Non-elective Group Research Articles

Enhanced recovery after non-elective colorectal surgery: Is it time for emergency general surgeons to follow suit?

BackgroundSurgical dogma suggests that enhanced recovery (ERAS) pathways are not feasible in the non-elective setting. This study challenges that dogma with the implementation of ERAS in non-elective colorectal surgery. MethodsSingle center review of all colorectal operations was performed following implementation of ERAS in non-elective colorectal surgery. Compliance and outcomes between elective and non-elective operations were compared. Results142 elective and 116 non-elective operations were performed with a compliance rate of 84 ​% and 46 ​%, respectively. Acceptable compliance was achieved with 7 metrics in the non-elective cohort. Elective operations were associated with an average LOS of 3 days and a 1 ​% SSI rate, compared to 8 days and 15 ​% in the non-elective group. On multivariate analysis, five ERAS metrics were associated with SSI. ConclusionsERAS pathways are often neglected in non-elective surgery. Acute Care Surgeons should recognize the ERAS principles that are appropriate for their patient population and implement these strategies into practice.

Is the outcome of elective vs non-elective patients undergoing transcatheter aortic valve implantation different? Results of a single-centre, observational assessment of outcomes at a large university clinic

BackgroundTranscatheter aortic valve implantation (TAVI) can either be conducted as an elective (scheduled in advance) or a non-elective procedure performed during an unplanned hospital admission. The objective of this study was to compare the outcomes of elective and non-elective TAVI patients.MethodsThis single-centre study included 512 patients undergoing transfemoral TAVI between October 2018 and December 2020; 378 (73.8%) were admitted for elective TAVI, 134 (26.2%) underwent a non-elective procedure. Our TAVI programme entails an optimized fast-track concept aimed at minimizing the total length of stay to ≤ 5 days for elective patients which in the German healthcare system is currently defined as the minimal time period to safely perform TAVI. Clinical characteristics and survival rates at 30 days and 1 year were analysed.ResultsPatients who underwent non-elective TAVI had a significantly higher comorbidity burden. Median duration from admission to discharge was 6 days (elective group 6 days versus non-elective group 15 days; p < 0.001), including a median postprocedural stay of 5 days (elective 4 days versus non-elective 7 days; p < 0.001). All-cause mortality at 30 days was 1.1% for the elective group and 3.7% for non-elective patients (p = 0.030). At 1 year, all-cause mortality among elective TAVI patients was disproportionately lower than in non-elective patients (5.0% versus 18.7%, p < 0.001). In the elective group, 54.5% of patients could not be discharged early due to comorbidities or procedural complications. Factors associated with a failure of achieving a total length of stay of ≤ 5 days comprised frailty syndrome, renal impairment as well as new permanent pacemaker implantation, new bundle branch block or atrial fibrillation, life-threatening bleeding, and the use of self-expanding valves. After multivariate adjustment, new permanent pacemaker implantation (odds ratio 6.44; 95% CI 2.59–16.00), life-threatening bleeding (odds ratio 4.19; 95% confidence interval 1.82–9.66) and frailty syndrome (odds ratio 5.15; 95% confidence interval 2.40–11.09; all p < 0.001, respectively) were confirmed as significant factors.ConclusionsWhile non-elective patients had acceptable periprocedural outcomes, mortality rates at 1 year were significantly higher compared to elective patients. Approximately only half of elective patients could be discharged early. Improvements in periprocedural care, follow-up strategies and optimized treatment of both elective and non-elective TAVI patients are needed.

Oocyte Cryopreservation: A 9-Year Single-Centre Experience

ObjectiveOocyte cryopreservation (OC) has increased in recent years; however, there is a paucity of published data on the use of cryopreserved oocytes and associated outcomes. MethodsA retrospective review of 748 OC cycles between 2013 and 2022 at a private fertility centre was performed. Outcome parameters for oocyte retrieval cycles were reviewed. For patients who returned for oocyte disposition, outcomes subsequent to oocyte re-warming, fertilization, and transfer were analyzed. ResultsThere were 748 OC cycles (653 elective and 95 non-elective) in 646 patients (556 elective and 90 non-elective). Patients were older at the time of freezing in the elective oocyte group compared with the non-elective group (36.5 vs. 28.8 y; P < 0.001). Sixty-five patients returned to warm and fertilize their oocytes (50 in the elective group and 15 in the non-elective group). The survival rate for warmed oocytes was 76.1% (541/711), and 66.2% of surviving oocytes were successfully fertilized, and 39.1% reached blastulation. Twenty-three patients underwent embryo transfers (10 after preimplantation genetic testing for aneuploidy), with 15 patients having at least 1 delivery or ongoing pregnancy. ConclusionsTo date, this is the largest published experience with OC in Canada. OC can lead to successful live births but does not guarantee a viable outcome for all patients. In this study, most patients with vitrified oocytes had not returned for disposition, so long-term follow-up is still required to verify the efficacy of OC.

