Predictor Of Serious Complications Research Articles

Trends and outcomes in the surgical management of young adults with knee osteoarthritis using high tibial osteotomy and unicompartmental knee arthroplasty.

A significant portion of knee osteoarthritis is diagnosed in patients under the age of 55, where greater activity demands make total knee arthroplasty less desirable. High tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are useful alternatives, but there is little understanding of which procedure is advantageous. Hence, this study examines the utilization, complication, and reoperation rates among the HTO vs. UKA in young patients with primary osteoarthritis. A retrospective review of the National Surgical Quality Improvement Program was performed to identify 2318 patients < 55years of age who received either a HTO or UKA for primary osteoarthritis between 2011 and 2021. Bivariate analyses compared preoperative and intraoperative characteristics among each procedure. Then, multivariate analyses examined if either procedure was associated with worse 30-day postoperative complications or need for reoperation, independent of the statistically significant pre- and intraoperative disparities. UKAs were performed 14.2 times more commonly than HTOs, and the patients selected for HTO were more likely to be younger, have a lower BMI, have the healthiest ASA Class score, and less likely to have hypertension requiring medication (p < 0.001). HTOs took 17.5% longer to perform and had a longer average length of stay (p < 0.001), while UKAs were more likely to be performed out-patient (p < 0.001). HTOs also had higher rates of serious complications (p = 0.02), overall complications (p = 0.004), and need for reoperation (p = 0.004). Multivariate modelling demonstrated that procedure type was not a predictor of serious complications, but the use of HTO was significantly associated with any complications (odds ratio = 3.63, p = 0.001) and need for reoperation (3.21, p = 0.029). Although healthier patients were selected for HTOs, UKAs were found to have a lower risk of complications and immediate reoperation. Additionally, UKAs had the advantage of lower operative burden, shorter length of stay, and a higher efficacy in outpatient settings.

A 5-year characterization of trends and outcomes in elderly patients undergoing elective bariatric surgery.

The North American population with severe obesity is aging and with that so will the number of elderly patients (≥ 65years) meeting indications for metabolic surgery. Trends in bariatric delivery in this population are poorly characterized and outcomes remain conflicting, limiting potential uptake and delivery. The MBSAQIP database was used to identify elderly patients (≥ 65years) undergoing elective bariatric surgery from 2015 to 2019. Our objectives were to analyze their unique characteristics, surgical operative trends, and outcomes by comparing to a non-elderly cohort. Multivariable logistic regression identified independent predictors of serious complications and 30-day mortality. There was a total of 751,607 patients, 5.3% (n = 39,854) were elderly. Mean ages were 43 ± 11years (non-elderly) versus 68 ± 3years (elderly). Elderly patients were less likely to be female (70.7% elderly; 80.1% non-elderly) and had lower BMI (43.17 ± 6.64kg/m2 elderly; 45.42 ± 7.87kg/m2 non-elderly). They had higher American Society of Anesthesiologists classification, lower functional status, more insulin dependent diabetes, and hypertension, among other comorbidities. There were no clinically significant differences between the most frequently performed bariatric surgery. Sleeve gastrectomy remained the most common (73.7% non-elderly; 72.3% elderly); however, operative time was longer among the elderly. Functional status was most predictive for both serious complications (OR 1.72; CI 1.53-1.94) and mortality (OR 2.92; CI 1.98-4.31). Surgery among elderly patients was associated with poorer 30-day postoperative outcomes across all categories and was independently associated with serious complications (OR 1.23; CI 1.17-1.30, p < 0.001; AR 4.64%) and 30-day mortality (OR 2.49; CI 2.00-3.11, p < 0.001; AR 0.27%), after adjusting for comorbidities. After adjusting for comorbidities, functional status remains the most predictive factor for poor outcomes; however, elderly patients have increased 30-day odds of serious complications and 30-day mortality, suggesting a need to tailor our approach to these individuals that carry a unique operative risk.

Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass: Indications, Prevalence, and Safety.

