Rural Hospital Performance in Guideline-Recommended Ischemic Stroke Thrombolysis, Secondary Prevention, and Outcomes.

BACKGROUND: Existing data suggested a rural-urban disparity in thrombolytic utilization for ischemic stroke. Here, we examined the use of guideline-recommended stroke care and outcomes in rural hospitals to identify targets for improvement. METHODS: This retrospective cohort study included patients (aged ≥18 years) treated for acute ischemic stroke at Get With The Guidelines-Stroke hospitals from 2017 to 2019. Multivariable mixed-effect logistic regression was used to compare thrombolysis rates, speed of treatment, secondary stroke prevention metrics, and outcomes after adjusting for patient- and hospital-level characteristics and stroke severity. RESULTS: Among the 1 127 607 patients admitted to Get With The Guidelines-Stroke hospitals in 2017 to 2019, 692 839 patients met the inclusion criteria. Patients who presented within 4.5 hours were less likely to receive thrombolysis in rural stroke centers compared with urban stroke centers (31.7% versus 43.5%; adjusted odds ratio [aOR], 0.72 [95% CI, 0.68-0.76]) but exceeded rural nonstroke centers (22.1%; aOR, 1.26 [95% CI, 1.15-1.37]). Rural stroke centers were less likely than urban stroke centers to achieve door-to-needle times of ≤45 minutes (33% versus 44.7%; aOR, 0.86 [95% CI, 0.76-0.96]) but more likely than rural nonstroke centers (aOR, 1.24 [95% CI, 1.04-1.49]). For secondary stroke prevention metrics, rural stroke centers were comparable to urban stroke centers but exceeded rural nonstroke centers (aOR of 1.66, 1.94, 2.44, 1.5, and 1.72, for antithrombotics within 48 hours of admission, antithrombotics at discharge, anticoagulation for atrial fibrillation/flutter, statin treatment, and smoking cessation, respectively). In-hospital mortality was similar between rural and urban stroke centers (aOR, 1.11 [95% CI, 0.99-1.24]) or nonstroke centers (aOR, 1.00 [95% CI, 0.84-1.18]). CONCLUSIONS: Rural hospitals had lower thrombolysis utilization and slower treatment times than urban hospitals. Rural stroke centers provided comparable secondary stroke prevention treatment to urban stroke centers and exceeded rural nonstroke centers. These results reveal important opportunities and specific targets for rural health equity interventions.

Neighborhood-level Social Vulnerability and Prevalence of Cardiovascular Risk Factors and Coronary Heart Disease.

Social determinants of health are implicated in the geographic variation in cardiovascular diseases (CVDs). The social vulnerability index (SVI) is an estimate of a neighborhood's potential for deleterious outcomes when faced with natural disasters or disease outbreaks. We sought to investigate the association of the SVI with cardiovascular risk factors and the prevalence of coronary heart disease (CHD) in the United States at the census tract level. We linked census tract SVI with prevalence of census tract CVD risk factors (smoking, high cholesterol, diabetes, high blood pressure, low physical activity and obesity), and prevalence of CHD obtained from the behavioral risk factor surveillance system. We evaluated the association between SVI, its sub-scales, CVD risk factors and CHD prevalence using linear regression. Among 72,173 census tracts, prevalence of all cardiovascular risk factors increased linearly with SVI. A higher SVI was associated with a higher CHD prevalence (R2 = 0.17, P < 0.0001). The relationship between SVI and CHD was stronger when accounting for census-tract median age (R2 = 0.57, P < 0.0001). A multivariable linear regression model including 4 SVI themes separately explained considerably more variation in CHD prevalence than the composite SVI alone (50.0% vs 17.3%). Socioeconomic status and household composition and disability were the SVI themes most closely associated with cardiovascular risk factors and CHD prevalence. In the United States, social vulnerability can explain significant portion of geographic variation in CHD, and its risk factors. Neighborhoods with high social vulnerability are at disproportionately increased risk of CHD and its risk factors. Social determinants of health are implicated in the geographic variation in cardiovascular diseases (CVDs). We investigated the association of social vulnerability index (SVI) with cardiovascular risk factors and the prevalence of coronary heart disease (CHD) in the United States at the census tract level. We show that cardiovascular risk factors and CHD were more common with higher SVI. A multivariable linear regression model including 4 SVI themes separately explained considerably more variation in CHD prevalence than the composite SVI alone (50.0% vs 17.3%). Socioeconomic status and household composition and/or disability were the SVI themes most closely associated with cardiovascular risk factors and CHD prevalence.

