Admission For Surgery Research Articles

Ist die akute Appendizitis ein chirurgischer Notfall?

Acute appendicitis is one of the most common causes of acute abdomen. Whereas patients with acomplicated form of appendicitis need prompt surgery, short preoperative delays are tolerable for patients with uncomplicated appendicitis. Delays of up to 8 h between hospital admission and beginning of surgery are not associated with increased rates of perforation or postoperative complications.

Complete state-wide outcomes in elective colon cancer surgery.

Maintaining high standards in colon cancer surgery requires the measurement of quality indicators and the re-allocation of resources to address deficiencies. We used state-wide administrative data to determine the inpatient mortality for patients undergoing elective colon cancer surgery and to compare individual hospital rates. The Dr Foster Quality Investigator Tool was used to explore the Victorian Admitted Episodes Dataset for elective admissions for colon cancer surgery between 2012 and 2016. The inpatient mortality rate, 30-day readmission rate and the proportion of patients with increased length of stay were measured. Risk-adjusted rates were used to compare public and private hospitals. A peer group of 14 hospitals were studied using funnel plots to determine inter-hospital variation in mortality. There were 6120 colectomies performed for colon cancer in Victoria over 3 years. The crude inpatient mortality rate was 1.3%. It was significantly higher in public than private hospitals, even after risk adjustment. Variation in crude mortality was demonstrated among 14 selected hospitals. The lowest volume hospitals had significantly higher inpatient mortality rates. Right hemicolectomy was the commonest procedure performed. Using an efficient method of complete state-wide data capture, we have demonstrated that the inpatient mortality rate after elective colon cancer surgery in Victoria is low. However, complexity remains around the interpretation of inter-hospital variation, defining outliers, and comparing outcomes between public and private hospitals. Resolving these complexities and defining additional quality indicators remain a priority in the use of administrative data to audit the quality of colon cancer care.

Impact of venous thromboembolism during admission for meningioma surgery on hospital charges and postoperative complications

Surgical resection of meningiomas has been associated with high rates of venous thromboembolic events (VTE) as compared with all other intracranial tumors. There is a paucity of data regarding the clinical complications and comorbidities associated with this cohort yet the underlying pathophysiological mechanism for this tumor-specific finding remains unclear. Our goal was to determine the various impacts of VTE on meningioma surgery in a large cohort of inpatient admissions. This retrospective analysis utilized discharge data from the National Inpatient Sample (NIS) from 2002 to 2010. Patient demographics, comorbidities, length of stay, hospital charges, and postoperative complications were compared between patients with and without VTE. Of 20,259 patients, 426 (2.1%) experienced a VTE. Compared to the non-VTE cohort, patients that experienced a VTE were older (62.7 ± 13.7 vs. 57.2 ± 14.7; p < 0.001), were more commonly male (38.0% vs 30.1%; p = 0.001), had longer hospitalizations (18.8 vs 6.6 days; p < 0.001), and incurred significantly greater hospital charges ($195,837 vs $74,434; p < 0.001). VTE patients experienced significantly higher rates of acute postoperative complications including shock, hemorrhage, wound dehiscence, infection, intracerebral hemorrhage, hemiparesis/hemiplegia, stroke, and death during admission. Odds ratio of aforementioned postsurgical complications remained significantly higher both before and after adjusting for age and sex (all p < 0.01). Occurrence of VTE in patients undergoing meningioma resection portends greater hospital charges, most likely attributed to longer lengths of admission. Increased postoperative complications and mortality in the VTE group warrants further investigation and wariness of the surgeon when treating surgical candidates of meningioma.

Implementation of day of surgery admission for rectal cancer surgery in Ireland following a national centralisation programme.

Centralisation of rectal cancer surgery has altered the delivery of colorectal cancer care in Ireland. This has resulted in an increased demand for elective surgical beds in designated centres. This study aimed to assess if day of surgery admission (DOSA), in conjunction with implementation of a coordinated enhanced recovery pathway can reduce length of stay following elective rectal cancer resection. This is a retrospective review from a single institution. Our prospectively maintained Dendrite® Database was interrogated. Three time points were analysed across a 7-year period (2011, 2012, 2016). The first predates the introduction of a dedicated DOSA programme, the next was directly thereafter, and the final was 5-years post-implementation. These dates coincide with the centralisation of rectal cancer surgery to this centre. Outcomes included unadjusted length of stay and rates of DOSA pre-and post-implementation of the programme. The introduction of a DOSA pathway resulted in a fivefold increase in day of surgery admissions and a related 3-day reduction in average length of stay within a single year of implementation. This further improved in 2016, showing an almost 83% increase (15.90-98.50%) in day of surgery admission and a reduction in average length of stay from 16.4 to 12.4days when compared to 2011. Despite an increase in caseload of 54%, an estimated 272 bed days were saved. This demonstrated that DOSA is sustainable and highly effective in tackling the increased inpatient bed demands associated with the growing requirement for elective surgery.