Sleeve gastrectomy (SG) frequently requires conversion to Roux-en-Y gastric bypass (RYGB) due to gastroesophageal reflux disease (GERD) or weight recurrence. Current evidence evaluating the safety of conversion from SG to RYGB and its indications is limited to single centers. The objective was to determine the rate of serious complications and mortality of conversion of SG to RYGB (SG-RYGB) compared to primary RYGB (P-RYGB). This was a retrospective analysis of the MBSAQIP database which includes 30-day outcomes. Individuals undergoing P-RYGB or SG-RYGB were included. Multivariable logistic regression was performed to determine if revisional surgery was an independent predictor of serious complications or mortality. In 2020 and 2021, 84,543 (86.3%) patients underwent P-RYGB and 13,432 (13.7%) underwent SG-RYGB. SG-RYGB cohort had lower body mass index, lower rates of diabetes and hypertension, and higher rates of GERD. GERD was the most common indication for revision (55.3%) followed by weight regain (24.4%) and inadequate weight loss (12.7%). SG-RYGB had longer operative times (145 vs. 125min, p < 0.001) and a higher rate of serious complications (7.2 vs. 5.0%, p < 0.001). This included higher rates of anastomotic leak (0.5 vs. 0.4%, p = 0.002), bleeding (2.0 vs. 1.6%, p < 0.001), and reoperation (3.0 vs. 1.9%, p < 0.001) but not death (0.1 vs. 0.1%, p = 0.385). On multivariable analysis, SG-RYGB was independently predictive of serious complications (OR 1.21, 95%CI 1.12 to 1.32, p < 0.001) but not mortality (p = 0.316). While SG-RYGB is safe with a low complication rate, SG-RYGB was associated with a higher rate of serious complications compared to P-RYGB.

Atrial dysrhythmias are independent predictors of serious complications and 30-day mortality after elective bariatric surgery: a retrospective study of 731,981 patients.

The objectives of this study were to characterize the prevalence of atrial dysrhythmias for elective bariatric surgery patients and to explore their impact on postoperative outcomes. Data was extracted from the North American Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to2019. All primary Roux-en-Y gastric bypass and sleeve gastrectomy procedures were included. Patients with atrial dysrhythmias (ADs) were identified as patients coded as receiving preoperative therapeutic anticoagulation without a prior history of deep vein thrombosis, venous thromboembolism, pulmonary embolism, or other conditions requiring anticoagulation. Multivariable logistic regression analysis was used to determine the impact of preoperative ADs on postoperative complications and 30-day mortality. We evaluated 731,981 patients, of whom 13,591 (1.9%) had preoperative ADs. Patients with ADs were more likely to be older, have a higher body mass index, and be male. Metabolic co-morbidities also were more common in those with ADs, as demonstrated by the higher rates of medication use and insulin-dependent diabetes, hypertension, dyslipidemia, and sleep apnea. After adjusting for co-morbidities using multivariable logistic regression, AD was the single greatest independent predictor of serious complications and 30-day mortality. ADs were observed in approximately 2% of MBSAQIP patients. ADs are among the greatest independent predictors of serious complications and mortality, suggesting that these patients are associated with a higher perioperative risk profile warranting further optimization.

Post-Operative but Not Pre-Operative COVID-19 Predicts Serious Complications and Mortality Following Elective Bariatric Surgery.

