United States National Inpatient Sample Research Articles

Sex differences in the prevalence of vascular disease and risk factors in young hospitalized patients with psoriasis.

BackgroundPsoriasis is an inflammatory skin disease associated with atherosclerotic cardiovascular disease (ASCVD) risk factors and vascular disease. The relative impact of psoriasis on vascular disease is the strongest in young patients with psoriasis, yet data are lacking on how sex differences influence cardiovascular risk factors and vascular disease in these patients.ObjectiveThis observational study aimed to identify the burden of cardiovascular risk factors and vascular disease in patients with psoriasis and to explore whether this burden is different between men and women age < 35 years.MethodsYoung (age ≥ 20 and < 35 years) hospitalized patients with psoriasis from the United States National Inpatient Sample were compared with those matched patients without psoriasis. Vascular disease was defined as ASCVD and/or venous thromboembolic disease. Multivariable logistic regression was used to determine the associations between psoriasis, sex, ASCVD risk factors, and vascular disease.ResultsOverall, patients with psoriasis (n = 18,353) were more often obese (16% vs. 6%); smokers (31% vs. 17%); and diagnosed with diabetes mellitus (10% vs. 6%), hypertension (16% vs. 8%), hyperlipidemia (6% vs. 2%), ASCVD (2.2% vs. 1.6%), and deep vein thrombosis (6% vs. 4%; all p < .001) compared with patients without psoriasis (n = 55,059; matched by age, sex, and race). When stratified by sex, women with psoriasis were more likely to have multiple cardiovascular risk factors and ASCVD (odds ratio: 2.6; 95% confidence interval [2.1-3.1]) compared with men with psoriasis (odds ratio: 1.2; 95% confidence interval [0.9-1.4]; interaction p < .01). The association between psoriasis and ASCVD in women remained unchanged after multivariable adjustment for traditional cardiovascular risk factors.ConclusionPsoriasis was associated with cardiovascular disease and risk factors in young hospitalized patients, with stronger associations among women than among men.

Depression is associated with worse outcomes among women undergoing breast reconstruction following mastectomy

The causes of depression after breast reconstruction include worse outcomes, longer recovery times, and, sometimes, additional operations. Despite a plethora of data examining the effect of depression after breast reconstruction, there is little information to assess if concurrent depression affects patient outcomes in a similar manner. Thus, we sought to answer this question: Do depressed women undergoing breast reconstruction have worse outcomes? The United States National Inpatient Sample was queried during 2010-2013 for all patients undergoing breast reconstruction after mastectomy. Patients with a diagnosis of depression at the time of breast reconstruction were compared to those who did not have depression at the time of breast reconstruction; patients who had any of the corresponding ICD-9 procedure codes for breast reconstruction and the single diagnostic code for depression included in their electronic medical record were included in the database sample. Significance testing and risk-adjusted multivariate logistic regression were performed with SPSS. A total of 175,508 patients were included in this study, of which 35,473 had depression at the time of breast reconstruction and 140,035 did not. Depression was associated with an increased age, length of stay, greater cost of care, more comorbidities, and higher incidence of pulmonary, hematologic, gastrointestinal, infectious, wound, and venous thromboembolic complications, p<0.05. Pulmonary, genitourinary, and hematologic complications, infection, VTE, wound, and transfusion were associated with depression when a multivariate risk-adjusted regression was performed. A co-morbid diagnosis at the time of breast reconstruction should prompt the breast reconstruction team to ensure that depressed patients have their depression managed and all co-morbidities optimized and treated prior to undergoing breast reconstruction to ensure optimal patient outcomes.

Saddle pulmonary embolism and in-hospital mortality in patients with cancer.

