RESUMEN
Resting state functional magnetic resonance imaging (R-fMRI) offers insight into how synchrony within and between brain networks is altered in disease states. Individual and disease-related variability in intrinsic connectivity networks may influence our interpretation of R-fMRI data. We used a personalized approach designed to account for individual variation in the spatial location of correlation maxima to evaluate R-fMRI differences between Parkinson's disease (PD) patients who showed cognitive decline, those who remained cognitively stable and cognitively stable controls. We compared fMRI data from these participant groups, studied at baseline and 18 months later, using both network-based statistics (NBS) and calculations of mean inter- and intra-network connectivity within pre-defined functional networks. The NBS analysis showed that PD participants who remained cognitively stable showed exclusively (at baseline) or predominantly (at follow-up) increased intra-network connectivity, whereas decliners showed exclusively reduced intra-network and inter- (ventral attention and default mode) connectivity, in comparison with the control group. Evaluation of mean connectivity between all regions of interest (ROIs) within a priori networks showed that decliners had consistently reduced inter-network connectivity for ventral attention, somatomotor, visual and striatal networks and reduced intra-network connectivity for ventral attention network to striatum and cerebellum. These findings suggest that specific functional connectivity covariance patterns differentiate PD cognitive subtypes and may predict cognitive decline. Further, increased intra and inter-network synchrony may support cognitive function in the face of PD-related network disruptions.
Asunto(s)
Disfunción Cognitiva , Imagen por Resonancia Magnética , Red Nerviosa , Enfermedad de Parkinson , Humanos , Enfermedad de Parkinson/fisiopatología , Enfermedad de Parkinson/diagnóstico por imagen , Masculino , Femenino , Disfunción Cognitiva/fisiopatología , Disfunción Cognitiva/diagnóstico por imagen , Disfunción Cognitiva/etiología , Imagen por Resonancia Magnética/métodos , Anciano , Persona de Mediana Edad , Red Nerviosa/diagnóstico por imagen , Red Nerviosa/fisiopatología , Estudios Longitudinales , Encéfalo/fisiopatología , Encéfalo/diagnóstico por imagenRESUMEN
PURPOSE: To report use trends of plasma exchange (PLEX) as well as sociodemographic and medical comorbidities associated with PLEX in the United States. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Adult patients (≥ 18 years) admitted for inpatient hospitalization with a primary diagnosis of optic neuritis (ON). METHODS: Data from the National Inpatient Sample database was compiled to assess PLEX use rates between 2000 and 2020. The cohorts of patients receiving PLEX versus not receiving PLEX were analyzed between quarter 4 of 2015 through 2020 (International Classification of Diseases, Tenth Revision [ICD-10], only) for patient sociodemographic variables, medical diagnoses, insurance types, hospital characteristics, cause of disease, time to therapy, length of stay (LOS), and total charges incurred. MAIN OUTCOME MEASURES: Incidence of ON, incidence of PLEX, demographics, diagnoses associated with PLEX therapy, total charges, and LOS. RESULTS: From 2000 through 2020, 11 209 patients hospitalized with a primary diagnosis of ON were identified, with a significant majority managed at urban teaching hospitals. Use of PLEX increased steadily over 2 decades from 0.63% to 5.46%. Use was greatest in the western United States and least in the eastern United States. In the subset of ICD-10 cases, 3215 patients were identified. The median time to therapy of PLEX was 1 day after admission, and PLEX use was highest in patients with neuromyelitis optica spectrum disorder (NMOSD) (21.21%) and lowest in multiple sclerosis-associated ON (3.80%). Use of PLEX was associated with significantly longer LOS and higher total charges incurred. Medical comorbidities associated with PLEX included adverse reaction to glucocorticoids (adjusted odds ratio [aOR], 31.50), hemiplegia (aOR, 28.48), neuralgia (aOR, 4.81), optic atrophy (aOR, 3.74), paralytic strabismus (aOR, 2.36), and psoriasis (aOR, 1.76). CONCLUSIONS: Over the last 2 decades in the United States, PLEX therapy for ON has increased, with the highest use in the western United States and for patients with the diagnosis NMOSD ON. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.