Neighborhood Socioeconomic Disadvantage Associated With Increased 90-Day Mortality Following Radical Cystectomy.

OBJECTIVE: To examine relationships between neighborhood socioeconomic disadvantage and outcomes following radical cystectomy (RC). MATERIALS AND METHODS: A retrospective single institution study of consecutive RCs performed for bladder cancer between 2011 and 2019. Major complications, mortality and survival outcomes were compared using Cochran-Armitage or Kruskal-Wallis tests. Cox proportional hazards models were used for time-to-event analyses. RESULTS: A total of 906 patients were included in analysis. Overall 90-day mortality was 2.98% (27/906). Ninety-day mortality rates observed in the least (first) and most (fourth) disadvantaged ADI quartiles were 0% (0/115) and 6.5% (12/185), respectively. Patients from the fourth quartile demonstrated worse overall survival and recurrence free survival than those in the first quartile. ADI quartile was positively associated with muscle invasive (P = .0006) and node positive (P = .042) disease. ADI percentile was an independent predictor for 90-day mortality (adjusted OR: 1.022, CI: 1.004-1.04, P = .015). CONCLUSION: Higher rates of mortality and worse oncologic outcomes were observed for patients residing in the most disadvantaged quartile. ADI was associated with higher likelihood of 90-day mortality and may therefore be useful in patient counseling, risk stratification, and post-discharge management.

Mechanisms of socioeconomic differences in COVID-19 screening and hospitalizations.

BACKGROUND: Social and ecological differences in early SARS-CoV-2 pandemic screening and outcomes have been documented, but the means by which these differences have arisen are not well understood. OBJECTIVE: To characterize socioeconomic and chronic disease-related mechanisms underlying these differences. DESIGN: Observational cohort study. SETTING: Outpatient and emergency care. PATIENTS: 12900 Cleveland Clinic Health System patients referred for SARS-CoV-2 testing between March 17 and April 15, 2020. INTERVENTIONS: Nasopharyngeal PCR test for SARS-CoV-2 infection. MEASUREMENTS: Test location (emergency department, ED, vs. outpatient care), COVID-19 symptoms, test positivity and hospitalization among positive cases. RESULTS: We identified six classes of symptoms, ranging in test positivity from 3.4% to 23%. Non-Hispanic Black race/ethnicity was disproportionately represented in the group with highest positivity rates. Non-Hispanic Black patients ranged from 1.81 [95% confidence interval: 0.91-3.59] times (at age 20) to 2.37 [1.54-3.65] times (at age 80) more likely to test positive for the SARS-CoV-2 virus than non-Hispanic White patients, while test positivity was not significantly different across the neighborhood income spectrum. Testing in the emergency department (OR: 5.4 [3.9, 7.5]) and cardiovascular disease (OR: 2.5 [1.7, 3.8]) were related to increased risk of hospitalization among the 1247 patients who tested positive. LIMITATIONS: Constraints on availability of test kits forced providers to selectively test for SARS-Cov-2. CONCLUSION: Non-Hispanic Black patients and patients from low-income neighborhoods tended toward more severe and prolonged symptom profiles and increased comorbidity burden. These factors were associated with higher rates of testing in the ED. Non-Hispanic Black patients also had higher test positivity rates.

Relationship Between Glenoid Component Shift and Osteolysis After Anatomic Total Shoulder Arthroplasty: Three-Dimensional Computed Tomography Analysis.

