Risk Of Serious Morbidity Research Articles

3D Bioprinting-Tunable Small-Diameter Blood Vessels with Biomimetic Biphasic Cell Layers.

Blood vessel damage resulting from trauma or diseases presents a serious risk of morbidity and mortality. Although synthetic vascular grafts have been successfully commercialized for clinical use, they are currently only readily available for large-diameter vessels (>6 mm). Small-diameter vessel (<6 mm) replacements, however, still present significant clinical challenges worldwide. The primary objective of this study is to create novel, tunable, small-diameter blood vessels with biomimetic two distinct cell layers [vascular endothelial cell (VEC) and vascular smooth muscle cell (VSMC)] using an advanced coaxial 3D-bioplotter platform. Specifically, the VSMCs were laden in the vessel wall and VECs grew in the lumen to mimic the natural composition of the blood vessel. First, a novel bioink consisting of VSMCs laden in gelatin methacryloyl (GelMA)/polyethylene(glycol)diacrylate/alginate and lyase was designed. This specific design is favorable for nutrient exchange in an ambient environment and simultaneously improves laden cell proliferation in the matrix pore without the space restriction inherent with substance encapsulation. In the vessel wall, the laden VSMCs steadily grew as the alginate was gradually degraded by lyase leaving more space for cell proliferation in matrices. Through computational fluid dynamics simulation, the vessel demonstrated significantly perfusable and mechanical properties under various flow velocities, flow viscosities, and temperature conditions. Moreover, both VSMCs in the scaffold matrix and VECs in the lumen steadily proliferated over time creating a significant two-cell-layered structure. Cell proliferation was confirmed visually through staining the markers of alpha-smooth muscle actin and cluster of differentiation 31, commonly tied to angiogenesis phenomena, in the vessel matrices and lumen, respectively. Furthermore, the results were confirmed quantitatively through gene analysis which suggested good angiogenesis expression in the blood vessels. This study demonstrated that the printed blood vessels with two distinct cell layers of VECs and VSMCs could be potential candidates for clinical small-diameter blood vessel replacement applications.

British Association of Urological Surgeons suprapubic catheter practice guidelines – revised

AimsTo report the updated and revised British Association of Urological Surgeons (BAUS) guideline on indications, safe insertion and subsequent care of suprapubic catheters (SPCs).MethodsThe existing BAUS guideline on the insertion of SPCs was reviewed and has been updated in light of both activity and outcome data published since the original guideline was written. A systematic review of all new data from 2010 onwards was carried out. This updated guideline is largely evidence‐based but, where evidence was lacking, is based on the consensus of expert opinion from members of the BAUS Section of Female, Neurological and Urodynamic Urology.ResultsSuprapubic catheterization is widely used and generally considered a safe procedure. There is, however, a small risk of serious complications including bowel injury. The BAUS has produced an updated consensus statement on SPC use with the aim of minimizing risks and establishing best practice. Areas for future research and development are also highlighted. This review has been commissioned and approved by the BAUS and the Section of Female, Neurological and Urodynamic Urology.ConclusionsWhile SPC insertion is generally regarded as a safe procedure, the risk of serious morbidity and death must always be considered and outlined to patients. These revised guidelines should assist in minimizing the morbidity associated with SPC usage.