Outcomes of reoperation for total arch replacement combined with frozen elephant trunk after previous cardiovascular surgery

BackgroundAortic arch replacement(TAR) combined with frozen elephant trunk (FET) technique is a high-risk operation after previous cardiovascular surgery. The aim of the study was to review our strategy and outcomes in this cohort. MethodData were reviewed for patients who underwent TAR combined with FET after previous cardiovascular surgery from January 2010 to December 2020. The patients were divided into elective group and non-selective group. Results63 eligible patients were divided into elective(n = 44) and non-elective(n = 19) groups. The interval between two operations was shorter in non-elective group than elective groups (P = 0.001). The indication for reoperation was different in two groups (P = 0.000), however, the type of reoperations has no differences. Cardiopulmonary bypass time was shorter in elective group than non-elective group (P = 0.000). The over-all 30-day mortality rate was 17.5%, and it was higher in non-elective group (P = 0.013). The 24h drainage increased in non-elective group (P = 0.001) as well as re-explore rate for bleeding (P = 0.022). Postoperative hospital stay prolonged in non-elective group (P = 0.002). However, rates of survival without further aortic events were 72.3 ± 7.1% in elective group, 72.9 ± 13.5% in non-elective group at 5 years, respectively (P = 0. 955). ConclusionReduced 30-day mortality and shortened post-operative hospital stay was observed in elective group, however, long-term survival rate without reintervention were not affected.

Factors affecting short-term survival in patients older than 85 treated with resection for stage II and III colon cancer

BackgroundPatients ≥85 years of age have high rates of colon cancer but disproportionately poor outcomes. Factors affecting short-term (90-day) survival in patients ≥85 undergoing surgery for stage II and III colon cancer were examined to identify potentially modifiable factors to improve outcomes. MethodsThe New York State Cancer Registry and Statewide Planning Research and Cooperative System were queried for patients ≥85 years who underwent colectomy for stage II and III colon cancer between 2004 and 2012. Regression analyses were performed for factors associated with 90-day mortality and stratified by elective and nonelective surgery. ResultsIn total, 3,779 patients ≥85 years of age underwent colectomy between 2004 and 2012 for stage II or III colon cancer. Of these, 48.4% underwent nonelective colectomy, 79.9% had an open operation, and 90-day survival was 83.2%. Worse survival was associated with nonelective surgery (odds ratio = 3.81, 95% confidence interval = 3.03–4.89). Improved survival in the nonelective and overall groups was associated with a minimally invasive operation (nonelective group: odds ratio = 0.35, 95% confidence interval = 0.21–0.58; overall group: odds ratio = 0.50, 95% confidence interval = 0.36–0.73) and discharged to another health care facility (nonelective group: odds ratio = 0.30, 95% confidence interval = 0.22–0.39; overall group: odds ratio = 0.42, 95% confidence interval = 0.33–0.53). High surgeon annual operating volume was associated with improved survival in the elective and nonelective groups (P < .001). ConclusionFactors associated with greater odds of 90-day mortality in this population include nonelective surgery, preoperative weight loss, and multiple comorbidities, whereas a minimally invasive approach was associated with lower mortality. Potential areas to improve outcomes in this population include using a multidisciplinary team approach, addressing frailty preoperatively when possible, and potentially reconsidering screening guidelines for colorectal cancer to reduce rates of emergency operations.

The Impact of Non-Elective Admission on Cost of Care and Length of Stay in Anterior Cervical Discectomy and Fusion: A Propensity-Matched Analysis.

