Known Risk Factors For Complications Research Articles

Obstetrics Outcomes: A Comparison between Birthing Center and Conventional Labor Ward

Introduction: Birthing Centers (BC) are increasingly accepted worldwide as an alternate low cost place of birth. The concept is especially relevant for developing countries with limited resources and constraints regarding availability of specialists and hospital beds. The various studies have concluded that when proper risk analyses are conducted and referral rules followed, there is no evidence of increased maternal or perinatal risk at BC compared to standard hospital deliveries. 
 Materials and Methods: This was a prospective, observational and comparative hospital based study done at Paropakar Maternity and Women’s Hospital (PMWH),Kathmandu. The study was conducted on pregnant women without any known risk factors for complications who were admitted in BC and labor ward (LW) for delivery. Details on mode of delivery, genital tract status, Postpartum hemorrhage (PPH) and neonatal outcomes were collected. Descriptive data analysis was done using SPSS. 
 Results: Out of 5132 deliveries, 25.3% had no known risk factor and hence were eligible for study; no statistically significant difference was observed between BC & LW in relation to mode of delivery, perineal trauma, PPH and neonatal outcomes; however, practice of episiotomy was significantly less frequent in BC. 
 Conclusion: When proper risk analyses are conducted and referral rules followed, there is no evidence of adverse obstetrics outcome at BC as compared to standard hospital deliveries. Triaging of low risk pregnancy to a BC is a viable strategy, especially in a resource poor country. This lessens the burden in standard maternity unit so that specialists will be able to provide a quality care to high risk pregnancies.

Spinal Anesthesia Associated With Increased Length of Stay Compared to General Anesthesia for Ankle Open Reduction Internal Fixation: A Propensity-Matched Analysis

General and spinal anesthesia are both utilized for patients undergoing open reduction internal fixation of the ankle, but there are little data comparing early complication rates. The purpose of this study was to compare duration of surgery, length of stay, and rates of postoperative adverse events within 30 days in patients undergoing open reduction internal fixation of ankle fracture using spinal versus general anesthesia. Adult patients who underwent open reduction internal fixation of a closed ankle fracture from 2012 to 2016 were retrospectively identified from American College of Surgeons National Surgical Quality Improvement Program. Duration of surgery, length of stay, 30-day adverse events, and unplanned readmissions were compared between patients who received general anesthesia and spinal anesthesia. Propensity adjustment with respect to known risk factors for complications and adjunctive regional block was used to match patients. Of the 10,795 patients included after applying the inclusion and exclusion criteria, 9862 (91.36%) received general anesthesia and 933 (8.64%) received spinal anesthesia. Using propensity-scored matching, 841 patients in the spinal cohort were matched to 3364 patients in the general cohort. Spinal anesthesia was associated with increased length of stay (+0.5 days, 95% confidence interval 0.23-0.77, p < .001). There were no differences in the rates of major/minor complications, mortality, transfusions, unplanned readmissions, or duration of surgery. General anesthesia is predominantly used for fixation of ankle fractures. While spinal anesthesia is associated with lower complication rates in hip and knee surgery, we found that it is associated with increased length of stay in patients undergoing open reduction internal fixation of the ankle within 30 days of surgery.

Does Staged Breast Reduction before Nipple-Sparing Mastectomy Decrease Complications? A Matched Cohort Study between Staged and Nonstaged Techniques.

Nipple-sparing mastectomy in patients with large, ptotic breasts is a reconstructive challenge. Staged breast reduction before prophylactic nipple-sparing mastectomy has been shown to decrease complications; however, a direct comparison of outcomes between staged and nonstaged techniques is lacking. A retrospective review of all patients that underwent staged breast reduction before nipple-sparing mastectomy was conducted. Staged cases were matched to nonstaged nipple-sparing mastectomy cases according to known risk factors for complications. Individual staged cases with appropriate matches in all these categories were then each paired to two nonstaged cases according to the nearest higher and lower mastectomy weight. Staged and nonstaged cohorts were compared with regard to demographics, operative characteristics, and reconstructive outcomes. Eighteen staged breast reductions were identified, performed at an average of 5.0 months before nipple-sparing mastectomy. Staged reductions were matched to 36 prophylactic nonstaged reductions. Average combined mastectomy weight (breast reduction and mastectomy weight) in the staged group was significantly higher than in the nonstaged group (992.6 g versus 640 g; p = 0.0004), although isolated mastectomy weights were comparable (607.1 g versus 640.0 g, respectively; p = 0.6311). Major mastectomy flap necrosis rates were significantly lower in the staged cohort than in the nonstaged cohort (0 percent versus 22.2 percent, respectively; p = 0.0415). Rates of minor mastectomy flap necrosis, partial nipple necrosis, and explantation trended lower in the staged cohort. In patients with large breast size, staged breast reduction before nipple-sparing mastectomy had significantly lower rates of major flap necrosis compared with nonstaged cases after controlling for other known risk factors for complications. Therapeutic, III.

