Independent Risk Factors For Failure Research Articles

Pain is an Independent Risk Factor for Failed Global Endometrial Ablation

Study ObjectiveTo determine whether pain, as part of an indication for global endometrial ablation, is an independent risk factor for failure. DesignRetrospective cohort study (Canadian Task Force classification II-2). SettingAcademic-affiliated community hospital. PatientsWomen undergoing global endometrial ablation with radiofrequency ablation (RFA), hydrothermablation (HTA), or uterine balloon ablation (UBA) between January 2003 and December 2015. InterventionsProcedure failure was defined as subsequent hysterectomy after the index ablation. Measurements and Main ResultsA total of 5818 women who underwent an endometrial ablation were identified, including 3706 with RFA (63.7%), 1786 with HTA (30.7%), and 326 with UBA (5.6%). Of the 5818 ablations, 437 (7.5%) involved pain (i.e., pelvic pain, dysmenorrhea, dyspareunia, lower abdominal pain, endometriosis, or adenomyosis) before ablation, along with abnormal uterine bleeding. Pain as part of the preoperative diagnoses before endometrial ablation was a significant risk factor for subsequent hysterectomy compared with all other diagnoses (19.2% vs 13.5%; p = .001). Consistent with previous studies, women who underwent ablation at an older age were less likely to fail, which held true even when one of the indications for ablation was related to pain (odds ratio, 0.96/year; 95% confidence interval, 0.95–0.97). When the pathology reports of women who underwent a hysterectomy were examined, women in the pain group had lower rates of adenomyosis than women without pain (38.1% vs 50.1%; p = .04). However, there was a trend toward a higher rate of endometriosis on pathology reports (14.3% vs 8.7%; p = .09) and even higher rates of visualized endometriosis identified by operative reports in women who had pain before their ablation (42.9% vs 15.8%; p < .001). Patients who had pain before their ablation were less likely to have myomas/polyps (p = .01). ConclusionPelvic pain before global endometrial ablation is an independent risk factor for failure.

Reamer-Irrigator-Aspirator bone graft harvesting for treatment of segmental bone loss: analysis of defect volume as independent risk factor for failure.

The management of segmental bone loss poses a significant clinical challenge. The purpose of this study was to conduct a retrospective evaluation of our experience in treating segmental bone loss, using Reamer-Irrigator-Aspirator (RIA)-harvested autologous bone graft. Between June 2008 and March 2015, 81 patients were treated with the RIA technique for multiple purposes. Inclusion criteria for this study were skeletal mature patients with segmental bone loss, due to acute trauma or non-union, who were treated with RIA-harvested bone graft. Exclusion criteria were skeletal immaturity, pathological fractures and indications for the RIA system other than bone graft harvesting. The primary outcome parameter was clinical and radiographical bone healing. During the study period, 72 patients met the inclusion criteria. In total, 39 patients (54.2%) were classified as having clinical and radiographical bone healing. Although univariate analysis could not reveal any significant influence of specific risk factors to predict the outcome, there was a trend towards statistical significance for defect volume. Further analysis indeed revealed that smaller defect volumes (<8cm3) had a lower risk of non-union. In approximately half of our study population, the use of the RIA technique for autologous bone graft harvesting in cases of segmental bone loss resulted in a successful outcome with bone healing. Defect size seems to be a critical issue regarding the outcome. Although our results are less promising than previously published, the RIA technique has its place in the treatment algorithm of segmental bone defects.

SMOKING IS A RISK FACTOR FOR PROLIFERATIVE VITREORETINOPATHY AFTER TRAUMATIC RETINAL DETACHMENT.