Retrospective cohort study. To evaluate the impact of admission status on patient outcomes and healthcare costs in anterior cervical discectomy and fusion (ACDF). Undergoing ACDF non-electively has been associated with higher patient comorbidity burdens. However, the impact of non-elective status on the total cost of hospital stay has yet to be quantified. Patients undergoing ACDF at a single institution were placed into elective or non-elective cohorts. Propensity score-matching analysis in a 5:1 ratio controlling for insurance type and comorbidities was used to minimize selection bias. Demographics were compared by univariate analysis. Cost of care, length of stay (LOS), and clinical outcomes were compared between groups using multivariable linear and logistic regression with elective patients as reference cohort. All analyses controlled for sex, preoperative diagnosis, elixhauser comorbidity index (ECI), age, length of surgery, number of segments fused, and insurance type. Of 708 patients in the final ACDF cohort, 590 underwent an elective procedure and 118 underwent a non-elective procedure. The non-elective group was significantly younger (53.7 vs. 49.5 yr; P = 0.0007). Cohorts had similar proportions of private versus public health insurance, although elective had higher rates of commercial insurance (39.22% vs. 15.25%; P < 0.0001) and non-elective had higher rates of managed care (32.77% vs. 56.78%; P < 0.0001). Operation duration was significantly longer in non-elective patients (158 vs. 177 minutes; P = 0.01). Adjusted analysis also demonstrated that admission status independently affected cost (+$6877, 95% confidence interval [CI]: $4906-$8848; P < 0.0001) and LOS (+4.9 days, 95% CI: 3.9-6.0; P < 0.0001) for the non-elective cohort. The non-elective cohort was significantly more likely to return to the operating room (OR: 3.39; 95% CI: 1.37-8.36, P = 0.0008) and experience non-home discharge (OR: 10.95; 95% CI: 5.00-24.02, P < 0.0001). Patients undergoing ACDF non-electively had higher cost of care and longer LOS, as well as higher rates of postoperative adverse outcomes.Level of Evidence: 3.

The Impact of Anaemia on The Clinical Outcomes of Infra-Inguinal Bypass for Critical Limb Ischaemia

Introduction: Anaemia in elective cardio-vascular surgery has been shown to have a detrimental impact on clinical outcomes and survival. Non-elective caseload is high in vascular surgery and the timely revascularisation in critical limb-ischaemia (CLI) significantly contributes towards this workload. The outcomes are hugely significant to the patient. Equally a 2017 Delphi consensus identified that improving outcomes in CLI are a top ten research priority. As such, this tertiary centre cohort study evaluates the impact of anaemia on CLI revascularisation outcomes. Methods: All infra-inguinal bypass operations for CLI between 2016 and 2018 were identified from a prospectively maintained database. Anaemia was defined as a pre-operative haemoglobin (Hb) of less than 120g/dL. ROC analysis was performs to support this ´cut-off´ Hb. Pre-, intra- and post-operative metrics were analysed to understand if anaemia impacted on clinical outcome. Comparative statistics and regression analyses were performed. Results: 124 bypasses for CLI were included. 45 were anaemic with an average Hb of 105 (9.5) vs. the non-anaemic 141.7 (14.7) group. Baseline comparisons were equivalent for age, gender, co-morbidity and medications, as were the duration of surgery and intra-operative blood loss. Post-operatively there was a greater rate of wound infection (p=0.036) and myocardial infarction (p=0.02) in the anaemic group. Regression analysis demonstrated that anaemic patients were 9(OR) times more likely to have an MI. The mean length of stay was longer in the anaemic group (26.8 (22.6) vs. 14(15.9) days (P=0.001). 1-year mortality was also higher in the anaemic group(P=0.037) and OR of 3.6(1.02 - 12.8)(P=0.046). Anaemia and length of stay significantly correlated with 1-year mortality. There was no difference in 30-day mortality or limb loss. A Hb of 111was the most sensitive and specific critical Hb for both MI and 1-year mortality. Conclusion: Pre-operative anaemia significantly increases the rate of complications and length of hospital stay following surgical revascularisation for CLI. It is also associated with higher 1-year mortality. Consequently, optimisation of baseline Hb may improve these outcomes in this high risk non-elective group of patients. Disclosure: Nothing to disclose

