Significant Difference In In-hospital Mortality Research Articles

Full Sternotomy, Hemisternotomy, and Minithoracotomy for Aortic Valve Surgery: Is There a Difference?

This study compared perioperative results and mortality rates of different approaches to perform aortic valve replacement (AVR), describing predictors favoring one approach over the others. All patients who underwent AVR were enrolled. The choice of the approach was left to surgeon's preference. Data were retrospectively collected, and the major baseline characteristics (including age, sex, body mass index, creatinine clearance, preoperative condition, cardiovascular risk factors, functional status, and left ventricular ejection fraction, etc.) and intraoperative variables were recorded. To adjust for differences in baseline characteristics between the study groups, a propensity score matching was performed. Linear and logistic regression analyses were performed. Partial upper hemisternotomy was performed in 820 patients (43%), right anterior minithoracotomy in 488 (26%), and median sternotomy in 599 (31%). After propensity score matching, three groups of 377 patients were obtained. Cardiopulmonary bypass and cross-clamp times were shorter in the right anterior minithoracotomy group than in the median sternotomy and partial upper hemisternotomy groups (p < 0.001). No significant differences in in-hospital mortality were observed (p= 0.9). Renal failure (odds ratio, 5.4; 95% confidence interval, 2.3 to 11.4; p < 0.0001), extracardiac arteriopathy (odds ratio, 2.9; 95% confidence interval, 1.1 to 6.7; p= 0.017), and left ventricular ejection fraction (odds ratio, 0.96; 95% confidence interval, 0.93 to 0.99; p= 0.009) emerged as independent predictors of in-hospital mortality. Minimal-access isolated aortic valve surgery is a reproducible, safe, and effective procedure with similar outcomes and operating times compared with conventional sternotomy.

PS01.196: SHORT-TERM AND MEDIUM-TERM OUTCOMES IN PATIENTS OVER 70 DIAGNOSED WITH OESOPHAGEAL CANCER

Abstract Background Oesophageal cancer incidence has increased over the last decade in the UK, particularly in older patients. Surgery, with or without perioperative chemotherapy, remains the gold standard treatment for patients with potentially curable disease. Currently, 41% of new cases of oesophageal cancer are in patients aged over 70. However, only 10% underwent surgery compared to 25% of those aged under 70. Concerns exist that advanced age may prejudice treatment decisions. The aim of our review is to evaluate the impact of age on outcomes in those undergoing planned curative treatment for oesophageal cancer. Methods A retrospective review of patients undergoing oesophagectomy for carcinoma between 2006 to 2016 at a single institution was performed. Patients were divided into two cohorts based on age at the time of diagnosis; under 70 years (Group A) and over 70 (Group B). Patients underwent a standardised staging protocol and treatment was decided by a multi-disciplinary team. Oesophagectomy was performed using a transthoracic approach with two field lymphadenectomy and perioperative chemo (radio) therapy used in those patients with locally advanced disease who were fit enough. Results There were 555 patients in Group A and 241 in Group B. Adenocarcinoma was the prevalent histological subtype in both cohorts: 76% (423) in Group A and 68% (165) in Group B. Median age at the time of diagnosis was 62 in Group A versus 74 in Group B. In Group A, 12% (18/343) did not receive neo-adjuvant treatment for locally advanced cancer versus 47% (101/212) in Group B (P &lt; 0.001). Median hospital stay was longer in Group B (18 v 15 days P = 0.02). There was no significant difference in hospital mortality (Group A 1% vs Group B 2.4% P = 0.37) and major complication rate (Group A 14% vs Group B 20% P = 0.31). Two-year survival was 66% (adenocarcinoma) and 78% (SCC) in Group A compared to 60% (adenocarcinoma) and 64% (SCC) in Group B. Conclusion These results demonstrate that patients over 70 can be treated successfully with minimal additional risk to morbidity and mortality. However, these patients are more likely to be denied neoadjuvant treatment which may compromise their long-term outcomes. Disclosure All authors have declared no conflicts of interest.

Impact of Arteriovenous Fistula for Hemodialysis on Clinical Outcomes of Coronary Artery Bypass

This study compared clinical outcomes between the use of in situ and free internal thoracic artery grafts in patients with upper extremity arteriovenous fistula who underwent coronary artery bypass. We reviewed 85 hemodialysis-dependent patients with upper extremity arteriovenous fistula who underwent coronary artery bypass with internal thoracic artery grafts. The patients were categorized into 2 groups; 48 (56%) with in situ graft ipsilateral to the arteriovenous fistula (group I) and 37 (44%) with free grafts anastomosed to the ascending aorta (group F). The follow-up period was 32.0 ± 38.1 months. The estimated overall survival rates at 3, 5, and 10 years were 89.5%, 81.6%, and 53%, respectively, for all discharged patients. There was no significant difference in in-hospital mortality, all-cause mortality, and freedom from major adverse cardiac events between the groups, although cardiac-related deaths occurred only in group I (n= 5). Ipsilateral in situ grafts were associated with hemodialysis-induced chest pain (odds ratio, 5.528; 95% confidence interval, 1.079 to 28.333; p= 0.040). The incidence of dialysis-induced chest pain in patients with in situ noncomposite, in situ composite, and free grafts was 45.5%, 19.4%, and 5.7%, respectively (p= 0.009). Mortality was not influenced by using the internal thoracic artery as an ipsilateral in situ graft in patients with upper extremity arteriovenous fistula. However, there was a risk of increased incidence of hemodialysis-induced chest pain that is most likely related to coronary steal. A free internal thoracic artery graft would be an alternative option in these patients.