BACKGROUND: The purpose of this study was to evaluate glenoid component position and radiolucency following anatomic total shoulder arthroplasty (TSA) using sequential 3-dimensional computed tomography (3D CT) analysis. METHODS: In a series of 152 patients (42 Walch A1, 16 A2, 7 B1, 49 B2, 29 B3, 3 C1, 3 C2, and 3 D glenoids) undergoing anatomic TSA with a polyethylene glenoid component, sequential 3D CT analysis was performed preoperatively (CT1), early postoperatively (CT2), and at a minimum 2-year follow-up (CT3). Glenoid component shift was defined as a change in component version or inclination of ≥3° from CT2 to CT3. Glenoid component central anchor peg osteolysis (CPO) was assessed at CT3. Factors associated with glenoid component shift and CPO were evaluated. RESULTS: Glenoid component shift occurred from CT2 to CT3 in 78 (51%) of the 152 patients. CPO was seen at CT3 in 19 (13%) of the 152 patients, including 15 (19%) of the 78 with component shift. Walch B2 glenoids with a standard component and glenoids with higher preoperative retroversion were associated with a higher rate of shift, but not of CPO. B3 glenoids with an augmented component and glenoids with greater preoperative joint-line medialization were associated with CPO, but not with shift. More glenoid component joint-line medialization from CT2 to CT3 was associated with higher rates of shift and CPO. A greater absolute change in glenoid component inclination from CT2 to CT3 and a combined absolute glenoid component version and inclination change from CT2 to CT3 were associated with CPO. Neither glenoid component shift nor CPO was associated with worse clinical outcomes. CONCLUSIONS: Postoperative 3D CT analysis demonstrated that glenoid component shift commonly occurs following anatomic TSA, with increased inclination the most common direction. Most (81%) of the patients with glenoid component shift did not develop CPO. Longer follow-up is needed to determine the relationships of glenoid component shift and CPO with loosening over time. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Association of Lymphopenia With Risk of Mortality Among Adults in the US General Population.

Importance: Immune dysregulation can increase the risk of infection, malignant neoplasms, and cardiovascular disease, but improved methods are needed to identify and quantify immunologic hazard in the general population. Objective: To determine whether lymphopenia is associated with reduced survival in outpatients. Design, Setting, and Participants: This retrospective cohort study of the National Health and Nutrition Examination Survey (NHANES) included participants enrolled from January 1, 1999, to December 31, 2010, a large outpatient sample representative of the US adult population. Associations were evaluated between lymphopenia and other immunohematologic (IH) markers, clinical features, and survival during 12 years of follow-up, completed on December 31, 2011. Spearman correlations, Cox proportional hazards regression models, and Kaplan-Meier curves were used in univariable and multivariable models, allowing for nonlinear associations with bivariate cubic polynomials. Data were analyzed from September 1, 2018, through July 24, 2019. Exposures: Absolute lymphocyte counts (ALC), red blood cell distribution width (RDW), and C-reactive protein (CRP) level. Main Outcomes and Measures: All-cause survival. Results: Among the 31 178 participants, the median (interquartile range) age at baseline was 45 (30-63) years, 16 093 (51.6%) were women, 16 260 (52.2%) were nonwhite, and overall 12-year rate of survival was 82.8%. Relative lymphopenia (≤1500/µL) and severe lymphopenia (≤1000/µL) were observed in 20.1% and 3.0%, respectively, of this general population and were associated with increased risk of mortality (age- and sex-adjusted hazard ratios [HRs], 1.3 [95% CI, 1.2-1.4] and 1.8 [95% CI, 1.6-2.1], respectively) due to cardiovascular and noncardiovascular causes. Lymphopenia was also associated with worse survival in multivariable models, including traditional clinical risk factors, and this risk intensified when accompanied by bone marrow dysregulation (elevated RDW) and/or inflammation (elevated CRP level). Ten-year mortality ranged from 3.8% to 62.1% based on lymphopenia status, tertile of CRP level, and tertile of RDW. A high-risk IH profile was nearly twice as common as type 2 diabetes (19.3% and 10.0% of participants, respectively) and associated with a 3-fold risk of mortality (HR, 3.2; 95% CI, 2.6-4.0). Individuals aged 70 to 79 years with low IH risk had a better 10-year survival (74.1%) than those who were a decade younger with a high-risk IH profile (68.9%). Conclusions and Relevance: These findings suggest that lymphopenia is associated with reduced survival independently of and additive to traditional risk factors, especially when accompanied by altered erythropoiesis and/or heightened inflammation. Immune risk may be analyzed as a multidimensional entity derived from routine tests, facilitating precision medicine and population health interventions.

The association between preinduction arterial blood pressure and postoperative cardiovascular, renal, and neurologic morbidity, and in-hospital mortality in elective noncardiac surgery: an observational study.