Quantifying the Effect of Anemia on Major Lower Limb Amputation

Introduction: Major Lower limb amputation (MLLA) for end stage vascular disease are unfortunately common. Approximately 4000 are performed each year within the UK. These patients have often suffered years of chronic disease and as such many are anaemic. A 2017 Delphi consensus identified that improving outcomes for amputees are included in the top ten research priorities in the UK. This tertiary center cohort study evaluates the impact of anaemia on the outcome of MLLA to help understand if there is a role in optimization of haemoglobin (Hb) to improve outcomes. Methods: A prospectively maintained database was reviewed. All MLLA between 2015 and 2018 were identified. Anaemia was defined as a pre-operative Hb of less than 120g/dL as per WHO guidance. In addition, a ROC analysis was performed to identify the most sensitive and specific 'critical Hb'. Groups were stratified accrodingly into non-anaemics, moderate anaemia (Hb of < 120-100) and severe anaemia (Hb < 100). Pre-, intra- and post-operative metrics were analyzed to understand if anaemia impacted on clinical outcome. Inter-group comparative statistics and regression analyses were performed. Results: 337 MLLA patients were included. 98 were not anaemic with an average Hb of 133(13.7) g/dL, 111 were mildly anaemic; Hb of 109(5.73) g/dL and 128 were severely anaemic with a mean Hb of 87.8(7.3) g/dL. Mean follow-up period was 22 months. Baseline comparisons were equivalent for age, gender, co-morbidity and medications, as were intra-operative blood loss for all groups. Length of stay was significantly longer with progressive anaemia with the non-anaemic group staying 26.7(25) days, for the moderate group 36.5(42) days and the severely anaemic group 36.6 (30) days (P=0.003). Overall anaemia was associated with a greater 22-month mortality (P=0.021), this was most significant in the severely anaemic group (P< 0.001). The non-anaemics had a probability of survival of 76% compared to the anaemic groups. Regression analysis also demonstrated that an incremental increase of Hb by 1g/dL leads to 2% increase in survival probability. The severely anaemic group fared worse for overall complications but there was no statistical difference in the specific wound complication or revision surgery rates in either anaemia group compared to the non-anaemics. Myocardial events were greatest in the mildly-anaemic group compared to the non-anaemic patients. ROC analysis revealed that 111g/dL to be the most sensitive and specific Hb level to predict, complications and long-term mortality. Conclusion: Pre-operative anaemia significantly increases the length of hospital stay following MLLA. It is also associated with higher long-term mortality and a lower Hb equates to a greater probability of death. Consequently, optimisation of baseline Hb may improve these outcomes in this high risk non-elective group of patients. More work is being undertaken to fully appreciate this relationship. Disclosure: Nothing to disclose

CONTEMPORARY OUTCOMES OF AORTIC ARCH REPAIR WITH HYPOTHERMIC CIRCULATORY ARREST: THE IMPACT OF URGENCY STATUS EVIDENCE FROM THE CANADIAN THORACIC AORTIC COLLABORATIVE

The aim of this study was to analyze the contemporary outcomes of patients undergoing aortic arch surgery with hypothermic circulatory arrest (HCA), according to their urgency status. A total of 2624 patients (62 years (0.3), 70% male, 63% elective vs 37 % non-elective) who underwent aortic arch repair with HCA among 12 Canadian centres between 2002 and 2018 (Figure.1). Elective patients were compared to non-elective (urgent, emergent & salvage surgery) for early in-hospital outcomes ( < 30 days). Overall in-hospital mortality occurred in 218 (8.3%) patients, with higher mortality in non-elective vs elective patients (15.7% vs 2.4%, p < 0.001). Adverse neurological events occurred in 307 patients (11.7%) [stroke 207 (7.9%), spinal cord injury 34 (1.3%) and transient ischemic attack 66 (2.9%)] with more neurological events in non-elective vs elective patients (15.6% vs 8.1%, p < 0.001). The risk of stroke was significantly higher in the non-elective group [n=114 (11.6%)] vs the elective group [n=91 (5.6%)]; p< 0.001). Antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion were employed in 1805 (70.1%) and 275 (10.7%) patients respectively, however, 373 (14.2%) patients underwent circulatory arrest with hypothermia alone. This contemporary series demonstrated the safety of cerebral circulatory arrest with good outcomes when conducted in cardiac surgery centres with aortic expertise. Nonetheless, mortality and morbidity remain higher in non-elective patients, hence, further research is needed to improve outcomes in non-elective aortic arch surgery.

Outcome of elective cholecystectomy for the treatment of gallbladder disease in dogs.