We sought to characterize the prevalence and subsequent impact of pre- and post-operative COVID-19 diagnosis on bariatric surgery outcomes. COVID-19 has transformed surgical delivery, yet little is known regarding its implications for bariatric surgery. The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) database was evaluated with three cohorts described: those diagnosed with COVID-19 pre-operatively (PRE), post-operatively (POST), and those without a peri-operative COVID-19 (NO) diagnosis. Pre-operative COVID-19 was defined as COVID-19 within 14days prior to the primary procedure while post-operative COVID-19 infection was defined as COVID-19 within 30days after the primary procedure. A total of 176,738 patients were identified, of which 174,122 (98.5%) had no perioperative COVID-19, 1364 (0.8%) had pre-operative COVID-19, and 1252 (0.7%) had post-operative COVID-19. Patients who were diagnosed with COVID-19 post-operatively were younger than other groups (43.0 ± 11.6years NO vs 43.1 ± 11.6years PRE vs 41.5 ± 10.7years POST; p < 0.001). Pre-operative COVID-19 was not associated with serious complications or mortality after adjusting for comorbidities. Post-operative COVID-19, however, was among the greatest independent predictors of serious complications (OR 3.5; 95% CI 2.8-4.2; p < 0.0001) and mortality (OR 5.1; 95% CI 1.8-14.1; p = 0.002). Pre-operative COVID-19 within 14days of surgery was not significantly associated with either serious complications or mortality. This work provides evidence that a more liberal strategy which employs early surgery after COVID-19 infection is safe as we aim to reduce the current bariatric surgery case backlog.

Obstructive Sleep Apnea Is Associated with Serious Complications But Not Increased Mortality Following Elective Bariatric Surgery: a Retrospective Cohort Study of 751,952 Patients.

The aim of the study was to characterize the prevalence of obstructive sleep apnea (OSA) in elective bariatric surgery patients and to determine if OSA is an independent predictor of 30-day serious complications and 30-day mortality among bariatric surgery patients. An analysis of the MBSAQIP database from 2015 to 2019 was conducted, and patients were stratified by OSA diagnosis. Data was extracted on patient age, sex, race, and comorbidities. A multivariate logistic regression model was created to evaluate the impact of OSA on 30-day serious complications and 30-day mortality. Of 751,952 patients, 287,180 (38.2%) were identified as having OSA. OSA patients were older (48.0 ± 11.4 vs. 42.2 ± 11.9years; p < 0.0001) and were of increased BMI (46.5 ± 8.5kg/m2vs. 44.6 ± 7.3kg/m2; p < 0.0001). OSA was not associated with 30-day mortality in the multivariable logistic regression model (OR 0.98, 95% CI 0.83-1.16; p = 0.829). OSA was associated with increased odds of 30-day serious complications (OR 1.33, 95% CI 1.30-1.36; p < 0.0001). In addition, dialysis (OR 3.07, 95% CI 2.68-3.52; p < 0.0001), positive venous thromboembolism history (OR 2.46, 95% CI 2.32-2.60; p < 0.0001), and oxygen dependence (OR 2.42, 95% CI 2.18-2.68; p < 0.0001) were all identified as major predictors of serious complications. We identified OSA as a modifiable factor predictive of serious complications following elective bariatric surgery. OSA is highly prevalent in this patient population, and it appears to be an important risk factor that deserves further attention in terms of peri-operative optimization strategies.

Hypoalbuminemia Predicts Serious Complications Following Elective Bariatric Surgery.

The aims of this study were to (1) characterize the prevalence of hypoalbuminemia (HA), (2) compare complication rates among HA and non-HA patients, and (3) determine the influence of HA on postoperative complications and 30-day mortality among bariatric surgery patients. Data was extracted from the MBSAQIP registry from 2015 to 2018. A presurgical serum albumin level of [Formula: see text] 3.5g/dL was used to organize the patient population into HA and non-HA cohorts. Bivariate analysis and multivariable logistic regression modeling were used. Of 590,971 patients, 42,618 (7.2%) were identified as having serum albumin levels [Formula: see text] 3.5g/dL. HA patients were younger (44.0 + / - 11.9 vs. 44.5 + / - 12.0years; p < 0.0001), were of increased BMI (48.5 + / - 9.0kg/m2 vs. 45.1 + / - 7.7kg/m2; p < 0.0001), and had a lower baseline functional status (1.6% vs. 1.0% dependent or partially dependent; p < 0.0001). HA patients had more anastomotic leaks (0.46% vs. 0.38%; p = 0.02), deep surgical site infections (0.37% vs. 0.24%; p < 0.0001), and composite serious complications (4.4% vs. 3.3%; p < 0.0001). At 30-day post-operation, complications including need for reintervention (1.6% vs. 1.2%; p < 0.0001), readmission (4.8% vs. 3.7%; p < 0.0001), and mortality (0.14% vs. 0.086%; p = 0.001) were all more prevalent among HA patients. After functional status, HA was the strongest modifiable predictor of serious complications but was not predictive of 30-day mortality. We identified HA as one of the greatest modifiable factors predictive of serious complications. Adoption of strategies to identify and improve preoperative serum albumin levels may reduce overall serious complications among elective bariatric surgery patients.