RESUMEN
OBJECTIVE: Carotid endarterectomy (CEA) is an effective treatment for carotid stenosis. All previous studies on racial disparity of CEA outcomes omitted Asian Americans. This study aimed to address this gap by investigating racial disparities in 30-day outcomes following CEA among Asian Americans. METHODS: Asian American and Caucasian patients who underwent CEA were identified in the American College of Surgeons National Surgical Quality Improvement Program targeted database from 2011 to 2021. Patients with age less than 18 years old were excluded. Patients with symptomatic and asymptomatic carotid stenosis were examined separately. A 1:5 propensity-score matching was used to address preoperative differences. Thirty perioperative outcomes were assessed. RESULTS: There were 380 Asian Americans (2.27%) and 13,250 Caucasians (79.18%) with symptomatic carotid stenosis who underwent CEA. Also, 289 Asian Americans (1.40%) and 18,257 Caucasians (88.14%) with asymptomatic carotid stenosis had CEA. Asian Americans undergoing CEA presented with higher comorbid burdens and more severe symptomology. Also, asymptomatic Asian Americans were more likely to undergo surgeries for mild stenosis (<50%), which is not in line with practice guidelines. After 1:5 propensity-matching, all symptomatic Asian Americans were matched to 1550 Caucasian patients, and all asymptomatic Asian Americans were matched to 1445 Caucasians; preoperative differences were addressed. Asian Americans exhibited low overall 30-day mortality (symptomatic, 1.61%; asymptomatic, 0.35%) and stroke (symptomatic, 2.26%; asymptomatic, 0.69%). All perioperative outcomes were comparable to Caucasians, with the exception that Asian Americans experienced longer operation times. CONCLUSIONS: Evidence suggested that Asian Americans with asymptomatic stenosis were underrepresented in CEA. After propensity-score matching, Asian Americans demonstrated comparable 30-day outcomes to Caucasians. These suggest that, when afforded equal access to quality health care, CEA serves as an effective treatment for carotid stenosis among Asian Americans. Therefore, efforts may be aimed at addressing health care access, potentially in the screening for asymptomatic carotid stenosis in Asian Americans. This would ensure they have equitable benefits from CEA. Nevertheless, the exact preoperative differences and long-term CEA outcomes in Asian Americans should warrant further examination in future studies.
Asunto(s)
Estenosis Carotídea , Endarterectomía Carotidea , Accidente Cerebrovascular , Humanos , Asiático , Constricción Patológica , Endarterectomía Carotidea/efectos adversos , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Resultado del Tratamiento , Blanco , Adulto , Estados UnidosRESUMEN
INTRODUCTION: Stanford Type A Aortic Dissection (TAAD) is characterized by a high in-hospital mortality rate and necessitates urgent surgical intervention. While socioeconomic status is known to influence health-care outcomes, its specific association with TAAD remains underexplored. This study aimed to investigate the population-based association between socioeconomic status with TAAD repair outcomes using a national registry. METHODS: Patients who had TAAD repair were identified in National Inpatient Sample from Q4 2015-2020. National Inpatient Sample stratified estimated median household income of residents within a patient's ZIP code. Patients residing in neighborhoods of incomes in the lowest and highest quartiles were selected as the study cohorts. Multivariable logistic regressions were used to compare in-hospital outcomes, adjusted for demographics, comorbid conditions, hospital characteristics, primary payer status, and transfer status. RESULTS: Compared to patients from high-income neighborhoods, patients in low-income communities had higher risks of mortality (adjusted odds ratio [aOR] 1.45, P = 0.01), acute kidney injury (aOR 1.225, P = 0.03), and infection (aOR 1.474, P = 0.02), as well as longer wait from admission to operation (24.96 ± 2.64 versus 18.00 ± 1.92 h, P = 0.03) and longer length of stay (15.06 ± 0.38 versus 13.80 ± 0.36 d, P = 0.01). In contrast, patients from low-income communities had less risk of hemorrhage/hematoma (aOR 0.691, P < 0.01) and lower total hospital charge (428,746 ± 10,658 versus 487,017 ± 16,770 US dollars, P < 0.01). CONCLUSIONS: Evidence suggests patients from lower-income communities may have limited access to health care and treatment delays, leading to higher mortality and complications. The underlying reasons for these disparities in economically disadvantaged communities warrant further investigation, which could focus on health-care accessibility, timely detection of TAAD, and prompt transfers to specialized centers.