Abstract IA24: The lifetime impact of cancer and cancer therapy

Abstract Survival rates after childhood cancer have increased dramatically in the past 50 years. More than 80% of children diagnosed with a malignancy now survive five years, with most going on to become long-term survivors. This has resulted in a growing population of childhood cancer survivors in the U.S., estimated to exceed 420,000 in 2013 and to approach half a million by 2020. Unfortunately, the same curative treatments that enable long-term survival also cause toxicities that leave many survivors with a substantial burden of adverse health and quality-of-life outcomes. Survivors have a 13-fold higher mortality rate than the general population. Eighty percent of childhood cancer survivors develop at least one severe, disabling, life-threatening, or fatal chronic health condition by age 45 years, and the average survivor will experience four such conditions by age 50 years. Specifically, survivors have increased risk compared to the general population for diseases often associated with aging, such as heart disease, diminished pulmonary function, and second cancers. The substantial burden of morbidity experienced by survivors translates to a significantly reduced quality of life compared to those without a cancer history. Thus, there is a critical need to better understand which survivors have the highest risk of serious morbidity and mortality, identify those with subclinical dysfunction, and inform intervention strategies for mitigating the burden of these late effects. Unfortunately, however, as survivors age into adulthood, most are no longer followed at their primary treatment institution, but by their community primary care providers, limiting our knowledge of long-term follow and late outcomes, a similar problem to that seen when survivors of adult malignancies participate in clinical trials where systematic follow-up ends at the five-year time point. To address this knowledge gap, the Childhood Cancer Survivor Study (CCSS) was developed. The CCSS is a multi-institutional, multidisciplinary, NCI-funded collaborative resource (U24 CA55727; PI: Gregory Armstrong) established to evaluate long-term outcomes among survivors of childhood cancer, largely by self-reported outcomes. It is a retrospective cohort consisting of &amp;gt;25,000 five-year survivors of childhood cancer who were diagnosed between 1970-1999 at one of 31 participating centers in the U.S. and Canada. Self-reported outcomes across a spectrum of chronic health conditions, psychosocial and cognitive function, and physical function outcomes have informed over 350 publications to date enumerating risk for this aging population. The results of the CCSS have advanced knowledge of late effects among survivors of childhood cancer. CCSS investigators have demonstrated that 60-90% of adults treated for cancer during childhood develop one or more chronic health conditions. They have also shown that by age 50 years, the cumulative incidence of self-reported severe, disabling, life-threatening, or fatal health condition was 53.6% among survivors compared with 19.8% among sibling control group. Among childhood cancer survivors who reach age 35 years of age without a previous severe, disabling, life-threatening, or fatal health condition, 25.9% will experience a new severe, disabling, life-threatening or fatal condition within 10 years as compared to 6% of healthy siblings. In addition to the findings related to an increased risk of morbidity and mortality from subsequent neoplasms and cardiac disease, CCSS has shown that long-term survivors are at risk of developing a variety of adverse outcomes that include organ dysfunction (e.g., pulmonary, gonadal), impaired growth and development, impaired cognitive function, difficulties obtaining employment and insurance, and compromises in the quality of life. Recently, the CCSS provided evidence that survivors treated in more recent eras have a significant reduction in late mortality attributable to two things: fewer deaths from recurrence or progression of primary cancer but more importantly, fewer deaths from treatment-related causes such as subsequent malignancies and cardiopulmonary death. In conclusion, the now decades-long strategy of designing pediatric cancer treatment regimens with a focus on adult health and avoidance of late effects appears to have been successful. Taken along with promotion of early detection of late effects and improved treatment of late effects, this approach has now translated to extend the lifespan of many survivors of childhood cancer. Future directions include the need to: (1) assess the true impact of screening and early detection of late effects on morbidity and mortality and evaluate interventions that improve screening rates as well as alter health behaviors, (2) expand individual risk prediction for poor outcomes, (3) further understand genetic susceptibility for late effects, and (4) target studies for both primary and secondary prevention of late effects, so that we not only extend the lifespan of survivors, but their health span as well. Citation Format: Greg Armstrong. The lifetime impact of cancer and cancer therapy [abstract]. In: Proceedings of the AACR Special Conference on the Advances in Pediatric Cancer Research; 2019 Sep 17-20; Montreal, QC, Canada. Philadelphia (PA): AACR; Cancer Res 2020;80(14 Suppl):Abstract nr IA24.

Editorial Comment: 2019 Musculoskeletal Infection Society Proceedings

Editorial Comment: 2019 Musculoskeletal Infection Society Proceedings

Minimally Invasive Proctectomy for Rectal Cancer: A National Perspective on Short-term Outcomes and Morbidity.

