Factors Associated with Urgent Amputation Status and Its Impact on Mortality.

BACKGROUND: Thirty-day mortality is higher after urgent major lower extremity amputations compared to elective lower extremity amputations. This study aims to identify factors associated with urgent amputations and to examine their impact on perioperative outcomes and long-term mortality. METHODS: Patients undergoing major lower limb amputation from 2013 to 2020 in the Vascular Quality Initiative were included. Urgent amputation was defined as occurring within 72 hr of admission. Associations with sociodemographic characteristics, comorbidities, and outcomes including postoperative complication, inpatient death, and long-term survival were compared using univariable tests and multivariable logistic regression. Long-term survival between groups was compared using Kaplan-Meier analysis. RESULTS: Of the 12,874 patients included, 4,850 (37.7%) had urgent and 8,024 (62.3%) had elective amputations. Non-White patients required urgent amputation more often than White patients (39.8% vs. 37.9%, P = 0.03). A higher proportion of Medicaid and self-pay patients presented urgently (Medicaid: 13.0% vs. 11.0%; self-pay: 3.4% vs. 2.5%, P < 0.001). Patients requiring urgent amputation were less often taking aspirin (55.6% vs. 60.1%, P < 0.001) or statin (62.2% vs. 67.2%, P < 0.001), had fewer prior revascularization procedures (41.0% vs. 48.8%, P < 0.001), and were of higher American Society of Anesthesiologists (ASA) class 4-5 (50.9% vs. 40.1%, P < 0.001). Urgent amputations were more commonly for uncontrolled infection (48.1% vs. 29.4%, P < 0.001) or acute limb ischemia (14.3% vs. 6.2%, P < 0.001). Postoperative complications were higher after urgent amputations (34.7% vs. 16.6%, P < 0.001), including need for return to operating room (23.8% vs. 8.4%, P < 0.001) and need for higher revision (15.2% vs. 4.5%, P < 0.001). Inpatient mortality was higher after urgent amputation (8.9% vs. 5.4%, P < 0.001). Multivariable analysis revealed non-White race, self-pay, homelessness, current smoking, ASA class 4-5, and amputations for uncontrolled infection or acute limb ischemia were associated with urgent status, whereas living in a nursing home or prior revascularization were protective. Furthermore, urgent amputation was associated with an increased odds of postoperative complication or death (odds ratio 1.86 [1.69-2.04], P < 0.001) as well as long-term mortality (odds ratio: 1.24 [1.13-1.35], P < 0.001). Kaplan-Meier analysis corroborated that elective status was associated with improvement of long-term survival. CONCLUSIONS: Patients requiring urgent amputations are more often non-White, uninsured, and less frequently had prior revascularization procedures, revealing disparities in access to care. Urgency was associated with a higher postoperative complication rate, as well as increased long-term mortality. Efforts should be directed toward reducing these disparities to improve outcomes following amputation.

Impact of Hospital Affiliation With a Flagship Hospital System on Surgical Outcomes.

OBJECTIVE: To compare general surgery outcomes at flagship systems, flagship hospitals, and flagship hospital affiliates versus matched controls. SUMMARY BACKGROUND DATA: It is unknown whether flagship hospitals perform better than flagship hospital affiliates for surgical patients. METHODS: Using Medicare claims for 2018 to 2019, we matched patients undergoing inpatient general surgery in flagship system hospitals to controls who underwent the same procedure at hospitals outside the system but within the same region. We defined a "flagship hospital" within each region as the major teaching hospital with the highest patient volume that is also part of a hospital system; its system was labeled a "flagship system." We performed 4 main comparisons: patients treated at any flagship system hospital versus hospitals outside the flagship system; flagship hospitals versus hospitals outside the flagship system; flagship hospital affiliates versus hospitals outside the flagship system; and flagship hospitals versus affiliate hospitals. Our primary outcome was 30-day mortality. RESULTS: We formed 32,228 closely matched pairs across 35 regions. Patients at flagship system hospitals (32,228 pairs) had lower 30-day mortality than matched control patients [3.79% vs. 4.36%, difference=-0.57% (-0.86%, -0.28%), P<0.001]. Similarly, patients at flagship hospitals (15,571/32,228 pairs) had lower mortality than control patients. However, patients at flagship hospital affiliates (16,657/32,228 pairs) had similar mortality to matched controls. Flagship hospitals had lower mortality than affiliate hospitals [difference-in-differences=-1.05% (-1.62%, -0.47%), P<0.001]. CONCLUSIONS: Patients treated at flagship hospitals had significantly lower mortality rates than those treated at flagship hospital affiliates. Hence, flagship system affiliation does not alone imply better surgical outcomes.