Endoscopy Timing in Patients with Acute Upper Gastrointestinal Bleeding.

Background/AimsThe role of very early (≤12 hours) endoscopy in nonvariceal upper gastrointestinal bleeding is controversial. We aimed to compare results of very early and early (12–24 hours) endoscopy in patients with upper gastrointestinal bleeding demonstrating low-risk versus high-risk features and nonvariceal versus variceal bleeding. MethodsThis retrospective study included patients with nonvariceal and variceal upper gastrointestinal bleeding. The primary outcome was a composite of inpatient death, rebleeding, or need for surgery or intensive care unit admission. Endoscopy timing was defined as very early and early. We performed the analysis in two subgroups: (1) high-risk vs. low-risk patients and (2) variceal vs. nonvariceal bleeding.ResultsA total of 102 patients were included, of whom 59.8% underwent urgent endoscopy. Patients who underwent very early endoscopy received endoscopic therapy more frequently (p=0.001), but there was no improvement in other clinical outcomes. Furthermore, patients at low risk and with nonvariceal bleeding who underwent very early endoscopy had a higher risk of the composite outcome. ConclusionsVery early endoscopy does not seem to be associated with improved clinical outcomes and may lead to poorer outcomes in specific populations with upper gastrointestinal bleeding. The actual benefit of very early endoscopy remains controversial and should be further clarified.

A Comparison of the Quick Sequential (Sepsis-Related) Organ Failure Assessment Score and the National Early Warning Score in Non-ICU Patients With/Without Infection.

The Sepsis-3 task force recommended the quick Sequential (Sepsis-Related) Organ Failure Assessment score for identifying patients with suspected infection who are at greater risk of poor outcomes, but many hospitals already use the National Early Warning Score to identify high-risk patients, irrespective of diagnosis. We sought to compare the performance of quick Sequential (Sepsis-Related) Organ Failure Assessment and National Early Warning Score in hospitalized, non-ICU patients with and without an infection. Retrospective cohort study. Large U.K. General Hospital. Adults hospitalized between January 1, 2010, and February 1, 2016. None. We applied the quick Sequential (Sepsis-Related) Organ Failure Assessment score and National Early Warning Score to 5,435,344 vital signs sets (241,996 hospital admissions). Patients were categorized as having no infection, primary infection, or secondary infection using International Classification of Diseases, 10th Edition codes. National Early Warning Score was significantly better at discriminating in-hospital mortality, irrespective of infection status (no infection, National Early Warning Score 0.831 [0.825-0.838] vs quick Sequential [Sepsis-Related] Organ Failure Assessment 0.688 [0.680-0.695]; primary infection, National Early Warning Score 0.805 [0.799-0.812] vs quick Sequential [Sepsis-Related] Organ Failure Assessment 0.677 [0.670-0.685]). Similarly, National Early Warning Score performed significantly better in all patient groups (all admissions, emergency medicine admissions, and emergency surgery admissions) for all outcomes studied. Overall, quick Sequential (Sepsis-Related) Organ Failure Assessment performed no better, and often worse, in admissions with infection than without. The National Early Warning Score outperforms the quick Sequential (Sepsis-Related) Organ Failure Assessment score, irrespective of infection status. These findings suggest that quick Sequential (Sepsis-Related) Organ Failure Assessment should be reevaluated as the system of choice for identifying non-ICU patients with suspected infection who are at greater risk of poor outcome.