To determine the incidence of retinal redetachment due to proliferative vitreoretinopathy after open-globe trauma in smokers and nonsmokers. A total of 892 patients comprising 893 open-globe injuries, in whom 255 eyes were diagnosed with a retinal detachment, and 138 underwent surgical repair were analyzed in a retrospective case-control study. Time to redetachment was examined using the Kaplan-Meier method and analysis of risk factors was analyzed using Cox proportional hazards modeling. Within one year after retinal detachment surgery, 47% (95% CI, 39-56%) of all 138 repaired retinas redetached because of proliferative vitreoretinopathy. Being a smoker was associated with a higher rate of detachment (adjusted hazard ratio 1.96, P = 0.01). As shown in previous studies, the presence of proliferative vitreoretinopathy at the time of surgery was also an independent risk factor for failure (adjusted hazard ratio 2.13, P = 0.005). Treatment with vitrectomy-buckle compared favorably to vitrectomy alone (adjusted hazard ratio 0.58, P = 0.04). Only 8% of eyes that redetached achieved a best-corrected visual acuity of 20/200 or better, in comparison to 44% of eyes that did not redetach (P < 0.001). Proliferative vitreoretinopathy is a common complication after the repair of retinal detachment associated with open-globe trauma, and being a smoker is a risk factor for redetachment. Further study is needed to understand the pathophysiologic mechanisms underlying this correlation.

Histopathological analysis of cold snare polypectomy and its indication for colorectal polyps 10-14 mm in diameter.

Cold snare polypectomy (CSP) is commonly used for treating colorectal polyps <10 mm in diameter. We evaluated the analysis and safety of CSP for larger polyps. We retrospectively analyzed 1006 colorectal polyps resected with CSP. Indication for CSP was polyps 2-14 mm that were diagnosed as benign neoplastic polyp by magnifying endoscopy. Various clinicopathological characteristics were analyzed. Multivariate analyses were used to determine the independent risk factors for failure of complete CSP resection. With respect to polyp size, we compared the therapeutic outcomes between polyps <10 mm and ≥10 mm. Additionally, the presence of muscularis mucosa in resected specimens was analyzed. Rates of en bloc resection and postoperative hemorrhage were 98.8% and 0.1%, respectively. Seven hundred and ninety-one neoplastic lesions were analyzed and negative margins were found in 70.5% of the lesions, Multivariate analysis showed that non-polypoid morphology, histology of intramucosal cancer + high-grade adenoma and sessile serrated adenoma and polyp were significant factors for incomplete resection. With respect to the difference between lesions ≥10 mm than in those <10 mm, rates of cancer and positive/unclear margins were significantly higher (5.0% vs 0.9%, P < 0.001; 40.6% vs 27.7%, P = 0.007) in the ≥10 mm with rates of postoperative hemorrhage not significantly different (0.8% vs 0.0%). Additionally, the loss of muscularis mucosa was found in 27.8% of all lesions. CSP is a safe procedure for polyps 2-14 mm. However, CSP has limitations in terms of the histopathological margin and loss of muscularis mucosa in specimens.

Factors influencing failure to rescue after pancreaticoduodenectomy: a National Surgical Quality Improvement Project Perspective

BackgroundFailure to rescue is the concept of death after a complication, and it is an important factor driving variation in mortality rates after pancreatic surgery. The purpose of this study was to conduct a retrospective review of a large, multi-institutional data set to describe patient-level risk factors for failure to rescue in greater detail. MethodsFrom the American College of Surgeons National Surgical Quality Improvement Program participant use file, 14,557 patients who underwent pancreaticoduodenectomy were identified. Of these, 4514 experienced at least one complication and were therefore at risk for failure to rescue. Multivariable logistic regression models to identify factors independently associated with failure to rescue. ResultsAge, American Society of Anesthesiologists class, ascites and/or varices, and disseminated malignancy were significant independent risk factors for failure to rescue. Participation of a resident was associated with reduced odds of failure to rescue. Patients who experienced an initial complication and then accumulated additional complications were more common in the failure to rescue group (68.6% versus 31.3%, P < 0.001). ConclusionsAccumulation of complications after pancreaticoduodenectomy is a significant risk factor for failure to rescue. Pancreatic surgery quality improvement programs should continue developing strategies to identify and intervene on post-pancreatectomy complications, especially in high-risk patients.