Saddle pulmonary embolism (PE) has been associated with an increased risk of 1year mortality when compared to non-saddle PE among patients with cancer. We sought to evaluate the association between saddle PE and in-hospital outcomes among patients with comorbid cancer. The 2013 and 2014 United States National Inpatient Sample was used to identify adult patients hospitalized for acute PE. Only patients with an International Classification Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code indicating comorbid cancer were included. Identified admissions were stratified into the following 2 cohorts: saddle (defined as ICD-9-CM code = 415.13) and non-saddle PE. Multivariable logistic regression was performed to determine the association between saddle PE and the odds of in-hospital mortality after adjustment for age ≥ 80years and sex. A total of 10,660 admissions for acute PE in patients with comorbid cancer were identified. Of which, 4.5% (n = 475) had a saddle PE. Median age was 67years (interquartile range = 58-76) and 48.9% were male. In-hospital mortality occurred in 6.1% of patients. Upon multivariable adjustment, the odds of in-hospital mortality were higher in saddle versus non-saddle PE (odds ratio = 1.51; 95% confidence interval 1.08-2.10). In this retrospective study of admissions for acute PE in patients with comorbid cancer, saddle PE was associated with a higher odds of in-hospital mortality.

A National Analysis on Predictors of Discharge to Rehabilitation After Corrective Surgery for Adolescent Idiopathic Scoliosis.

Retrospective study of a national database. To identify the incidence and risk factors for discharge to a rehabilitation facility after corrective surgery for adolescent idiopathic scoliosis (AIS). The vast majority of patients who undergo surgery for AIS are discharged home, with limited data on rates and causes for discharge to a rehabilitation facility. The United States National Inpatient Sample (NIS) database was queried for the years 2012 to 2014. Inclusion criteria were children aged 10 to 18 who underwent surgery for idiopathic scoliosis. Studied data included patient demographics, operative parameters, length of stay, and hospital charges. Perioperative complications were also examined, along with their association with discharge to an inpatient rehabilitation facility. Statistical analysis was performed via chi-squared testing and multivariate analysis, with significance defined as a P-value <0.05. A total of 17,275 patients were included (76.3% female, mean age 14 yr). Out of the entire cohort, 4.8% of patients developed a complication and 0.6% were discharged to a rehabilitation facility. The most common complications included respiratory failure (2.3%), reintubation (0.8%), and postoperative hematoma (0.8%). Following multivariate analysis, male sex (Odds ratio (OR) 4.7; 95% Confidence Interval (CI), 1.8-12.2; P = 0.002), revision surgery (OR 29.6; 95% CI, 5.7-153.5; P < 0.001), and development of a perioperative complication (OR 12.3; 95% CI, 4.7-32.4; P < 0.001) were found to be significant predictors of discharge to rehabilitation. Average length of stay was 8 ± 6 versus 5 ± 3 days and hospital charges were $254,425 versus $186,273 in the complication and control groups, respectively (both P < 0.001). Discharge to rehabilitation after AIS surgery is uncommon. However, patients who are male, undergo revision procedures, or develop a complication may have a higher risk of a non-routine discharge. Complication occurrence also resulted in significantly longer lengths of stay and healthcare costs. 3.

Characteristics of hospital admissions associated with implantable cardioverter defibrillator placement among adults with congenital heart disease

BackgroundCharacteristics of hospitalizations including healthcare utilization for adult patients with congenital heart disease (ACHD) at the time of implantable cardioverter defibrillator (ICD) placement has not been well studied. MethodsWe analyzed data from the 2002–2014 United States National Inpatient Sample (NIS). ICD implantation, CHD, complications, and indications for admissions were determined based on diagnostic codes among adults. Propensity score matching was performed, based on age, sex and in-hospital mortality index with a 10:1 ratio between adults without CHD and those with CHD, to determine relative healthcare utilization attributable to CHD. ResultsACHD accounted for 136,509 ± 3488 admissions of which 1451 ± 121 admissions (1.1 ± 0.06%) were associated with an ICD placement. ICD placement occurred most frequently among patients with TOF, VSD, and transposition complexes usually in the context of a dysrhythmia. Compared to those without CHD, ACHD patients had higher adjusted total hospital charges ($147,002 ± 5516 vs $132,455 ± 2182; p < 0.001), length of stay (6.2 ± 0.5 vs 5.2 ± 0.1 days; p < 0.001), lower readmission score (5.5 ± 0.5 vs 9.7 ± 0.1; p = 0.04) and a higher complication rate (13.4% vs 8.3%; p < 0.001). Dysrhythmias were more frequently the primary diagnosis for admission in the ACHD cohort (63% vs 38%; p < 0.001). ConclusionCompared to a matched non-CHD population, ACHD patients had greater healthcare utilization and had more frequent complications. The reasons underlying this difference bear investigation to improve care quality.