Assessing outpatient follow-up care compliance, complications, and sequelae in children hospitalized for isolated traumatic abdominal injuries

BackgroundCurrently there is limited knowledge on compliance with follow-up care in pediatric patients after abdominal trauma. The Indiana Network for Patient Care (INPC) is a large regional health information exchange with both structured clinical data (e.g., diagnosis codes) and unstructured data (e.g., provider notes). The objective of this study is to determine if regional health information exchanges can be used to evaluate whether patients receive all follow-up care recommended by providers. MethodsWe identified 61 patients treated at a Pediatric Level I Trauma Center who were admitted for isolated abdominal injuries. We analyzed medical records for two years following initial hospital discharge for injury using the INPC. The encounters were classified by the type of encounter: outpatient, emergency department, unplanned readmission, surgery, imaging studies, and inpatient admission; then further categorized into injury- and non-injury-related care, based on provider notes. We determined compliance with follow-up care instructions given at discharge and subsequent outpatient visits, as well as the prevalence of complications and sequelae. ResultsAfter reviewing patient records, we found that 78.7% of patients received all recommended follow-up care, 6.6% received partial follow-up care, and 11.5% did not receive follow-up care. We found that 4.9% of patients developed complications after abdominal trauma and 9.8% developed sequelae in the two years following their initial hospitalization. ConclusionsOur findings suggest that health information exchanges such as the INPC are useful in evaluation of follow-up care compliance and prevalence of complications/sequelae after abdominal trauma in pediatric patients. Level of evidenceLevel IV.

Defining growth potential and barriers to same day discharge total knee arthroplasty

Outpatient arthroplasty programs are becoming well established. Adverse event rates have been demonstrated to be no worse than inpatient arthroplasty in the literature for selected patients. The purpose of this study was to determine our rate of outpatient total knee arthroplasty (TKA), examine justification for exclusions, and estimate the proportion of TKAs that can occur safely on an outpatient basis. Retrospective case series of 400 consecutive TKAs from Oct 2014 to Mar 2017. Patient demographics, allocation to outpatient surgery vs standard admission, and reason for exclusion from outpatient surgery were recorded. Ninety-day Emergency department (ED) visits, readmission rates, and length of stay (LOS) were compared between groups using independent sample t test and Chi-squared test. Outpatients were younger (p = 0.001), had lower BMI (p < 0.001), and ASA scores (p < 0.001) than inpatients. One hundred twenty-five (31%) TKAs were assigned to outpatient surgery and 123 achieved discharge on the same day. There was no difference in 90-day ED visits (p = 0.889) or readmission rates (p = 0.338) between groups. Reasons for exclusion from outpatient surgery included medical (absolute 43% and relative 31%), distance > one hour from hospital (18%), no help (7%), and other/unclear (10%). LOS was significantly longer for medical than non-medical exclusions (p < 0.001) and for the absolute compared to relative medical exclusions (p = 0.004). Outpatient TKA is safe in selected patients, and inclusion can likely be broadened by addressing modifiable exclusions and narrowing medical exclusions. We found that 55% of our TKA population could be appropriate for outpatient surgery.

Emergency general surgery in the United Kingdom: A lot of general, not many emergencies, and not much surgery.

The provision of emergency general surgery services is a global issue, with important implications for patients and workforce. The aim of this study was to analyze the characteristics of emergency general surgical patients in the United Kingdom, with reference to diagnostic case mix, operative workload, comorbidity, discharge destination, and outcomes, to facilitate comparisons and future service development. This is a cross-sectional population-based study based in the National Health Service in Scotland, one of the home nations of the United Kingdom. All patients aged 16 or older admitted under the care of a general surgeon, as an emergency, to a National Health Service hospital in Scotland, in 2016, were included. There were 81,446 emergency general surgery admissions by 66,498 patients. Median episode age was 53 years. There were more female patients than male (55% vs 45%, p < 0.0001). The most common diagnoses were nonspecific abdominal pain (20.2%), cholecystitis (7.2%), constipation (3.4%), pancreatitis (3.1%), diverticular disease (3.1%), and appendicitis (3.1%). Only 25% of patients had operations (n = 20,292). The most frequent procedures were appendicectomy (13.1%), endoscopy (11.3%), and drainage of skin lesions (9.7%). Diagnoses and operations differed with age. Overall median length of stay was 1 day. With a 6-month follow-up, patients older than 75 years had a 19.8% mortality rate. Emergency general surgery in the United Kingdom is a high-volume, diagnostically diverse, and low-operative volume specialty with high short-term mortality rate in elderly patients. Consideration should be given to alternative service delivery models, which make better use of surgeons' skills while also ensuring optimal care for patients who are increasingly elderly and have complex chronic health problems. Epidemiologic study, level III.