Asunto(s)
Disección Aórtica , Mortalidad Hospitalaria , Clase Social , Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Disección Aórtica/cirugía , Disección Aórtica/mortalidad , Disección Aórtica/economía , Estados Unidos/epidemiología , Adulto , Sistema de Registros/estadística & datos numéricos , Estudios Retrospectivos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/etiología , Disparidades en Atención de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/economía , Estatus Socioeconómico BajoRESUMEN
INTRODUCTION: Frailty is a clinically identifiable condition characterized by heightened vulnerability. The 5-item Modified Frailty Index provides a concise calculation of frailty that has proven effective in predicting adverse perioperative outcomes across a variety of surgical disciplines. However, there is a paucity of research examining the validity of 11-item Modified Frailty Index (mFI-5) in carotid endarterectomy (CEA). This study aimed to investigate the association between mFI-5 and 30-day outcomes of CEA. METHODS: Patients underwent CEA were identified from American College of Surgeons National Surgical Quality Improvement Program targeted database from 2012 to 2021. Patients with age<18 were excluded. Patients were stratified into four cohorts based on their mFI-5 scores: 0, 1, 2, or 3+. Multivariable logistic regression was used to compare 30-day perioperative outcomes adjusting for preoperative variables with P value<0.1. RESULTS: Compared to controls (mFI-5 = 0), patients mFI-5 = 1 had higher risk of stroke (adjusted odds ratio [aOR] = 1.333, P = 0.02), unplanned operation (aOR = 1.38, P < 0.01), and length of stay (LOS) > 7 days (aOR = 0.814, P < 0.01). Patients with mFI-5 = 2 had higher stroke (aOR = 1.719, P < 0.01), major adverse cardiovascular events (MACE) (aOR = 1.315, P = 0.01), sepsis (aOR = 2.243, P = 0.01), discharge not to home (aOR = 1.200, P < 0.01), 30-day readmission (aOR = 1.405, P < 0.01). Compared with controls, patients with mFI-5≥3 had higher mortality (aOR = 1.997 P = 0.02), MACE (aOR = 1.445, P = 0.03), cardiac complications (aOR = 1.901, P < 0.01), pulmonary events (aOR = 2.196, P < 0.01), sepsis (aOR = 3.65, P < 0.01), restenosis (aOR = 2.606, P = 0.02), unplanned operation (aOR = 1.69, P < 0.01), LOS>7 days (aOR = 1.425, P < 0.01), discharge not to home (aOR = 2.127, P < 0.01), and 30-day readmission (aOR = 2.427, P < 0.01). CONCLUSIONS: The mFI-5 is associated with 30-day mortality and complications including stroke, MACE, cardiac complications, pulmonary complications, sepsis, and restenosis. Additionally, elevated mFI-5 scores correlate with an increased likelihood of unplanned operations, extended LOS, discharge to facilities other than home, and 30-day readmissions, all of which could negatively impact long-term prognosis. Therefore, mFI-5 can serve as a concise yet effective metric of frailty in patients undergoing CEA.