Assessing the Ambulatory Surgery Center Volume-Outcome Association.

Importance: In surgical patients, it is well known that higher hospital procedure volume is associated with better outcomes. To our knowledge, this volume-outcome association has not been studied in ambulatory surgery centers (ASCs) in the US. Objective: To determine if low-volume ASCs have a higher rate of revisits after surgery, particularly among patients with multimorbidity. Design, Setting, and Participants: This matched case-control study used Medicare claims data and analyzed surgeries performed during 2018 and 2019 at ASCs. The study examined 2328 ASCs performing common ambulatory procedures and analyzed 4751 patients with a revisit within 7 days of surgery (defined to be either 1 of 4735 revisits or 1 of 16 deaths without a revisit). These cases were each closely matched to 5 control patients without revisits (23 755 controls). Data were analyzed from January 1, 2018, through December 31, 2019. Main Outcomes and Measures: Seven-day revisit in patients (cases) compared with the matched patients without the outcome (controls) in ASCs with low volume (less than 50 procedures over 2 years) vs higher volume (50 or more procedures). Results: Patients at a low-volume ASC had a higher odds of a 7-day revisit vs patients who had their surgery at a higher-volume ASC (odds ratio [OR], 1.21; 95% CI, 1.09-1.36; P = .001). The odds of revisit for patients with multimorbidity were higher at low-volume ASCs when compared with higher-volume ASCs (OR, 1.57; 95% CI, 1.27-1.94; P < .001). Among patients with multimorbidity in low-volume ASCs, for those who underwent orthopedic procedures, the odds of revisit were 84% higher (OR, 1.84; 95% CI, 1.36-2.50; P < .001) vs higher-volume centers, and for those who underwent general surgery or other procedures, the odds of revisit were 36% higher (OR, 1.36; 95% CI, 1.01-1.83; P = .05) vs a higher-volume center. The findings were not statistically significant for patients without multimorbidity. Conclusions and Relevance: In this observational study, the surgical volume of an ASC was an important indicator of patient outcomes. Older patients with multimorbidity should discuss with their surgeon the optimal location of their care.

Sex disparities in patients with acute aortic dissection: A scoping review.

Disparities in outcomes for patients with cardiovascular disease and those undergoing cardiac or vascular operations are well-established. These disparities often span several dimensions and persist despite advancements in medical and surgical care; sex is among the most pervasive. Specifically, females sex has been implicated as a predictor of poor outcomes in both patients with acute type A aortic dissections (ATAADs) and type B aortic dissections (TBADs). For instance, one study, using the International Registry of Acute Aortic Dissection database, found that females with acute aortic dissection-including ATAAD and TBAD that were either medically or surgically managed-had 40% higher odds of in-hospital mortality than men. Notably, both types of acute aortic dissections affect men more commonly than females and can be life-threatening without prompt, appropriate treatment. The underlying mechanisms for these disparities are unclear but are thought to be multifactorial. The association of sex with patterns of disease and outcomes in patients with ATAAD or TBAD remains unclear, with conflicting reports from different studies. Thus, we sought to review the literature regarding sex disparities in patients with ATAAD and TBAD.

The Safety and Efficacy of the 445-nm Blue Laser for Operative Management of Benign Nonvascular Laryngeal Lesions.

The 445-nm blue laser combines the features of photocoagulative vascular lasers and cutting lasers in one device. The purpose of the present study was to evaluate the safety and efficacy of the 445-nm blue laser for the treatment of benign laryngeal pathologies, other than vascular lesions. Outcomes were compared to those when already-established therapies were used. METHODS: Adult voice center patients who underwent surgical intervention for vocal fold (VF) mass, VF scar, laryngeal stenosis, laryngeal web, or Reinke's edema were included in this retrospective study. Outcomes were compared to those achieved when traditional treatment modalities were used, including cold steel, CO2 laser, potassium-titanyl-phosphate (KTP) laser, and coblator. Strobovideolaryngoscopy footage was evaluated using a previously described model at four time points: postoperative visit #1: 1-14 days, postoperative visit #2: 30-60 days, postoperative visit #3: 61-365 days, postoperative visit #4: >365 days. RESULTS: Eighty cases using the blue laser and 153 controls (n = 78 cold steel, n = 51 KTP laser, n = 22 CO2 laser, n = 2 coblator) were included in this study. Procedures performed using blue laser included VF mass excision (n = 45), VF scar reduction (n = 16), laryngeal stenosis resection/repair (n = 25), laryngeal web excision (n = 7), and reduction of Reinke's edema (n = 1). On postoperative strobovideolaryngoscopy examination, the surgical objective score did not differ significantly between the blue laser cohort and all controls at any postoperative visit. VF edema did not differ significantly between the blue laser cohort and all controls at any postoperative visit. VF hemorrhage scores were significantly lower in the blue laser cohort compared to all controls at the first postoperative visit, but hemorrhage had resolved almost entirely by the second postoperative visit in all groups. Postoperative VF stiffness was worse in the blue laser group at the third postoperative visit compared to controls, but both groups had improved to similar levels by the fourth postoperative visit. The rate of lesion recurrence (24.29% versus 17.19%) did not differ significantly between the blue laser cohort and controls on multivariate analysis (Odds ratio [OR] = 1.081 [0.461-2.536]). The complication rate (12.50% versus 10.46%) did not differ significantly between the blue laser cohort and all controls on multivariate analysis (OR = 0.992 [0.375-2.624]). The blue laser was associated with a lower rate of revision surgery (30.00% versus 34.64%) on multivariate analysis (OR = 0.380 [0.168-0.859]). CONCLUSION: The 445-nm blue laser is safe and effective for the management of benign laryngeal lesions. It has efficacy and safety similar to those of traditional treatment modalities (including cold steel, CO2 laser, and KTP laser). Use of the blue laser may lead to lower rates of early postoperative hemorrhage and revision surgery. No adverse effects attributed directly to the use of the blue laser were observed in this study. Further research is encouraged to confirm or refute these findings.