Ascending Aorta Aneurysm: What is the Risk of Replacing the Aortic Root?

Background: In mildly dilated aortic root, the cost-benefit of replacing of the sinuses of Valsalva with reimplantation of thecoronary arteries or preserving them is still a matter of debate.Objective: The goal of this study was to analyze the postoperative and long-term morbidity and mortality of patients undergoingaortic root replacement versus aortic root surgery with sinuses of Valsalva preservation.Methods: Between 2002 and 2016, 426 patients underwent replacement of the ascending aorta. After excluding patients undergoingurgent procedures, genetic aortic diseases (except for bicuspid aortic valve), reoperations and surgery of the aortic arch,the cohort was made up of 259 patients. In 99 of them (38.2%) the ascending aorta was replaced, preserving the aortic root;these patients were compared with the remaining 160 (61.8%) patients who underwent replacement of the sinuses of Valsalva.Results: Patients undergoing preservation of the aortic root were older, had higher percentage of female sex, higher EuroSCOREand with greater incidence of bicuspid aortic valve and coronary artery disease. Cardiopulmonary bypass time was longer inthe group undergoing aortic root replacement. There were no significant differences in in-hospital mortality between bothgroups (1% in the group with preservation of the aortic root vs. 3.1% for replacement of the sinuses of Valsalva, p=0.272).Multivariate analysis showed that cardiopulmonary bypass was a predictor of in-hospital mortality. Survival at 8 years wassimilar in both groups. There were no new operations due to complications in the aorta during follow-up. At multivariateanalysis, age and mitral valve disease were identified as predictors of long-term mortality.Conclusion: Replacement of the ascending aorta, either replacing the aortic root or preserving the sinuses of Valsalva, is asafe procedure, with low in-hospital mortality. Preservation of the sinuses of Valsalva is not associated with greater rate ofevents or mortality at the long-term.

Outcomes of patients receiving a massive transfusion for major trauma.

The benefits of high transfusion ratios (plasma to red blood cells and platelets to red blood cells) on survival in injured patients who receive massive transfusions remain uncertain. This study aimed to assess the association between transfusion ratios and adverse events and survival in patients undergoing massive transfusion for major trauma. A retrospective observational study was conducted on patients who had major trauma using a Japanese national administrative database. The associations between transfusion ratios and outcomes (in-hospital mortality and incidence of adverse events) were analysed using a non-linear logistic generalized additive model (GAM). In a logistic generalized estimating equation model, adjusted for patient and hospital-level confounders, transfusion ratios were included as continuous or categorical variables (low, transfusion ratio 0·75 or less; intermediate, over 0·75 to 1·25; high, over 1·25). Some 1777 patients were included in the analysis, of whom 602 died in hospital. GAM plots of the transfusion ratios for in-hospital mortality demonstrated a downward convex unimodal curve. In-hospital mortality was similar with increasing transfusion ratios for plasma (adjusted odds ratio (OR) 1·13, 95 per cent c.i. 0·82 to 1·55; P = 0·446) and platelets (adjusted OR 0·84, 0·66 to 1·08; P = 0·171). Both plasma to red blood cell ratio (adjusted OR 1·77, 1·32 to 2·37; P < 0·001) and platelet to red blood cell ratio (adjusted OR 1·71, 1·35 to 2·15; P < 0·001) were significantly associated with a higher incidence of adverse events. No significant differences in in-hospital mortality were observed between the three transfusion categories (low, medium and high). In this study, transfusion strategies with high plasma to red blood cell and platelet to red blood cell ratios did not have survival benefits, but were associated with an increase in adverse events.

Association of Maternal Diabetes With Neonatal Outcomes of Very Preterm and Very Low-Birth-Weight Infants