Propensity-matched analysis of general versus spinal anaesthesia for patients undergoing ankle fracture surgery

Category: Ankle Introduction/Purpose: The choice of anaesthesia is a modifiable risk factor in optimizing post-operative outcomes in hip and knee surgery, with decreased rates of transfusion, thromboembolic events, and infection with the use of spinal anaesthesia versus general anaesthesia. Regional anaesthesia has been evaluated with respect to its effect on early pain in patients undergoing ORIF of the ankle, but there is no data regarding complication rates. The purpose of this study was to compare operating time, length of stay, and rates of post-operative adverse events within 30-days in patients undergoing open reduction and internal fixation (ORIF) of the ankle using spinal vs. general anaesthesia. Methods: Adult patients who underwent ORIF of a closed ankle fracture from 2012 to 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Patients who were operated on after admission from the ED are not included in the database. Operative time (skin to skin), length of stay, thirty-day adverse events, and unplanned readmissions were compared between patients who received general anaesthesia and those who received spinal anaesthesia. Propensity-adjustment with respect to known risk factors for complications and adjunctive regional block was used to match patients using a 1:4 ratio of spinal to general anaesthesia. Adverse events tracked included wound dehiscence, surgical site infection (superficial and deep), sepsis, venous thrombolic events, cardiac events, prolonged intubation, need for unplanned intubation, return to operating room, pneumonia, urinary tract infection, renal insufficiency, and re-admission within 30 days. Comparisons were performed using a propensity based multivariate analysis. Results: Of the 10,795 patients meeting inclusion criteria, 9,862 (91.4%) were treated with only general anaesthesia and 933 (8.6%) were treated with only spinal anaesthesia. Using propensity-scored matching, 822 patients in the spinal cohort were matched to 3,288 patients in the general cohort with similar baseline demographics (61.5% female, mean age 56.4). Procedure performed was similar in both cohorts (47% lateral malleolus ORIF, 34% bimalleolar ORIF, 10% trimalleolar ORIF, 8% medial malleolus ORIF, 1% posterior malleolus ORIF). Spinal anaesthesia was associated with increased length of stay (+0.5 days, 95% confidence interval (CI) 0.20-0.75, p&lt;0.001) and increased mortality (0.6% vs 0.2%, OR: 4.02, 95% CI 1.15-14.1, p=0.03). Rates of overall complications (4.0% vs 4.2%) and readmissions (0.8% vs 0.7%) were similar and available in Table 1. Conclusion: General anaesthesia is predominantly used for fixation of ankle fractures. While spinal anaesthesia is associated with lower complication rates in hip and knee surgery, we found no advantage in patients undergoing ORIF of the ankle.

Pulmonary Diagnostic Procedures in the Critically Ill

When faced with a critically ill patient with new pulmonary infiltrates on chest roentgenograms, the physician must choose the appropriate diagnostic procedure on the basis of the expected yields versus the potential complications. The first steps in any patient should include discontinuation of any nonessential medications, careful evaluation of fluid status to exclude cardiogenic pulmonary edema, and a review of likely diagnoses based on the patient's underlying disease. Although not likely to be of immediate utility, obtaining cultures of blood and other body fluids or sites and serologic testing may provide helpful information when combined with other procedures. Bronchoscopy is a reasonable first step in patients with a slow progression of disease or in those in whom the pulmonary process is discovered early in its course. As these patients often present with several of the known risk factors for complications with bronchoscopy, the decision to perform this procedure should not be made lightly. Transbronchoscopic lung biopsy adds additional risk to bronchoscopy but also increases the diagnostic yield considerably over lavages, brushing, and bronchial washings. Open lung biopsy offers high diagnostic yields and relatively low rates of serious complications. Because of the invasive nature of the procedure, there is often reluctance to perform it. In patients with rapidly progressive disease or conditions that make the risk of bronchoscopy unacceptably high, such as severe hypoxemia, bleeding diathesis, or cardiac compromise, prompt diagnosis requires that the physician consider open lung biopsy as a first diagnostic procedure. The physician must also consider whether making a specific diagnosis will be of benefit to the patient. Potential benefits of a specific diagnosis include stopping unnecessary empirical (and potentially toxic) therapies, instituting correct and specific therapy, and thus decreasing morbidity and mortality. The impact of specific diagnosis on morbidity and survival is often difficult to demonstrate. Discouraging notes have been sounded by studies of the effect of bronchoscopic or surgical diagnosis on the ultimate outcome for patients. For bronchoscopy with transbronchoscopic lung biopsy, although the overall diagnostic rate was 60 per cent, no difference in survival was noted between patients in whom a diagnosis was made and those in whom the nature of the pulmonary process remained unknown. Similarly, in a series of patients who underwent open lung biopsy, although the results of biopsy led to a therapeutic change in 70 per cent of the patients, only 16.5 per cent of the patients benefited from this change.(ABSTRACT TRUNCATED AT 400 WORDS)