Association between comorbid cancer and outcomes among admissions for acute ischemic stroke receiving systemic thrombolysis.

The impact of cancer on outcomes was not assessed in major trials of systemic thrombolysis in acute ischemic stroke. To evaluate the association between comorbid cancer and hospital outcomes among patients receiving systemic thrombolysis for the treatment of acute ischemic stroke. The 2013 and 2014 United States National Inpatient Sample was used to identify adult patients hospitalized for acute ischemic stroke who received systemic thrombolysis. Identified admissions were stratified into two cohorts based on the presence or absence of comorbid cancer. Multivariable logistic regression was performed to determine the association between comorbid cancer and the odds of in-hospital mortality and intracerebral hemorrhage after adjustment for age ≥75 years and comorbid atrial fibrillation. A total of 13,993 acute ischemic stroke admissions were treated with systemic thrombolysis. Of these, 3.0% ( n = 416) had comorbid cancer. The overall incidence of in-hospital mortality was 7.0% and intracerebral hemorrhage occurred in 7.6% of patients. Upon multivariable adjustment, comorbid cancer was not associated with an increased odds of in-hospital mortality (odds ratio = 1.24; 95% confidence interval = 0.88-1.76). However, the adjusted odds of intracerebral hemorrhage were higher among those with comorbid cancer (odds ratio = 1.60; 95% confidence interval = 1.17-2.17). In this retrospective study of admissions for acute ischemic stroke receiving thrombolysis, comorbid cancer was not associated with a higher odds of in-hospital mortality but was associated with an increased odds of intracerebral hemorrhage. Factors driving this observed association should be explored in data sets containing clinical variables.

Impact of Bariatric Surgery on Outcomes of Patients with Inflammatory Bowel Disease: a Nationwide Inpatient Sample Analysis, 2004-2014.

There is a paucity of data regarding the benefits of bariatric surgery in patients with inflammatory bowel disease (IBD). The primary aim of this study was to evaluate the role of bariatric surgery on clinical outcomes among hospitalized patients with IBD. The United States (US) National Inpatient Sample database was queried between 2004 and 2014 for discharges with co-diagnoses of morbid obesity and IBD. Hospitalizations with a history of prior-bariatric surgery were also identified. The primary outcome was in-hospital mortality. Secondary outcomes included renal failure, under-nutrition, thromboembolic events, strictures, fistulae, length of stay, and hospitalization costs. Using Poisson regression, adjusted incidence risk ratios (IRR) were derived for clinical outcomes in patients with prior-bariatric surgery compared to those without bariatric surgery. Among 15,319 patients with a discharge diagnosis of IBD and morbid obesity, 493 patients (3.2%) had bariatric surgery. From 2004 to 2014, the proportion of obese IBD patients that underwent bariatric surgery declined (5.2 versus 3.1%). In a multivariable analysis, prior-bariatric surgery was associated with decreased IRR for renal failure, under-nutrition, and fistulae formation in morbidly obese IBD patients [(IRR 0.1; 95% CI 0.02-0.3; P<0.001), (IRR 0.2; 95% CI 0.05-0.8; P=0.03), and (IRR 0.1; 95% 0.2-08; P=0.03), respectively]. Bariatric surgery did not influence mortality (P=0.99). Despite a gradual increase in morbid obesity among patients with IBD, there has been a decrease in proportion of overall bariatric surgeries. Bariatric surgery appears to reduce morbidity in obese patients with IBD.