Diabetes in pregnancy is associated with a 2-times to 3-times higher rate of very preterm birth than in women without diabetes. Very preterm infants are at high risk of death and severe morbidity. The association of maternal diabetes with these risks is unclear. To determine the associations between maternal diabetes and in-hospital mortality, as well as neonatal morbidity in very preterm infants with a birth weight of less than 1500 g. This retrospective cohort study was conducted at 7 national networks in high-income countries that are part of the International Neonatal Network for Evaluating Outcomes in Neonates and used prospectively collected data on 76 360 very preterm, singleton infants without malformations born between January 1, 2007, and December 31, 2015, at 24 to 31 weeks' gestation with birth weights of less than 1500 g, 3280 (4.3%) of whom were born to diabetic mothers. Any type of diabetes during pregnancy. The primary outcome was in-hospital mortality. The secondary outcomes were severe neonatal morbidities, including intraventricular hemorrhages of grade 3 to 4, cystic periventricular leukomalacia, retinopathy of prematurity needing treatment and bronchopulmonary dysplasia, and other morbidities, including respiratory distress, treated patent ductus arteriosus, and necrotizing enterocolitis. Odds ratios (ORs) with 95% confidence intervals were estimated, adjusted for potential confounders, and stratified by gestational age (GA), sex, and network. The mean (SD) birth weight of offspring born to mothers with diabetes was significantly higher at 1081 (262) g than in offspring born to mothers without diabetes (mean [SD] birth weight, 1027 [270] g). Mothers with diabetes were older and had more hypertensive disorders, antenatal steroid treatments, and deliveries by cesarean delivery than mothers without diabetes. Infants of mothers with diabetes were born at a later GA than infants of mothers without diabetes. In-hospital mortality (6.6% vs 8.3%) and the composite of mortality and severe morbidity (31.6% vs 40.6%) were lower in infants of mothers with diabetes. However, in adjusted analyses, no significant differences in in-hospital mortality (adjusted OR, 1.16 (95% CI, 0.97-1.39) or the composite of mortality and severe morbidity (adjusted OR, 0.99 (95% CI, 0.88-1.10) were observed. With few exceptions, outcomes of infants born to mothers with and without diabetes were similar regardless of infant sex, GA, or country of birth. In high-resource settings, maternal diabetes is not associated with an increased risk of in-hospital mortality or severe morbidity in very preterm infants with a birth weight of fewer than 1500 g.

Contemporary Trends and Comparative Outcomes With Adjunctive Inferior Vena Cava Filter Placement in Patients Undergoing Catheter-Directed Thrombolysis for Deep Vein Thrombosis in the United States: Insights From the National Inpatient Sample

ObjectivesThe aim of this study was to investigate the contemporary trends and comparative effectiveness of adjunctive inferior vena cava filter (IVCF) placement in patients undergoing catheter-directed thrombolysis (CDT) for treatment of proximal lower extremity or caval deep vein thrombosis. BackgroundCDT is being increasingly used in the management of proximal deep vein thrombosis. Although a significant number of patients treated with CDT undergo adjunctive IVCF placement, the benefit of this practice remains unknown. MethodsThe National Inpatient Sample database was used to identify all patients with proximal or caval deep vein thrombosis who underwent CDT (with and without adjunctive IVCF placement) in the United States between January 2005 and December 2013. A propensity score–matching algorithm was then used to derive 2 matched groups of patients (IVCF and no IVCF) for comparative outcomes (mortality and major and minor bleeding) and resource use analysis. ResultsOf the 7,119 patients treated with CDT, 2,421 (34%) received IVCFs. There was no significant difference in in-hospital mortality (0.7% vs 1.0%; p = 0.20), procedure-related hemorrhage (1.4% vs. 1.0%; p = 0.23), or intracranial hemorrhage (0.7% vs. 0.6%; p = 0.70) between the IVCF (n = 2,259) and no-IVCF (n = 2,259) groups, respectively. Patients undergoing IVCF placement had higher rates of hematoma (3.4% vs 2.1%; p = 0.009), higher in-hospital charges ($104,049 ± 75,572 vs. $92,881 ± 80,194; p < 0.001) and increased length of stay (7.3 ± 5.6 days vs. 6.9 ± 6.9 days; p = 0.046) compared with the no-IVCF group. ConclusionsThis nationwide observational study suggests that one-third of all patients undergoing CDT receive IVCFs. IVCF use was not associated with a decrease in in-hospital mortality but was associated with higher inpatient charges and longer length of stay.

Incidence, Determinants, and Outcomes of Left and Right Radial Access Use in Patients Undergoing Percutaneous Coronary Intervention in the United Kingdom: A National Perspective Using the BCIS Dataset

ObjectivesThe authors sought to determine the relationships between left radial access (LRA) or right radial access (RRA) and clinical outcomes using the British Cardiovascular Intervention Society (BCIS) database. BackgroundLRA has been shown to offer procedural advantages over RRA in percutaneous coronary intervention (PCI) although few data exist from a national perspective around its use and association with clinical outcomes. MethodsThe authors investigated the relationship between use of LRA or RRA and clinical outcomes of in-hospital or 30-day mortality, major adverse cardiovascular events (MACE), in-hospital stroke, and major bleeding complications in patients undergoing PCI between 2007 and 2014. ResultsOf 342,806 cases identified, 328,495 (96%) were RRA and 14,311 (4%) were LRA. Use of LRA increased from 3.2% to 4.6% from 2007 to 2014. In patients undergoing a repeat PCI procedure, the use of RRA dropped to 72% at the second procedure and was even lower in females (65%) and patients >75 years of age (70%). Use of LRA (compared with RRA) was not associated with significant differences in in-hospital mortality (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 0.90 to 1.57; p = 0.20), 30-day mortality (OR: 1.17, 95% CI: 0.93 to 1.74; p = 0.16), MACE (OR: 1.06, 95% CI: 0.86 to 1.32; p = 0.56), or major bleeding (OR: 1.22, 95% CI: 0.87 to 1.77; p = 0.24). In propensity match analysis, LRA was associated with a significant decrease in in-hospital stroke (OR: 0.52, 95% CI: 0.37 to 0.82; p = 0.005). ConclusionsIn this large PCI database, use of LRA is limited compared with RRA but conveys no increased risk of adverse outcomes, but may be associated with a reduction in PCI-related stroke complications.