Perioperative outcomes of reconstructive surgery for apical prolapse in the very elderly: a national contemporary analysis.

It is predicted that the number of women aged 80years or older will more than triple by 2050. In the US, women have a 13% lifetime risk of undergoing pelvic organ prolapse surgery. Our aim was to compare the perioperative outcomes following various reconstructive approaches for apical prolapse surgery in the very elderly. The National Surgical Quality Improvement Program database was used to identify women age ≥ 80years of age who underwent reconstructive apical prolapse surgery from 2010 to 2017. Perioperative morbidity of vaginal colpopexy, minimally invasive sacrocolpopexy (MISC) and abdominal sacrocolpopexy (ASC) were compared. The primary outcome was the rate of composite serious complications. Univariate and multivariate logistic regression was used to identify independent predictors of serious complications. A total of 1012 patients were identified: vaginal (n = 792), MISC (n = 151) and ASC (n = 69). The composite serious complication rate was higher in the ASC group compared to vaginal/MISC groups (18.8% vs. 9.3% and 9.3%, p < 0.05). ASC had higher rates of blood transfusion, thromboembolism and reintubation. Life-threatening complications, readmission, pneumonia, stroke and 30-day mortality were lowest in the vaginal group. ASC (aOR 2.27), age > 85years (aOR 1.98), operative time > 3h (aOR 2.02), baseline dyspnea (aOR 2.17), "other race" (aOR 2.04), preoperative coagulopathy (aOR 2.92) and ASA (aOR 1.47) were associated with composite serious complications. ASC is associated with higher perioperative morbidity in the very elderly population. MISC and vaginal colpopexy have similar rates of composite serious complications; however, vaginal colpopexy is overall the safest approach in this population.

Evaluation of the Trends, Characteristics, and Outcomes in North American Youth Undergoing Elective Bariatric Surgery.

Severe obesity is increasingly common in youth and young adults, but outcomes following bariatric surgery remain largely unknown. The purpose of this study was to examine the trends, clinical characteristics, and postoperative outcomes of youth who underwent bariatric surgery. This retrospective cohort study was conducted using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to 2018 inclusive. All youth and young adults aged 15-24 who underwent elective sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were included. Bivariate analysis of trends, clinical characteristics, and postoperative outcomes was performed using Chi-squared tests for categorical variables and independent two sample t test for continuous variables. Multivariable logistic regression modeling was used to determine patient and operative factors predictive of serious complications. A total of 21,592 youth and young adults underwent bariatric surgery during the study time frame, representing 3.7% of total cases (n = 583,567) within the MBSAQIP. The cohort had a mean age of 21.5 ± 2.0years and a mean BMI of 47.2 ± 8.0kg/m2 and were predominantly female (84%). A relatively constant number of youth and young adult cases per hospital were observed over time (7.4 cases/center in 2015 vs. 6.7 cases/center in 2018). Overall, < 5% of cases required reoperation, reintervention, and readmission, or led to serious complications within 30days of surgery. Multivariable logistic regression analysis identified RYGB as the single greatest independent predictor of serious complications (OR 3.1; 95% CI 2.58-3.64; p < 0.0001). Additional factors predictive of serious complications included female sex (OR 1.31; 95% CI 1.01-1.70; p = 0.04), sleep apnea (OR 1.27; 95% CI 1.02-1.58), and non-insulin-dependent diabetes (OR 1.35; 95% CI 1.04-1.75; p = 0.025). Bariatric surgery in youth is safe but comprised only 3.7% of total MBSAQIP cases from 2015 to 2018. These data should serve as a call to government and healthcare agencies to develop policies and strategies that prioritize bariatric surgery for young people living with severe obesity.