Prior randomized trials showed comparable short-term outcomes between open and minimally invasive proctectomy (MIP) for rectal cancer. We hypothesize that short-term outcomes for MIP have improved as surgeons have become more experienced with this technique. Rectal cancer patients who underwent elective abdominoperineal resection (APR) or low anterior resection (LAR) were included from the American College of Surgeons National Surgical Quality Improvement Program database (2016-2018). Patients were stratified based on intent-to-treat protocol: open (O-APR/LAR), laparoscopic (L-APR/LAR), robotic (R-APR/LAR), and hybrid (H-APR/LAR). Multivariable logistic regression analysis was used to assess the impact of operative approach on 30-day morbidity. A total of 4471 procedures were performed (43.41% APR and 36.59% LAR); O-APR 42.72%, L-APR 20.99%, R-APR 16.79%, and H-APR 19.51%; O-LAR 31.48%, L-LAR 26.34%, R-LAR 17.48%, and H-LAR 24.69%. Robotic APR and LAR were associated with shortest length of stay and significantly lower conversion rate. After adjusting for other factors, lap, robotic and hybrid APR and LAR were associated with decreased risk of overall morbidity when compared to open approach. R-APR and H-APR were associated with decreased risk of serious morbidity. No difference in the risk of serious morbidity was observed between the four LAR groups. Appropriate selection of patients for MIP can result in better short-term outcomes, and consideration for MIP surgery should be made.

Clinical ultrasonography in patients who inject drugs (the CUPID protocol): an illustrated case series.

In 2017, there were ≈47,600 opioid overdose‐related deaths in the United States. US emergency department (ED) visits for suspected opioid overdose increased by 30% between July 2016 and September 2017.2 The current US opioid epidemic makes it critical for emergency physicians to be aware of common and uncommon infectious and non‐infectious complications of injection drug use. Point‐of‐care ultrasound has become a widely available, non‐invasive diagnostic tool in EDs across the United States and worldwide. The increasing population of injection drug use patients is at risk for serious morbidity and mortality from an array of disease states amenable to ultrasound‐based diagnosis. We propose a protocol for clinical ultrasonography in patients who inject drugs (the CUPID protocol), a focused, 3‐system point‐of‐care ultrasound approach emphasizing cardiovascular, thoracic, and musculoskeletal imaging. The protocol is a screening tool, designed to detect high risk infectious and noninfectious complications of injection drug use.

Innate and Adaptive Immune Responses in HELLP Syndrome.

Innate and adaptive immune involvement in hemolysis, elevated liver enzymes and low platelet (HELLP) syndrome is an understudied field, although it is of high clinical importance. This syndrome implies a risk of serious morbidity and mortality to both the mother and the fetus during pregnancy. It was proposed that HELLP syndrome occurs in a circulatory inflammatory milieu, that might in turn participate in a complex interplay between the secreted inflammatory immunomodulators and immune cell surface receptors. Meanwhile, reported immune cell attenuation during HELLP may consequently lead to a prolonged immunoactivation and tissue damage. In this regard, learning more about the immune components of this syndrome should widen the understanding of the HELLP pathophysiology and eventually enable development of novel immune-based therapeutics. This review aims to summarize and discuss the recent and previous findings of the innate and adaptive immune responses during HELLP in order to update the current knowledge of the immune involvement in HELLP pathogenesis.