BACKGROUND: The association between preinduction blood pressure (BP) and postoperative outcomes after noncardiac surgery is poorly understood. Whether this association depends on the presence of risk factors for poor cardiovascular outcomes remains unclear. Accordingly, we evaluated the association between preinduction BP and its different components; isolated systolic hypertension (ISH) and wide pulse pressure (WPP), and postoperative complications in patients with and without revised cardiac risk index (RCRI) components. METHODS: We analysed consecutive patients undergoing elective noncardiac surgery at Cleveland Clinic. Separate analyses were undertaken for patients with and without any RCRI components. Preinduction BP was assessed both continuously and according to hypertension stages. Logistic regression was used to assess the association between the BP values and composite of in-hospital mortality as well as cardiovascular, renal, and neurologic morbidity. We considered the following potential confounding factors in our analysis; year of surgery, age, sex, race, BMI, and American College of Cardiology/American Heart Association surgical procedure risk classification. RESULTS: Of 58 276 patients, 10 512 had one or more RCRI components. For those with no RCRI, no significant relationship was found between preinduction BP and outcome after adjustment for confounders. For patients with RCRI, the adjusted incidence was the greatest among those with normal preinduction SBP and DBP of less than 70 mmHg. Among patients with preinduction DBP greater than 75 mmHg, risk rose slightly with increasing SBP. However, we found no association between preinduction hypertension stages, ISH, or WPP and the composite outcome in patients with and without RCRI. CONCLUSION: Preinduction low DBP less than 70 mmHg or SBP greater than 160 mmHg and not ISH, nor WPP were associated with an increased risk of postoperative complications in noncardiac surgery patients with one or more RCRI components.

Red Cell Storage Duration Does Not Affect Outcome after Massive Blood Transfusion in Trauma and Nontrauma Patients: A Retrospective Analysis of 305 Patients.

BACKGROUND: Prolonged storage of packed red blood cells (PRBCs) may increase morbidity and mortality, and patients having massive transfusion might be especially susceptible. We therefore tested the hypothesis that prolonged storage increases mortality in patients receiving massive transfusion after trauma or nontrauma surgery. Secondarily, we considered the extent to which storage effects differ for trauma and nontrauma surgery. METHODS: We considered surgical patients given more than 10 units of PRBC within 24 hours and evaluated the relationship between mean PRBC storage duration and in-hospital mortality using multivariable logistic regression. Potential nonlinearities in the relationship were assessed via restricted cubic splines. The secondary hypothesis was evaluated by considering whether there was an interaction between the type of surgery (trauma versus nontrauma) and the effect of storage duration on outcomes. RESULTS: 305 patients were given a total of 8,046 units of PRBCs, with duration ranging from 8 to 36 days (mean ± SD: 22 ± 6 days). The odds ratio [95% confidence interval (CI)] for in-hospital mortality corresponding to a one-day in mean PRBC storage duration was 0.99 (0.95, 1.03, P = 0.77). The relationship did not differ for trauma and nontrauma patients (P = 0.75). Results were similar after adjusting for multiple potential confounders. CONCLUSIONS: Mortality after massive blood transfusion was no worse in patients transfused with PRBC stored for long periods. Trauma and nontrauma patients did not differ in their susceptibility to prolonged PRBC storage.

The Association Between Mild Intraoperative Hypotension and Stroke in General Surgery Patients.

BACKGROUND: Intraoperative hypotension may contribute to perioperative strokes. We therefore tested the hypothesis that intraoperative hypotension is associated with perioperative stroke. METHODS: After institutional review board approval for this case-control study, we identified patients who had nonneurological, noncardiac, and noncarotid surgery under general anesthesia at the Cleveland Clinic between 2005 and 2011 and experienced a postoperative stroke. Control patients not experiencing postoperative stroke were matched in a 4-to-1 ratio using propensity scores and restriction to the same procedure type as stroke patients. The association between intraoperative hypotension, measured as time-integrated area under a mean arterial pressure (MAP) of 70 mm Hg, and postoperative stroke was assessed using zero-inflated negative binomial regression. RESULTS: Among 106 337 patients meeting inclusion criteria, we identified 120 who had confirmed postoperative stroke events based on manual chart review. Four-to-one propensity matching yielded a final matched sample of 104 stroke cases and 398 controls. There was no association between stroke and intraoperative hypotension. Stroke patients were not more likely than controls to have been hypotensive (odds ratio, 0.49 [0.18-1.38]), and among patients with intraoperative hypotension, stroke patients did not experience a greater degree of hypotension than controls (ratio of geometric means, 1.07 [0.76-1.53]). CONCLUSIONS: In our propensity score-matched case-control study, we did not find an association between intraoperative hypotension, defined as MAP < 70 mm Hg, and postoperative stroke.

Practice Variation Among Hospitals in Revascularization Therapy and Its Association With Procedure-related Mortality.