OBJECTIVE To determine mortality rates for dogs undergoing cholecystectomy and variables associated with failure to survive to hospital discharge. DESIGN Retrospective cohort study. ANIMALS 70 dogs that underwent cholecystectomy for biliary tract disease at a companion animal referral hospital from 2009 through 2015. PROCEDURES Medical records of dogs were reviewed and data collected; dogs with biliary diversion surgery were excluded. Included dogs were grouped by whether cholecystectomy had been elective (ie, dogs with no or mild clinical signs, with no indication of biliary obstruction, or that initially underwent surgery for a different procedure) or nonelective (ie, dogs with icterus and questionable patency of the biliary system). Mortality rates (proportions of dogs that failed to survive to hospital discharge) were compared between various groups. RESULTS 45 (64%) dogs were included in the elective group and 25 (36%) in the nonelective group. Group mortality rates were 2% (1/45) and 20% (5/25), respectively, and differed significantly. Overall mortality rate was 9% (6/70). Serum albumin concentration was significantly lower and serum alanine aminotransferase activity and total bilirubin concentration were significantly higher in nonsurviving versus surviving dogs. Dogs with vomiting, signs of lethargy or anorexia, icterus, or azotemia were less likely to survive than dogs without these signs. CONCLUSIONS AND CLINICAL RELEVANCE Dogs that underwent elective cholecystectomy had a considerably lower mortality rate than previously reported. Elective cholecystectomy may be an appropriate recommendation for dogs with early signs of biliary disease to avoid the greater mortality rate associated with more advanced disease and nonelective cholecystectomy.

Thromboembolic Events In Elective vs Non-Elective Foot &amp; Ankle Surgery

Category: Ankle, Arthroscopy, Hindfoot, Lesser Toes, Midfoot/Forefoot, Sports, Trauma Introduction/Purpose: The occurrence of venous thromboembolisms (VTE) in the management of foot and ankle conditions can lead to serious and sometimes fatal complications. The reported incidence range of symptomatic deep venous thrombosis (DVT) following various foot and ankle procedures is wide, ranging from 0.01% to 23.4%. The incidence of asymptomatic DVT is likely higher and has been reported to be up to 34% in patients with Achilles ruptures. In line with the wide variability in incidence data, there remains a lack of consensus in determining the necessity to implement DVT prophylaxis after foot and ankle surgery. The purpose of this study was to examine the National Surgical Quality Improvement Program (NSQIP) database to assess the 30- day risk of VTE in foot and ankle surgery. Methods: The ACS-NSQIP database for the years 2011-2014 was queried for patients undergoing elective versus non-elective foot and ankle surgery with a total of 72 Current Procedural Terminology (CPT) codes included. Those undergoing procedures for an infectious process or oncologic procedures were excluded. A total of 18,632 cases were included for analysis in our study with 11,744 being elective and 6,888 non-elective surgeries. A univariate analysis of thromboembolic parameters included in the database was conducted to measure the difference between the two cohorts. Results: There were a total of 6,888 non-elective (36.97%) and 11,744 elective surgeries (63.03%). The incidence of DVT was 32 (0.33%) for elective and 39 (0.46%) for non-elective surgery with no statistical significance (P=0.37). The incidence of pulmonary embolisms (PE) was 24 (0.35%) for the non-elective and 20 (0.17%) for the elective group with the non-elective group having a statistically significant increase (P = 0.0156). The incidence of cerebral vascular accidents (CVA) was 8 (0.06%) for males and 1 (0.009%) for females with males having a statistically significant higher incidence of CVA (P = 0.0318). Patients under age 65 had a statistically higher risk (P = 0.0194) of a CVA occurrence with an odds ratio of 0.132 times greater than those over the age of 65. Conclusion: Non-elective Foot &amp; Ankle surgery is an independent risk factor for pulmonary embolism. Males under the age of 65 years old are more likely to experience CVAs with residual deficits. However, the overall incidence of PE and CVA are exceedingly low in our study with an incidence of under half a percent. The incidence of DVT was also low, under 0.5% for the non-elective group and 0.33% for the elective group. Therefore, surgeons should weigh the risks and benefits of anticoagulation, especially in elective foot and ankle surgery, prior to the initiation of anticoagulation therapy.

Development of the ultrasonography learning model for undergraduate medical students: A case study of the Faculty of Medicine, Burapha University

BackgroundUltrasound technology is generally considered to be reliable and widely used by physicians today. Therefore, given the efficacy and popularity of the technology, the need for quality ultrasound education is evident. Ultrasound training for undergraduate medical students has been increasingly incorporated into school curriculums, but the teaching methods can vary significantly among medical schools. Among many different choices, one effective teaching model was proposed which added hands-on ultrasound experience on live patients that was supervised by radiologists in the last clinical year. MethodsA 2-week radiology elective course was offered for 6th-year medical students at Burapha University Hospital, Chonburi, Thailand in the academic year 2014. Fourteen medical students participated in the elective course. Additionally, students who chose radiology as their elective were provided an ultrasound experience on live patients in real-life clinical settings. All 6th-year medical students then completed a 25-ultrasound image quiz, and completed a questionnaire at the end of the academic year. The ultrasound test scores were compared between the elective and nonelective students. The students' background characteristics were determined by a grade point average and the ultrasound experience was determined by the number of scans. These were collected, and analyzed to establish their relationship with the ultrasound test scores. The students' opinions were also surveyed. ResultsFourteen medical students participated in the elective course. The ultrasound test scores in the elective group were significantly higher than those in the nonelective group (p=0.013). The students' background characteristics and ultrasound experience had no significant relationship with the ultrasound test scores. ConclusionBy adding hands-on ultrasound experience using live patients proctored by radiologists for final year medical students, in the space of 2 weeks, an effective ultrasound learning model for undergraduate medical students can be provided. This model should be considered in the curricular design.