Treatment of esophageal anastomotic leakage with self-expanding metal stents: analysis of risk factors for treatment failure

Background and study aim: The endoscopic placement of self-expandable metallic esophageal stents (SEMS) has become the preferred primary treatment for esophageal anastomotic leakage in many institutions. The aim of this study was to investigate possible risk factors for failure of SEMS-based therapy in patients with esophageal anastomotic leakage. Patients and methods: Beginning in 2003, all patients with an esophageal leak were initially approached and assessed for temporary closure with a SEMS. Until 2014, all patients at the Karolinska University Hospital with a leak from an esophagogastric or esophagojejunal anastomosis were identified. Data regarding the characteristics of the patients and leaks and the treatment outcomes were compiled. Failure of the SEMS treatment strategy was defined as death due to the leak or a major change in management strategy. The risk factors for treatment failure were analyzed with simple and multivariable logistic regression statistics. Results: A total of 447 patients with an esophagogastric or esophagojejunal anastomosis were identified. Of these patients, 80 (18 %) had an anastomotic leak, of whom 46 (58 %) received a stent as first-line treatment. In 29 of these 46 patients, the leak healed without any major change in treatment strategy. Continuous leakage after the application of a stent, decreased physical performance preoperatively, and concomitant esophagotracheal fistula were identified as independent risk factors for failure with multivariable logistic regression analysis. Conclusion: Stent treatment for esophageal anastomotic leakage is successful in the majority of cases. Continuous leakage after initial stent insertion, decreased physical performance preoperatively, and the development of an esophagotracheal fistula decrease the probability of successful treatment.

Success of Bubble CPAP in Treatment of Respiratory Distress Syndrome in Preterm Infants

Background: To observe the survival of preterm infants with respiratory distress syndrome treated with bubble CPAP in a tertiary care hospital. Methods: This prospective observational study was conducted in the NICU of Civil hospital Sukkur from 1st July 2013 to 18th August 2015. All consecutively born preterm neonates with gestational age between 27 weeks to 36 weeks of gestation, admitted to the neonatal intensive care unit with respiratory distress are included in the study. These neonates were managed by Bubble continuous positive airway pressure (bCPAP) in combination with surfactant (bovine derivative) via intubation, Surfactant replacement, extubation (INSURE) protocol Success was considered when neonates were clinically stable and required 90% and PaCO2 <40-45 mmHg. Results: Mean age of enrolled infants was 1.35 ± 0.60 days, 70 (57.9%) were males and 51 (42.1%) were female, mean weight was 1.76 ± 0.37 kg and mean gestational age was 33 ± 2.3 weeks. Overall 77 (63.6%) preterm infants were successfully weaned off from CPAP. Multivariable analysis showed weight of infant less than 1.5 kg or 8.63 (95% CI: 1.71-43.57), respiratory rate of more than 70 breaths per minute, or 9.59 (95% CI: 2.59-35.52), nasal flaring or 3.35 (95% CI: 1.08-10.31) and typical findings of RDS on chest X-rays 12.04 (95% CI: 1.89-76.52) are independent risk factors for failure of bCPAP. However, gestational age 0.70 (95% CI: 0.54-0.89) is protective against failure. Conclusion: bCPAP has a high proportion of success in the management of respiratory distress syndrome in preterm. It could be most useful in resource-constrained settings.

Association between Body Mass Index and Sputum Culture Conversion among South Korean Patients with Multidrug Resistant Tuberculosis in a Tuberculosis Referral Hospital

BackgroundMultidrug-resistant tuberculosis (MDR-TB) is an important global health problem. Furthermore, the time to identify a positive sputum culture is an important risk factor for the spread of tuberculosis, and several factors can predict a prolonged time to culture conversion. Moreover, the relationship between poor nutritional status and infectious disease is clearly established. Therefore, the present study aimed to investigate the association between body mass index (BMI) and sputum culture conversion within 3 months among patients with MDR-TB.Materials and MethodsWe retrospectively evaluated 218 patients with MDR-TB who were treated at a large tuberculosis referral hospital in South Korea between January 2005 and December 2010. The outcome of interest was defined as sputum culture conversion within 3 months, and we analyzed the association between BMI and this outcome.ResultsAmong the 218 patients, 53 patients (24.3%) had a low BMI (<18.5 kg/m2). In the multivariate Cox proportional-hazards regression analysis, failure to achieve sputum culture conversion within 3 months was independently associated with having a low BMI (hazard ratio [HR]: 1.741, 95% confidence interval [CI]: 1.006–3.013; P = 0.047) and a positive sputum smear at the initiation of therapy (HR: 8.440, 95% CI: 1.146–62.138, P = 0.036).ConclusionLow BMI (<18.5 kg/m2) was an independent risk factor for failure to achieve sputum culture conversion within 3 months among patients with MDR-TB.