Open Lung Biopsy in Nonresolving Acute Respiratory Distress Syndrome Commonly Identifies Corticosteroid-Sensitive Pathologies, Associated With Better Outcome.

Approximately half of the patients undergoing lung biopsy for nonresolving acute respiratory distress syndrome exhibit another histologic pattern than diffuse alveolar damage, with some of the pathologies characterized by a potential response to corticosteroids. This study aimed to assess whether open lung biopsy performed in the ICU for nonresolving acute respiratory distress syndrome was able to identify steroid-sensitive diseases and whether patients with a steroid-sensitive pathology experienced different clinical courses and outcomes. Retrospective analysis. One 22-bed mixed ICU within a tertiary medical center. Patients age greater than or equal to 16 years old who met the Berlin definition for acute respiratory distress syndrome and underwent open lung biopsy from January 2007 to January 2017. None. During the study period, 695 patients diagnosed with acute respiratory distress syndrome were identified, 51 (7%) of whom underwent open lung biopsy. An alternative diagnosis to diffuse alveolar damage was found in 29 patients (57%), and a steroid-sensitive pathology was identified in 19 (37%). In-hospital and 180-day mortality rates were 55% and 61%, respectively. There was a significant difference in hospital mortality and 180-day mortality rates between patients with steroid-sensitive pathology and those with steroid-resistant pathology (37% vs 65%; p < 0.045 and 37% vs 75%; p < 0.007, respectively). We did not identify any variable that could reliably predict a steroid-sensitive histologic pattern before open lung biopsy. Open lung biopsy was able to identify a steroid-sensitive pathology in a significant proportion of nonresolving acute respiratory distress syndrome patients. These patients had a better outcome, with lower hospital mortality and 180-day mortality.

Unidad de cuidados intermedios tras la cirugía cardiaca: impacto en la estancia media y la evolución clínica

Introduction and objectivesCurrent postoperative management of adult cardiac surgery often comprises transfer from the intensive care unit (ICU) to a conventional ward. Intermediate care units (IMCU) permit hospital resource optimization. We analyzed the impact of an IMCU on length of stay (both ICU and in-hospital) and outcomes (in-hospital mortality and 30-day readmissions) after adult cardiac surgery (IMCU-CS). MethodsFrom November 2012 to April 2015, 1324 consecutive patients were admitted to a university hospital for cardiac surgery. In May 2014, an IMCU-CS was established for postoperative care. For the purposes of this study, patients were classified into 2 groups, depending on the admission period: pre-IMCU-CS (November 2012-April 2014, n=674) and post-IMCU-CS (May 2014-April 2015, n=650). ResultsThere were no statistically significant differences in age, sex, risk factors, comorbidities, EuroSCORE 2, left ventricular ejection fraction, or the types of surgery (valvular in 53%, coronary in 26%, valvular plus coronary in 11.5%, and aorta in 1.8%). The ICU length of stay decreased from 4.9±11 to 2.9±6 days (mean±standard deviation; P<.001); 2 [1-4] to 1 [0-3] (median [Q1-Q3]); in-hospital length of stay decreased from 13.5±15 to 12.7±11 days (mean±standard deviation; P=.01); 9 [7-13] to 9 [7-11] (median [Q1-Q3]), in pre-IMCU-CS to post-IMCU-CS, respectively. There were no statistically significant differences in in-hospital mortality (4.9% vs 3.5%; P=.28) or 30-day readmission rate (4.3% vs 4.2%; P=.89). ConclusionsAfter the establishment of an IMCU-CS for postoperative cardiac surgery, there was a reduction in ICU and in-hospital mean lengths of stay with no increase in in-hospital mortality or 30-day readmissions.Full English text available from: www.revespcardiol.org/en

Trans-Sulcal Endoport-Assisted Evacuation of Supratentorial Intracerebral Hemorrhage: Initial Single-Institution Experience Compared to Matched Medically Managed Patients and Effect on 30-Day Mortality.