Risk of Stroke After Colorectal Surgery for Cancerous Versus Benign Conditions

BackgroundCancer treatment, specifically surgical intervention, as a possible stroke trigger is understudied. MethodsUsing the Nationwide Readmissions Database and validated diagnosis and procedure codes, we identified adults with index admissions for colorectal surgery for colorectal adenocarcinoma (Group A) and compared them to admissions for colorectal surgery for benign conditions (Group B) and hepatobiliary or pancreatic surgery for benign conditions (Group C). Within the colorectal cancer cohort, we further identified patients who underwent open versus laparoscopic surgery. The primary outcome was readmission for ischemic or hemorrhagic stroke up to 1 year. Cumulative risk of ischemic stroke was calculated using risk survival statistics, and hazard ratios (HR) were calculated using adjusted Cox regression. ResultsPatients in Group A had higher 3-month readmission rates for ischemic and hemorrhagic strokes than those in Groups B and C. Higher risk of ischemic stroke (HR 1.46, 95% confidence interval [CI] 1.20-1.79) in Group A compared to Group B was eliminated following adjustments for illness severity and vascular risk factors. Comparing types of colorectal surgical intervention for cancer, there was significantly greater risk of ischemic stroke with open versus laparoscopic surgery, despite adjusting for vascular risk factors (HR 1.70, 95% CI 1.15-2.52). ConclusionsWe found elevated risk of ischemic stroke up to 1 year following open surgery for colorectal adenocarcinoma compared to laparoscopic. More research is necessary to clarify the underlying surgery-related mechanisms that contribute to elevated risk.

Interhospital transfer for emergency general surgery: An independent predictor of mortality

BackgroundEmergency general surgery (EGS) admissions account for more than 3 million hospitalizations in the US annually. We aim to better understand characteristics and mortality risk for EGS interhospital transfer patients compared to EGS direct admissions. MethodsUsing the 2002–2011 Nationwide Inpatient Sample we identified patients aged ≥18 years with an EGS admission. Patient demographics, hospitalization characteristics, rates of operation and mortality were compared between patients with interhospital transfer versus direct admissions. ResultsInterhospital transfers comprised 2% of EGS admissions. Interhospital transfers were more likely to be white, male, Medicare insured, and had higher rates of comorbidities. Interhospital transfers underwent more procedures/surgeries and had a higher mortality rate. Mortality remained elevated after controlling for patient characteristics. ConclusionsInterhospital transfers are at higher risk of mortality and undergo procedures/surgeries more frequently than direct admissions. Identification of contributing factors to this increased mortality may identify opportunities for decreasing mortality rate in EGS transfers.

P6194Factors associated with the need for, and the impact of, extracorporeal membrane oxygenation in children with congenital heart disease during admissions for cardiac surgery

P6194Factors associated with the need for, and the impact of, extracorporeal membrane oxygenation in children with congenital heart disease during admissions for cardiac surgery

Relevance of a specialised nurse in thoracic surgery.

This review of the development of a specialist nursing service within a thoracic surgery centre looks at the implementation of a specialist nursing role. An analysis of the needs of the service allowed identification of areas where specialist nursing input could have a positive impact on the patient pathway: (I) a nurse-led clinic for review of patients who require early review after discharge, in particular those discharged home with chest drains, was developed; (II) improvements to the patient pathway such as day of surgery admission were introduced along with a reduction in the number of patients who require admission to intensive care after surgery; (III) the specialist nurse leads on the introduction of new technology such as electronic chest drains. The specialist nurse works in the follow-up clinic, seeing patients autonomously, with a particular emphasis on patients under long-term follow-up after thoracic surgery. A telephone clinic has been introduced for patients on long-term CT follow-up. These are well received by patients; (IV) specialist nurses also work on in-patient wards, providing specialist input to the patient pathway, and can also take on work traditionally undertaken by junior medical staff. To be successful the specialist nursing role needs to be supported by the multidisciplinary team (MDT). These roles are developed to meet the needs of each unit and can have a very positive impact on the patient pathway.