Risk factors for failure of repeat midurethral sling surgery for recurrent or persistent stress urinary incontinence.

To study the outcomes following repeat midurethral sling (MUS) surgery in patients with persistent or recurrent stress urinary incontinence after failure of primary MUS surgery and risk factors for surgical failure. The medical records of 24 patients who underwent repeat MUS surgery at a single tertiary center from January 2004 to February 2014 were reviewed. The types of MUS used for the repeat surgey were transobturator, retropubic and single incision slings. Objective cure was defined as no demonstrable involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction observed during filling cystometry, and subjective cure was defined as a negative response to Urogenital Distress Inventory six (UDI-6) question 3 during follow-up between 6months and 1year postoperatively. The change in the inclination angle between the urethra and pubic axis was measured with introital ultrasonography and the cotton swab test performed. The objective and subjective cure rates were 79.2% and 75%, respectively. There were no differences in demographics between the patients with failure of surgery and those with successful surgery. Significant independent risk factors for failure of repeat MUS surgery were a change in cotton swab angle at restand straining of <30° (OR 4.6, 95% CI 2.5-7.9°), a change in inclination angle of <30° (OR 4.6, 95% CI 2.5-7.9°), intrinsic sphincter deficiency (OR 3.4, 95% CI 1.8-6.1) and a mean urethral closure pressure of <60 cmH2O (OR 2.9, 95% CI 1.5-4.5). In one patient the bladder was perforated. Repeat MUS surgery is safe and has a good short-term success rate, both objectively and subjectively, with independent risk factors for failure related to bladder neck hypomobility and poor urethral function.

Independent Risk Factors for Failure of Nonoperative Management in Patients with Splenic Injury

Objective: It is crucial to assess non-operative management (NOM) of risk failures before it is preferred as a management option for treatment of splenic trauma or rupture. The purpose of this study is to investigate the outcome of non-operative management of splenic trauma, and to determine the independent predictive factors effecting NOM failure. Material and Methods: Seventy-seven patients among all of consecutive patients admitted with splenic trauma between January 2005 and June 2015 were included in the study. The patients were divided into two groups. Group 1: Successfully treated with non-operative management, and Group 2: The failure of non-operative management. Data recorded included patient demographics, vital signs, injury mechanism, Injury Severity Score (ISS), splenic trauma grade, hematologic parameters, Glasgow Coma Scale (GCS), transfusion requirements, and length of hospital stay. Results: There were 66 (85.7 %) patients in group 1, while only 11 patients (14.3%) in group 2. Mechanism of injury was blunt in seventy-one patients and, penetrating in 6 patients. ISS [Odds Ratio=1.293; 95% CI=1.045-1.601; p=0.018] and blood transfusion [Odds Ratio=2,739; 95% CI= 1.140-6,581; p=0.024] were detected to be an independent predictive factors for the failure of non-operative management. Group 1 has significantly higher hospitalization period (7.73±2.867 vs 6.67±2.289). Conclusions: Non-operative management failure risk is crucial and higher in patients with high ISS and in patients who require much blood transfusion in first 24 hours. Special attention should be paid to these patients if non-operative management becomes the preferred management option.

Is It Possible to Predict the Failure of Noninvasive Mechanical Ventilation for Acute Respiratory Failure Due to Pneumonia?

