Impact of socioeconomic deprivation on incidence and outcomes of acute type A aortic dissection repair in New Zealand.

BACKGROUND: Socioeconomic deprivation (SED) has been associated with increased 30-day mortality and reduced long-term survival after surgical repair of acute type A aortic dissection (ATAAD). The study aimed to determine the incidence rate ratio of ATAAD in New Zealand population with higher and lower SED indices and to evaluate any association between SED and outcomes after ATAAD repair. METHODS: This was a retrospective cohort study. Patients who underwent ATAAD repair from March 2003 to May 2020 were identified. Overseas patients, those with chronic aortic dissection, and those who died in hospital before the operation were excluded. The total number of New Zealand residents was estimated based on the national 2018 Census. RESULTS: A total of 363 ATAAD patients met the eligibility criteria. The incidence of ATAAD was 70% greater in those who were more socioeconomically deprived (higher SED) compared with less socioeconomically deprived (lower SED) New Zealanders (odds ratio = 1.7; 95% confidence interval [CI] = 1.4-2.1; p < .0005). Postoperative cardiogenic shock, renal failure, pulmonary embolism, and respiratory failure were more common in the higher than in the lower SED group. Both groups had similar operative and in-hospital mortality and time intervals in the intensive care unit and hospital. Both groups had similar freedom from reoperation (hazards ratio [HR] = 1.1; 95% CI = 0.5-2.6; p = .746) and long-term survival (HR = 0.73; 95% CI = 0.5-1.1; p = .115). CONCLUSION: The incidence of ATAAD is greater in more socioeconomically deprived New Zealand residents. Following ATAAD repair, SED is not associated with worse short- or long-term outcomes in the universal health care system.

Impact of the Duration of Global Cardiac Ischaemia on Outcomes of Acute Type A Aortic Dissection Repair.

BACKGROUND: The current management of acute type A aortic dissection (ATAD) repair does not consider the safe duration of cardiac ischaemia as an operative strategy. We aimed to evaluate whether the duration of cardiac ischaemia during ATAD repair can predict operative mortality and to determine the optimum cardiac ischaemia time that is associated with better outcomes. METHODS: This was a retrospective observational study. Patients who underwent ATAD repair from 2003 to 2020 were identified from our hospital records. RESULTS: Three hundred and sixty three (363) ATAD patients met eligibility criteria. The median patient age was 61 years, 221 (61%) patients were male. Duration of cardiac ischaemia was associated with operative mortality (Odds ratio [OR] =1.01; p<0.0005). Its optimal cut-off point was equal to or above 149.5 minutes (95% CI: 126.2-172.8). In patients with a shorter period (less than 150 mins) of cardiac ischaemia, a valve-sparing root repair was used more often (OR=2.5; 95% CI: 1.6-3.9; p<0.001). Procedures that had the longer period of cardiac ischaemia included the Bentall procedure (OR=10.9; 95% CI: 4.9-27.4; p<0.001), descending thoracic aorta replacement (OR=4.3; 95% CI: 1.007-18.7; p=0.049) and concomitant cardiac surgery (OR=4.7; 95% CI: 2-11.1; p<0.001). Operations associated with shorter cardiac ischaemia were associated with lower in-hospital mortality and better long-term survival. CONCLUSION: This study determined that the duration of cardiac ischaemia in ATAD repair is linked to operative mortality. Further studies are required to confirm that ATAD patients with surgical repair involving less than 150 minutes of cardiac ischaemic time have lower in-hospital mortality and better long-term survival.

How to repair an acquired Gerbode defect using an aortic root xenograft.