Impact of Medicaid expansion on outcomes after abdominal aortic aneurysm repair.

OBJECTIVE: Lack of insurance has been independently associated with an increased risk of in-hospital mortality after abdominal aortic aneurysm repair, possibly due to worse control of comorbidities and delays in diagnosis and treatment. Medicaid expansion has improved insurance rates and access to care, potentially benefiting these patients. We sought to assess the association between Medicaid expansion and outcomes after abdominal aortic aneurysm repair. METHODS: A retrospective analysis of Healthcare Cost and Utilization Project State Inpatient Databases data from 14 states between 2012 and 2018 was conducted. The sample was restricted to first-record abdominal aortic aneurysm repairs in adults under age 65 in states that expanded Medicaid on January 1, 2014 (Medicaid expansion group) or had not expanded before December 31, 2018 (non-expansion group). The Medicaid expansion and non-expansion groups were compared between pre-expansion (2012-2013) and post-expansion (2014-2018) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors, open vs endovascular repair, and standard errors clustered by state. Our primary outcome was in-hospital mortality. Outcomes were stratified by insurance type. RESULTS: We examined 8995 patients undergoing abdominal aortic aneurysm repair, including 3789 (42.1%) in non-expansion states and 5206 (57.9%) in Medicaid expansion states. Rates of Medicaid insurance were unchanged in non-expansion states but increased in Medicaid expansion states post-expansion (non-expansion: 10.9% to 9.8%; P = .346; expansion: 9.7% to 19.7%; P < .001). One in 10 patients from both non-expansion and Medicaid expansion states presented with ruptured aneurysms, which did not change over time. Rates of open repair decreased in both non-expansion and Medicaid expansion states over time (non-expansion: 25.1% to 19.2%; P < .001; expansion: 25.2% to 18.4%; P < .001). On adjusted difference-in-differences analysis between expansion and non-expansion states pre-to post-expansion, Medicaid expansion was associated with a 1.02% absolute reduction in in-hospital mortality among all patients (95% confidence interval, -1.87% to -0.17%; P = .019). Additionally, among patients who were either on Medicaid or were uninsured (ie, the patients most likely to be impacted by Medicaid expansion), a larger 4.17% decrease in in-hospital mortality was observed (95% confidence interval, -6.47% to -1.87%; P < .001). In contrast, no significant difference-in-difference in mortality was observed for privately insured patients. CONCLUSIONS: Medicaid expansion was associated with decreased in-hospital mortality after abdominal aortic aneurysm repair among all patients and particularly among patients who were either on Medicaid or were uninsured. Our results provide support for improved access to care for patients undergoing abdominal aortic aneurysm repair through Medicaid expansion.

Efficacy of therapeutic plasma exchange in patients with severe COVID-19: A systematic review and meta-analysis.