Impact of Hypothyroidism on Occurrence and Outcome of Acute Coronary Syndrome from the National Inpatient Sample

Thyroid hormones have a profound effect on cardiovascular physiology. We utilized a large national inpatient database in the United States (National Inpatient Sample) to study hypothyroidism in relation to the prevalence of coronary heart disease (CHD) and its impact on outcomes (mortality, the length of stay, and hospitalization cost) in the acute coronary syndrome (ACS) subgroup of CHD patients. We found that although hypothyroidism has an increased association with CHD (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.09 to 1.12, p <0.001), the odds of developing ACS in these CHD patients is lower in the hypothyroid group (OR 0.71, 95% CI 0.70 to 0.72, p <0.001) after adjusting for multiple risk factors. Additionally, patients with hypothyroid ACS have a reduced odds of in-hospital mortality (OR 0.86, 95% CI 0.83 to 0.88, p <0.001), shorter length of stay by 0.45 days (p <0.001), and lower hospitalization cost by $1,531.45 (p <0.001) compared with the euthyroid group. Our findings suggest that hypothyroidism has an increased CHD risk but a lower risk of development of ACS in hospitalized CHD patients, as well as a better short-term prognosis including ACS-associated mortality.

Risikofaktoren für perioperativen Retinaarterienverschluss in der Herzchirurgie

Calway T et al. Perioperative retinal artery occlusion: risk factors in cardiac surgery from the United States National Inpatient Sample 1998 – 2013. Ophthalmology 2017; 124: 189 – 196

Incidence, predictors, and outcomes associated with pneumothorax during cardiac electronic device implantation: A 16-year review in over 3.7 million patients

Pneumothorax (PTX) is a potential complication of vascular access during cardiac implantable electronic device (CIED) procedures and is being scrutinized as a health care-acquired condition. The purpose of this study was to determine the trends in PTX incidence in the United Stated over a 16-year period and to determine whether PTX is associated with increased mortality after adjustment for other factors. Using weighted sampling in the largest inpatient health database in the United States (National Inpatient Sample), we evaluated data from patients with a primary procedure of CIED implantation from 1998 to 2013 who had at least 1 new vascular access (new or upgrade of prior CIED). The unadjusted and adjusted associations of PTX with mortality and other parameters were examined. Among 3,764,703 CIED procedures, PTX occurred in 47,839 cases (1.3%). The apparent incidence of PTX peaked at 1.6% in 2012 and 2013, although this result may have been affected by a concomitant decrease of inpatient (vs outpatient) CIED. PTX was significantly associated with pulmonary complications, chest tube insertion, length of stay, and costs. Mortality was statistically higher in patients with PTX (1.2% vs 0.7%; P <.001), a relationship that remained significant in a multivariate logistic regression analysis (odds ratio 1.50, 95% confidence interval 1.36-1.65; P <.001). Age >80 years, female gender, Caucasian race, chronic obstructive pulmonary disease, and dual-chamber (vs single-chamber) device were all associated with higher odds for PTX occurrence. Placement of a chest tube was a major determinant of worse outcomes and higher costs. PTX remains an important complication of CIED procedures and is associated with increased morbidity, mortality, and costs.

Perioperative acute myocardial infarction associated with non-cardiac surgery

Acute myocardial infarction (AMI) is a significant cardiovascular complication following non-cardiac surgery. We sought to evaluate national trends in perioperative AMI, its management, and outcomes. Patients who underwent non-cardiac surgery from 2005 to 2013 were identified using the United States National Inpatient Sample. Perioperative AMI was evaluated over time. Propensity score matching was used to compile a cohort of AMI patients managed invasively (defined as cardiac catheterization or coronary revascularization) vs. conservatively. The primary outcome was in-hospital all-cause mortality. Among 9 566 277 hospitalizations for major non-cardiac surgery, perioperative AMI occurred in 84 093 (0.88%). Over time, the rate of perioperative AMI per 100 000 surgeries declined by 170 [95% confidence intervals (95% CI) 158-181], from 898 in 2005 to 729 in 2013 (P for trend <0.0001). Perioperative AMI occurred most frequently in patients undergoing vascular (2.0%), transplant (1.6%), and thoracic (1.5%) surgery. In-hospital mortality was higher in patients with perioperative AMI than those without AMI [18.0% vs. 1.5%, P < 0.0001; adjusted odds ratio (OR) 5.76, 95% CI 5.65-5.88]. Mortality associated with perioperative AMI declined over time (adjusted OR 0.86, 95% CI 0.84-0.88). In a propensity-matched cohort of 34 650 patients with perioperative AMI, invasive management was associated with lower mortality than conservative management (8.9% vs. 18.1%, P < 0.001; OR 0.44, 95% CI 0.41-0.47). In an observational cohort study from the USA, perioperative AMI occurs in 0.9% of patients undergoing major non-cardiac surgery and is strongly associated with in-hospital mortality. Invasive management of such patients may mitigate some of this excess risk, and further research on the management of perioperative AMI is warranted.