Similar result after non-elective and elective surgery for lumbar disc herniation: an observational study based on the SweSpine register.

Surgery for lumbar disc herniation (LDH) is most often elective, but intense pain may require more urgent, non-elective, treatment. It was hypothesized that non-elective treatment could be associated with a less favourable outcome than elective surgery. The aim of this study was to compare 1-2-year outcome after non-elective and elective surgery for treatment of para-median LDH using data from the Swedish Spine register (SweSpine). Pre- and postoperative data were available for 301 non-elective and 2364 elective cases. Patient reported outcome measures (PROMs) were; Visual Analogue Scale (VAS) leg and back pain, Oswestry Disability Index (ODI), EuroQol five-Dimensions (EQ-5D) and patient satisfaction. Postoperative p values were adjusted for baseline differences. Preoperative mean (SD) in the non-elective and elective groups were for VAS leg pain 81 (22) and 65 (24), for VAS back pain 51 (33) and 45 (28), for ODI 66 (20) and 45 (17) and for EQ-5D 0.024 (0.35) and 0.31 (0.33), respectively, (p for all<0.001). Postoperative VAS leg pain was 23 (28) in the non-elective group and 20 (26) in the elective group (p=0.19). Corresponding figures were for VAS back pain 25 (27) and 24 (27) (p=0.69), ODI 19 (17) and 17 (17) (p=0.052) and for EQ-5D 0.70 (0.28) and 0.73 (0.29) (p=0.73). Patient satisfaction did not differ between the groups (p=0.78). Even if non-elective patients preoperatively had substantially more pain, higher disability and poorer quality of life than elective patients, postoperative differences were clinically small. Patient satisfaction did not differ.

Elective removal of cervical cerclage and onset of spontaneous labor

ObjectiveTo determine the time interval between elective removal of cervical cerclage and onset of spontaneous labor. MethodsA retrospective cohort study was conducted between January 2005 and December 2012 at a tertiary care hospital in Lisbon, Portugal. All singleton pregnancies with a McDonald or Shirodkar cerclage electively removed at 36–37weeks were evaluated for the time interval between cerclage removal and spontaneous labor. Delivery within 72hours after cerclage removal was compared between patients with elective cerclage and those with non-elective cerclage. In the non-elective group, a sub-analysis of the results for ultrasound- and physical examination-indicated cerclage was performed. ResultsThirty-eight women were included. The time interval between cerclage removal and spontaneous labor did not differ significantly between the elective and the non-elective group (15.6±7.6 vs 10.9±7.4days; P=0.063). A higher incidence of delivery 72hours after cerclage removal was seen in the non-elective group but this was not significant (P=0.061). There were no differences regarding the time interval from elective removal of cervical cerclage to onset of spontaneous labor between ultrasound-indicated and physical examination-indicated cerclage. ConclusionRegardless of the indication for cervical cerclage, the probability of delivery soon after elective cerclage removal is low.

Outcomes of a System-Wide Protocol for Elective and Nonelective Coronary Angioplasty at Sites Without On-site Surgery: The Mayo Clinic Experience