Our experiences with pancreatoduodenectomy: risk factors and outcomes analysis

Pancreatoduodenectomy (PD) is the main surgical option for pancreatic neoplasms, duodenal neoplasms and other lesions located in the pancreatic head and periampullary region. Despite the prompt progress in surgical technologies and the persistent innovation of postoperative treatments over the last decades, post-pancreaticoduodenectomy complications (PPCs) remains high, which may lead to several potential poor outcomes, including prolonged hospital stays, increased medical costs and mortality. The purposes of this study were to analyze all type of PPCs and to identify associated factors related. Cross-sectional design was used. Patients, who underwent PD in Fatmawati General Hospital Jakarta between January 2017 and December 2018 were retrospectively analyzed. We classify PPCs for 45 patients who had undergone PD, ten variables were considered significant predictors of serious complications. The predictors included age, sex, obesity, smoking status, the presence of a comorbidity, nutritional status, combined vascular resection, intraoperative blood transfusion, serum albumin and bilirubin laboratory. Clinically, the most relevant postoperative complication of PD is a pancreatic fistula (PF), which is often associated with the development of life-threatening intra-abdominal complications. Pancreaticoduodenectomy remains the only curative option for patients with a malignant neoplasm. Good preoperative assessment and preparation support reduced the morbidity and mortality rate associated with PD

Pathophysiological mechanisms of coronavirus disease (COVID-19) progression and fatal complications in patients with diabetes

Pandemic of the coronavirus disease (COVID-19) is still one of the most acute medical and social problem in the world. It’s well known that development of severe complications, including acute respiratory distress syndrome, is most often associated with comorbid condition and patients age (category over 50 years). Diabetes mellitus is the most common endocrine disease, clinical and epidemiological trials confirm it’s a high risk factor for progression and mortality in patients with COVID-19.The aim of the work was to analyze the data of the scientific literature on the suspected pathophysiological mechanisms between diabetes mellitus and coronavirus disease association.The article highlights role of angiotensin-converting enzyme-2 expression changes, which is defined as a functional target on the cell surface for SARS-CoV-2 penetration. The review analyzes the results of experimental studies about effects of medicines included in diabetes clinical protocols (insulin, glucagon like peptide-1 analogues, thiazolidinediones derivates, angiotensin-converting enzyme inhibitors, angiotensin-2 receptor blockers, statins) on ACE-2 activity. Immunological disorders in diabetes mellitus patients, may significantly affect the COVID-19 state, in particular, due late hyperinflammatory condition and cytokine storm syndrome formation, which are predictors of serious complications, including acute respiratory distress syndrome. The results of the retrospective clinical study that involves people with COVID-19 and diabetes mellitus who don’t have other comorbidities were analyzed.Conclusions. The data presented in current review necessitate further clinical trials for objective assessment of the potential benefits and risks of medicines used in patients with diabetes under COVID-19 and for treatment regimens revision in case of adverse effect on disease progression and state. The review data indicate a high risk of unfavorable prognosis of SARS-CoV-2 infection in patients with diabetes mellitus.