The surgical management of supratentorial intracerebral hemorrhages (ICH) remains controversial due to large trials failing to show clear benefits. Several minimally invasive techniques have emerged as an alternative to a conventional craniotomy with promising results. To report our experience with endoport-assisted surgery in the evacuation of supratentorial ICH and its effects on outcome compared to matched medical controls. Retrospective data were gathered of patients who underwent endoport-assisted evacuation between January 2014 and October 2016 by a single surgeon. Patients who were managed medically during the same period were matched to the surgical cohort. Previously published cohorts investigating the same technique were analyzed against the present cohort. Sixteen patients were identified and matched to 16 patients treated medically. Location, hemorrhage volume, and initial Glasgow Coma Scale (GCS) score did not differ significantly between the 2 cohorts. The mean volume reduction in the surgical cohort was 92.05% ± 7.05%. The improvement in GCS in the surgical cohort was statistically significant (7-13, P = .006). Compared to the medical cohort, endoport-assisted surgery resulted in a statistically significant difference in in-hospital mortality (6.25% vs 75.0%, P < .001) and 30-d mortality (6.25% vs 81.25%, P < .001). Compared to previously published cohorts, the present cohort had lower median preoperative GCS (7 vs 10, P = .02), but postoperative GCS did not differ significantly (13 vs 14, P = .28). Endoport-assisted surgery is associated with high clot evacuation and decreases 30-d mortality compared to a similar medical group.

Effectiveness of dexmedetomidine versus propofol on extubation times, length of stay and mortality rates in adult cardiac surgery patients: a systematic review and meta-analysis.

To determine the effects of dexmedetomidine versus propofol on extubation time, intensive care unit (ICU) length of stay, total hospital length of stay and in-hospital mortality rates in cardiac surgery patients. Recovery from cardiovascular surgery involves weaning from mechanical ventilation. Mechanical ventilation decreases the work of breathing for patients by inhaling oxygen and exhaling carbon dioxide via a ventilator or breathing machine. Prolonged mechanical ventilation is associated with complications, such as pneumonia and lung injury, and increases the risk of morbidity and mortality. Major risk factors that contribute to lung injury are due to high tidal volumes and barotrauma. Cardiac surgery patients remain on the ventilator postoperatively due to the high dose opioid-based anesthesia and the initial vulnerable hemodynamic state. An important component of postoperative management following cardiac surgery is the use of sedation to reduce the stress response, facilitate assisted ventilation, and provide anxiolysis. Propofol and dexmedetomidine are two common sedative agents with differing pharmacological profiles used to provide comfort and minimize hemodynamic disturbances during this recovery phase. Choice of drug may have an impact on length of mechanical ventilation, length of stay and mortality. Participants included were ≥18 years, of any gender or ethnicity, undergoing valvular surgery, coronary artery bypass graft (CABG) surgery, or valvular surgery and CABG. Studies were excluded if participants received both dexmedetomidine and propofol concurrently as a primary sedative. Interventions were propofol compared to dexmedetomidine as continuous infusions for sedation after cardiac surgery. All variations of dosages and duration of both sedative agents were included. Outcomes of interest were: total time (hours) of mechanical ventilation after cardiac surgery, specifically from end of surgery to extubation; total length of stay (LOS) in the ICU (hours) following cardiac surgery, specifically from ICU admission to transfer to medical ward; total hospital LOS (hours) following cardiac surgery, from date of admission to date of discharge; and in-hospital mortality rates, from date of admission to date of discharge. Randomized controlled trials (RCTs), controlled trials, and prospective and retrospective cohort studies were considered for inclusion. A search was conducted in MEDLINE via PubMed, Embase, Trip Database, ProQuest Nursing and Allied Health Source Database, Web of Science, ProQuest Dissertations and Theses Global, and MedNar to locate both published and unpublished studies between January 1, 1999 and November 23, 2017. Two reviewers assessed the methodological quality using standardized critical appraisal instruments from the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Quantitative data were extracted using the standardized data extraction tool from JBI SUMARI. Data were pooled using Comprehensive Meta-Analysis Software Version 3 (Biostat, NJ, USA). Mean differences (95% confidence interval [CI]) and effect size estimates were calculated for continuous outcomes. Meta-analysis using a random-effects model was performed for length of mechanical ventilation, ICU LOS, and hospital LOS. Results have been presented in narrative form when findings could not be pooled using meta-analysis. Standard GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) evidence assessment of outcomes has been reported. A total of four studies were included in the review. Meta-analysis of three cohort studies revealed dexmedetomidine to be superior to propofol with an average reduction of 4.18 hours (95% CI -6.69 to -1.67, p = 0.001) on the extubation times, an average 9.89 hour (95% CI -18.6 to -1.19, p = 0.03) reduction in ICU LOS, and an average 37.9 hour (95% CI, -60.41 to -15.46, p = 0.00) reduction in overall hospital LOS. A RCT was excluded from pooling for meta-analysis, but its results were congruent with meta-analysis results. There was lack of sufficient data to perform meta-analysis on in-hospital mortality rates. In postoperative cardiac surgery patients, dexmedetomidine is associated with a shorter time to extubation, shorter ICU LOS, and shorter hospital LOS in postoperative cardiac surgery patients compared to propofol. The quality of evidence for these findings however is low and no recommendations can be made to change current practice. There was insufficient evidence to determine significant differences in-hospital mortality rates. Sedation protocols still need to be formulated.There are significant gaps in the literature. Areas of further research include additional well-designed and appropriately powered RCTs with wide inclusion criteria to reflect this surgical population; quantitative, transparent, and standardized sedation, weaning, and extubation protocols; precise and standardized methods and measurements for interventions and outcomes, and short- and long-term morbidity and mortality follow-up.