A 74-year old female patient presented with a 3-week history of fever, general weakness, and later developed complete heart block. On admission, the patient was febrile (temperature of 39°C) and tachypnoeic (respiratory rate of 29/min) with oxygen saturation of 95% on 2 L of oxygen. Her heart rate was 60 beats/min (VVI pacing), arterial blood pressure was 135/60 mm Hg and the Glasgow Coma Scale was 15. On chest auscultation, she had a harsh systolic murmur over her left precordium and bilateral rales. Blood tests demonstrated moderate anemia (hemoglobin of 95 g/L), leucocytosis (white blood cell count of 13.13 x 10^9/L), hypoalbuminemia (albumin concentration of 18 g/L), normal liver function tests and creatinine clearance of 45 ml/min. Computed tomography aortography demonstrated an irregular mass arising from the aortic root that extended into the right atrium (RA) and a fistulous tract (the Gerbode defect) between the left ventricular outflow tract (LVOT) and the right ventricle (RV). Transoesophageal echocardiography showed large vegetation in the RA and left to right cardiac shunt through the Gerbode defect from the LVOT to the RA and the RV. Using cardiopulmonary bypass, the patient underwent resection of the aortic cusps, debridement of the aortic root, septal and anterior leaflets of the tricuspid valve, and the membranous septum. The Gerbode defect was closed with an autologous pericardial patch, then a sliding annuloplasty of the septal leaflet of the tricuspid valve was performed. Finally, the aortic root was replaced with a 23 mm Freestyle xenograft.

How to replace a bioprosthetic aortic valve within the Bentall graft.

The Bentall procedure using a bioprosthesis-containing conduit carries the risk of structural valve deterioration within the patients' lifetime. Failed aortic bioprosthesis replacement requires a redo aortic root replacement that is associated with significant morbidity and mortality. We describe an original "neo-annulus" technique of aortic valve replacement (AVR) within the Bentall graft. This technique involves an incision of the Bentall valve-containing aortic root conduit, cutting the stainless wireform stent and the inner plastic stent of the bioprosthetic valve at the tips of commissure posts with a wire cutter, removal of semilunar fragments of the remaining stainless wire, division of the fabric of the valve between the valve sewing cuff and the Elgiloy alloy base ring leaving the sewing cuff of the excised aortic valve bioprosthesis attached to the Bentall conduit as a "neo-annulus". Subsequently, this neo-annulus is stitched with interrupted 2/0 Ticrone sutures and another prosthetic aortic valve implanted inside of the old Bentall conduit. The graft incision is closed with a continuous 4/0 polypropylene suture.

Socio-Economic Disparity is Not Linked to Outcome Following Heart Transplantation in New Zealand.

BACKGROUND: Socio-economic deprivation (SED) is emerging as a risk factor for acute graft rejection (AR) and reduced survival of heart transplant (HT) recipients. The study aim was to evaluate any association between SED status of HT recipients and the development of early AR and long-term survival in New Zealand. METHODS: This was a retrospective cohort study. Over a 30-year period, 329 HT recipients were identified from the Australian and New Zealand Heart Transplant Registry. All patients were divided into two groups according to the 2013 New Zealand Deprivation Index (NZDep2013) Score. Heart transplant recipients with NZDep2013 scores of 1,030 and above that corresponded to the eighth, ninth and tenth NZDep2013 deciles were allocated to the higher SED group and those with NZDep2013 scores below 1,030 to the lower SED group. RESULTS: The incidence of early AR in the higher SED group was 1.158/person-years and in the lower SED group 1.156/person-years. The crude incidence rate ratio was 1.0 (95% CI: 0.71-1.44; p = 0.9997). The prevalence of early AR in the higher SED group was 1.13/person-years and 1.15/person-years in the lower SED group. The crude prevalence rate ratio was 0.98/person-year (95% CI: 0.68-1.41/person-years; p = 0.468). In the higher SED group, mortality was 5.6/100 person-years (95% CI: 4.3-7.4/100 person-years) and 5.2/100 person-years (95% CI: 4.3-6.3/100 person-years) in the lower SED group. The adjusted mortality rate ratio estimate was 1.2 (95% CI: 0.8-1.7; p = 0.426). The higher and lower SED groups had similar survival (p = 0.196). CONCLUSION: Socio-economic disparity in New Zealand HT recipients has no negative impact on the development of AR or survival.