Risikofaktoren für perioperativen Retinaarterienverschluss in der Herzchirurgie

Calway T et al. Perioperative retinal artery occlusion: risk factors in cardiac surgery from the United States National Inpatient Sample 1998 – 2013. Ophthalmology 2017; 124: 189 – 196

Perioperative Retinal Artery Occlusion: Risk Factors in Cardiac Surgery from the United States National Inpatient Sample 1998–2013

To study the incidence and risk factors for retinal artery occlusion (RAO) in cardiac surgery. Retrospective study using the National Inpatient Sample (NIS). The NIS was searched for cardiac surgery. Retinal artery occlusion was identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Postulated risk factors based on literature review were included in multivariate logistic models. Diagnosis of RAO. A total of 5 872 833 cardiac operative procedures were estimated in the United States from 1998 to 2013, with 4564 RAO cases (95% confidence interval [95% CI], 4282-4869). Nationally estimated RAO incidence was 7.77/10 000 cardiac operative procedures from 1998 to 2013 (95% CI, 7.29-8.29). Associated with increased RAO were giant cell arteritis (odds ratio [OR], 7.73; CI, 2.78-21.52; P < 0.001), transient cerebral ischemia (OR, 7.67; CI, 5.31-11.07; P < 0.001), carotid artery stenosis (OR, 7.52; CI, 6.22-9.09; P < 0.001), embolic stroke (OR, 4.43; CI, 3.05-6.42; P < 0.001), hypercoagulability (OR, 2.90; CI, 1.56-5.39; P < 0.001), myxoma (OR, 2.43; CI, 1.39-4.26; P= 0.002), diabetes mellitus (DM) with ophthalmic complications (OR, 1.89; CI, 1.10-3.24; P= 0.02), and aortic insufficiency (OR, 1.85; CI, 1.26-2.71; P= 0.002). Perioperative bleeding, aortic and mitral valve surgery, and septal surgery increased the odds of RAO. Negatively associated with RAO were female gender (OR, 0.77; CI, 0.66-0.89; P < 0.001), thrombocytopenia (OR, 0.79; CI, 0.62-1.00; P= 0.049), acute coronary syndrome (OR, 0.72; CI, 0.58-0.89; P= 0.003), atrial fibrillation (OR, 0.82; CI, 0.70-0.95; P= 0.01), congestive heart failure (OR, 0.73; CI, 0.60-0.88; P < 0.001), DM 2 (OR, 0.74; CI, 0.61-0.89; P= 0.001), and smoking (OR, 0.82; CI, 0.70-0.97; P= 0.02). Risk factors for RAO in cardiac surgery include giant cell arteritis, carotid stenosis, stroke, hypercoagulable state, and DM with ophthalmic complications; associated with lower risk were female gender, thrombocytopenia, acute coronary syndrome, atrial fibrillation, congestive heart failure, DM 2, and smoking. Surgery in which the heart was opened (e.g., septal repair) versus surgery in which it was not (e.g., CABG) and perioperative bleeding increased the risk of RAO.

Management and outcomes of acute myocardial infarction in patients with chronic kidney disease