BACKGROUND: While substantial practice variation in coronary revascularization has been described and deviation from clinical practice guidelines has been associated with worse outcomes, the degree to which this is driven by flawed decision making and/or appropriate deviation associated with comorbid conditions is unknown. We evaluated heterogeneity in procedure use, and the extent to which hospital-level practice variation is related to surgical mortality. METHODS: We analyzed data on 554,563 inpatients undergoing either percutaneous coronary intervention or coronary artery bypass grafting at 391 centers in 6 states. Procedure-specific risk models were developed based on demographics and comorbidities, allowing for differential effects of comorbidities for each sex. For each patient, the revascularization procedure that minimized predicted probability of inhospital mortality was designated as the model-preferred procedure.Hospital-level discordance rates-the proportion of cases in each hospital for which the opposite from the model-preferred procedure was performed-were calculated. Hierarchical linear models were used to analyze the relationship between HDRs and hospital-level risk-standardized mortality ratios (RSMRs). RESULTS: Comorbidities and demographics alone explained between 68% and 86% of overall variation in inhospital mortality (corresponding C-statistics of 0.84-0.93). The mean (SD) HDR was 26.3% (9.6%). There was a positive independent association between HDRs and inhospital mortality, with a 10% increase in HDR associated with an 11% increase in RSMR (P<0.001). CONCLUSIONS: Variance in procedure use according to model preference was strongly associated with worse outcomes. A systematic approach to incorporating comorbidity as part of the decision-making process for coronary revascularization is needed.

The Association Between Rheumatoid Arthritis and Adverse Postoperative Outcomes: A Retrospective Analysis.

BACKGROUND: Patients with rheumatoid arthritis have a high overall incidence of mortality, primarily because of cardiovascular complications. Thus, we tested the primary hypothesis that rheumatoid arthritis is independently associated with increased postoperative cardiovascular complications. Second, we determined whether rheumatoid arthritis is associated with increased thromboembolic complications, microcirculatory complications, and mortality. METHODS: We obtained censuses of 2009 to 2010 inpatient hospital discharge data across 7 states (Arizona, California, Florida, Iowa, Maryland, Michigan, and New Jersey). Rheumatoid arthritis was identified using the present-on-admission diagnosis code 714.0. Each rheumatoid arthritis discharge that had surgery was propensity matched to a control discharge. Multivariable logistic regression was used to compare matched rheumatoid arthritis and control patients on risk of in-hospital cardiovascular complications. RESULTS: Among 5.5 million qualifying discharges, the matching procedure yielded successful 66,886 matched pairs. One thousand ninety-five (1.64%) of the matched rheumatoid arthritis discharges and 1006 (1.50%) of the matched controls had in-hospital cardiovascular complications. The adjusted odds ratio (99% confidence interval) was estimated at 1.08 (0.96-1.21; P = 0.08). There were no significant differences in the odds of in-hospital thromboembolic complications (1.03 [0.93-1.15]; P = 0.42), in-hospital microcirculatory complications (0.94 [0.86-1.01]; P = 0.03), or in-hospital mortality (1.11 [0.98-1.25]; P = 0.04). CONCLUSIONS: Rheumatoid arthritis was not associated with an increased risk for postoperative cardiovascular complications.

Empirical Treatment Effectiveness Models for Binary Outcomes.

Randomized trials provide strong evidence regarding efficacy of interventions but are limited in their capacity to address potential heterogeneity in effectiveness within broad clinical populations. For example, a treatment that on average is superior may be distinctly worse in certain patients. We propose a technique for using large electronic health registries to develop and validate decision models that measure-for distinct combinations of covariate values-the difference in predicted outcomes among 2 alternative treatments. We demonstrate the methodology in a prototype analysis of in-hospital mortality under alternative revascularization treatments. First, we developed prediction models for a binary outcome of interest for each treatment. Decision criteria were then defined based on the treatment-specific model predictions. Patients were then classified as receiving concordant or discordant care (in relation to the model recommendation), and the association between discordance and outcomes was evaluated. We then present alternative decision criteria and validation methodologies, as well as sensitivity analyses that investigate 1) the imbalance between treatments on observed covariates and 2) the aggregate impact of unobserved covariates. Our methodology supplements population-average clinical trial results by modeling heterogeneity in outcomes according to specific covariate values. It thus allows for assessment of current practice, from which cogent hypotheses for improved care can be derived. Newly emerging large population registries will allow for accurate predictions of outcome risk under competing treatments, as complex functions of predictor variables. Whether or not the models might be used to inform decision making depends on the extent to which important predictors are available. Further work is needed to understand the strengths and limitations of this approach, particularly in relation to those based on randomized trials.