We conducted this systematic review and meta-analysis to evaluate the existing evidence and to quantitatively synthesise evidence on the impact of therapeutic plasma exchange (TPE) on severe COVID-19 patients. This systematic review and meta-analysis protocol was prospectively registered on PROSPERO (CRD42022316331). We systemically searched six electronic databases (PubMed, Scopus, Web of Science, ScienceDirect, clinicaltrial.gov, and Cochrane Central Register of Controlled Trials) from inception until 1 June 2022. We included studies comparing patients who received TPE versus those who received the standard treatment. For risk of bias assessment, we used the Cochrane risk of bias assessment tool, the ROBINS1 tool, and the Newcastle Ottawa scale for RCTs, non-RCTs, and observational studies, respectively. Continuous data were pooled as standardized mean difference (SMD), and dichotomous data were pooled as risk ratio in the random effect model with the corresponding 95% confidence intervals (CI). Thirteen studies (one randomized controlled trials (RCT) and 12 non-RCTs) were included in the meta-analysis, with a total of 829 patients. There is a moderate-quality evidence from one RCT that TPE reduces the lactic dehydrogenase (LDH) levels (SMD -1.09, 95% CI [-1.59 to -0.60]), D-dimer (SMD -0.86, 95% CI [-1.34 to -0.37]), and ferritin (SMD -0.70, 95% CI [-1.18 to -0.23]), and increases the absolute lymphocyte count (SMD 0.54, 95% CI [0.07-1.01]), There is low-quality evidence from mixed-design studies that TPE was associated with lower mortality (relative risk 0.51, 95% CI [0.35-0.74]), lower IL-6 (SMD -0.91, 95% CI [-1.19 to -0.63]), and lower ferritin (SMD -0.51, 95% CI [-0.80 to -0.22]) compared to the standard control. Among severely affected COVID-19 patients, TPE might provide benefits such as decreasing the mortality rate, LDH, D-dimer, IL-6, and ferritin, in addition to increasing the higher absolute lymphocyte count. Further well-designed RCTs are needed.

Redefining Multimorbidity in Older Surgical Patients.

BACKGROUND: Multimorbidity in surgery is common and associated with worse postoperative outcomes. However, conventional multimorbidity definitions (≥2 comorbidities) label the vast majority of older patients as multimorbid, limiting clinical usefulness. We sought to develop and validate better surgical specialty-specific multimorbidity definitions based on distinct comorbidity combinations. STUDY DESIGN: We used Medicare claims for patients aged 66 to 90 years undergoing inpatient general, orthopaedic, or vascular surgery. Using 2016 to 2017 data, we identified all comorbidity combinations associated with at least 2-fold (general/orthopaedic) or 1.5-fold (vascular) greater risk of 30-day mortality compared with the overall population undergoing the same procedure; we called these combinations qualifying comorbidity sets. We applied them to 2018 to 2019 data (general = 230,410 patients, orthopaedic = 778,131 patients, vascular = 146,570 patients) to obtain 30-day mortality estimates. For further validation, we tested whether multimorbidity status was associated with differential outcomes for patients at better-resourced (based on nursing skill-mix, surgical volume, teaching status) hospitals vs all other hospitals using multivariate matching. RESULTS: Compared with conventional multimorbidity definitions, the new definitions labeled far fewer patients as multimorbid: general = 85.0% (conventional) vs 55.9% (new) (p < 0.0001); orthopaedic = 66.6% vs 40.2% (p < 0.0001); and vascular = 96.2% vs 52.7% (p < 0.0001). Thirty-day mortality was higher by the new definitions: general = 3.96% (conventional) vs 5.64% (new) (p < 0.0001); orthopaedic = 0.13% vs 1.68% (p < 0.0001); and vascular = 4.43% vs 7.00% (p < 0.0001). Better-resourced hospitals offered significantly larger mortality benefits than all other hospitals for multimorbid vs nonmultimorbid general and orthopaedic, but not vascular, patients (general surgery difference-in-difference = -0.94% [-1.36%, -0.52%], p < 0.0001; orthopaedic = -0.20% [-0.34%, -0.05%], p = 0.0087; and vascular = -0.12% [-0.69%, 0.45%], p = 0.6795). CONCLUSIONS: Our new multimorbidity definitions identified far more specific, higher-risk pools of patients than conventional definitions, potentially aiding clinical decision-making.

The Safety of Performing Surgery at Ambulatory Surgery Centers Versus Hospital Outpatient Departments in Older Patients With or Without Multimorbidity.

