbidities. Bivariate analysis showed that patients with diabetes and smokers were more likely to have a surgical complication. Multivariate analysis showed diabetes and tobacco use as independent predictors of complications. The disease states or combinations placing patients at the highest risk of a postoperative complication were the diabetic-smoker-obese, diabetic-smoker, diabetic-obese, diabetic, and smoker-obese groups. The diabetic-smoker-obese patient population had a 42.02% predicted rate of postoperative complications. Diabetes and tobacco use are independent risk factors for complications after operative treatment of CTS, TF, and DQ. Obesity when coexisting with diabetes mellitus (DM) and/or tobacco use increased the risk of complications. When the 3 patient factors evaluated, DM, obesity, and tobacco use, were present, the rate of complications was 42.02%. Careful assessment and discussion should occur before proceeding with operative treatment for simple hand conditions in patients with the risk factors studied.

Determinants of complications in first ever acute stroke patients: a prospective observational study from India

Background and Aims: Post-stroke complications can lead to frequent and major causes of death in the early phases after an acute stroke. Aims of the present study were to determine the association of several risk factors with the occurrence of poststroke complications, the predictors for the development of complications, and to evaluate how these complications affected the overall prognosis among subjects with the first ever acute stroke. This study is the pioneer study of this kind from Eastern India. Previous national and international studies on this lack uniformity in their results probably because of the following reasons: no standard definitions for complications following the stroke, varied follow-up periods ranging from 1 week to 30 months, type and severity of stroke affecting the incidence, and finally, the demographic variables. Methods: This was an observational, prospective study, in which a total of 521 adult male and female patients who had a first-ever acute stroke, aged between 12 years to 75 years were enrolled over a period of 2 years (September 2016 to September 2018), admitted in Department of Neuromedicine, Bangur Institute of Neurosciences (BIN), Kolkata, India. Patients with first ever acute stroke were studied for post-stroke complications (predefined with standard criteria) during the hospital stay at Bangur Institute of Neurosciences (BIN), Kolkata, India, and their association with risk factors, severity of stroke (National Institutes of Health Stroke Scale Score, NIHSS), length of hospital stay (in days) and outcome (Modified Rankin Scale, MRS) were assessed. Results: A total of screened 498 patients who were admitted at Bangur Institute of Neurosciences (BIN), Kolkata, India, with first ever acute stroke were recruited. The mean age was 61.02 years (range 23-75 years), the majority being male (n = 307; 61.6%). Post-stroke complication during hospital stay was documented in 270 patients (54.2%)(males and females combined). In logistic regression analysis, multiple risk factors (OR, 1.571; 95% CI, 1.084-2.278; P-0.017), severity of stroke (National Institutes of Health Stroke Scale Score, NIHSS) (OR, 1.425; 95% CI, 1.027-1.976; P-0.034) and length of hospital stay (in days) (OR, 3.565; 95% CI, 2.029-6.264; P &lt; 0.0001) were the most robust predictors of occurrence of complications. The independent predictors of poor outcome in subjects with complications were: chest infection (OR, 2.07; 95% CI, 1.006-4.26; P = 0.048), bedsores (OR, 2.26; 95% CI, 1.03-4.94; P-0.042), and seizures (OR, 5.072; 95% CI, 1.08-23.79; P-0.039). Conclusion: In our study, the most independent predictors of complications were severity of stroke and length of hospital stay. This observation might help clinicians in taking appropriate measures towards preventing post-stroke complications and thereby improving outcome following a stroke.

Five-year outcome of peripherally inserted central catheters in adults: a separated infectious and thrombotic complications analysis.

To assess infectious and thrombotic complications of peripherally inserted central catheters (PICCs) in adults. A 5-year prospective cohort study. Tertiary-care teaching hospital in Seville, Spain. Adult patients undergoing PICC insertion. Catheter-associated bloodstream infection (CABSI) including catheter-related bloodstream infection (CRBSI), primary bacteremia (PB), and upper extremity deep vein thrombosis (UEDVT) were recorded. Independent predictors of complications were assessed by multivariate analysis. In total, 1,142 PICCs were inserted, with 153,191 catheter days (median, 79). Complications included 66 cases of CABSI (5.78%; 0.43‰ catheter days), 38 cases of CRBSI (3.33%; 0.25‰ catheter days), 28 cases of PB (2.45%; 0.18‰ catheter days), and 23 cases of UEDVT (2.01%; 0.15‰ catheter days). The median times to infection were 24, 41, and 60 days for CRBSI, PB, and UEDVT, respectively. Parenteral nutrition (odds ratio [OR], 3.40; 95% confidence interval [CI], 1.77-6.52) and admission to the hematology ward (OR, 4.90; 95% CI, 2.25-10.71) were independently associated with CRBSI and PB, respectively. Admission to the hematology ward (OR, 12.46; 95% CI, 2.49-62.50) or to the oncology ward (OR, 7.89; 95% CI, 1.77-35.16) was independently associated with UEDVT. The crude mortality rate was 24.8%. Only 2 patients died of complications. PICCs showed a low rate of thrombotic and infectious complications. Compared to PB, CRBSI showed significantly different risk factors, a higher incidence density per catheter days, and a shorter median time to infection. Separate analyses of CRBSI and PB are more specific and clinically useful when analyzing infectious complications.