Impact of neoadjuvant radiation on postoperative outcomes of patients with pancreatic cancer undergoing pancreatoduodenectomy

Presenter: Samer AlMasri MD | University of Pittsburgh Medical Center Background: Neoadjuvant chemotherapy (NC) and chemoradiation (NCRT) are increasingly used to downstage pancreatic adenocarcinoma (PDA), particularly in head tumors requiring pancreatoduodenectomy (PD). While NCRT may increase margin negative rates and sterilize regional lymph nodes, its impact on postoperative morbidity remains poorly characterized. This study aimed to compare the impact of NCRT and NC on the postoperative morbidity of patients with PDA undergoing PD. Methods: A single-center, retrospective analysis of consecutive patients with PDA treated with NC or NCRT followed by PD between 2009 and 2019 was performed. All complications within the first post-operative year were recorded. Logistic regression analysis was performed to identify predictors of morbidity. Kaplan-Meier estimates and Cox proportional analysis were performed with overall survival (OS) and complication-free survival as the primary outcome. Results: Of 354 patients, 271 received NC and 83 received NCRT [60% received SBRT and 40% received other RT (EBRT/ IMRT/ 3D-conformal therapy)]. Mean age was 66.4 years and 50.6% were females. Patients who received NCRT were more likely to be females, had higher rates of locally advanced disease, arterial involvement and received higher number of NC cycles (all p<0.05). Compared to NC, patients who received NCRT had higher rates of open surgeries and vascular resections, longer operative times, higher operative blood loss and rates of ICU admissions, longer hospital stay, higher 90-day mortality, serious complications (Clavien grade >3), lower rates of receipt of adjuvant therapy, and higher rate of complications within 1 year (all p<0.05). <br>Patients who received NCRT had significantly higher rates of GI bleed (p=0.012) and portomesenteric vessel thrombosis (p=0.0001) (Table). The most common cause of GI bleed in patients who received NCRT was a pseudoaneurysm (66.67%). On multivariate analysis, NCRT remained associated with longer (>10 days) post-operative hospital stay (OR=2.38; p=0.008), higher rate of serious complications (OR=1.95; p=0.04) and less receipt of adjuvant therapy (OR=0.41; p=0.011). On subgroup analysis of various RT modalities, SBRT was not a significant predictor of serious complications (OR=1.23; p=0.65) on multivariate analysis.<br>Patients who received NCRT had significantly shorter complication free survival within the first post-operative year compared to those who received NC, on Kaplan-Meier (p=0.018) and Cox- regression analysis (HR=1.5; p=0.049). Median OS of patients who received NCRT was not significantly different from those who received NC (28.7 vs. 31.4 months; p=0.962). Conclusion: NCRT is associated with increased morbidity following PD, which may be explained by a higher proportion of locally advanced disease and vascular resections in this cohort. In this analysis, neoadjuvant SBRT was not associated with serious complications and may offer a safer alternative to NCRT, warranting its prospective analysis.

Risk factors of serious postoperative complications after pancreaticoduodenectomy and risk calculators for predicting postoperative complications: a nationwide study of 17,564 patients in Japan.

BackgroundThe morbidity rate after pancreaticoduodenectomy remains high. The objectives of this retrospective cohort study were to clarify the risk factors associated with serious morbidity (Clavien–Dindo classification grades IV–V), and create complication risk calculators using the Japanese National Clinical Database.MethodsBetween 2011 and 2012, data from 17,564 patients who underwent pancreaticoduodenectomy at 1,311 institutions in Japan were recorded in this database. The morbidity rate and associated risk factors were analyzed.ResultsThe overall and serious morbidity rates were 41.6% and 4.5%, respectively. A pancreatic fistula (PF) with an International Study Group of Pancreatic Fistula (ISGPF) grade C was significantly associated with serious morbidity (P < 0.001). Twenty‐one variables were considered statistically significant predictors of serious complications, and 15 of them overlapped with those of a PF with ISGPF grade C. The predictors included age, sex, obesity, functional status, smoking status, the presence of a comorbidity, non‐pancreatic cancer, combined vascular resection, and several abnormal laboratory results. C‐indices of the risk models for serious morbidity and grade C PF were 0.708 and 0.700, respectively.ConclusionsPreventing a PF grade C is important for decreasing the serious morbidity rate and these risk calculations contribute to adequate patient selection.