SESSION TITLE: Chest Infections Posters I SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM PURPOSE: Non-invasive mechanical ventilation (NIMV) treatment in patients with acute hypoxemic respiratory failure due to pneumonia are controversial. The aim of this study is to determine the prognosis, failure rate of NIMV and risk factors for intubation in these patients. METHODS: Patients who were treated with NIMV for acute respiratory failure due to pneumonia in our intensive care unit (ICU) were assessed retrospectively. Demographic, clinical characteristics and laboratory results of patients were recorded. RESULTS: Eighty four patients (29 female, age 67 years, APACHE II score 17.5±7.0, median PaO2/FiO2 rate 222) were included in this study. NIMV was started on the first day after admission to ICU. The acute respiratory failure develpoed due to community, hospital acquired, healthcare associated pneumonia and pneumonia in immunocompromised patients (29.8%, 22.6%, 16.7%, 29.8%, respectively). 59.5% of patients were intubated on the second day because of failure of NIMV. In the patients of of whom the NIV failed, the baseline APACHE II score, respiratory rate and EPAP level were higher (p=0.008, p=0.001, p=0.002, respectively) and PaO2/FiO2 rate, hemoglobine, albumin levels were lower (p=0.001, p=0.001, p=0.001, respectively). The mortality rate due to acute respiratory failure was 58.3%. Hemoglobine level of <10 g/dl, existence of ARDS, absence of COPD and administration of vasopressor treatment were found to be independent risk factors for failure of NIMV (OR values were 11.09, 5.61, 6.17, 33.93 respectively) . CONCLUSIONS: NIMV can be applied to the patients who have acute hypoxemic respiratory failure due to pneumonia. However, there is a probability of failure of NIMV due to anemia, development of ARDS and baseline requirement for vasopressor treatment at baseline. CLINICAL IMPLICATIONS: NIMV can be used for the treatment of acute hypoxemic respiratory failure due to pneumonia. On the other hand, some factors such as aneima, existence of ARDS and vasopressor treatment at baseline may cause the failure of NIMV. Therefore, while applying NIMV in this group of patients, they should be monitored carefully. DISCLOSURE: The following authors have nothing to disclose: ALEV GURGUN, Imren Nesil, Pervin Korkmaz Ekren, Funda Elmas Uysal, Feza Bacakoglu No Product/Research Disclosure Information

Utility of the Instability Severity Index Score in Predicting Failure After Arthroscopic Anterior Stabilization of the Shoulder

Background: The redislocation rate after arthroscopic stabilization for anterior glenohumeral instability is up to 30%. The Instability Severity Index Score (ISIS) was developed to preoperatively rationalize the risk of failure, but it has not yet been validated by an independent group. Purpose: To assess the utility of the ISIS in predicting failure of arthroscopic anterior shoulder stabilization and to identify other preoperative factors for failure. Study Design: Case-control study; Level of evidence, 3. Methods: A case-control study was performed on 141 consecutive patients, comparing those who suffered failure of arthroscopic stabilization with those who had successful arthroscopic stabilization. The mean follow-up time was 47 months (range, 24-132 months). The ISIS was applied retrospectively, and an analysis was performed to establish independent risk factors for failure. A receiver operator coefficient curve was constructed to set a threshold ISIS for considering alternative surgery. Results: Of 141 patients, 19 (13.5%) suffered recurrent instability. The mean ISIS of the failed stabilization group was higher than that of the successful stabilization group (5.1 vs 1.7; P < .001). Independent risk factors for failure were Hill-Sachs lesion (P < .001), glenoid bone loss (P < .001), age <21 years at the time of surgery (P < .001), age at first dislocation (P = .01), competitive-level participation in sports (P < .001), and participation in contact or overhead sports (P = .03). The presence of glenoid bone loss carried the highest risk of failure (70%). There was a 70% risk of failure if the ISIS was ≥4, as opposed to a 4% risk of failure if the ISIS was <4. Conclusion: This is the first completely independent study to confirm that the ISIS is a useful preoperative tool. It is recommended that surgeons consider alternative forms of stabilization if the ISIS is ≥4.

Predictors of failure in the Advanced Trauma Life Support course

BackgroundOver 1 million healthcare providers have participated in the Advanced Trauma Life Support course. No studies have evaluated factors that predict course performance. This study aims to identify these predictors. MethodsAll participants taking the course at 2 centers over a 4-year period were identified. Demographics, background, and performance data were extracted. Participants who failed were compared with those who did not. Stepwise logistic regression analysis was used to identify independent risk factors for failure. ResultsSeven hundred forty-four healthcare providers participated in the course; 89.5% passed and 10.5% failed. Failure rates were lowest (.0%) among Trauma/Surgical Critical Care (SCC) providers and highest among pediatric providers (28.6%). Stepwise logistic regression identified age greater than 55, English as a second language, pretest score less than 75, and non-Trauma/SCC and non-Emergency Medicine background as predictors of failure. ConclusionsA failure rate of 10.5% was demonstrated among the course participants. Age greater than 55, English as second language, pretest score less than 75, and non-Trauma/SCC and non-Emergency Medicine backgrounds were associated with failure. These subgroups may benefit from performance improvement measures.