Association of preoperative glucose concentration with myocardial injury and death after non-cardiac surgery (GlucoVISION): a prospective cohort study

Myocardial injury after non-cardiac surgery (MINS) is the most common perioperative cardiovascular complication and is independently associated with 30-day mortality. We aimed to assess the association between preoperative glucose concentration and postoperative MINS and mortality. The VISION study is a prospective cohort study done at 12 centres in eight countries. Patients aged 45 years or older who required at least one overnight hospital admission for non-cardiac surgery were enrolled from Aug 6, 2007, to Jan 11, 2011. In the GlucoVISION analysis, we assessed the relations between preoperative casual or fasting glucose concentration and MINS within 3 days after surgery using logistic regression, and 30-day mortality using Cox proportional regression, in people with and without diabetes. 11 954 patients were included in this analysis, of whom 2809 (23%) had diabetes. Within the first three postoperative days, MINS occurred in 813 (7%) patients. 249 (2%) patients died by day 30. More patients with diabetes had MINS (odds ratio [OR] 1·98 [95% CI 1·70-2·30]; p<0·0001), and died (OR 1·41 [1·08-1·86]; p=0·016) than did patients without diabetes. Casual glucose concentrations were associated with MINS in all patients (adjusted OR 1·06 [1·04-1·09] per 1 mmol/L increment in glucose; p=0·0003), and with death in patients without diabetes (adjusted hazard ratio [HR] 1·13 [95% CI 1·05-1·23] per mmol/L; p=0·002). We noted a progressive relation between unadjusted fasting glucose concentration and both MINS (OR 1·14 [1·08-1·20] per mmol/L; p<0·0001), driven by the effect in the subgroup without previous diabetes (pinteraction=0·025), and 30-day mortality (HR 1·10 [1·02-1·19] per mmol/L; p=0·013). For patients without diabetes, casual glucose of more than 6·86 mmol/L and fasting glucose of more than 6·41 mmol/L predicted MINS (OR 1·71 [1·36-2·15]; p<0·0001, and OR 2·71 [1·85-3·98]; p<0·0001, respectively). For patients with diabetes, only casual glucose concentration more than 7·92 mmol/L predicted MINS (OR 1·47 [1·10-1·96]; p=0·0096). Preoperative glucose concentration, particularly casual glucose concentration, predicts risk for postoperative cardiovascular outcomes, especially in patients without diabetes. Full funding sources listed at the end of the paper (see Acknowledgments).

Radiation Exposure in Pediatric Intensive Care Unit Patients: How Much Is Too Much?

We aimed to determine median cumulative radiation exposure in pediatric intensive care unit (PICU) patients, proportion of patients with high radiation exposure (above annual average radiation per person of 6.2 mSv), and determine risk factors for high exposure. This was a retrospective chart review of PICU patients up to 18 years of age admitted to a large community hospital over 2 years. Radiologic studies and radiation exposure were determined for each patient, and total hospital radiation exposure was classified as high (>6.2 mSv) or not (≤6.2 mSv). Median radiation exposure per patient was 0.2 mSv (interquartile range = 2.1) and 11.7% of patients received >6.2 mSv radiation during their hospitalization. Factors associated with high radiation exposure included admission for trauma or surgery, number of computed tomography scans, age, and PICU length of stay (all P < .0001). We concluded that subsets of PICU patients are at risk of high radiation exposure. Policies and protocols may help minimize radiation exposure among PICU patients.

Incidence and trends of cardiac complications in major abdominal surgery

IntroductionCardiovascular complications are the leading cause of death after noncardiac surgery. Major abdominal operations represent the largest category of procedures considered to have an increased risk of cardiovascular complications. The current aim was to examine trends in the incidence of mortality, perioperative myocardial infarction, and cardiac arrest to determine the presence of potential volume-outcome relationships. MethodsWe performed a retrospective analysis of the Nationwide Inpatient Sample for patients undergoing elective, open abdominal esophagectomy, gastrectomy, pancreatectomy, nephrectomy, hepatectomy, splenectomy, and colectomy (major abdominal surgery) during 2008–2014. Univariate and multivariate analyses were performed to determine the impact of operative volume on rates of myocardial infarction, cardiac arrest, and mortality. ResultsOf the 962,754 elective admissions for major abdominal surgery, 1.4% experienced in-hospital mortality, 0.7% myocardial infarction, and 0.35% cardiac arrest. Myocardial infarction and cardiac arrest were associated with a 24-fold increase in risk of perioperative mortality. Compared with institutions that have a very low volume of operations, those hospitals with larger volumes of operations had a decreased risk of cardiac arrest and incident mortality after cardiovascular complications, but the odds of myocardial infarction were greatest at higher operative-volume hospitals. The annual all-cause mortality and myocardial infarction rates decreased over time, but the incidence of cardiac arrest increased. ConclusionMyocardial infarction or cardiac arrest after major abdominal surgery increased the odds of mortality with superior rescue after cardiovascular complications at higher volume institutions. Across all US hospitals performing major abdominal surgery, the rate of cardiac arrest increased without a concomitant increase in myocardial infarction or mortality. Novel targets for risk modification of myocardial infarction and cardiac arrest as well as investigation of processes that facilitate rescue after these complications at higher operative-volume hospitals are needed to delineate quality improvement opportunities.