Acute Infective Bloody Diarrhea in Children Below Five Years Admitted to Children Welfare Hospital in Medical City - Baghdad During 2015

Bloody diarrhea in young children is usually a sign of invasive enteric infection that carry a substantial risk of serious morbidity and death. Objectives : to identify the proportion of infective bloody diarrhea out of total number of gastro-enteritis cases ,also to identify the prevalence of different etiological agents and to find the relation between the main infective etiological types of bloody diarrhea and some sociodemographic factors of this study. Retrospective study was conducted in Children Welfare Teaching Hospital / Baghdad during period extending from 1 st of January to 30 th of June 2016. Information was collected by reviewing the records of patients with acute infective bloody diarrhea under 5 years of age admitted during 2015. The study revealed that the proportion of infective bloody diarrhea was 10. 9% out of the total gastroenteritis (788) cases admitted during 2015, and Entamoeba Histolytica was the most common isolated pathogen in the study42 (48%) patients. followed by E.coli 15 cases (17.4%), shigella, salmonella 7(8%) and 4(4.7%) respectively . The most vulnerable age was those below 2 years (58%) and males were affected more than females (1.3:1), (37%) were bottle fed. The majority had chlorinated tap water supply (82.6%).

The Clinical Impact of Delayed Management of Hirschsprungs Disease

Background: Hirschsprung's disease (HD) is a developmental disorder of the enteric nervous system that is characterized by the absence of ganglion cells in the myenteric and submucosal plexus from the anorectum for a variable colonic or intestinal distance. HD is a congenital bowel motility disorder which occurs in approximately one of every 5000 live births. This results in a lack of peristalsis leading to a huge dilatation of the colon proximal to the aganglionic bowel. Aim of work: The purpose of the present study is to investigate the clinical impact of delayed management of children with HD. and how it would affect their outcomes? Methods: The present study was performed in the period from July 2018 to august 2019 in Pediatric Surgery Department of Zagazig University Hospital. 18 patients enrolled inprospective clinical study Results: The delayed diagnosis of HD is associated with a different pattern of presentation compared with neonatal HD. Most of the cases were presented by chronic constipation, abdominal distension and bilious vomiting. Moreover, outcome is worse in older children who are diagnosed with this disease. Conclusions: HD in older children associated with long hospital stay, increased cost of treatment compared with the younger children. Postoperative outcome in older children associated not only with increased risk of serious morbidities but also indirectly affect their long-term outcome.

Cardiac Dysfunction in Severely Burned Patients: Current Understanding of Etiology, Pathophysiology, and Treatment.

Patients who experience severe burn injuries face a massive inflammatory response resulting in hemodynamic and cardiovascular complications. Even after immediate and appropriate resuscitation, removal of burn eschar and covering of open areas, burn patients remain at high risk for serious morbidity and mortality. As a result of the massive fluid shifts following the initial injury, along with large volume fluid resuscitation, the cardiovascular system is critically affected. Further, increased inflammation, catecholamine surge, and hypermetabolic syndrome impact cardiac dysfunction, which worsens outcomes of burn patients. This review aimed to summarize the current knowledge about the effect of burns on the cardiovascular system.A comprehensive search of the PubMed and Embase databases and manual review of articles involving effects of burns on the cardiovascular system was conducted.Many burn units use multimodal monitors (e.g., transpulmonary thermodilution) to assess hemodynamics and optimize cardiovascular function. Echocardiography is often used for additional evaluations of hemodynamically unstable patients to assess systolic and diastolic function. Due to its noninvasive character, echocardiography can be repeated easily, which allows us to follow patients longitudinally.The use of anabolic and anticatabolic agents has been shown to be beneficial for short- and long-term outcomes of burn survivors. Administration of propranolol (non-selective β-receptor antagonist) or oxandrolone (synthetic testosterone) for up to 12 months post-burn counteracts hypermetabolism during hospital stay and improves cardiac function.A comprehensive understanding of how burns lead to cardiac dysfunction and new therapeutic options could contribute to better outcomes in this patient population.

Invasive Respiratory or Vasopressor Support and/or Death as a Proposed Composite Outcome Measure for Perioperative Care Research.