Clinical and economic consequences of failure of initial antibiotic therapy for patients with community-onset complicated intra-abdominal infections.

ObjectivesComplicated intra-abdominal infection (cIAI) is infection that extends beyond the hollow viscus of origin into the peritoneal space, and is associated with either abscess formation or peritonitis. There are few studies that have assessed the actual costs and outcomes associated with failure of initial antibiotic therapy for cIAI. The aims of this study were to evaluate risk factors and impact on costs and outcomes of failure of initial antibiotic therapy for community-onset cIAI.MethodsA retrospective study was performed at eleven tertiary-care hospitals. Hospitalized adults with community-onset cIAI who underwent an appropriate source control procedure between August 2008 and September 2011 were included. Failure of initial antibiotic therapy was defined as a change of antibiotics due to a lack of improvement of the clinical symptoms and signs associated with cIAI in the first week.ResultsA total of 514 patients hospitalized for community-onset cIAI were included in the analysis. The mean age of the patients was 53.3 ± 17.6 years, 72 patients (14%) had health care-associated infection, and 48 (9%) experienced failure of initial antibiotic therapy. Failure of initial antibiotic therapy was associated with increased costs and morbidity. After adjustment for covariates, patients with unsuccessful initial therapy received an additional 2.9 days of parenteral antibiotic therapy, were hospitalized for an additional 5.3 days, and incurred $3,287 in additional inpatient charges. Independent risk factors for failure of initial antibiotic therapy were health care-associated infection, solid cancer, and APACHE II ≥13.ConclusionsTo improve outcomes and costs in patients with community-onset cIAI, rapid assessment of health care-associated risk factors and severity of disease, selection of an appropriate antibiotic regimen accordingly, and early infection source control should be performed.

Colonization of Klebsiella pneumoniae Inside Fistula Tracts

This study was designed to investigate the risk factors affecting glue-assisted closure (GAC) in the enterocutaneous fistula (ECF) patients receiving glue application. ECF is a challenging problem in surgical practice, and it is difficult to resolve by spontaneous closure. Currently, GAC is popular when treating fistulas, but data related to risk factors are limited. We retrospectively analyzed 82 patients with 93 ECFs, who had autologous glue sealing from 2010 to 2012 in a referral center. Their demographic data, clinical records, and fistula characteristics were collected. Both univariate analysis and multivariate Cox proportional hazards model were used to determine the prognostic factors affecting closure. During the 14-day treatment period, 78.5% (73/93) of the fistulas achieved GAC. We excluded 3 reopened fistulas and investigated 90 ECFs from 79 patients. Univariate analysis demonstrated that patients with high levels of CRP, high CRP:prealbumin ratio, elevated blood glucose, and specific pathogen colonization, together with lower GI location, greater output volume, and shorter tract length, had a poor outcome (P<0.05). Using multivariate analysis, monomicrobial and polymicrobial colonization with Klebsiella pneumoniae inside the fistula tracts (hazard ratio, 0.191; 95% confidence interval, 0.045-0.810; P=0.025) was a statistically significant risk factor for failure of fistula closure. The presence of monomicrobial and polymicrobial colonization with K. pneumoniae in fistulous tracts was an independent risk factor for failure of GAC in patients receiving glue application. Better debridement of the tracts should be performed before the glue sealing.

Synergistic impact of acute kidney injury and high level of cervical spinal cord injury on the weaning outcome of patients with acute traumatic cervical spinal cord injury