The Association Between Sjögren Syndrome and Adverse Postoperative Outcomes: A Historical Cohort Study Using Administrative Health Data.

BACKGROUND: Sjögren syndrome is a chronic autoimmune disorder of the exocrine glands associated with cardiovascular events. We aimed to evaluate postoperative complications in patients with Sjögren syndrome undergoing noncardiac surgery. Specifically, we tested the primary hypothesis that patients with Sjögren syndrome have a greater risk of postoperative cardiovascular complications than those without the disease. Our secondary hypotheses were that patients with Sjögren syndrome are at greater risk of thromboembolic complications, microcirculatory complications, and mortality. METHODS: We obtained censuses of 2009 to 2010 inpatient hospital discharges across 7 states. Sjögren syndrome was identified by the present-on-admission diagnosis code 710.2. Each Sjögren n syndrome discharge was propensity matched to 4 control discharges. A generalized linear model was used to compare matched Sjögren syndrome patients and controls on risk of in-hospital cardiovascular complications, thromboembolic complications, microcirculatory complications, and mortality. RESULTS: Among 5.5 million qualifying discharges, our final matched sample contained 22,785 matched discharges, including 4557 with Sjögren syndrome. Sixty-six (1.45%) of the matched discharges with Sjögren syndrome and 213 (1.17%) of the matched controls had associated in-hospital cardiovascular complications. The adjusted odds ratio (99% confidence interval) was estimated at 1.14 (0.79-1.64), which was not statistically significant (P = 0.35). There were no significant differences in the odds of in-hospital thromboembolic complications (1.12 [0.82-1.53]; P = 0.36), in the odds of in-hospital microcirculatory complications (0.98 [0.77-1.26]; P = 0.86), or in the odds of in-hospital mortality (1.11 [0.76-1.61]; P = 0.49). CONCLUSIONS: The presence of Sjögren syndrome does not place patients at an increased risk for postoperative complications or in-hospital mortality.

Postoperative Hypoxemia Is Common and Persistent: A Prospective Blinded Observational Study.

BACKGROUND: The incidence, severity, and duration of postoperative oxygen desaturation in the general surgical population are poorly characterized. We therefore used continuous pulse oximetry to quantify arterial oxygen saturation (SpO2) in a cross-section of patients having noncardiac surgery. METHODS: Oxygen saturation, blinded to clinicians, was recorded at 1-minute intervals in patients >45 years old for up to 48 hours after noncardiac surgery in 1250 patients from Cleveland Clinic Main Campus and 250 patients from the Juravinski Hospital. We determined (1) the cumulative minutes of raw minute-by-minute values below various hypoxemic thresholds; and (2) the contiguous duration of kernel-smoothed (sliding window) values below various hypoxemic thresholds. Finally, we compared our blinded continuous values with saturations recorded during routine nursing care. RESULTS: Eight hundred thirty-three patients had sufficient data for analyses. Twenty-one percent had ≥10 min/h with raw SpO2 values <90% averaged over the entire recording duration; 8% averaged ≥20 min/h <90%; and 8% averaged ≥5 min/h <85%. Prolonged hypoxemic episodes were common, with 37% of patients having at least 1 (smoothed) SpO2 <90% for an hour or more; 11% experienced at least 1 episode lasting ≥6 hours; and 3% had saturations <80% for at least 30 minutes. Clinical hypoxemia, according to nursing records, measured only in Cleveland Clinic patients (n = 594), occurred in 5% of the monitored patients. The nurses missed 90% of smoothed hypoxemic episodes in which saturation was <90% for at least one hour. CONCLUSIONS: Hypoxemia was common and prolonged in hospitalized patients recovering from noncardiac surgery. The SpO2 values recorded in medical records seriously underestimated the severity of postoperative hypoxemia.

Intraoperative core temperature patterns, transfusion requirement, and hospital duration in patients warmed with forced air.