BACKGROUND: Surgery for older Americans is increasingly being performed at ambulatory surgery centers (ASCs) rather than hospital outpatient departments (HOPDs), while rates of multimorbidity have increased. OBJECTIVE: To determine whether there are differential outcomes in older patients undergoing surgical procedures at ASCs versus HOPDs. RESEARCH DESIGN: Matched cohort study. SUBJECTS: Of Medicare patients, 30,958 were treated in 2018 and 2019 at an ASC undergoing herniorrhaphy, cholecystectomy, or open breast procedures, matched to similar HOPD patients, and another 32,702 matched pairs undergoing higher-risk procedures. MEASURES: Seven and 30-day revisit and complication rates. RESULTS: For the same procedures, HOPD patients displayed a higher baseline predicted risk of 30-day revisits than ASC patients (13.09% vs 8.47%, P < 0.0001), suggesting the presence of considerable selection on the part of surgeons. In matched Medicare patients with or without multimorbidity, we observed worse outcomes in HOPD patients: 30-day revisit rates were 8.1% in HOPD patients versus 6.2% in ASC patients ( P < 0.0001), and complication rates were 41.3% versus 28.8%, P < 0.0001. Similar patterns were also found for 7-day outcomes and in higher-risk procedures examined in a secondary analysis. Similar patterns were also observed when analyzing patients with and without multimorbidity separately. CONCLUSIONS: The rates of revisits and complications for ASC patients were far lower than for closely matched HOPD patients. The observed initial baseline risk in HOPD patients was much higher than the baseline risk for the same procedures performed at the ASC, suggesting that surgeons are appropriately selecting their riskier patients to be treated at the HOPD rather than the ASC.

Analyzing Impact of Multimorbidity on Long-Term Outcomes after Emergency General Surgery: A Retrospective Observational Cohort Study.

BACKGROUND: Little is known about the impact of multimorbidity on long-term outcomes for older emergency general surgery patients. STUDY DESIGN: Medicare beneficiaries, age 65 and older, who underwent operative management of an emergency general surgery condition were identified using Centers for Medicare & Medicaid claims data. Patients were classified as multimorbid based on the presence of a Qualifying Comorbidity Set (a specific combination of comorbid conditions known to be associated with increased risk of in-hospital mortality in the general surgery setting) and compared with those without multimorbidity. Risk-adjusted outcomes through 180 days after discharge from index hospitalization were calculated using linear and logistic regressions. RESULTS: Of 174,891 included patients, 45.5% were identified as multimorbid. Multimorbid patients had higher rates of mortality during index hospitalization (5.9% vs 0.7%, odds ratio [OR] 3.05, p < 0.001) and through 6 months (17.1% vs 3.4%, OR 2.33, p < 0.001) after discharge. Multimorbid patients experienced higher rates of readmission at 1 month (22.9% vs 11.4%, OR 1.48, p < 0.001) and 6 months (38.2% vs 21.2%, OR 1.48, p < 0.001) after discharge, lower rates of discharge to home (42.5% vs 74.2%, OR 0.52, p < 0.001), higher rates of discharge to rehabilitation/nursing facility (28.3% vs 11.3%, OR 1.62, p < 0.001), greater than double the use of home oxygen, walker, wheelchair, bedside commode, and hospital bed (p < 0.001), longer length of index hospitalization (1.33 additional in-patient days, p < 0.001), and higher costs through 6 months ($5,162 additional, p < 0.001). CONCLUSIONS: Older, multimorbid patients experience worse outcomes, including survival and independent function, after emergency general surgery than nonmultimorbid patients through 6 months after discharge from index hospitalization. This information is important for setting recovery expectations for high-risk patients to improve shared decision-making.

Association between anaesthesia type and arteriovenous fistula maturation.

Background: Whereas general anaesthesia is commonly used for haemodialysis fistula creation, regional or local anaesthesia has been posited to lead to better fistula maturation outcomes. We sought to measure the association between anaesthesia type and arteriovenous fistula maturation. Methods: We performed a secondary analysis of data from the Hemodialysis Fistula Maturation study, a multicentre prospective cohort study of advanced chronic kidney disease patients who underwent single-stage upper extremity fistula creation between 2010 and 2013. We evaluated the relationship between anaesthesia type and unassisted (without maturation-facilitating interventions) or overall (unassisted or assisted) fistula maturation using multivariable logistic regression. Results: Among 602 participants, 336 (55.8%) received regional/local anaesthesia and 266 (44.2%) received general anaesthesia. Unassisted maturation occurred in 164/309 patients (53.1%) after regional/local vs 91/226 patients (40.3%) after general anaesthesia (P=0.003). After adjustment for patient factors and fistula type, regional/local anaesthesia was associated with greater odds of unassisted maturation than general anaesthesia (odds ratio 1.72, 95% confidence interval 1.24-2.39; P=0.001). However, after further adjustment for clinical centre fixed effects, odds of unassisted maturation did not differ by anaesthesia type (odds ratio 1.03, 95% confidence interval 0.78-1.36; P=0.830). Similar findings were observed for overall maturation and composite endpoints accounting for potential survivorship bias. Conclusions: Regional/local anaesthesia was associated with increased odds of fistula maturation when adjusting for patient factors and fistula type. However, this association did not persist after adjusting for centre fixed effects. Future research is needed to better understand the relationship between anaesthesia type and centre factors to optimise outcomes after fistula surgery.