One stent versus two stents for distal LM PCI: insights from the experience of a high volume center

Abstract Introduction Distal left main (LM) PCIremains a challenge. One of the most debated issues is whether to use a single vs 2 stent provisional strategy. While most studies and guidelines favour a single stent strategy, the recent DK-CRUSH V trial has shown better results with a 2 stent strategy. Objective To evaluate the performance of a single vs dual stent strategy for LM PCI in a real-world population setting. Methods Single-center procedural prospective registry of patients (pts) submitted to LM PCI from 2015–2018, with retrospective event analysis. Demographic, clinical data and procedure characteristics were analysed. Results were obtained with χ2 test, T student test, Kaplan-Meier survival analysis, logistic and Cox regression. Results 100 pts (73 men; 69±11 years) were included. Co-morbidities were very frequent (85 had hypertension, 54 had diabetes, 71 had dyslipidemia and 39 were past smokers). 32 had reduced LVEF (&amp;lt;40%) and 45 previous CABG. The decision to proceed to PCI vs surgery was undertaken individually by the local HeartTeam. Most of the procedures (57) were in an acute coronary syndrome setting (11 in STEMI, 7 with cardiogenic shock). The anatomical distribution of the lesions was: distal in 69 pts (61 involved the LAD and or Cx ostium), mid shaft in 7 pts, ostial in 18 pts and diffuse in 6 pts. Protected left main PCI encompassed 41% of the procedures. The complication rate was 7%. During a mean follow-up of 866±400 days, there were 4 peri-procedural deaths, 1-year mortality rate of 10% and 22 pts died overall. In pts submitted to distal LM PCI, a single stent was used in 49 pts (66%) versus a 2 stent approach in 23 pts (31%). The only significant difference between these groups were diabetes (66% in the single stent vs 32% in the 2 stent group, p=0.006) and protected LM (51% in the single stent vs 26.1% in the two stent group, p=0.046). While a 2 stent strategy was associated with higher mortality by Kaplan Meyer analysis (LogRank = 11.07, p=0.001), it was not an independent predictor of mortality in Cox regression. Cox univariate analysis identified LVEF &amp;lt;40% (OR 2.2, CI 1.01–4.9, p=0.047) and complications (OR 3.1, CI 1.4 – 6.9, p=0.004) as the only predictors of death. In multivariate analysis, only the latter was an independent predictor of mortality (OR 2.6, IC 1.1–5.9, p=0.028). The use of a 2 stent strategy was significantly associated with complications (χ2=5.1 p=0.024)) and was the only independent predictor of it (OR 3.8, IC 1.1–12.8, p=0.03). This was true even in the subgroup of protected LM PCI. Conclusion In a real-world setting of challenging LM PCI cases, a single stent strategy for distal LM PCI performed better. The use of 2 stents was an independent predictor of complications, strongly associated with increased risk of death. While a LM PCI must be undertaken on an individual basis, a single stent provisional strategy, whenever feasible, seems to be the best option. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Hospita Santa Maria

Impact of hyperglycaemia on complications in patients who had a stroke after thrombolysis

BackgroundWe sought to investigate whether admission hyperglycaemia is associated with complications in patients who had an acute ischaemic stroke (AIS) treated with intravenous recombinant tissue plasminogen activator and, if so,...

Are outpatient three- and four-level anterior cervical discectomies and fusion safe?

BACKGROUND CONTEXTThe safety of outpatient one- and two-level anterior cervical discectomy and fusion (ACDF) has been validated in a number of recent studies. However, recent advancements in anesthetic and surgical technique have rendered procedures previously only performed in an inpatient setting, such as three- and four-level ACDF, potentially amenable to outpatient management. PURPOSEThe present study aimed to investigate the safety of outpatient three- and four-level ACDF. STUDY DESIGNRetrospective cohort study PATIENT SAMPLEThe National Surgical Quality Improvement Program – a large, prospectively-collected registry – was queried to identify patients undergoing three- and four-level ACDF in an inpatient and outpatient setting. OUTCOME MEASURESThe rates of total complications, perioperative blood transfusion, and unplanned hospital readmission in three- and four-level ACDF by inpatient or outpatient surgery status. METHODSBaseline patient characteristics and 30-day outcomes were tabulated and compared by inpatient or outpatient status using bivariate analysis. A multivariate analysis was also employed to adjust for differences in baseline patient characteristics when comparing outcomes, and was also used to identify independent predictors of complications and readmissions in patients undergoing three- and four-level ACDF. RESULTSIn total 3,441 patients underwent three- or four-level ACDF, with 2,718 (79.0%) procedures occurring inpatient and 723 (21.0%) outpatient. Of patients undergoing outpatient ACDF, 596 patients (82.4%) underwent a three-level and 127 patients (17.6%) underwent four-level procedures. There was an increase in the utilization of outpatient procedures, increasing from 7.0% to 32.9% between 2011 and 2018. Patients undergoing outpatient surgery were younger, white, more likely to have three-level fusions (vs four-level), had a lower American Society of Anesthesiologists (ASA) classification, and were less likely to have a history of diabetes mellitus or dependent functional status. Among the inpatient and outpatient cohorts, there was no significant difference in the rates of total complications (4.49% vs 2.49%) or unplanned readmissions (4.96% vs 3.72%). Increasing age, operative duration, and ASA classification were independent predictors of complications and readmissions, however, inpatient or outpatient surgery status and number of levels fused was not. CONCLUSIONSThis present study represents one of the largest cohorts of patients undergoing outpatient three- and four-level ACDF. Outpatient multilevel ACDF is performed in younger and healthier patients, with three-level procedures more commonly the four-level. There was no observed increased rates of total complications or readmissions in patients undergoing outpatient relative to inpatient surgery, however, we did identify increased age, operative duration, and ASA classification as independent predictors of these complications. Patient selection for outpatient procedures is of the highest importance, and future studies developing reproducible selection criteria are warranted.