Effects of modifiable prehospital factors on survival after out-of-hospital cardiac arrest in rural versus urban areas

BackgroundThe modifiable prehospital system factors, bystander cardiopulmonary resuscitation (CPR), emergency medical services (EMS), response time, and EMS physician attendance, may affect short- and long-term survival for both rural and urban out-of-hospital cardiac arrest (OHCA) patients. We studied how such factors influenced OHCA survival in a mixed urban/rural region with a high survival rate after OHCA.MethodsWe analyzed the association between modifiable prehospital factors and survival to different stages of care in 1138 medical OHCA patients from an Utstein template-based cardiac arrest registry, using Kaplan-Meier type survival curves, univariable and multivariable logistic regression and mortality hazard plots.ResultsWe found a significantly higher probability for survival to hospital admission (OR: 1.84, 95% CI 1.43–2.36, p < 0.001), to hospital discharge (OR: 1.51, 95% CI 1.08–2.11, p = 0.017), and at 1 year (OR: 1.58, 95% CI 1.11–2.26, p = 0.012) in the urban group versus the rural group. In patients receiving bystander CPR before EMS arrival, the odds of survival to hospital discharge increased more than threefold (OR: 3.05, 95% CI 2.00–4.65, p < 0.001). However, bystander CPR was associated with increased patient survival to discharge only in urban areas (survival probability 0.26 with CPR vs. 0.08 without CPR, p < 0.001). EMS response time ≥ 10 min was associated with decreased survival (OR: 0.61, 95% CI 0.45–0.83, p = 0.002), however, only in urban areas (survival probability 0.15 ≥ 10 min vs. 0.25 < 10 min, p < 0.001). In patients with prehospital EMS physician attendance, no significant differences were found in survival to hospital discharge (OR: 1.37, 95% CI 0.87–2.16, p = 0.17). In rural areas, patients with EMS physician attendance had an overall better survival to hospital discharge (survival probability 0.17 with EMS physician vs. 0.05 without EMS physician, p = 0.019). Adjusted for modifiable factors, the survival differences remained.ConclusionsOverall, OHCA survival was higher in urban compared to rural areas, and the effect of bystander CPR, EMS response time and EMS physician attendance on survival differ between urban and rural areas. The effect of modifiable factors on survival was highest in the prehospital stage of care. In patients surviving to hospital admission, there was no significant difference in in-hospital mortality or in 1 year mortality between OHCA in rural versus urban areas.

In-hospital complication rate following microendoscopic versus open lumbar laminectomy: a propensity score-matched analysis

Background ContextThe incidence of postoperative complications after microendoscopic laminectomy (MEL) has not been compared with that after open laminectomy in a large study, so it is not clear whether MEL is a safer procedure. PurposeThe objective of this study was to compare postoperative morbidity and mortality following lumbar laminectomy between patients treated with MEL and with open laminectomy. Study DesignThis is a retrospective cohort study with propensity score-matched analysis. Patient SampleData of patients who underwent elective spinal surgery between July 2010 and March 2013 were extracted from the Diagnosis Procedure Combination database, a nationwide inpatient database in Japan. Outcome MeasuresClinical outcomes included length of hospital stay, occurrence of major complications (cardiac events, respiratory complications, pulmonary embolism, stroke, and acute renal failure), surgical site infection (SSI), postoperative delirium, and in-hospital death. Materials and MethodsPropensity score matching was performed to adjust for measured confounding factors, including patient age, sex, Charlson Comorbidity Index, body mass index, smoking status, blood transfusion, duration of anesthesia, number of operated disc levels, and type of hospital and hospital volumes. The clinical outcomes of one-to-one propensity-matched pairs of the MEL and the open laminectomy groups were compared. ResultsOf 23,317 patients identified in the database, 1,536 underwent MEL (6.6%). By one-to-one propensity score matching, 1,536 pairs were selected. The distributions of patient backgrounds were closely balanced between the MEL and the open laminectomy groups. An analysis of 1,536 pairs revealed that there was a significantly lower incidence of major postoperative complications in those who underwent MEL (1.0% vs. 2.8% for open laminectomy, risk difference 1.8%, 95% confidence interval [CI] 0.9%–2.9%), SSI (0.5% vs. 1.6% for open laminectomy, risk difference 1.1%, 95% CI 0.4%–1.9%), and postoperative delirium (1.1% vs. 2.3% for open laminectomy, risk difference1.2%, 95% CI 0.3%–2.1%). The length of hospital stay was significantly shorter in those treated with MEL (12 days vs. 16 days for open laminectomy, p<.001). There was no significant difference in in-hospital mortality between the groups. ConclusionsPatients who underwent MEL were significantly less likely to experience major postoperative complications and were less likely to develop SSI and postoperative delirium than those who underwent open laminectomy.