Diagnostic inflammatory markers in acute cholangitis.

BACKGROUND: The 2018 Tokyo guidelines for acute cholangitis (AC) use white cell count (WCC) as one of the diagnostic criteria. However, the 2018 Tokyo guidelines grading does not provide guidance for AC patients with normal WCC. In this situation, other inflammatory biomarkers also can be used to diagnose AC and grade severity, but their diagnostic values are yet undetermined. The aims of this study were to evaluate the discriminative powers of common inflammatory markers compared with WCC for diagnosing AC and to determine their diagnostic cutoff levels. METHODS: This was a retrospective cohort study. Over 2 y, 96 patients who underwent endoscopic biliary decompression were identified from the Auckland City Hospital Radiology Department database. Only patients with a confirmed diagnosis of AC were included in the study. Thirty-four patients with AC and 18 controls met eligibility criteria. RESULTS: Comparing areas under the receiver operating characteristic curves, it was the lymphocyte count, neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein (CRP) that had the highest discriminative powers in diagnosing AC. Values of WCC for diagnosing AC were equal to or above 9.6 × 109/L, neutrophil count equal to or exceeding 4.9 × 109/L, lymphocyte count equal to or below 1.3 × 109/L, NLR 5.3 and above, albumin equal to or below 30.5 g/L, and CRP concentration 23.5 mg/L or above. CONCLUSIONS: Lymphocyte count, NLR, and CRP have superior discriminative powers to WCC, albumin, and neutrophil count and can be useful in the diagnosis of AC.

Socioeconomic deprivation is not associated with reduced survival of lung transplant recipients.

BACKGROUND: Important risk factors for long-term survival of lung transplant (LT) recipients are infection, acute graft rejection (AR) and chronic lung allograft dysfunction (CLAD). Socioeconomic deprivation (SED) is associated with increased graft failure rate after heart and kidney transplantation, but has not been investigated in LT recipients. The aim of this study was to evaluate an association between LT recipients' SED status and development of AR, CLAD, and long-term survival. METHODS: This was a retrospective cohort study. Over a 23 y period, 233 patients were identified from the Auckland City Hospital Lung Transplant Registry, Auckland, New Zealand. All patients were divided into two groups according to the 2013 New Zealand Deprivation Index Score. RESULTS: The incidence of AR in the higher SED group was 34.0/100 person-y (95% confidence interval [CI]: 24.7-46.7/100 person-y) and in the lower SED group 40.2/100 person-y (95% CI: 33.5-48.3/100 person-y) (P = 0.373). The incidence of CLAD in the higher SED group was 10.7/100 person-y (95% CI: 6.2-18.4/100 person-y) and 9.3 (6.9-12.5/100 person-y) in the lower SED group (P = 0.645). Mortality in the higher SED group was 12.9/100 person-y (95% CI: 9.2-17.9/100 person-y) and 12.4/100 person-y (95% CI: 10.0-15.3/100 person-y) in the lower SED group (P = 0.834). CONCLUSIONS: SED status of LT recipients in New Zealand has no negative effect on development of AR, CLAD, and patients' survival.

Evaluation of neutrophil-to-lymphocyte ratio as a potential biomarker for acute cholecystitis.