There is a need for a clinically relevant and feasible outcome measure to facilitate clinical studies in perioperative care medicine. This large-scale retrospective cohort study proposed a novel composite outcome measure comprising invasive respiratory or vasopressor support (IRVS) and death. We described the prevalence of IRVS in patients undergoing major abdominal surgery and assessed the validity of combining IRVS and death to form a composite outcome measure. We retrospectively collected perioperative data for 2776 patients undergoing major abdominal surgery (liver, colorectal, gastric, pancreatic, or esophageal resection) at Kyoto University Hospital. We defined IRVS as requirement for mechanical ventilation for ≥24 hours postoperatively, postoperative reintubation, or postoperative vasopressor administration. We evaluated the prevalence of IRVS within 30 postoperative days and examined the association between IRVS and subsequent clinical outcomes. The primary outcome of interest was long-term survival. Multivariable Cox proportional regression analysis was performed to adjust for the baseline patient and operative characteristics. The secondary outcomes were length of hospital stay and hospital mortality. In total, 85 patients (3.1%) received IRVS within 30 postoperative days, 15 of whom died by day 30. Patients with IRVS had a lower long-term survival rate (1- and 3-year survival probabilities, 66.1% and 48.5% vs 95.2% and 84.0%, respectively; P < .001, log-rank test) compared to those without IRVS. IRVS was significantly associated with lower long-term survival after adjustment for the baseline patient and operative characteristics (adjusted hazard ratio, 2.72; 95% confidence interval, 1.97-3.77; P < .001). IRVS was associated with a longer hospital stay (median [interquartile range], 65 [39-326] vs 15 [12-24] days; adjusted P < .001) and a higher hospital mortality (24.7% vs 0.5%; adjusted P < .001). Moreover, IRVS was adversely associated with subsequent clinical outcomes including lower long-term survival (adjusted hazard ratio, 1.78; 95% confidence interval, 1.21-2.63; P = .004) when the analyses were restricted to 30-day survivors. Patients with IRVS can experience ongoing risk of serious morbidity and less long-term survival even if alive at postoperative day 30. Our findings support the validity of using IRVS and/or death as a composite outcome measure for clinical studies in perioperative care medicine.

Outcomes associated with hospital admissions for accidental opioid overdose in British Columbia: a retrospective cohort study

ObjectivesTo study the association between accidental opioid overdose and neurological, respiratory, cardiac and other serious adverse events and whether risk of these adverse events was elevated during hospital readmissions compared...

Mortality and Morbidity in Office-Based General Anesthesia for Dentistry in Ontario.

Our objective was to estimate the prevalence of mortality and serious morbidity for office-based deep sedation and general anesthesia (DS/GA) for dentistry in Ontario from 1996 to 2015. Data were collected retrospectively in 2 phases. Phase I involved the review of incidents, and phase II involved a survey of DS/GA providers. In phase I, cases involving serious injury or death for dentistry under DS/GA, sourced from the Office of the Chief Coroner of Ontario and from the Royal College of Dental Surgeons of Ontario (RCDSO), were reviewed. Phase II involved a survey of all RCDSO-registered providers of DS/GA in which they were asked to estimate the number of DS/GAs administered in 2015 and the number of years in practice since 1996. Clinician data were pooled to establish an overall number of DS/GAs administered in dental offices in Ontario from 1996 to 2015. Prevalence was calculated using phase I (numerator) and phase II (denominator) findings. The estimated prevalence of mortality in the 20-year period from 1996 to 2015 was 3 deaths in 3,742,068 cases, with an adjusted mortality rate of 0.8 deaths per 1 million cases. The estimated prevalence of serious morbidity was 1 injury in 3,742,068 cases, which adjusts to a serious morbidity rate of 0.25 per 1 million cases. The mortality rate found in this study was slightly lower than those published by earlier studies conducted in Ontario. The risk of serious morbidity was found to be low and similar to other studies investigating morbidity in office-based dental anesthesia.

Laparoscopic Sleeve Gastrectomy Is Associated with Lower 30-Day Morbidity Versus Laparoscopic Gastric Bypass: an Analysis of the American College of Surgeons NSQIP.