Have outcomes improved in trauma patients age 90 years and older over the past decade: Experience at a level II trauma center

IntroductionManaging trauma in the elderly is challenging and requires a multidisciplinary team approach. The aim of this study is to characterize and compare outcomes in patients 90 years and older in the last two decades. MethodsRetrospective review of trauma patients 90 years and older admitted from 1996 to 2015. The patients were divided into two groups: Early Decade (ED) and Late Decade (LD). ResultsA total of 1697 patients were recorded, 551 (ED) and 1146 (LD). The mean age was 92.92 ± 8(90–108)[ED] and 92.9 ± 2.7(90–105)[LD] years. The most common mechanism and type of injury was falls and extremity trauma. Hospital length of stay (LOS) was shorter in the LD. There was no significant difference in in-hospital mortality or ICU LOS. ConclusionTrauma admission has increased in the last decade. However, in-hospital mortality remains low. It is important for multidisciplinary teams to allocate resources to treat this elderly population.

Circadian Distribution of Acute Myocardial Infarction in Different Age Groups

Many epidemiologic studies reported a morning peak in the incidence of acute myocardial infarction (AMI). However, clinical outcomes and the relation between age distribution and circadian pattern have not been fully investigated in a large number of patients. Our study aimed to clarify the impacts of onset time in circadian variation on incidence and clinical outcomes of AMI according to age. From the Korea Acute Myocardial Infarction Registry, we gathered data of 20,685 patients from 53 centers in Republic of Korea. Data from a total of 19,915 patients (11,339 ST elevation myocardial infarction, 8,576 non-ST elevation myocardial infarction) were analyzed from the registry, after exclusion of diagnoses other than AMI. A morning-dominant incidence was shown by sinusoidal function, in all patients and in all separate age groups (age < 55, 55 ≤ age < 75, 75 ≤ age). In-hospital mortality and major adverse cardiovascular events (MACEs), including cardiac deaths, noncardiac deaths, recurrent myocardial infarction, repeated percutaneous coronary intervention, and coronary artery bypass graft at 1, 12, and 24 months' follow-up, were compared in 4 periods (00:00~05:59, 06:00~11:59, 12:00~17:59, and 18:00~23:59), and no significant difference was noted. Kaplan-Meier curve was drawn for death and MACE-free survival, and no significant different event-free survival was depicted (p value = 0.31). In conclusion, the incidences of myocardial infarction by onset time were uneven in 24 hours, in all patients and age groups, by sinusoidal function. However, there were no significant differences in in-hospital mortality or MACEs in the 4 time periods during 24 months of follow-up.

Extended sleeve lobectomy for centrally located non-small-cell lung cancer: a 20-year single-centre experience.

Extended sleeve lobectomy (ESL), an atypical bronchoplasty with resection of more than 1 lobe, might be technically demanding but has certain theoretical advantages, including the avoidance of pneumonectomy. However, clinical outcomes after ESL are not well known. Between March 1995 and December 2015, 540 patients with centrally located non-small-cell lung cancer underwent sleeve resection. Among them, 63 patients underwent an ESL procedure. We retrospectively analysed those patients in terms of hospital mortality, postoperative complications and local recurrence and compared clinical outcomes with patients who underwent simple sleeve lobectomy in the same period. The 63 patients were classified into 4 groups: anastomosis between the right main and lower bronchi (n = 14), anastomosis between the right main and upper bronchi (n = 37), anastomosis between the left main and basal segmental bronchi (n = 4) and anastomosis between the left main and upper divisional bronchi (n = 8). No operative deaths occurred within 30 days, but there were 2 in-hospital deaths from postoperative acute lung injury. Ten (16%) patients had anastomosis-related complications including 3 strictures, 5 bronchopleural fistulas and 2 pulmonary vein thromboses. There were no significant differences in in-hospital mortality (3% vs 3%, P = 0.67), anastomosis-related complications (16% vs 9%, P = 0.07) and loco-regional recurrence rate (8% vs 10%, P = 0.63) between ESL and simple sleeve lobectomy. According to our findings, ESL is a safe and feasible procedure that does not compromise oncological principles. It can be considered an appropriate alternative to pneumonectomy and should be considered in patients with centrally located tumours.

Abstract WP84: National Inpatient Sample Analysis of Unruptured Intracranial Aneurysms: Trends in Treatment and In-Hospital Complications 2002-2014