To compare outcomes of percutaneous coronary interventions (PCIs) at 2 community hospitals without on-site surgery (Franciscan Skemp Healthcare and Immanuel St. Joseph's Hospital) with a center with on-site surgery (Saint Marys Hospital). Using a matched case-control design, we studied 1842 elective and 667 nonelective PCI procedures (myocardial infarction [MI]/cardiogenic shock) performed from January 1, 1999, through December 31, 2007. The quality assurance protocol included operator volume and training, application of a risk-adjustment model, transport protocol, and database participation. We compared in-hospital mortality and/or emergent coronary artery bypass surgery after PCI at Franciscan Skemp Healthcare and Immanuel St. Joseph's Hospital, which do not have on-site surgery, with Saint Marys Hospital, a medical center with the capability to perform coronary artery bypass grafting on site. Of 22 baseline variables, significant imbalances between matched groups were present in only 3 (hyperlipidemia, history of MI, American College of Cardiology/American Heart Association B2/C type lesion) in the elective group and 2 (Canadian Cardiovascular Society class III/IV angina, multivessel disease) in the nonelective group. The primary end point occurred in 0.3%, 0.1%, and 0.6% of patients undergoing elective PCI (P=.07) and 3.3%, 3.3%, and 3.7% of patients undergoing nonelective PCI (P=.65) at Immanuel St. Joseph's Hospital, Franciscan Skemp Healthcare, and Saint Marys Hospital, respectively. The in-hospital mortality rate at Immanuel St. Joseph's Hospital and Franciscan Skemp Healthcare was comparable to that at Saint Marys Hospital for both elective (0.3%, 0.1%, 0.4%; P=.24) and nonelective PCI (2.6%, 2.4%, 3.1%; P=.49). No patient undergoing elective PCI required transfer for emergency cardiac surgery. Of the 21 transfers, 20 (95%) were in the setting of MI and cardiogenic shock or left main/3-vessel disease; 18 patients (86%) survived to discharge. Optimal outcomes with PCI have been observed at community hospitals without on-site cardiac surgical programs with application of a prospective, standardized quality assurance protocol.

ELECTIVE VS NON-ELECTIVE RADIAL ARTERY GRAFTS: COMPARING MIDTERM RESULTS THROUGH 64-SLICE COMPUTED TOMOGRAPHY

Left internal thoracic artery to left anterior descending artery (LITA-LADA) grafting has become a fundamental part of the coronary artery bypass graft procedure (CABG). This grafting in turn has led to an increased use of other arterial conduits, of which the radial artery (RA) is most popular. Whether RA grafting can be used in the emergency patient is controversial. 47 patients with critical stenosis (>70%) in all target vessels underwent CABG with LITA and RA grafts from 1996 to 2003. Patients were divided into elective (23 patients) and non-elective groups (24 patients) with LITA and RA grafts per patient being similar in both groups. Of these 47 patients, 5 died from non-cardiac complications and 12 were unavailable. Thus, 30 patients (71% of survivors) were studied by multidetector computed tomography. A total of 36 LITA and 64 RA grafts were studied. The RA patency rate for elective and non-elective grafts were 82% (31/38) and 85% (22/26), respectively (p=0.75). The RA had a similar patency rate for all target vessels ranging from 73% to 100%. Only one patient had a redo CABG and 29 (97%) are free from angina or re-intervention. LITA-LADA had a 92% (11/12) and 100% (10/10) patency rate for elective and non-elective groups, respectively (p=0.37). The sequential LITA-diagonal-LADA in the elective group had a 50% (03/06) patency rate, which was significantly lower than the 100% (08/08) patency rate of the non-elective group (p=0.02). Radial Artery grafts can be used in both elective and non-elective patients with excellent results.

Initiation of home mechanical ventilation in children with neuromuscular diseases

Objective To determine how often home mechanical ventilation (HMV) is instituted electively in children with respiratory failure from neuromuscular diseases and whether there were opportunities to discuss therapeutic options with patients/families before respiratory failure. Methods Patients with neuromuscular disease (n = 73) requiring HMV (age, 2 months to 24 years) were studied. Whether HMV was initiated nonelectively because of acute respiratory failure or electively before acute respiratory failure, and opportunities for health care providers to discuss therapeutic options with patients/families before acute respiratory failure (hospitalization with pneumonia, clinic visits for preoperative evaluation, pulmonary function testing [PFT] and/or polysomnography [PSG]) were recorded. Results HMV was initiated electively in 21% of patients with neuromuscular disease; 69% of the nonelective HMV group had HMV initiated after respiratory failure caused by pneumonia. In the nonelective group, opportunities for discussion of therapeutic options with the patients and families could have occurred before respiratory failure during 111 hospitalizations for pneumonia, 13 preoperative evaluations, 43 abnormal PFTs, and 24 abnormal PSGs. Conclusions Most patients with neuromuscular disease had HMV initiated nonelectively after acute respiratory failure caused by pneumonia. Opportunities for discussing the therapeutic options with patients and families before respiratory failure were missed or ineffective. (J Pediatr 2003;142:481-5)

Obesity as an independent risk factor for infectious morbidity in patients who undergo cesarean delivery