Laparoscopic sleeve gastrectomy (LSG) has rapidly gained popularity as a single-stage operation for the treatment of morbid obesity, as patients undergoing LSG have been shown to achieve similar weight loss and resolution of obesity-related comorbidities in comparison to those undergoing Roux-en-Y gastric bypass (RYGB), the "gold standard" bariatric operation. Although LSG poses fewer technical challenges than RYGB, little is known about differences in short-term outcomes among patients undergoing LSG and RYGB. We hypothesized that LSG is associated with lower 30-day risk-adjusted serious morbidity. Preoperative characteristics and 30-day outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) Participant Use Files (PUF) 2010-2014 were selected for all patients who underwent LSG or RYGB. Descriptive comparisons were performed using chi-square and Wilcoxon's rank-sum tests as appropriate. The primary outcome was a risk-adjusted composite measure of 30-day serious morbidity and mortality. We analyzed records for 47,982 (42.0%) and 66,380 (58.0%) patients undergoing LSG and RYGB, respectively. On univariate analysis, LSG patients had a lower rate of organ space infection (0.45% vs. 0.68%, p < 0.001), lower rate of bleeding requiring transfusions (1.00% vs. 1.60%, p < 0.001), lower rate of sepsis (0.34% vs. 0.49%, p < 0.001), and septic shock (0.12% vs. 0.22%, p < 0.001) and required fewer unplanned reoperations (1.34% vs. 2.56%, p < 0.001) than RYGB patients. Both groups had similar rates of deep venous thrombosis (0.33% vs. 0.28%, p = 0.15) and pulmonary embolism (0.17% vs. 0.21%, p = 0.15). Mortality was lower among LSG patients (0.09% vs. 0.14%, p = 0.01). On multivariate analysis, RYGB was associated with higher risk-adjusted 30-day serious morbidity than LSG (odds ratio 1.61; 95% CI 1.52-1.71, p < 0.001). Older age, female gender, higher BMI, and insulin-dependent diabetes were also associated with risk of serious morbidity (C-statistic = 0.60). Serious morbidity following bariatric surgery is uncommon; however, LSG may be associated with modest protection from adverse 30-day outcomes in comparison to RYGB. Our conclusion is limited by the difference in baseline risk factors of the populations studied.

Catheter-directed thrombolysis of deep vein thrombosis: literature review and practice considerations.

Deep vein thrombosis (DVT) is a major health problem worldwide. The risk of pulmonary embolism following DVT is well established, but the long-term vascular sequelae of DVT are often underappreciated, costly to manage, and can have extremely detrimental effects on quality of life. Treatment of DVT classically involves oral anticoagulation, which reduces the risk of pulmonary embolism but does not remove the clot. Anticoagulation therefore does little to prevent the venous damage and scarring that occurs following DVT, leaving the patient at risk for permanent venous insufficiency and development of post-thrombotic syndrome (PTS). Catheter-directed thrombolysis (CDT) is a minimally invasive endovascular treatment that is used as an adjunct to anticoagulation. CDT lowers the risk of PTS by reducing clot burden and protecting against valvular damage. A catheter is advanced directly to the site of thrombosis under fluoroscopy followed by a slow, prolonged infusion of a relatively low dose of thrombolytic agent. CDT restores venous patency faster than anticoagulation, which hastens the relief of acute symptoms. Adjunctive CDT modalities have become increasingly popular among interventional radiologists, allowing for additional mechanical thrombectomy or ultrasound-enhanced thrombolysis at the time of catheter placement. These pharmacomechanical CDT (PCDT) techniques have the potential to reduce treatment time and associated healthcare costs. Numerous observational and retrospective studies have consistently shown a benefit of CDT plus anticoagulation over anticoagulation alone for prevention of PTS. Patients with long life expectancy and acute thrombosis involving the iliac and proximal femoral veins (iliofemoral DVT) have the greatest benefit from CDT, which may decrease the risk of PTS and/or decrease the severity of PTS symptoms if they do occur. Randomized controlled trials remain limited but generally support the observational data. CDT also plays an important role in those with acute limb-threatening venous occlusion or severe symptoms from DVT. Although adverse outcomes are rare, a potential devastating outcome is intracranial bleeding. While the available literature suggests the risk of serious morbidity from bleeding is quite rare, the absolute risk of bleeding is not clear and will require outcomes data from randomized trials. Future studies should also examine the cost-effectiveness of CDT for PTS prevention, particularly with respect to quality-adjusted life years, and compare the effectiveness of available PCDT devices.

