Improving mortality trends for hospitalization of aortic dissection in the National Inpatient Sample.

OBJECTIVE: Population-based assessment of aortic dissection (AD) hospitalizations in the general United States population is limited. We assessed the current trends in AD admissions and in-hospital mortality for surgical and medical AD treatment. METHODS: Patients admitted for primary diagnosis of AD were identified from the National Inpatient Sample database (2003-2012). Patients were identified by International Classification of Diseases-Ninth Revision diagnosis codes and categorized by treatment type: type A open surgical repair (TASR), type B open surgical repair (TBSR), thoracic endovascular aortic repair (TEVAR), and medical management (MM). Our primary outcomes were to evaluate admission trends and in-hospital mortality of AD. Secondary outcomes included postoperative complications. We used weighted national estimates of admissions to assess trends over time using linear regression. We also identified factors associated with mortality via a hierarchical multivariable logistic regression model. RESULTS: We identified 15,641 patients (60.7% male; mean age, 63.5 years) admitted with a primary diagnosis of AD between 2003 and 2012. Intervention types included TASR in 3253 (20.8%), TBSR in 3007 (19.2%), TEVAR in 1417 (9.1%), and MM in 7964 (50.9%). Overall weighted admissions for AD increased significantly, from 6980 in 2003 to 8875 in 2012 (P < .01, test of trend), with increases in admission for TASR, from 1143 in 2003 to 2130 in 2012 (P < .01, test of trend), and TEVAR from 96 in 2005 to 1130 in 2012 (P < .01, test of trend). TBSR and MM admissions were stable, with TBSR admissions at 1519 in 2003 and 1540 in 2012 (P = .9, test of trend) and MM admissions at 4319 in 2003 and 4075 in 2012 (P = .8, test of trend). During the same interval, overall in-hospital mortality rates for AD decreased from 18.1% to 13.0% (P < .01, test of trend). When stratified by intervention type, mortality rates decreased for TASR, from 20.5% to 14.8% (P < .01, test of trend), for TBSR, from 18.0% to 14.3% (P = .03, test of trend), and for MM, from 17.5% to 13.9% (P < .01, test of trend). Mortality rates for TEVAR were stable, with an average mortality of 7.9% (P = .8, test of trend) during the study period. Factors associated with increased mortality included older age, Caucasian race, nonelective admission, pre-existing peripheral vascular disease, and acute postoperative complication of myocardial infarction, stroke, or kidney failure. Admissions at a center with high surgical volume were associated with a decreased mortality for TBSR admissions only (odds ratio, 0.55; 95% confidence interval, 0.4-0.7). CONCLUSIONS: Overall and surgical admission rates for AD appear to be increasing, and in-hospital mortality rates are decreasing. TEVAR mortality remains mostly unchanged, however, suggesting targets for further improvement in mortality for AD treatment. Decreased mortality for TBSR at centers with a high surgical volume may suggest a need for regionalization of AD care.

Chronic venous ulcer: minimally invasive treatment of superficial axial and perforator vein reflux speeds healing and reduces recurrence.

BACKGROUND: Chronic venous ulcer (CVU) is common and is responsible for significant health care expenditures worldwide. Compression is the mainstay of treatment, but long-term compliance with this therapy is often inconsistent, particularly in the elderly and infirm. Surgical ablation of axial and perforator reflux has been used as an adjunct to compression to reduce recurrence rates and assist healing. These surgical techniques are being replaced by minimally invasive procedures, such as thermal ablation and foam sclerotherapy, in the treatment of uncomplicated venous disease. The role for these techniques in the treatment of CVU is just beginning to be defined. METHODS: Eighty-six patients with CVU with 95 active ulcers (Clinical, Etiology, Anatomy, Physiology-CEAP clinical class 6) presenting to a multispecialty wound clinic were retrospectively reviewed and analyzed by leg. All patients underwent duplex scanning for venous insufficiency. Ulcer dimensions at each visit were recorded and used to calculate healing rates. Presence or absence of ulcer recurrence at 1-year follow-up was recorded. Ulcers treated with compression alone ("compression group") were compared with those treated with compression and minimally invasive interventions, such as thermal ablation of superficial axial reflux and ultrasound-guided foam sclerotherapy (UGFS) of incompetent perforating veins and varicosities ("intervention group"). RESULTS: The average age in the intervention and compression groups was 67 and 71 years, respectively (P = not significant [NS]). Body mass index was 32.4 ± 9.5 and 33.6 ± 11.8 kg/m(2), in the compression and intervention groups, respectively (P = not significant [NS]). Ulcers were recurrent in 42% of the intervention group and 26% of the compression group (P = NS). In the intervention group, 33% had radiofrequency ablation of axial reflux, 31% had UGFS of perforators, and 29% had both treatments. The only complication of intervention was a single case of cellulitis requiring hospitalization. Compared with the compression group, the ulcers in the intervention group healed faster (9.7% vs. 4.2% per week; P = 0.001) and showed fewer recurrences at 1-year follow-up (27.1% vs. 48.9 %; P < 0.015). Multivariate analysis showed use of intervention was the strongest determinant of healing with a coefficient of variation of 7.432, SE 2.406, P = 0.003. Analysis of just the intervention group before and after intervention using matched pairs showed acceleration of healing after intervention from ranging from a median of 1.2% (interquartile range [IQR], 14.3) to 9.7% (IQR, 11.3) per week (P ≤ 0.001). CONCLUSIONS: Minimally invasive ablation of superficial axial and perforator vein reflux in patients with active CVU is safe and leads to faster healing and decreased ulcer recurrence when combined with compression alone in the treatment of CVU.

Perceived Barriers to Exercise in the First Trimester of Pregnancy.

Regular physical activity has been shown to improve pregnancy outcomes. We sought to identify barriers to exercise during the first trimester of pregnancy. Five hundred forty-nine pregnant women in their first trimester rated barriers to exercise on a scale of 1 (not a barrier) to 5 (a huge barrier) and recorded physical activity (minutes/week). Women were placed into one of three classifications, nonexercisers (zero exercise), infrequent exercisers (<150 minutes/week), or exercisers (≥150 minutes/week). The greatest barriers (mean) were nausea/fatigue (3.0) and lack of time (2.6). Exercisers reported significantly lower barrier levels. Nausea/fatigue was a greater barrier for nonexercisers compared to exercisers (3.6 vs 2.8, p < .001). Focusing education and interventions on these barriers may help pregnant women achieve healthy exercise levels.

The success and safety of endovenous ablation in patients with previous superficial venous thrombosis: a retrospective case-control study.

OBJECTIVES: Retrospective case-control study to determine the failure and endovenous heat-induced thrombosis (EHIT) rates of endovenous ablation (EVA) in patients with a history of superficial venous thrombosis (SVT). METHODS: Study and control groups each consisted of 73 patients with or without the history of SVT, who underwent EVA between June 2010 and July 2012. All patients were followed with venous duplex ultrasound. Procedural failure and EHIT rates were considered primary outcomes. RESULTS: There was no difference in EHIT or failure rates between study and control groups (P = 1.00). There was no difference in EHIT or failure rates between patients with and without the history of venous thromboembolism (VTE), with and without the history of VTE and/or SVT, with and without the history of thrombophilia, and on and off anticoagulation for either group or the combined study population. For the combined study population, failure rate was higher in patients with a history of VTE. CONCLUSIONS: Although EVA seems to be safe and effective in patients with a history of SVT, vein access in this patient group might require multiple attempts.