Transient right bundle branch block: A rare manifestation in cardiac contusion

Transient right bundle branch block following blunt cardiac injury is a known but under-recognized manifestation of cardiac contusion. The first case documented in the medical literature occurred in 1952 in a 22-year-old man who was thrown from a motorcycle. Due to their relatively anterior location, the right ventricle and right bundle branch are at particular risk of injury in contusion. We present here a case in which a 24-year-old man suffered a blunt chest trauma leading to a right bundle branch block and elevated troponin levels, consistent with cardiac contusion. His conduction system abnormalities rapidly resolved and he recovered completely, with no clinical sequelae.<Learning objective: Cardiac contusion is a heterogeneous syndrome with widely variable clinical manifestations and severity. Transient right bundle branch block has been described as a self-limited and benign manifestation of cardiac contusion. This case highlights the need for a better understanding of the natural history and predictors of serious complications of cardiac contusion, which can aid in determining appropriate diagnostic studies, risk stratification, and treatment.>

3047 POSTER MASCC Score as a Predictor of Serious Complications in Febrile Neutropenic Patients Admitted for Intravenous Antibiotics

3047 POSTER MASCC Score as a Predictor of Serious Complications in Febrile Neutropenic Patients Admitted for Intravenous Antibiotics

Predictors and outcome of grade 3 ischemia in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Purpose Grade 3 ischemia (G3I: distortion of the terminal portion of the QRS complex) is a predictor of serious complications after acute myocardial infarction. However, less is known about which patients are more prone to present with G3I. Methods Patients who were enrolled in the Ongoing Tirofiban In Myocardial infarction Evaluation trial 2 were included. These patients were divided in 2 groups based on the enrolment electrocardiogram: grade 2 ischemia (G2I) or G3I. Results Between June 2004 and November 2007, 1308 patients with interpretable electrocardiograms were enrolled. Grade 3 ischemia was found in 426 (32.6%) patients. Patients with G3I were older, more often male, more often had diabetes, had a Thrombolysis In Myocardial Infarction (TIMI) risk score of greater than 3, had 3 vessel disease, had an anterior infarction, more often presented in Killip class greater than 1, less often had a preprocedural TIMI 3 flow, and less often had a myocardial blush grade 3 post-PCI. One hour post-PCI, residual ST deviation was higher in patients with G3I compared with patients with G2I. Furthermore, G3I was associated with more major cardiac events (including death, myocardial infarction, urgent target vessel revascularization). After multivariate adjustment, G3I was an independent predictor of failure of ST-segment resolution 1 hour post-PCI (odds ratio, 1.4; 95% confidence interval, 1.1-1.9) and 30-day mortality (odds ratio, 3.2; 95% confidence interval, 1.2-8.7). Conclusion Grade 3 ischemia was associated with high-risk patient criteria (older age, diabetes, TIMI risk score >3, Killip class >1, and anterior myocardial infarction) and represents a subgroup of high-risk patients who seems to be associated with poor myocardial reperfusion and worse outcome.

Predictors of Serious Complications Associated with Lower Gastrointestinal Endoscopy in a Major City-Wide Health Region

There are limited data regarding complications associated with colonoscopy and flexible sigmoidoscopy in usual clinical practice in Canada. To determine the risk factors for lower gastrointestinal (GI) endoscopy-associated complications in usual clinical practice. All outpatient lower GI endoscopies performed in Winnipeg (Manitoba) between April 1, 2004 and March 31, 2006, were identified from the provincial physicians' claims database. All subsequent hospital admissions within 30 days that documented potential complications associated with lower GI endoscopies were identified from the electronic hospital discharges database and reviewed. Multivariate generalized estimating equation regression analysis was performed to determine independent factors (patient, endoscopist and procedure) associated with the risk of developing complications. There were 29,990 outpatient lower GI endoscopies performed in Winnipeg during the years studied. Seventy-seven (0.26%) procedures were associated with complications requiring hospitalization within 30 days of the index procedure. Stricture dilation (rate ratio [RR] 23.14; 95% CI 6.70 to 76.51), polypectomy (RR 5.93; 95% CI 3.66 to 9.62), increasing patient age (for each year increase in age, RR 1.03; 95% CI 1.01 to 1.05) and performance of endoscopy by low-volume endoscopists (fewer than 200 procedures per year, RR 2.28; 95% CI 1.18 to 4.42) and family physicians (RR 2.23; 95% CI 1.39 to 3.58) were independently associated with complications. The results of the present study suggest that increasing patient age, complex procedures and performance of the index procedure by low-volume endoscopists are independent risk factors for lower GI endoscopy-associated complications in usual clinical practice. This suggests that it may be time to consider implementing minimum volume requirements for endoscopists performing non-screening lower GI endoscopies.