BACKGROUND: The diagnosis of acute cholecystitis (AC) is frequently associated with an increase in white cell count (WCC) and C-reactive protein (CRP). However, one or both of these inflammatory biomarkers can be normal in AC. The aim of this study was to evaluate and compare the discriminative powers of the neutrophil-to-lymphocyte ratio (NLR) with WCC and CRP in diagnosing AC. METHODS: This was a retrospective cohort study. For more than a period of 5 y, 1959 patients were identified from the cholecystectomy Registry. Laparoscopic cholecystectomy patients with histologic evidence of AC were included if they also had preoperative WCC and CRP measurements. Eligibility criteria were met by 177 patients. These patients were compared with 45 control subjects who had normal gallbladder histology. RESULTS: One unit of increase in the NLR was associated with a 2.5 times increase in the odds of AC (odds ratio = 2.48; 95% confidence interval [CI], 1.5-4.1; P < 0.0005). NLR cutoff values of 4.1 (95% CI, 3.42-4.79), 3.25 (95% CI, 1.95-4.54), and 4.17 (95% CI, 3.76-4.58) were diagnostic for the overall AC, mild, and moderate-severe AC, respectively. The NLR areas under the receiver operating characteristic curve in AC, mild, and moderate-severe AC were 94% (95% CI, 91%-97%), 87% (95% CI, 81%-93%), and 98% (95% CI, 96%-100%), respectively. The discriminative power of an NLR was superior to that of the WCC and similar to CRP for diagnosing AC and different grades of severity. CONCLUSIONS: NLR can be considered as a potential inflammatory biomarker for AC.

C-reactive protein measurement is not associated with an improved management of acute cholecystitis: a plié for a change.

BACKGROUND: The diagnosis of acute cholecystitis (AC) is challenging and may result in a delay in surgical treatment and increased mortality. The 2007 and 2013 Tokyo Guidelines for AC proposed to use C-reactive protein (CRP) as an additional bench mark of AC. The aim of this study was to evaluate whether CRP measurement influences management of patients with AC. METHODS: For more than a period of 5 y (May 2004 to June 2009), 1959 patients were identified from the audit of cholecystectomies in North Shore, Waitakere and Southern Cross hospitals at Waitemata District Health Board, Auckland, New Zealand. The exclusion criteria were elective and private patients, patients without AC on histologic examination of gallbladders, and patients with acute acalculous cholecystitis. RESULTS: A total of 414 patients met eligibility criteria. Compared with the non-CRP group, patients who had CRP measured had a longer time to operation theater and a greater proportion of acute gangrenous cholecystitis on histologic examination of excised gallbladders, but similar postoperative complication rate, index, and total hospital stay. Time to operation theater was not associated with development of acute gangrenous cholecystitis (odds ratio, 1.0; 95% confidence interval, 0.996-1.01; P = 0.797), but correlated with the index hospital admission length (correlation coefficient, 0.6092; P < 0.001). CONCLUSIONS: CRP measurement does not influence management of patients with AC. To improve quality of care and to minimize health care provider costs physiologically fit patients with more advanced forms of AC and higher values of CRP should have their operation performed earlier than patients with mild AC and a lower concentration of CRP.

C-reactive protein has a better discriminative power than white cell count in the diagnosis of acute cholecystitis.

BACKGROUND: The diagnosis of acute cholecystitis (AC) is challenging and may result in a delay in surgery, hospital discharge, and increased mortality. To improve its diagnosis, C-reactive protein (CRP) has been proposed as a benchmark. The aim of this study was to evaluate discriminative power of CRP against white cell count (WCC) in AC. METHODS: This was a retrospective cohort study. Over a 5-y period, 1959 patients were identified from the audit of cholecystectomies. The exclusion criteria were coexisting acute surgical conditions, absence of blood tests within 3 d before hospital admission for elective surgery, and private patients. RESULTS: The eligibility criteria were met by 1843 patients. Comparison of the area under receiver operating characteristic (AUC) curve of CRP and WCC in acute on chronic, edematous, necrotic, suppurative, and gangrenous AC showed a better discriminative power of CRP. Both tests performed equally well in patients with pericholecystic abscess and gallbladder perforation. CRP was superior than WCC in mild AC, AUC = 0.93 (95% confidence interval [CI], 0.9-0.95) and 0.79 (95% CI, 0.74-0.84), P < 0.00005, in moderate and severe AC, AUC = 0.99 (95% CI, 0.97-1.0) and 0.92 (95% CI, 0.88-0.97), P = 0.009, and in all forms of AC combined, AUC = 0.94; (95% CI, 0.92-0.97) and 0.83 (95% CI, 0.79-0.87), respectively, P < 0.00005. CONCLUSIONS: CRP has a better discriminative power than WCC in most forms of AC and is a useful diagnostic marker of AC.