The Differential Impact of Medicaid Expansion on Disparities in Outcomes Following Peripheral Vascular Intervention.

BACKGROUND: Peripheral artery disease (PAD) disproportionately affects nonwhite, Hispanic/Latino, and low socioeconomic status patients, who are less likely to have insurance and routine healthcare visits. Medicaid expansion (ME) has improved insurance rates and access to care, potentially benefitting these patients. We sought to assess the impact of ME on disparities in outcomes after peripheral vascular intervention (PVI) for PAD. METHODS: A retrospective analysis of prospectively-collected Vascular Quality Initiative PVI procedures between 2011 and 2019 was conducted. The sample was restricted to first-record procedures in adults under the age 65 in states that expanded Medicaid on January 1, 2014 (ME group) or had not expanded before January 1, 2019 (non-expansion [NE] group). ME and NE groups were compared between pre-expansion (2011-2013) and post-expansion (2014- 2019) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors and clinical center and year fixed effects. Our primary outcome was 1-year major amputation. Secondary outcomes included trends in presentation, 30-day mortality, 1-year mortality, and 1-year primary and secondary patency. Outcomes were stratified by race and ethnicity. RESULTS: We examined 34,313 PVI procedures, including 20,378 with follow-up data. Rates of Medicaid insurance increased post-expansion in ME and NE states (ME 16.7% to 23.0%, P < 0.001; NE 10.0% to 11.9%, P = 0.013) while rates of self-pay decreased in ME states only (ME 4.6% to 1.8%, P < 0.001; NE 8.1% to 8.4%, P = 0.620). Adjusted difference-in-differences analysis revealed lower odds of urgent/emergent PVI among all patients and all nonwhite patients in ME states post-expansion compared to NE states (all: odds ratio [OR] 0.53 [95% confidence interval 0.33-0.87], P = 0.011; nonwhite: OR 0.41 [0.19-0.88], P = 0.023). No differences were observed for 1-year major amputation (OR 0.70 [0.43-1.14], P = 0.152), primary patency (OR 0.93 [0.63-1.38], P = 0.726), or secondary patency (OR 1.29 [0.69-2.41], P = 0.431). Odds of 1-year mortality were higher in ME states post-expansion compared to NE states (OR 2.50 [1.07-5.87], P = 0.035), although 30-day mortality was not different (OR 2.04 [0.60-6.90], P = 0.253). Notably, odds of 1-year major amputation among Hispanic/Latino patients decreased in ME states post-expansion compared to NE states (OR 0.11 [0.01-0.86], P = 0.036). CONCLUSIONS: ME was associated with lower odds of 1-year major amputation among Hispanic/Latino patients who underwent PVI for PAD. ME was also associated with lower odds of urgent/emergent procedures among patients overall and nonwhite patients specifically. However, 1-year mortality increased in the overall cohort. Further study is needed to corroborate our findings that ME may have benefits for certain underserved populations with PAD.

Retardo na transferência do pronto-socorro para a unidade de terapia intensiva: impacto nos desfechos do paciente. Um estudo retrospectivo / Delayed intensive care unit admission from the emergency department: impact on patient outcomes. A retrospective study

RESUMO Objetivo: Estudar o impacto do retardo na admissão à unidade de terapia intensiva em mais do que 4 horas nos desfechos de pacientes críticos. Métodos: Este foi um estudo observacional retrospectivo, no qual pacientes adultos admitidos diretamente do pronto-socorro para a unidade de terapia intensiva foram divididos em dois grupos: Tempo Adequado, se admitidos dentro de 4 horas, e Admissão Retardada, nos casos em que a admissão demorou mais do que 4 horas para ocorrer. Compararam-se, entre os grupos, o tempo de permanência na unidade de terapia intensiva e a taxa de mortalidade na unidade de terapia intensiva e no hospital. Foi realizado pareamento por escore de propensão para correção de desequilíbrios. Utilizou-se uma análise de regressão logística para explorar retardo da admissão como fator independente de risco para mortalidade na unidade de terapia intensiva. Resultados: Durante o período do estudo, 1.887 pacientes foram admitidos diretamente do pronto-socorro para a unidade de terapia intensiva, sendo que 42% dessas admissões foram retardadas. Os pacientes com retardo tiveram permanências na unidade de terapia intensiva significantemente mais longas e maior mortalidade na unidade de terapia intensiva e no hospital. Esses resultados persistiram após pareamento dos grupos por escore de propensão. O retardo da admissão foi fator independente de risco para mortalidade na unidade de terapia intensiva (RC = 2,6; IC95% 1,9 - 3,5; p < 0,001). A associação de retardo e mortalidade na unidade de terapia intensiva surgiu após período de retardo de 2 horas e foi mais alta após período de retardo de 4 horas. Conclusão: O retardo da admissão do pronto-socorro para a unidade de terapia intensiva é fator de risco independente para mortalidade na unidade de terapia intensiva, sendo a associação mais forte após retardo de 4 horas.