T2059 Predictors of Serious Complications Due to Clostridium difficile Infection

T2059 Predictors of Serious Complications Due to Clostridium difficile Infection

Predictors of serious complications due to Clostridium difficile infection

Identifying individuals with severe Clostridium difficile infection (CDI) at risk for major complications has become an important objective. Presence of clinical variables that predict complications from CDI would have the potential to strongly influence management. To determine which clinical variables predict complications from CDI. Cross-sectional study of all individuals admitted to Temple University Hospital between 12/1/03 and 7/1/08 with the primary discharge diagnosis of CDI were eligible. Only patients experiencing their first episode of CDI were included. Abstracted data included demographic, physiological, laboratory, radiological, endoscopic, pharmacy and outcome data. Response was categorized as none, partial or complete. Complications attributed to CDI were defined as colon resection or death. Overall 32 of 200 patients (16%) experienced a complication due to CDI including death (n = 20) and colectomy (n = 12). White blood cell count above 30,000 cells/mm(3) (OR = 4.06; 95% CI, 1.28-12.87) and a rise in the creatinine to over 50% above baseline (OR = 7.13; 95% CI, 3.05-16.68) predicted a complication. AROC for percent rise in serum creatinine was 0.73 (95% CI: 0.64-0.85) and 0.62 (95% CI: 0.58-0.80) for white blood cell count. Severe white blood cell count elevation and a rise in the creatinine to over 50% above baseline are important independent predictors of serious adverse events due to CDI. These patients likely would benefit from more intensive care and early surgical consultation.

Tricyclic Antidepressant Poisoning

Tricyclic antidepressants remain a common cause of fatal drug poisoning as a result of their cardiovascular toxicity manifested by ECG abnormalities, arrhythmias and hypotension. Dosulepin and amitriptyline appear to be particularly toxic in overdose. The principal mechanism of toxicity is cardiac sodium channel blockade, which increases the duration of the cardiac action potential and refractory period and delays atrioventricular conduction. Electrocardiographic changes include prolongation of the PR, QRS and QT intervals, nonspecific ST segment and T wave changes, atrioventricular block, right axis deviation of the terminal 40 ms vector of the QRS complex in the frontal plane (T 40 ms axis) and the Brugada pattern (downsloping ST segment elevation in leads V1-V3 in association with right bundle branch block). Maximal changes in the QRS duration and the T 40 ms axis are usually present within 12 hours of ingestion but may take up to a week to resolve. Sinus tachycardia is the most common arrhythmia due to anticholinergic activity and inhibition of norepinephrine uptake by tricyclic antidepressants but bradyarrhythmias (due to atrioventricular block) and tachyarrhythmias (supraventricular and ventricular) may occur. Torsade de pointes occurs uncommonly. Hypotension results from a combination of reduced myocardial contractility and reduced systemic vascular resistance due to alpha-adrenergic blockade. Life-threatening arrhythmias and death due to tricyclic antidepressant poisoning usually occurs within 24 hours of ingestion. Rapid deterioration is common. Level of consciousness at presentation is the most sensitive clinical predictor of serious complications. Although a QRS duration >100 ms and a rightward T 40 ms axis appear to be better predictors of cardiovascular toxicity than the plasma tricyclic drug concentration, they have at best moderate sensitivity and specificity for predicting complications.