Sa1361 CHOLANGIOSCOPY-GUIDED HOLMIUM LASER LITHOTRIPSY IN THE TREATMENT OF DIFFICULT BILE DUCT STONES- A SINGLE CENTER EXPERIENCE

Using standard techniques, the treatment of bile duct stones is highly effective in 85-90% of cases. In 5-15% the stones are classified as “difficult” due to their size, location, form, calcification or altered anatomy. For these situations alternative treatment options are needed. Cholangioscopy- guided laser- or electrohydraulic lithotripsy increases the success rate of the bile duct stones treatment up to 100%. To evaluate the efficacy, safety and cost- effectiveness of the cholangioscopy guided laser lithotripsy for the treatment of difficult bile duct stones in the context of complications, price and mean procedure time. Data was collected retrospectively from January 2016 to September 2017. All the patients had previous single-session ERCP, sphincterotomy with or without large balloon dilation and plastic stenting performed and bile duct stones were characterized as “difficult” after attempts for extraction using standard techniques or after detection of anatomical abnormalities of the biliary system /strictures/. Patients were scheduled for cholangioscopy with the SpyGlass DS system (Boston Scientific, Marlborough, MA, USA). A 200 μm single use laser fiber (Cook Medical, Bloomington, IN, USA) was positioned close to the stone and lithotripsy was performed until complete fragmentation has been achieved (Settings- 1,2 mJ, 8Hz). The procedure was followed by balloon- or basket extraction of fragments. CBD clearance was confirmed by cholangioscopy. Further interventions were rescheduled if needed. For the period a total of 16 cholangioscopy- guided holmium laser lithotripsies were performed in 14 patients. 2 complications were documented- hemobilia caused discontinuation of the procedure in a patient with essential thrombocitopaenia and a case of mild cholangitis treated with i.v. antibiotic for 5 days. Nasobiliary drainage was left for 24 hours in 2 patients, 2 patients received temporary plastic stents for cholangitis- profilaxis due to residual debris . No serious adverse events requiring surgery, blood transfusions or ICU admission were noted. Cholangioscopy guided Holmium laser lithotripsy is a safe and effective option to treat difficult bile duct stones. The early implementation avoids multiple ERCP- sessions, surgery and related complications in patients, unsuitable for standard endoscopic treatment. Carefull patient selection is needed in relation with the cost- effectiveness and procedure duration.Table 1ResultsNumber of patients14Impacted CBD stones6/14 (42,8%)CBD stones8/14 (57%)Stones in the common hepatic duct2/14 (14,2%)Intrahepatic stones3/14 (21,4%)Stones in the cystic duct1/14 (7,1%)Size of the stones10-35 mmNumber of sessions until complete clearance1,14Duration of the procedure90-180 min.Complications2/14 (14,2%) Open table in a new tab

Test-retest reliability of drug-induced sleep endoscopy using midazolam.

Drug-induced sleep endoscopy (DISE) has been suggested to be a valuable method for determining the obstruction patterns causing sleep-disordered breathing. However, since DISE is not performed throughout the duration of sleep but for less than 1 hour, the reproducibility and reliability of DISE are questionable. Therefore, we aimed to determine the test-retest reliability of DISE using midazolam. Thirty-four patients diagnosed with obstructive sleep apnea were prospectively included in this study. The patients underwent 2 separate DISE examinations that were performed at different days using the same drug and technique. For a more accurate comparison, the depth of sleep and examination time were identically controlled. VOTE classification was used to classify the obstruction findings, and the findings of upper airway obstruction were compared between the 2 tests. There were 30 men and four women; the mean age was 45.4 ± 13.1 years. The mean apnea-hypopnea index was 38.3 ± 22.6, and the lowest oxygen saturation was 77.5% ± 12.4%. The lateral wall of the oropharynx, tongue base, and epiglottis showed very good agreement, and the velum showed good agreement between the first and second DISE examinations. The reliability of DISE is debatable because it observes only a small portion of the total sleep, but this study suggests that DISE is a reliable test because the findings of 2 separate DISE examinations on different days showed a high concordance rate.