Abstract Objective: To study the impact of delayed admission by more than 4 hours on the outcomes of critically ill patients. Methods: This was a retrospective observational study in which adult patients admitted directly from the emergency department to the intensive care unit were divided into two groups: Timely Admission if they were admitted within 4 hours and Delayed Admission if admission was delayed for more than 4 hours. Intensive care unit length of stay and hospital/intensive care unit mortality were compared between the groups. Propensity score matching was performed to correct for imbalances. Logistic regression analysis was used to explore delayed admission as an independent risk factor for intensive care unit mortality. Results: During the study period, 1,887 patients were admitted directly from the emergency department to the intensive care unit, with 42% being delayed admissions. Delayed patients had significantly longer intensive care unit lengths of stay and higher intensive care unit and hospital mortality. These results were persistent after propensity score matching of the groups. Delayed admission was an independent risk factor for intensive care unit mortality (OR = 2.6; 95%CI 1.9 - 3.5; p < 0.001). The association of delay and intensive care unit mortality emerged after a delay of 2 hours and was highest after a delay of 4 hours. Conclusion: Delayed admission to the intensive care unit from the emergency department is an independent risk factor for intensive care unit mortality, with the strongest association being after a delay of 4 hours.

The Management of Wrist Fractures During COVID-19: A Preliminary Report.

Background Due to the current COVID-19 pandemic, there has been an increase in the need for the virtual follow-up of patients. These innovations in clinical care have helped to reduce hospital attendance of patients and the spread of the virus. Injuries such as wrist fractures that are non-obligatory are increasingly being followed up virtually. This paper compares the early experience of management of wrist fractures in a District General Hospital in the United Kingdom during the COVID-19 pandemic lockdown with a similar period before. Methods A retrospective study of the management and clinical follow-up of all skeletally mature patients seen in the Accident and Emergency (A&E) department with a radiologically confirmed distal radius fracture after imposition of COVID-19 lockdown measures in the United Kingdom (between March 23, 2020 and May 24, 2020), and comparison with a control group of patients with distal radius fractures seen within a similar time frame the previous year (March 23, 2019 to May 24, 2019). Results During the COVID-19 lockdown, a total of 39 skeletally mature patients (85% females; average age of 70.4 years [SD: 14.6]) who had suffered a wrist fracture were seen. A total of 23% of the patients had surgical fixation. The others were managed conservatively and followed up regularly in the fracture clinic and by virtual telephone consultation in 15% (p > 0.05) compared to the previous year. Three patients who had an AO/OTA Type-C fracture were not keen on surgery, citing the COVID-19 pandemic. Patients had their operations at 5.2 days post-injury on average compared to the pre-COVID average of 6.4 days post-injury. Conclusion This preliminary study showed that patients considered "high risk" (as per the UK government guidance on shielding and protecting people who are clinically extremely vulnerable from COVID-19) with low functional demands who had suffered fractures of the distal radius were followed up mostly virtually after their first A&E attendance, thereby eliminating unnecessary hospital attendances. There was no difference in the epidemiology of wrist fractures pre- and post-COVID-19 lockdown. No COVID-positive patients were treated. The limitations of this study are the fact that it is cross-sectional with a lack of patient-reported outcome measures (PROM). As this was only a preliminary study to assess initial results, it will be followed up by a full report assessing outcomes at defined intervals.

Modified Early Warning Score como preditor de readmissão à unidade de terapia intensiva dentro de 48 horas: um estudo observacional retrospectivo / Modified Early Warning Score as a predictor of intensive care unit readmission within 48 hours: a retrospective observational study