OBJECTIVE: Our purpose was to evaluate obesity (body mass index greater than 30.0) as an independent risk factor for infectious morbidity in women having elective or nonelective cesarean deliveries. METHODS: Charts of 611 patients undergoing cesarean were reviewed. After exclusion of those with pre-existing chorioamnionitis, 574 cases were separated into two groups (elective or nonelective cesarean) and then subdivided based on the presence or not of postdelivery infectious morbidity. Estimated blood loss, operative time, number of vaginal examinations, labor length, use of internal monitors, body mass index (BMI), and obesity (BMI greater than 30.0) were then recorded. Student t test, χ 2, multivariate analysis, and receiver operating characteristics curves were used where appropriate (significance: P < .05). RESULTS: The mean gestational age at delivery was 38.3 weeks. Three hundred sixty patients had nonelective cesareans, and 214 had elective cesareans. Prophylactic antibiotics were used for 86.6% of the nonelective group and 75.2% of the elective group. In the nonelective group and after multivariate analysis, significant risk factors for postoperative infections were as follows: labor length (18.4 hours versus 10.9, P < .003), number of vaginal examinations (6.1 versus 4.5, P < .001), BMI (36.6 versus 32.3, P < .001), and obesity (81.8% versus 57.3%, P < .001). For the elective group, a higher BMI (38.9 versus 32.2, P < .003), and black race (63.2% versus 11.5%, P < .001) were found to be significant. CONCLUSION: Our data suggest that obesity is a independent risk factor for postcesarean infectious morbidity and endomyometritis, even if the cesarean is elective and prophylactic antibiotics are given.

Obesity as an Independent Risk Factor for Infectious Morbidity in Patients Who Undergo Cesarean Delivery

In Brief OBJECTIVE Our purpose was to evaluate obesity (body mass index greater than 30.0) as an independent risk factor for infectious morbidity in women having elective or non-elective cesarean deliveries. METHODS Charts of 611 patients undergoing cesarean were reviewed. After exclusion of those with pre-existing chorioamnionitis, 574 cases were separated into two groups (elective or nonelective cesarean) and then subdivided based on the presence or not of postdelivery infectious morbidity. Estimated blood loss, operative time, number of vaginal examinations, labor length, use of internal monitors, body mass index (BMI), and obesity (BMI greater than 30.0) were then recorded. Student t test, χ2, multivariate analysis, and receiver operating characteristics curves were used where appropriate (significance: P < .05). RESULTS The mean gestational age at delivery was 38.3 weeks. Three hundred sixty patients had nonelective cesareans, and 214 had elective cesareans. Prophylactic antibiotics were used for 86.6% of the nonelective group and 75.2% of the elective group. In the nonelective group and after multivariate analysis, significant risk factors for postoperative infections were as follows: labor length (18.4 hours versus 10.9, P < .003), number of vaginal examinations (6.1 versus 4.5, P < .001), BMI (36.6 versus 32.3, P < .001), and obesity (81.8% versus 57.3%, P < .001). For the elective group, a higher BMI (38.9 versus 32.2, P < .003), and black race (63.2% versus 11.5%, P < .001) were found to be significant. CONCLUSION Our data suggest that obesity is a independent risk factor for postcesarean infectious morbidity and endomyometritis, even if the cesarean is elective and prophylactic antibiotics are given. Obesity is an independent risk factor for post–cesarean delivery infectious morbidity.

Consequences of delay in surgical treatment of biliary disease

Background: Delay of laparoscopic cholecystectomy after the diagnosis of uncomplicated biliary disease is common at our institution. This study assessed the effect of delay of operation for symptomatic biliary disease. Methods: A cohort of 251 patients was retrospectively reviewed at Parkland Memorial Hospital with follow-up available for 168 patients (67%) from January 1998 to July 1998. Data were analyzed using Student’s t test and the chi-square test. Results: Of the 88 patients with the initial diagnosis of biliary colic, 69 (78%) underwent elective laparoscopic cholecystectomy. Thirty-six patients made a total of 44 return visits the emergency department with a recurrent attack of biliary colic or a complication of gallstone disease. Mean operative time increased from 94 minutes for elective operations to 122 minutes for nonelective operations and hospital stay increased from 0.6 days to 6.1 days. Conversion to open operation increased from 6% in the elective group to 26% in the nonelective group. Conclusions: Delay of surgical therapy is associated with complications, increased operative times, higher conversion to open cholecystectomy, and prolonged hospitalization. We conclude that patients with symptomatic cholelithiasis should undergo early cholecystectomy.