Diagnostic inflammatory markers of acute cholangitis in liver transplant recipients.

BACKGROUND: Acute cholangitis (AC) after liver transplantation occurs in 8-12% patients and remains a significant cause of patients' morbidity and mortality. The 2018 Tokyo guidelines use white blood cell count and C-reactive protein (CRP) as diagnostic criteria in AC. However, these and other common inflammatory markers have not been assessed in immunosuppressed liver transplant (LT) recipients with AC. The aims of this study were to compare the discriminative powers of common inflammatory markers, define the best inflammatory marker and determine the diagnostic cut-off values for the inflammatory markers in LT recipients with AC. METHODS: This was a retrospective cohort study. Over 16 years 212 LT recipients who underwent endoscopic biliary decompression were identified from hospital records. Thirty LT recipients with AC and 30 LT recipients without AC were randomly drawn in a 1:1 ratio. RESULTS: Among inflammatory markers, CRP had the highest discriminative power for diagnosing AC. The areas under the receiver operating characteristics curves for CRP, white blood cell count, lymphocyte count and neutrophil-to-lymphocyte ratio were 95% (95% confidence interval (CI): 91-98), 59% (95% CI: 50-68), 65% (95% CI: 53-77) and 70% (95% CI: 59-80), respectively. The cut-off value of CRP for diagnosing AC was equal to or above 9.5 mg/L. CONCLUSION: CRP has the best discriminative power compared with other commonly used inflammatory markers for diagnosing AC in LT recipients. The optimal cut-off value for CRP concentration in diagnosing AC is equal to or above 9.5 mg/L.

Refusal of treatment by mentally competent patient: the choice of doctor-patient relationship models.

INTRODUCTION: In modern medicine professional relationship between the clinician and the patient is patient-centered. Patients become actively involved in the treatment decision making process and are encouraged to express their health-related preferences. Some patients may, however, refuse a favorable risk/benefit ratio treatment. This manuscript presents three cases of refusal of treatment by mentally competent surgical patients and discusses differences in their management. CONCLUSION: To achieve the best medical outcome for patients who possess the Actual Understanding test of mental competence clinicians use the deliberate model of medical professional relationship. For patients demonstrating the Understanding test of mental competence and wishing to utilize their health-related preferences physicians are obliged to deploy the interpretive model of doctor-patient relationship. In mentally competent patients with an illness-induced acute psychological regression the interpretive model of doctor-patient relationship as an initial strategy and cognitive behavior therapy can be useful in modifying treatment rejecting behavior and improving medical outcome.

Screening acute cholangitis patients for sepsis.

BACKGROUND: Acute cholangitis (AC) complicated by septic shock is associated with 40% mortality. The best screening method for diagnosing sepsis in patients with AC is unknown. In this study, we aimed to compare the discriminative powers of systemic inflammatory response syndrome criteria (SIRS test) and the 2018 Tokyo Guidelines for moderate cholangitis (TG18 test) in screening AC patients for sepsis and to estimate their predictive abilities. METHODS: This was a retrospective diagnostic accuracy study in which the TG18 and SIRS tests were applied to two groups of patients; 52 patients with 70 hospital admissions had AC with shock index ≥0.7 and 46 patients with 57 hospital admissions had AC with shock index <0.7, uncomplicated choledocholithiasis, obstructive jaundice and biliary stent removal. RESULTS: The sensitivity and specificity for the TG18 test in identifying AC patients with sepsis were 69% and 68%, respectively. The SIRS test applied to the same patient cohort yielded 93% sensitivity and 79% specificity. The SIRS test had a larger area under the receiver operating characteristic curve, 86% and 69%, respectively (P = 0.0004). With a sepsis prevalence of 23% in patients with biliary tract infections, the positive predictive value (PPV) for the SIRS test was 57% (95% confidence interval (CI) 44-69%) and the negative predictive value was 97% (95% CI 94-99%). The PPV and negative predictive value for the TG18 criteria were 39% (95% CI 30-50%) and 88% (95% CI 83-92%), respectively. CONCLUSION: The SIRS test had better discriminative power in identifying AC patients with sepsis than the TG18 criteria, but had a low PPV.