Introduction: Our objective was to determine trends in treatment preference and in-hospital complications of patients undergoing elective and non-elective treatment for unruptured intracranial aneurysms (UIA) in the United States over a 12-year period. Methods: We identified patients from the National Inpatient Sample database who were electively or non-electively admitted to the hospital with a primary ICD 9 diagnosis of unruptured intracranial aneurysm (437.3) from 2002 to 2014. We identified the method of treatment (surgical clipping or endovascular coiling) and studied in-hospital complications. Results: We identified 111,811 patients with UIAs between 2002 to 2014. Of these patients, 89,599 (80.1%) of patients were electively admitted. Approximately 47% (42,112) of patients underwent surgical clipping, while 53% (47,487) of patients underwent endovascular coiling. Of 22,212 patients who were admitted non-electively, 38.6% (8570) patients underwent surgical clipping and 61.4% (13,642) underwent endovascular coiling. There was a significantly higher proportion of patients treated with endovascular coiling for non-electively admitted patients as compared to elective admissions. For electively treated UIAs there were no significant differences in in-hospital mortality between the two treatment groups. Iatrogenic cerebrovascular accidents and intracranial hemorrhage were significantly less common in the endovascular coiling group throughout the study period. For non-electively treated UIAs, there was no significant difference in hospital mortality over the 12-year period. The rate of iatrogenic cerebrovascular accidents was generally lower for endovascular coiling with the exception of 2003. Endovascular coiling resulted in a significantly lower rate of iatrogenic cerebrovascular accidents in 2004 and 2008-2012. Intracranial hemorrhage was significantly less common in the endovascular group in 2004 and 2008-2014. Conclusions: Endovascular therapy has lower rates of in-hospital iatrogenic cerebrovascular accidents, and similar rates of mortality. The rate of endovascular and surgical therapies has plateaued since approximately 2005.

Weekend effect in upper gastrointestinal bleeding: a systematic review and meta-analysis.

AimTo perform a systematic review and meta-analysis of the weekend effect on the mortality of patients with upper gastrointestinal bleeding(UGIB).MethodsThe review protocol has been registered in the PROSPERO International Prospective Register of Systematic Reviews (registration number: CRD42017073313) and was written according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We conducted a search of the PUBMED, COCHRANE, EMBASE and CINAHL databases from inception to August 2017. All observational studies comparing mortality between UGIB patients with weekend versus weekday admissions were included. Articles that were published only in abstract form or not published in a peer-reviewed journal were excluded. The quality of articles was assessed using the Newcastle-Ottawa Scale. We pooled results from the articles using random-effect models. Heterogeneity was evaluated by the chi-square-based Q-test and I2test. To address heterogeneity, we performed sensitivity and subgroup analyses. Potential publication bias was assessed via funnel plot.ResultsEighteen observational cohort studies involving 1,232,083 study patients were included. Weekend admission was associated with significantly higher 30-day or in-hospital mortality in all studies (OR = 1.12, 95% CI [1.07–1.17], P < 0.00001). Increased in-hospital mortality was also associated with weekend admission (OR = 1.12, 95% CI [1.08–1.17], P < 0.00001). No significant difference in in-hospital mortality was observed between patients admitted with variceal bleeding during the weekend or on weekdays (OR = 0.99, 95% CI [0.91–1.08], P = 0.82); however, weekend admission was associated with a 15% increase in in-hospital mortality for patients with non-variceal bleeding (OR = 1.15, 95% CI [1.09–1.21], P < 0.00001). The time to endoscopy for weekday admission was significantly less than that obtained for weekend admission (MD = −2.50, 95% CI [−4.08–−0.92], P = 0.002).ConclusionsThe weekend effect is associated with increased mortality of UGIB patients, particularly in non-variceal bleeding. The timing of endoscopic intervention might be a factor that influences mortality of UGIB patients.

Early Clinical Outcomes of Tricuspid Ring Annuloplasty Using the New Three-dimensional Annuloplasty Ring, Tri-Ad

We evaluated the early clinical outcomes of tricuspid ring annuloplasty using the Tri-Ad ring and compared the results of the Tri-Ad ring with those of MC3 ring, a widely used three-dimensional (3D) ring. From 2007 to 2017, 227 patients underwent tricuspid ring annuloplasty (TAP) for functional tricuspid regurgitation using the new 3D ring, Tri-Ad. In total, 191 patients underwent TAP with a MC3 ring and 36 patients underwent TAP with a Tri-Ad ring. Tri-Ad rings have been used since January 2015. Propensity score-matched analysis was performed (n = 36 in each group). Mean ± SD duration of follow-up was 67 ± 37 months. Operative mortality occurred in nine patients and postoperative complications in 39, which included atrial fibrillation (n = 9), low cardiac output syndrome (n = 15), and bleeding requiring reoperation (n = 15). There were no significant differences in operative mortality and postoperative complications (p = .650 and p = .423, respectively). In the Tri-Ad group, both tricuspid regurgitation grade and systolic pulmonary artery pressure significantly decreased compared with its preoperative values in predischarge echocardiography (from 2.00 ± 1.19 mmHg to 1.17 ± 0.81 mmHg [p < .001] and from 43.11 ± 13.21 mmHg to 38.58 ± 8.61 mmHg [p < .001], respectively). There were no ring-related complications, such as atrioventricular block or ring dehiscence during follow-up in Tri-Ad group. In matched patients, there were no significant differences in in-hospital mortality, postoperative complications, or tricuspid valve-related events (p = .310, p = .502, and p = .1.00, respectively). The Tri-Ad ring, a new 3D ring, showed comparable early clinical outcomes and echocardiographic results to the MC3 ring. However, a long-term follow-up study is required to confirm the safety and efficacy of this new device.