BackgroundChronic kidney disease (CKD) is associated with cardiovascular disease and acute myocardial infarction (AMI). Contemporary management and outcomes of AMI in patients with CKD have not been reported. MethodsWe analyzed United States National Inpatient Sample data for patients admitted with AMI with or without CKD from 2007 to 2012. Propensity score matching was used to identify patients with AMI and CKD with similar baseline characteristics who were managed invasively (cardiac catheterization, percutaneous coronary intervention [PCI], or coronary artery bypass graft surgery [CABG]) or conservatively. The primary outcome was in-hospital all-cause mortality. ResultsAmong 753,782 patients admitted with AMI, 17.8% had a diagnosis of CKD. Patients with CKD had lower odds of invasive management (49.9% vs. 73.1%; adjusted OR 0.57, 95% CI 0.57–0.58), were less likely to undergo revascularization (adjusted OR 0.60, 95% CI 0.59–0.61), and had higher in-hospital mortality (8.4% vs. 5.0%; adjusted OR 1.55, 95% CI 1.51–1.59) than those without CKD. In a propensity-matched cohort of 89,630 CKD patients treated for AMI with invasive vs. conservative management, invasive management was associated with lower in-hospital mortality overall (5.9% vs. 10.9%, p<0.001; OR=0.51 (0.49–0.54)) as well as in subgroups by MI type and severity of CKD. ConclusionsPatients with AMI and CKD are less likely to receive invasive management, coronary revascularization, and have higher in-hospital mortality than patients without CKD. Invasive management of AMI was associated with lower in-hospital mortality versus conservative management in all patients, regardless of CKD severity.

National Lupus Hospitalization Trends Reveal Rising Rates of Herpes Zoster and Declines in Pneumocystis Pneumonia.

ObjectiveInfection is a leading cause of morbidity and mortality in systemic lupus erythematosus (SLE). Therapeutic practices have evolved over the past 15 years, but effects on infectious complications of SLE are unknown. We evaluated trends in hospitalizations for severe and opportunistic infections in a population-based SLE study.MethodsData derive from the 2000 to 2011 United States National Inpatient Sample, including individuals who met a validated administrative definition of SLE. Primary outcomes were diagnoses of bacteremia, pneumonia, opportunistic fungal infection, herpes zoster, cytomegalovirus, or pneumocystis pneumonia (PCP). We used Poisson regression to determine whether infection rates were changing in SLE hospitalizations and used predictive marginals to generate annual adjusted rates of specific infections.ResultsWe identified 361,337 SLE hospitalizations from 2000 to 2011 meeting study inclusion criteria. Compared to non-SLE hospitalizations, SLE patients were younger (51 vs. 62 years), predominantly female (89% vs. 54%), and more likely to be racial/ethnic minorities. SLE diagnosis was significantly associated with all measured severe and opportunistic infections. From 2000 to 2011, adjusted SLE hospitalization rates for herpes zoster increased more than non-SLE rates: 54 to 79 per 10,000 SLE hospitalizations compared with 24 to 29 per 10,000 non-SLE hospitalizations. Conversely, SLE hospitalizations for PCP disproportionately decreased: 5.1 to 2.5 per 10,000 SLE hospitalizations compared with 0.9 to 1.3 per 10,000 non-SLE hospitalizations.ConclusionsAmong patients with SLE, herpes zoster hospitalizations are rising while PCP hospitalizations are declining. These trends likely reflect evolving SLE treatment strategies. Further research is needed to identify patients at greatest risk for infectious complications.