Moderate to late preterm intrauterine growth restriction: A restrospective, observational study of the indications for delivery and outcomes in an Australian perinatal centre.

The management of preterm intrauterine growth restriction is limited to fetal surveillance and timely delivery. Despite the existence of evidence-based guidelines, uncertainty regarding the optimal timing of delivery is common, and management remains individualised for each patient. To provide recent Australian data on the indications for delivery of moderate to late preterm growth restricted infants and the outcomes of these deliveries. Retrospective study of singleton live births delivered between 32+0 and 36+6weeks gestation over a three-year period (2012-2014) at a Melbourne Metropolitan Hospital. 'Small for gestational age' (birthweight<10th centile for gestation) identified intrauterine growth restricted infants. Indications for iatrogenic delivery were broadly categorised into maternal, fetal or pregnancy related. Obstetric and neonatal outcome variables were compared to other preterm infants using logistic regression. Of the 146 (18.6%) small for gestational age infants born during the study period, 103 were iatrogenic deliveries, most commonly due to fetal indications (53.4%). Small for gestational age infants had higher odds of hypoglycaemia (adjusted odds ratio=1.87, 95% CI: 1.23-2.84, P=0.003) and jaundice (1.52, 1.01-2.28, P=0.043) than their appropriately grown counterparts; however, there was no increase in the risk of serious morbidity or mortality. In this cohort, iatrogenic preterm delivery of small for gestational age infants between 32+0 and 36+6weeks gestation was most commonly due to fetal indications and did not increase the risk of serious, short-term neonatal outcomes compared to their appropriately grown counterparts.

Optimizing Surgical Quality Datasets to Care for Older Adults: Lessons from the American College of Surgeons NSQIP Geriatric Surgery Pilot

Surgical quality datasets can be better tailored toward older adults. The American College of Surgeons (ACS) NSQIP Geriatric Surgery Pilot collected risk factors and outcomes in 4 geriatric-specific domains: cognition, decision-making, function, and mobility. This study evaluated the contributions of geriatric-specific factors to risk adjustment in modeling 30-day outcomes and geriatric-specific outcomes (postoperative delirium, new mobility aid use, functional decline, and pressure ulcers). Using ACS NSQIP Geriatric Surgery Pilot data (January 2014 to December 2016), 7 geriatric-specific risk factors were evaluated for selection in 14 logistic models (morbidities/mortality) in general-vascular and orthopaedic surgery subgroups. Hierarchical models evaluated 4 geriatric-specific outcomes, adjusting for hospitals-level effects and including Bayesian-type shrinkage, to estimate hospital performance. There were 36,399 older adults who underwent operations at 31 hospitals in the ACS NSQIP Geriatric Surgery Pilot. Geriatric-specific risk factors were selected in 10 of 14 models in both general-vascular and orthopaedic surgery subgroups. After risk adjustment, surrogate consent (odds ratio [OR] 1.5; 95% CI 1.3 to 1.8) and use of a mobility aid (OR 1.3; 95% CI 1.1 to 1.4) increased the risk for serious morbidity or mortality in the general-vascular cohort. Geriatric-specific factors were selected in all 4 geriatric-specific outcomes models. Rates of geriatric-specific outcomes were: postoperative delirium in 12.1% (n= 3,650), functional decline in 42.9% (n= 13,000), new mobility aid in 29.7% (n= 9,257), and new or worsened pressure ulcers in 1.7% (n= 527). Geriatric-specific risk factors are important for patient-centered care and contribute to risk adjustment in modeling traditional and geriatric-specific outcomes. To provide optimal patient care for older adults, surgical datasets should collect measures that address cognition, decision-making, mobility, and function.