Low-dose erythropoietin treatment is not associated with clinical benefits in severely anaemic Jehovah's Witnesses: a plea for a change.

BACKGROUND: Jehovah's Witnesses who refuse blood transfusion have high mortality. Erythropoietin (EPO) has been used as an alternative to blood transfusion. The optimal dosing of EPO in anaemic Jehovah's Witnesses is unknown. The aim of our study was to evaluate the clinical benefits of treatment with a low dose (<600 IU/kg/week) of epoietin beta (EPO-ß). MATERIALS AND METHODS: This was an observational study, retrospectively considering a 10-year period during which 3,529 adult Jehovah's Witnesses with a total of 10,786 hospital admissions were identified from databases of four major public hospitals in New Zealand. Patients with severe symptomatic anaemia (haemoglobin <80 g/L) who were unable to tolerate physical activity were included in the study. Patients treated without EPO were assigned to the conventional therapy group and those treated with EPO to the EPO treatment group. RESULTS: Ninety-one Jehovah's Witnesses met the eligibility criteria. Propensity score matching yielded a total of 57 patients. Patients treated with conventional therapy and those treated with EPO had similar durations of severe anaemia (average difference 6.25 days, 95% confidence interval [CI]: -3.77-16.27 days; p=0.221). The mortality rate among Jehovah's Witnesses treated with conventional therapy was 4.68 per year (95% CI: 2.23-9.82), while that in those treated with EPO was 2.77 per year (95% CI: 0.89-8.60). Treatment with EPO was associated with a mortality ratio of 0.59 (95% CI: 0.1-2.6; p=0.236). Both groups of patients had similar in-hospital survival (p=0.703). DISCUSSION: Treatment with low-dose EPO-ß was not associated with either shorter duration of severe anaemia or a reduction in mortality.

Late two-stage laparoscopic cholecystectomy is associated with an increased risk of major bile duct injury.

BACKGROUND: Late laparoscopic cholecystectomy (LC) after endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy (ES) for common bile duct (CBD) stone clearance, two-stage LC (TSLC), is associated with difficult surgical dissection and an increased rate of conversion to open procedure. The purpose of the study was to evaluate whether the interval between ERCP/ES and LC is associated with major bile duct injury (BDI) and determine an optimal period for TSLC. METHODS: This was a retrospective cohort study of adult patients who underwent LC. The exclusion criteria were absence of CBD stones on imaging or ERCP, surgical treatment of choledocholithiasis, post-operative endoscopic CBD stone clearance and open cholecystectomy. RESULTS: The eligibility criteria were met by 183 patients. There were six major BDIs (3%). Comparisons of the early and late TSLC showed statistically significant difference in major BDI at 16-week cut-offs. Binomial regression analysis demonstrated that late (≥16 weeks) TSLC was associated with 10-fold increase in major BDI (95% confidence interval: 1.1-95.7, P = 0.043). Survival analysis comparing early (<16 weeks) with late (≥16 weeks) TSLC demonstrated that both groups had similar survival time (log-rank test: 0.317). CONCLUSION: General surgeons should be aware of the increasing risk of major BDI with delaying TSLC and perform interval LC before week 16.