Risk Factors Associated With Adverse Outcomes After Ventral Hernia Repair With Component Separation

BackgroundOver 350,000 surgeries are performed for ventral hernias (VHs) annually. Abdominal wall component separation has been more frequently used for the management of VHs. The goal of this study is to better understand factors associated with component separation complication rates. MethodsThe National Inpatient Sample (2005-2014) was used to identify all patients with an International Classification of Diseases ninth Revision diagnosis of VHs who underwent open VH repair with a pedicleor graft advancement flap. All cases included in this study were elective and not associated with additional procedures. Demographic, clinical, and hospital characteristics were extracted. Independent predictors of complications and outcomes were determined by multivariable regression analysis. ResultsComponent separation was performed in 4346 patients. Mean age was 56; majority were female (55%) and white (80%). Most patients (73%) underwent surgery in an urban teaching hospital; mesh was used in 80% of cases and 11% were smokers. Hypertension was the most common comorbidity (50%), followed by obesity (26%), diabetes mellitus (DM) (23%), coronary artery disease (11%), and chronic obstructive pulmonary disease (COPD) (8%). Half of the patients (50%) had private insurance, and 35% had Medicare. Patients were distributed equally over household income quartiles. The mortality rate was 0.5%; median length of stay was 5 d. Overall complication rate was 25% (wound 11%, intraoperative 5%, infectious 11%, and pulmonary 8%). Mesh was associated with a lower rate of wound complications (10% versus 15%, P = 0.001). On multivariable analysis, patients with COPD (odds ratio: 2.02; 95% confidence interval: 1.58-2.59), obesity (1.37; 1.16-1.63), DM (1.3; 1.09-1.55), and those in the lowest income quartile (1.44; 1.06-1.96) had higher overall complication rates. ConclusionsConsistent with other studies, patients with COPD, Obesity, DM, and lower income status were associated with increased complications after component separation.

Do-Not-Resuscitate status is an independent risk factor for medical complications and mortality among geriatric patients sustaining hip fractures

BackgroundThe purpose of this study was to compare outcomes after hip fracture surgery between DNR/DNI and full code cohorts to determine whether DNR/DNI status is an independent predictor of complications and mortality within one year. A significant number of geriatric hip fracture patients carry a code status designation of DNR/DNI (Do-Not-Resuscitate/Do-Not-Intubate). There is limited data addressing how this designation may influence prognosis. MethodsA retrospective chart review of all geriatric hip fractures treated between 2002 and 2017 at a single level-I academic trauma center was performed. 434 patients were eligible for this study with 209 in the DNR/DNI cohort and 225 in the full code cohort. The independent variable was code-status and dependent variables included patient demographics, surgery performed, American Society of Anesthesiologists, score, Charlson Comorbidity Index, significant medical and surgical complications within one year of surgery, duration of follow-up by an orthopaedic surgeon, duration of follow-up by any physician, and mortality within 1 year of surgery. One-year complication rates were compared, and multiple logistic regression analyses were performed to analyze the relationship between independent and dependent variables. ResultsThe DNR/DNI cohort experienced significantly more surgical complications compared to the full code cohort (14.8% vs 7.6%, p = 0.024). There was a significantly higher rate of medical complications and mortality in the DNR/DNI cohort (57.9% vs 36%, p < 0.001 and 19.1% vs 3.1%, p = 0.037, respectively). In the regression analysis, DNR/DNI status was an independent predictor of a medical complication (odds ratio 2.33, p = 0.004) and one-year mortality (odds ratio 9.69, p < 0.001), but was not for a surgical complication (OR 1.95, p = 0.892). ConclusionsIn our analysis, DNR/DNI code status was an independent risk factor for postoperative medical complications and mortality within one year following hip fracture surgery. The results of our study highlight the need to recognize the relationship between DNR/DNI designation and medical frailty when treating hip fractures in the elderly population.