Cell-free deoxyribonucleic acid as a prognostic marker of bowel ischemia in patients with small bowel obstruction

Patients with strangulation small bowel obstruction are at a high risk for serious morbidity and mortality due to ischemic bowel. Measuring serum, cell-free deoxyribonucleic acid levels could help recognize early cell death. Our hypothesis was that small bowel ischemia or necrosis is associated with increases in serum cell-free deoxyribonucleic acid and that recovery is associated with a decrease in cell-free deoxyribonucleic acid levels. A prospective cohort study in addition to standard treatment of patients admitted with a diagnosis of small bowel obstruction. The participants were divided into groups depending on the presence of ischemic or necrotic bowel according to operative and clinical outcome. Clinical data and serum-based cell-free deoxyribonucleic acid levels were compared. Cell-free deoxyribonucleic acid levels from these 2 groups also were compared with a third group of healthy controls. In the study, 58 patients were enrolled, and 18 patients (31%) underwent operation. During the operative procedure, ischemic or necrotic bowel was found in 10 cases (17%). Serum levels of cell-free deoxyribonucleic acid at the time of admission in the ischemic/necrotic bowel group were increased compared with patients with well perfused or spontaneously recovered bowel (P=.03). Cell-free deoxyribonucleic acid levels decreased on the day after admission in 88% of the nonoperated patients. No significant differences were found in demographics, medical background, imaging performed, and cause of obstruction nor in clinical admission data. Surgeons currently rely on imprecise clinical parameters, including degree of pain, abdominal tenderness, leukocytosis etc to decide when operative intervention is needed. The association of cell-free deoxyribonucleic acid with small bowel obstruction, ischemia, and recovery supports our hypothesis and suggests that this biomarker is a potential surrogate of small bowel perfusion.

Top 10 Research Questions Related to Preventing Sudden Death in Sport and Physical Activity

ABSTRACTParticipation in organized sport and recreational activities presents an innate risk for serious morbidity and mortality. Although death during sport or physical activity has many causes, advancements in sports medicine and evidence-based standards of care have allowed clinicians to prevent, recognize, and treat potentially fatal injuries more effectively. With the continual progress of research and technology, current standards of care are evolving to enhance patient outcomes. In this article, we provided 10 key questions related to the leading causes and treatment of sudden death in sport and physical activity, where future research will support safer participation for athletes and recreational enthusiasts. The current evidence indicates that most deaths can be avoided when proper strategies are in place to prevent occurrence or provide optimal care.

Interstage Home Monitoring After Newborn First-Stage Palliation for Hypoplastic Left Heart Syndrome: Family Education Strategies

Children born with hypoplastic left heart syndrome are at high risk for serious morbidity, growth failure, and mortality during the interstage period, which is the time from discharge home after first-stage hypoplastic left heart syndrome palliation until the second-stage surgical intervention. The single-ventricle circulatory physiology is complex, fragile, and potentially unstable. Multicenter initiatives have been successfully implemented to improve outcomes and optimize growth and survival during the interstage period. A crucial focus of care is the comprehensive family training in the use of home surveillance monitoring of oxygen saturation, enteral intake, weight, and the early recognition of "red flag" symptoms indicating potential cardiopulmonary or nutritional decompensation. Beginning with admission to the intensive care unit of the newborn with hypoplastic left heart syndrome, nurses provide critical care and education to prepare the family for interstage home care. This article presents detailed nursing guidelines for educating families on the home care of their medically fragile infant with single-ventricle circulation.