IntroductionRespiratory neuromuscular impairment severity is known to predict weaning outcome among patients with cervical spinal cord injury; however, the impact of non-neuromuscular complications remains unexplored. This study was to evaluate possible neuromuscular and non-neuromuscular factors that may negatively impact weaning outcome. MethodsFrom September 2002 to October 2012, acute traumatic cervical spinal cord injury patients who had received mechanical ventilation for >48h were enrolled and divided into successful (n=54) and unsuccessful weaning groups (n=19). Various neuromuscular, non-neuromuscular factors and events during the intensive care unit stay were extracted from medical charts and electronic medical records. Variables presenting with a significant difference (p<0.2) between these two groups were included in the univariate analysis. Following univariate analysis, those significantly different variables (p<0.05) were subjected to multivariate logistic regression to identify independent predictors of unsuccessful weaning. ResultsCompared to successful weaning patients, unsuccessful weaning patients were older; more often had high level of cervical spinal cord injury (C1–3), lower pulse rates, and lower Glasgow Coma Scale score on admission, higher peak blood urea nitrogen, lower trough albumin, and lower trough blood leukocyte counts. Furthermore, unsuccessful weaning patients had a higher incidence of pneumonia, acute respiratory distress syndrome, shock and acute kidney injury during the intensive care unit stay. Multivariate logistic regression analysis revealed acute kidney injury and high level of cervical spinal cord injury were independent risk factors for failure of weaning. Importantly, patients with both risk factors showed a large increase in odds ratio for unsuccessful weaning from mechanical ventilation (p<0.001). ConclusionsThe presence of acute kidney injury during the intensive care unit stay and high level of cervical spinal injury are two independent risk factors that synergistically work together producing a negative impact on weaning outcome.

Effectiveness of conservative therapy and helmet therapy for positional cranial deformation.

The authors investigated the effectiveness of conservative (repositioning therapy with or without physical therapy) and helmet therapy, and identified factors associated with treatment failure. A total of 4378 patients evaluated for deformational plagiocephaly and/or deformational brachycephaly were assigned to conservative (repositioning therapy, n = 383; repositioning therapy plus physical therapy, n = 2998) or helmet therapy (n = 997). Patients were followed until complete correction (diagonal difference <5 mm and/or cranial ratio <0.85) or 18 months. Rates of correction were calculated, and independent risk factors for failure were identified by multivariate analysis. Complete correction was achieved in 77.1 percent of conservative treatment patients; 15.8 percent required transition to helmet therapy (n = 534), and 7.1 percent ultimately had incomplete correction. Risk factors for failure included poor compliance (relative risk, 2.40; p = 0.009), advanced age (relative risk, 1.20 to 2.08; p = 0.008), prolonged torticollis (relative risk, 1.12 to 1.74; p = 0.002), developmental delay (relative risk, 1.44; p = 0.042), and severity of the initial cranial ratio (relative risk, 1.41 to 1.64; p = 0.044) and diagonal difference (relative risk, 1.31 to 1.48; p = 0.027). Complete correction was achieved in 94.4 percent of patients treated with helmet therapy as first-line therapy and in 96.1 percent of infants who received helmets after failed conservative therapy (p = 0.375). Risk factors for helmet failure included poor compliance (relative risk, 2.42; p = 0.025) and advanced age (relative risk, 1.13 to 3.08; p = 0.011). Conservative therapy and helmet therapy are effective for positional cranial deformation. Treatment may be guided by patient-specific risk factors. In most infants, delaying helmet therapy for a trial of conservative treatment does not preclude complete correction. Therapeutic, III.

Damage Control Resuscitation Protocol and the Management of Open Abdomens in Trauma Patients

Although the use of damage control laparotomy (DCL) is well established, the effect of damage control resuscitation (DCR) on the management of open abdomens is relatively poorly studied. The aim of the present study was to determine the predictors for failure to achieve primary fascial closure (PFC) after DCL in the setting of a massive transfusion (MT) and DCR. This is a retrospective review over a 12-year period of all patients that underwent MT and DCL. Patients who achieved PFC were compared with those who did not (NPFC). Student's t tests were used to compare the two groups. A multiple logistic regression model was performed to identify independent risk factors for failure to attain PFC. Of 174 patients, 101 achieved PFC. Mean (± standard deviation) age was 35.6 ± 14.9 years for PFC and 36.3 ± 14.0 years for NPFC (P = 0.75). Admission Glasgow Coma Scale score was 11.4 ± 4.6 for PFC and 10.6 ± 5.0 for NPFC (P = 0.25). Initial lactate (7.3 ± 3.8 vs 7.7 ± 4.1, P = 0.50), hemoglobin (11.3 ± 1.9 vs 11.0 ± 2.2, P = 0.43), systolic blood pressure (108 ± 44 vs 107 ± 35, P = 0.82), Injury Severity Score (34 ± 14 vs 36 ± 15, P = 0.32), and abdominal Abbreviated Injury Score (3.6 ± 1.1 vs 3.9 ± 1.0, P = 0.13) were similar between the two groups. There was no difference in total blood products administered at 24 hours (46 ± 26 vs 49 ± 29 units, P = 0.45). Logistic regression identified increasing volume of crystalloid at 24 hours (odds ratio, 0.86; 95% confidence interval, 0.74 to 0.99; P = 0.047), earlier operative year (2.1; 1.52 to 2.91; P < 0.001), and increased number of procedures (0.32, 0.18 to 0.58; P < 0.001) as independent predictors for failure to obtain PFC. Injury severity is not associated with failure to achieve PFC, whereas administration of large-volume crystalloid resuscitation, increasing number procedures, and earlier year of DCL are independent predictors for failure to achieve PFC. Application of DCR to DCL techniques results in an improvement in ability to achieve PFC.