Subchondral stem cell therapy versus contralateral total knee arthroplasty for osteoarthritis following secondary osteonecrosis of the knee.

Total knee arthroplasty (TKA) implanted in patients with secondary osteonecrosis (ON) related to corticosteroids have relatively poor outcome (20% revision rate) at a mean follow-up of only eightyears. With the hypothesis that subchondral bone marrow injection might improve knees in these patients, we evaluated 30 patients who had bilateral knee osteoarthritis with severe joint space narrowing and received TKA in one knee and subchondral bone marrow concentrate injection in the contralateral knee. A prospective randomized controlled clinical trial was carried out in 60 knees of 30 patients (mean age 28years, 18-41) who presented bilateral osteoarthritis secondary to knee ON related to corticosteroids in relation with different severe medical conditions. During the same anesthesia, one knee received TKA; for the other knee, a bone marrow graft containing an average of 6500 MSCs/mL (counted as CFU-F, range 3420 to 9830) was delivered to the subchondral bone of the femur and tibia. The length of anesthesia related to each procedure (bone marrow aspiration and subchondral injection of concentrated bone marrow versus total knee arthroplasty) was measured. Peri-operative outcomes, morbidity, complications, and safety of the two procedures were compared. Subsequent admissions for revision surgery were identified. At the most recent follow-up (average of 12years, range 8 to 16years), clinical outcomes of the patient (Knee Society score) were obtained along with radiological imaging outcomes (MRIs for knees with subchondral bone marrow injection). Anesthesia related to the TKA side was longer than for the cell therapy group. Medical and surgical complications were more frequent after TKA. A higher number of thrombophlebitis was observed on the side with TKA (15%) versus none on the side with cell therapy (0%). At the most recent follow-up (average of 12years, range 8 to 16years), six (out of 30) TKA knees needed subsequent surgery versus only one with cell therapy. The Knee Score had improved and remained similar in the TKA and cell therapy groups (respectively 80.3 points ± 11 versus 78.3 ± 23); 21 patients preferred the knee with cell therapy and 9 preferred the knee with TKA. Knees with cell therapy had improvement on cartilage and bone marrow lesions observed at the site of bone marrow subchondral injection. Subchondral autologous bone marrow concentrate was an effective procedure for treating young patients with knee osteoarthritis following secondary ON of the knee related to corticosteroids with a lower complication rate and a quicker recovery as compared with TKA.

Predicting readmission risk shortly after admission for CABG surgery.

Reducing preventable hospital readmissions after coronary artery bypass graft (CABG) surgery has become a national priority. Predictive models can be used to identify patients at high risk for readmission. However, the majority of the existing models are based on data available at discharge. We sought to develop a model to predict hospital readmission using data available soon after admission for isolated CABG surgery. Fifty risk factors were included in a bivariate analysis, 16 of which were significantly associated (P < 0.05) with readmissions and were entered into a multivariate logistic regression and removed stepwise, using backward elimination procedures. The derived model was then validated on 896 prospective isolated CABG cases. Of 2589 isolated CABG patients identified between December 1, 2010, and June 30, 2014, 237(9.15%) were readmitted within 30 days. Five risk factors were predictive of 30-day all-cause readmission: age (odds ratio [OR] = 1.03; 95% confidence interval [CI]: 1.01-1.05; P = 0.004), prior heart failure (OR = 1.55; 95%CI: 1.07-2.24; P = 0.020), total albumin prior to surgery (OR = 0.68; 95%CI: 0.05-0.94; P = 0.021), previous myocardial infarction (OR = 1.44; 95%CI: 1.00-2.08; P = 0.50), and history of diabetes (OR = 1.54; 95%CI: 1.09-2.19; P = 0.015). The area under the curve c-statistic was 0.63 in the derivation sample and 0.65 in the validation sample showing good discrimination. A 30-day all-cause readmission among isolated CABG patients can be predicted soon after admission with a small number of risk factors.