BACKGROUND: Core temperature patterns in patients warmed with forced air remain poorly characterized. Also unknown is the extent to which transient and mild intraoperative hypothermia contributes to adverse outcomes in broad populations. METHODS: We evaluated esophageal (core) temperatures in 58,814 adults having surgery lasting >60 min who were warmed with forced air. Independent associations between hypothermic exposure and transfusion requirement and duration of hospitalization were evaluated. RESULTS: In every percentile subgroup, core temperature decreased during the first hour and subsequently increased. The mean lowest core temperature during the first hour was 35.7 ± 0.6°C. Sixty-four percent of the patients reached a core temperature threshold of <36°C 45 min after induction; 29% reached a core temperature threshold of <35.5°C. Nearly half the patients had continuous core temperatures <36°C for more than an hour, and 20% of the patients were <35.5°C for more than an hour. Twenty percent of patients had continuous core temperatures <36°C for more than 2 h, and 8% of the patients were below 35.5°C for more than 2 h. Hypothermia was independently associated with both transfusions and duration of hospitalization, although the prolongation of hospitalization was small. CONCLUSIONS: Even in actively warmed patients, hypothermia is routine during the first hour of anesthesia. Thereafter, average core temperatures progressively increase. Nonetheless, intraoperative hypothermia was common, and often prolonged. Hypothermia was associated with increased transfusion requirement, which is consistent with numerous randomized trials.

Association of thoracic epidural analgesia with risk of atrial arrhythmias after pulmonary resection: a retrospective cohort study.

PURPOSE: Atrial arrhythmias are common after non-cardiac thoracic surgery. We tested the hypothesis that TEA reduces the risk of new-onset atrial arrhythmias after pulmonary resection. METHODS: We evaluated patients who had pulmonary resection. New-onset atrial arrhythmias detected before hospital discharge was our primary outcome. Secondary outcomes included other cardiovascular complications, pulmonary complications, time-weighted average pain score over 72 h, and duration of hospitalization. Patients with combination of general anesthesia and TEA were matched on propensity scores with patients given general anesthesia only. The matched groups were compared by use of logistic regression, linear regression, or Cox proportional hazards regression, as appropriate. RESULTS: Among 1,236 patients who had pulmonary resections, 937 received a combination of general anesthesia and TEA (TEA) and 299 received general anesthesia only (non-TEA). We successfully matched 311 TEA patients with 132 non-TEA patients. We did not find a significant association between TEA and postoperative atrial arrhythmia (odds ratio (95 % CI) of 1.05 (0.50, 2.19), P = 0.9). TEA was not significantly associated with length of hospital stay or postoperative pulmonary complications (odds ratio (95 % CI) of 0.71 (0.22, 2.29), P = 0.47). TEA patients experienced fewer postoperative cardiovascular complications; although the association was not statistically significant (odds ratio (95 % CI) of 0.30 (0.06, 1.45), P = 0.06). Time-weighted average pain scores were similar in the two groups. CONCLUSION: TEA was not associated with reduced occurrence of postoperative atrial arrhythmia. Although postoperative pulmonary complications were similar with and without TEA, TEA patients tended to experience fewer cardiovascular complications.

The 2-year cost-effectiveness of 3 options to treat lumbar spinal stenosis patients.

Lumbar spinal stenosis (LSS) may result from degenerative changes of the spine, which lead to neural ischemia, neurogenic claudication, and a significant decrease in quality of life. Treatments for LSS range from conservative management including epidural steroid injections (ESI) to laminectomy surgery. Treatments vary greatly in cost and success. ESI is the least costly treatment may be successful for early stages of LSS but often must be repeated frequently. Laminectomy surgery is more costly and has higher complication rates. Minimally invasive lumbar decompression (mild(®) ) is an alternative. Using a decision-analytic model from the Medicare perspective, a cost-effectiveness analysis was performed comparing mild(®) to ESI or laminectomy surgery. The analysis population included patients with LSS who have moderate to severe symptoms and have failed conservative therapy. Costs included initial procedure, complications, and repeat/revision or alternate procedure after failure. Effects measured as change in quality-adjusted life years (QALY) from preprocedure to 2 years postprocedure. Incremental cost-effectiveness ratios were determined, and sensitivity analysis conducted. The mild(®) strategy appears to be the most cost-effective ($43,760/QALY), with ESI the next best alternative at an additional $37,758/QALY. Laminectomy surgery was the least cost-effective ($125,985/QALY).

Continuous transversus abdominis plane block catheter analgesia for postoperative pain control in renal transplant.