Interferon lambda-3 polymorphism and response to pegylated interferon in patients with hepatitis D.

Specific single nucleotide polymorphisms (SNPs) near the interferon lambda-3 (IFNλ3) gene (formerly interleukin 28B) influence the response to treatment with interferon in hepatitis C patients. We aimed to investigate such an influence in hepatitis D patients. The study population consisted of hepatitis D patients who were previously treated with pegylated interferon for one year and who were spontaneous clearers of the virus post recent superinfection. The SNP of IFNλ3, rs12979860, was determined by polymerase chain reaction-restriction fragment length polymorphism protocol. The total number of patients was 64; median age was 30.5 years and 53 were male. The number of patients with sustained virological response 1 year post-treatment was 17, non-responders 29, relapsers 11 and spontaneous clearers post superinfection 7. Cirrhosis was present in 28 (44%). IFNλ3, rs12979860 genotype CC, was present in 41 (64.1%), CT in 21 (32.8%) and TT in 2 (3.1%). There was no difference in the body mass index, baseline alanine aminotransferase, hepatitis B e antigen and HBV DNA status among patients with sustained response and response failure (no response or relapse). The median age of response failures was 33.5 years compared to 26 in responders (P=0.024). They had higher gamma glutamyl transferase levels (P=0.030) and cirrhosis (P=0.003). Genotype CC was present in 29/40 of response failures compared to 9/17 of the responders (P=0.152). Logistic regression analysis showed that cirrhosis was the independent risk factor for failure to have a response (P=0.001). 4/7 patients with spontaneous clearance had genotype CC. IFNλ3 rs12979860 SNP does not have any significant influence on long-term hepatitis D clearance. Presence of cirrhosis may influence the response.

Tumor progression during preoperative chemotherapy predicts failure to complete 2-stage hepatectomy for colorectal liver metastases: results of an Italian multicenter analysis of 130 patients.

We aimed to evaluate the feasibility and long-term results of 2-stage hepatectomy (TSH) in patients with bilobar colorectal liver metastases (CRLM). We performed a retrospective multicenter study including 4 Italian hepatobiliary surgery units. One hundred thirty patients were selected for TSH between 2002 and 2011. The primary endpoint was feasibility of TSH and analysis of factors associated with failure to complete the procedure. The secondary endpoint was the long-term survival analysis. Patients presented with synchronous CRLM in 80.8% of cases, with a mean number of 8.3 CRLM and with concomitant extrahepatic disease in 20.0% of cases. The rate of failure to complete TSH was 21.5% and tumor progression was the most frequent reason for failure (18.5% of cases). Primary tumor characteristics, type, number, and distribution of CRLM were not associated with significantly different risks of disease progression. Multivariable logistic regression analysis showed that tumor progression during prehepatectomy chemotherapy was the only independent risk factor for failure to complete TSH. The 5- and 10-year overall survival rates for patients who completed TSH were 32.1% and 24.1%, respectively, with a median survival of 43 months. Duration of prehepatectomy chemotherapy ≥6 cycles was found to be the only independent predictor of overall and disease-free survival. This study showed that selection of patients by response to prehepatectomy chemotherapy may be extremely important before planning TSH because tumor progression while receiving prehepatectomy chemotherapy was associated with significantly higher risk of failure to complete the second stage. For patients who completed the TSH strategy, long-term outcomes can be achieved with results similar to those observed after single-stage hepatectomy.