Editors' commentary

Notwithstanding the headline debate about whether an “endovascular-first” or an “open surgery-first” strategy is preferable or safer, the most important issue raised by our debaters—and one which should concern all of us—is that a diagnosis of acute mesenteric ischemia (AMI) is still invariably delayed and usually only considered once the patient has become too ill to undergo any form of meaningful intervention. The data from the United States National Inpatient Sample, which showed that only 15% of AMI patients were actually treated and that only 3% had the chance to benefit from endovascular or open revascularization, make extremely depressing reading. Put another way; almost nine of every 10 patients with a diagnosis of suspected AMI will undergo no active treatment. Such bleak statistics demand that medical professionals (of all disciplines) be made more aware of the importance of at least considering a diagnosis of AMI in their patients. Returning to the “meat” of the debate, our contributors have provided positive and negative data regarding their respective positions. That is not surprising, given the nature of a debate. We suspect, however, that a significant proportion of our surgical readers will rarely (or never) consider an endovascular-first strategy for the treatment of their AMI patients (unlike patients with chronic mesenteric ischemia), largely because of an intuitively held belief (espoused by Drs Orr and Endean) that endovascular strategies have little to offer in these acute life-threatening situations and that emergency laparotomy is mandatory to gauge the severity of ischemia, enable revascularization, as well as allowing the resection of compromised bowel before it worsens and precipitates multiorgan failure. However, Martin Björck has also shown that surgeons may have been wrong to uncritically dismiss a role for an endovascular-first strategy. This is supported by international registries reporting that up to 50% of contemporary arterial revascularizations for AMI now follow an endovascular-first strategy, with bailout surgical bypass possible in up to half of those cases where an endovascular intervention failed to recanalize the superior mesenteric artery. One would not expect to have observed such an increase in the proportion of interventional therapies if an endovascular-first strategy was associated with poorer outcomes compared with the traditional open surgical approach. There are obvious advantages to either strategy. Endovascular therapy is less invasive, can be done under local anesthesia, avoids a major laparotomy in compromised individuals, and (perhaps most importantly) finishes with completion angiography to identify and treat residual thrombus and defects, thereby optimizing the overall quality of the revascularization. The Achilles' heel of an endovascular-first strategy, however, is determining exactly when someone needs a second-look laparotomy to identify the patient with persisting focal bowel ischemia before it perforates. Martin Björck advocates a liberal approach to second-look laparotomy, but when one is required is not always apparent. The open surgery-first approach, as stated by Drs Orr and Endean, is more generalizable and does not require complex endovascular skills, which may not be available in most hospitals. This type of patient is usually too ill to transfer to another more experienced endovascular institution, usually because of the delay in diagnosis. As with most issues in medicine, a “one size fits all” strategy rarely works, and it is inevitable that endovascular and open surgery will evolve complementary roles in the management of AMI. This will be particularly true in the era of hybrid endovascular theaters where the patient can undergo any combination of the two approaches as well as laparoscopy. Moreover, the addition of open retrograde SMA angioplasty or stenting, or both, will increase revascularization options while at the same time permitting the surgeon to inspect the bowel for areas of doubtful viability. However, any meaningful debate about whether an endovascular-first or an open surgery-first strategy is safer in AMI patients is pointless unless the medical profession becomes much better at diagnosing AMI early. That remains the most important challenge facing all of us. Debate: Whether an endovascular-first strategy is the optimal approach for treating acute mesenteric ischemiaJournal of Vascular SurgeryVol. 62Issue 3PreviewAcute mesenteric ischemia continues to be a life-threatening insult in often-elderly patients with many comorbidities. Recognition and correct diagnosis can be an issue leading to delays in therapy that result in loss of bowel or life, or both. The basic surgical principals in treating acute mesenteric ischemia have long been early recognition, resuscitation, urgent revascularization, resection of necrotic bowel, and reassessment with second-look laparotomies. Endovascular techniques now offer a less invasive alternative, but whether an endovascular-first or open surgery-first approach is preferred in most patients is unclear. Full-Text PDF Open Archive

Perioperative Mortality in Patients with Pulmonary Hypertension Undergoing Major Joint Replacement

There is a paucity of perioperative outcomes data for patients with chronic pulmonary hypertension (PHTN) undergoing noncardiac surgery. Clinicians, therefore, have little information on which to evaluate the risk for morbidity and mortality in this patient population. In this study, we evaluated the incidence and risks of perioperative morbidity and mortality in patients with PHTN undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Using the largest inpatient database in the United States (National Inpatient Sample), we identified entries for THA and TKA between the years of 1998 and 2006. Patients with the diagnosis of PHTN were identified and matched to those without the disease based on health-related demographic variables. Perioperative mortality was considered the primary outcome. Multivariate logistic regression models were fitted to assess the impact of PHTN on in-hospital mortality. We identified 670,516 entries for TKA and 360,119 for THA. Of those patients, 2184 (0.3%) and 1359 (0.4%), respectively, had the diagnosis of PHTN (average annual rate of 1180 for TKA [range, 507-2073] and 739 for THA [range, 467-1054]). Patients with PHTN undergoing THA experienced an approximately 4-fold increased adjusted risk of mortality (2.4% vs 0.6%), and those undergoing TKA a 4.5-fold increased adjusted risk of mortality (0.9% vs 0.2%) compared with patients without PHTN in the matched sample (P < 0.001 for each comparison). Patients with primary PHTN undergoing THA experienced the highest mortality rate (5% [95% CI, 2.3%-7.7%]). This analysis demonstrates that patients with PHTN are at increased risk for perioperative mortality after THA and TKA.