PURPOSE: Continuous transversus abdominis plane (TAP) block using a catheter has proven its usefulness in reducing opioid requirements and pain scores after lower abdominal surgery. However, there are no reports of its successful use after renal transplant. We tested the hypothesis that continuous TAP block would retrospectively reduce opioid requirement, nausea score and hospital stay after renal transplant surgery. METHODS: In a retrospective study, we reviewed the data from 63 adult renal transplant recipients-31 with patient-controlled TAP analgesia with standing orders for intravenous as well as oral opioids as needed and 32 with intravenous patient-controlled analgesia. The TAP catheter was inserted preoperatively using an ultrasound-guided technique. Infusion of ropivacaine 0.2 % at 8 ml basal, 12 ml bolus and a lockout interval of 60 min were maintained for 48 h postoperatively. The primary outcome was total morphine-equivalent dose during the 48-h postoperative period. Secondary outcomes were pain and nausea scores for the 48-h postoperative period. RESULTS: The mean 48-h postoperative morphine-equivalent doses [95 % confidence interval] for patient-controlled intravenous analgesia and TAP catheter were 197 [111, 349] and 50 [28, 90], respectively, which were significantly different (P = 0.002). The mean 48-h average verbal response pain scores were 2.94 [2.39, 3.50] and 2.49 [1.93, 3.06], respectively, which were not significantly different (P = 0.26). The mean nausea scores were 0.66 [0.46, 0.87] and 0.60 [0.40, 0.81], respectively, which were not significantly different (P = 0.69). There was no difference regarding hospital stay. CONCLUSION: The use of continuous TAP analgesia for postoperative analgesia after renal transplant was effective in reducing the morphine-equivalent requirements.

Blood Type O is not associated with increased blood loss in extensive spine surgery.

STUDY OBJECTIVE: To investigate whether Type O blood group status is associated with increased intraoperative blood loss and requirement of blood transfusion in extensive spine surgery. DESIGN: Retrospective comparative study. SETTING: University-affiliated, non-profit teaching hospital. MEASUREMENTS: Data from 1,050 ASA physical status 1, 2, 3, 4, and 5 patients who underwent spine surgeries involving 4 or more vertebral levels were analyzed. Patients with Type O blood were matched to similar patients with other blood types using propensity scores, which were estimated via demographic and morphometric data, medical history variables, and extent of surgery. Intraoperative estimated blood loss (EBL) was compared among matched patients using a linear regression model; intraoperative transfusion requirement in volume of red blood cells, fresh frozen plasma, platelet, cryoprecipitate, cell salvaged blood, volume of intraoperative infusion of hetastarch, 5% albumin, crystalloids, and hospital length of hospital (LOS) were compared using Wilcoxon rank-sum tests. MAIN RESULTS: Intraoperative EBL and requirement of blood product transfusion were similar in patients with Type O blood group and those with other blood groups. CONCLUSION: There was no association between Type O blood and increased intraoperative blood loss or blood transfusion requirement during extensive spine surgery, with similar hospital LOS in Type O and non-O patients.

Performance comparisons in major uro-oncological surgeries between the USA and Japan.

OBJECTIVES: To elucidate the differences in clinical practice between the USA and Japan in major types of uro-oncological surgery by a head-to-head comparison of national databases in the two countries. METHODS: We compared variations in surgical modality, length of stay, total charges, caseload centralization, transfusion incidence, and in-hospital mortality between the two countries for four major types of uro-oncological surgery (radical prostatectomy, radical cystectomy, nephrectomy and nephroureterectomy) in 2011. Additionally, the chronological changes in surgical modalities were investigated for 2009-11. The national estimates were based on data from the Japanese Diagnosis Procedure Combination database and the US National Inpatient Sample. RESULTS: For radical prostatectomy, radical cystectomy, nephrectomy and nephroureterectomy, minimally-invasive surgery accounted for 24.2% versus 70.2%, 0% versus 14.0%, 50.7% versus 30.7% and 50.2% versus 30.5%, respectively, in Japan versus the USA in 2011. Although minimally-invasive surgery has become increasingly frequent in both countries, the major procedures were robot-assisted surgery in the USA and laparoscopic surgery in Japan. The USA was generally characterized by a slightly younger age at operation, far higher hospital volume, a shorter length of stay, higher charges and less use of transfusion than Japan. CONCLUSIONS: The findings suggest substantial differences between the USA and Japan regarding clinical practices in uro-oncological surgery. Standing at the beginning of robotic surgery era in Japan, the precise recognition of these differences will aid a proper understanding of clinical practices.