RESUMO Objetivo: Avaliar a hipótese de que o Modified Early Warning Score (MEWS) por ocasião da alta da unidade de terapia intensiva associa-se com readmissão, e identificar o nível desse escore que prediz com maior confiabilidade a readmissão à unidade de terapia intensiva dentro de 48 horas após a alta. Métodos: Este foi um estudo observacional retrospectivo a respeito do MEWS de pacientes que receberam alta da unidade de terapia intensiva. Comparamos dados demográficos, escores de severidade, características da doença crítica e MEWS de pacientes readmitidos e não readmitidos. Identificamos os fatores associados com a readmissão em um modelo de regressão logística. Construímos uma curva Característica de Operação do Receptor para o MEWS na predição da probabilidade de readmissão. Por fim, apresentamos o critério ideal com maior sensibilidade e especificidade. Resultados: A taxa de readmissões foi de 2,6%, e o MEWS foi preditor significante de readmissão, juntamente do tempo de permanência na unidade de terapia intensiva acima de 10 dias e traqueostomia. A curva Característica de Operação do Receptor relativa ao MEWS para predizer a probabilidade de readmissão teve área sob a curva de 0,82, e MEWS acima de 6 teve sensibilidade de 0,78 (IC95% 0,66 - 0,9) e especificidade de 0,9 (IC95% 0,87 - 0,93). Conclusão: O MEWS associa-se com readmissão à unidade de terapia intensiva, e o escore acima de 6 teve excelente precisão como preditor prognóstico.

ABSTRACT Objective: To evaluate the hypothesis that the Modified Early Warning Score (MEWS) at the time of intensive care unit discharge is associated with readmission and to identify the MEWS that most reliably predicts intensive care unit readmission within 48 hours of discharge. Methods: This was a retrospective observational study of the MEWSs of discharged patients from the intensive care unit. We compared the demographics, severity scores, critical illness characteristics, and MEWSs of readmitted and non-readmitted patients, identified factors associated with readmission in a logistic regression model, constructed a Receiver Operating Characteristic (ROC) curve of the MEWS in predicting the probability of readmission, and presented the optimum criterion with the highest sensitivity and specificity. Results: The readmission rate was 2.6%, and the MEWS was a significant predictor of readmission, along with intensive care unit length of stay > 10 days and tracheostomy. The ROC curve of the MEWS in predicting the readmission probability had an AUC of 0.82, and a MEWS > 6 carried a sensitivity of 0.78 (95%CI 0.66 - 0.9) and specificity of 0.9 (95%CI 0.87 - 0.93). Conclusion: The MEWS is associated with intensive care unit readmission, and a score > 6 has excellent accuracy as a prognostic predictor.

Kidney transplantation and donation in the transgender population: A single-institution case series.

The medical needs of the transgender population are increasingly recognized within the US health care system. Hormone therapy and gender-affirming surgery present distinct anatomic, hormonal, infectious, and psychosocial issues among transgender kidney transplant donors and recipients. We present the first reported experience with kidney transplantation and donation in transgender patients. A single-center case series (January 2014-December 2018) comprising 4 transgender kidney transplant recipients and 2 transgender living donors was constructed and analyzed. Experts in transplant surgery, transplant psychiatry, transplant infectious disease, pharmacy, and endocrinology were consulted to discuss aspects of care for these patients. Four transgender patients identified as male-to-female and 2 as female-to-male. Three of 6 had gender-affirming surgeries prior to transplant surgery, 1 of whom had further procedures posttransplant. Additionally, 4 patients were on hormone therapy. All 6 had psychiatric comorbidities. The 4 grafts have done well, with an average serum creatinine of 1.45 mg/dL at 2 years (range 1.01-1.85 mg/dL). However, patients encountered various postoperative complications, 1 of which was attributable to modified anatomy. Thus, transgender kidney transplant patients can present novel challenges in regard to surgical considerations as well as pre- and posttransplant care. Dedicated expertise is needed to optimize outcomes for this population.

Thoracolumbar Injury Classification and Severity Score in Children: A Validity Study.

BACKGROUND: The Thoracolumbar Injury Classification and Severity Score (TLICS) has been shown to be a valid tool for assessing the need for surgical intervention in adult patients. There is limited insight into its usefulness in children. OBJECTIVE: To assess the validity of the TLICS system in pediatric patients. METHODS: The medical records for pediatric patients with acute, traumatic thoracolumbar fractures at two Level 1 trauma centers were reviewed retrospectively. A TLICS score was calculated for each patient using computed tomography and magnetic resonance images, along with the neurological examination recorded in the patient's medical record. TLICS scores were compared with the type of treatment received. Receiver operating characteristic (ROC) curve analysis was employed to quantify the validity of the TLICS scoring system. RESULTS: TLICS calculations were completed for 165 patients. The mean TLICS score was 2.9 (standard deviation ± 2.7). Surgery was the treatment of choice for 23% of patients. There was statistically significant agreement between the TLICS suggested treatment and the actual treatment received (P < 0.001). The ROC curve calculated using multivariate logistic regression analysis of the TLICS system's parameters as a tool for predicting treatment demonstrated excellent discriminative ability, with an area under the ROC curve of 0.96, which was also statistically significant (P < 0.001). CONCLUSION: The TLICS system demonstrates good validity for selecting appropriate thoracolumbar fracture treatment in pediatric patients.