Asunto(s)
Endarterectomía Carotidea , Fragilidad , Cardiopatías , Sepsis , Accidente Cerebrovascular , Humanos , Adolescente , Fragilidad/complicaciones , Fragilidad/diagnóstico , Fragilidad/epidemiología , Endarterectomía Carotidea/efectos adversos , Medición de Riesgo , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Factores de Riesgo , Sepsis/complicaciones , Estudios RetrospectivosRESUMEN
BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure used to alleviate patients with chronic liver cirrhosis and portal hypertension. Racial disparities were present in TIPS where numerous studies suggested African American patients experience higher in-hospital mortality rates. However, the incidence of post-TIPS surgical complications, such as HE, has yet to be examined among African Americans. Therefore, this study aimed to provide a comprehensive examination of the disparities in TIPS procedures among African American patients. METHODS: The study compared African American and Caucasian patients who underwent TIPS procedures in the National Inpatient Sample (NIS) database from the last quarter of 2015-2020 after ICD-10 change. Preoperative variables, including demographics, comorbidities, primary payer status, and hospital characteristics, were examined and multivariable analysis was used to assess outcomes correcting preoperative variables with p < 0.1. RESULTS: Compared to Caucasians, African Americans had higher in-hospital mortality (16.18 vs 8.22%, aOR 1.781, p < 0.01), hepatic encephalopathy (33.09 vs 27.44%, aOR 1.300, p = 0.05), and acute kidney injury (45.59 vs 29.60%, aOR 2.019, p < 0.01). Using the generalized linear model, African Americans have longer length of stay (11.04 ± 0.77 days vs 8.54 ± 0.16 days, p < 0.01). CONCLUSION: Despite a higher prevalence of cirrhosis, African Americans continue to have marked underrepresentation in TIPS procedures in recent years. Their underrepresentation, in conjunction with higher mortality, morbidity, and increased comorbidity conditions, could imply disparity in accessing care. This finding underscores the necessity for improved access to diagnostic and therapeutic services for African Americans with liver cirrhosis.
Asunto(s)
Hipertensión Portal , Cirrosis Hepática , Derivación Portosistémica Intrahepática Transyugular , Humanos , Negro o Afroamericano , Encefalopatía Hepática/epidemiología , Encefalopatía Hepática/etiología , Hipertensión Portal/cirugía , Pacientes Internos , Cirrosis Hepática/complicaciones , Cirrosis Hepática/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Disparidades en Atención de SaludRESUMEN
BACKGROUND: Stanford Type A Aortic Dissection (TAAD) is an emergent condition with high in-hospital mortality. Gender disparity in TAAD has been a topic of ongoing debate. This study aimed to conduct a population-based examination of gender disparities in short-term TAAD outcomes using the National/Nationwide Inpatient Sample (NIS) database, the largest all-payer database in the US. METHODS: Patients undergoing TAAD repair were identified in NIS from the last quarter of 2015-2020. Multivariable logistic regressions were used to compare in-hospital outcomes between male and female patients, adjusted for demographics, comorbidities, hospital characteristics, primary payer status, and transfer status. RESULTS: There were 1454 female and 2828 male patients identified who underwent TAAD repair. Female patients presented with TAAD were at a more advanced mean age (64.03 ± 13.81 vs. 58.28 ± 13.43 years, p < 0.01) and had greater comorbid burden. Compared to male patients, female patients had higher risks of in-hospital mortality (17.88% vs. 13.68%, adjusted odds ratio (aOR) = 1.266, p = 0.01). In addition, female patients had higher pericardial complications (20.29% vs. 17.22%, aOR = 1.227, p = 0.02), but lower acute kidney injury (AKI; 39.96% vs. 53.47%, aOR = 0.476, p < 0.01) and venous thromboembolism (VTE; 1.38% vs. 2.65%, aOR = 0.517, p = 0.01). Female patients had comparable time from admission to operation and transfer-in status, longer hospital stays, but fewer total hospital expenses. CONCLUSION: Female patients were 1.27 times as likely to die in-hospital after TAAD repair but had less AKI and VTE. While there is no evidence suggesting delay in TAAD repair for female patients, the disparities might stem from other differences such as in care provided or intrinsic physiological variations.
Asunto(s)
Disección Aórtica , Mortalidad Hospitalaria , Humanos , Femenino , Masculino , Disección Aórtica/cirugía , Disección Aórtica/mortalidad , Persona de Mediana Edad , Anciano , Estados Unidos/epidemiología , Factores Sexuales , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Aneurisma de la Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/mortalidad , Bases de Datos FactualesRESUMEN
BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a common comorbid condition that can be associated with postoperative mortality and morbidity. However, the outcome profile of patients with COPD after breast reconstruction has yet to be established. Therefore, this study aimed to assess the postoperative outcomes in patients with COPD who underwent autologous (ABR) and implant-based breast reconstruction (IBR). METHODS: National Inpatient Sample was used to identify patients who underwent ABR or IBR from Q4 2015 to 2020. Multivariable logistic regressions were used to compare inhospital outcomes between COPD and non-COPD patients while adjusting for demographics, primary payer status, hospital characteristics, and comorbidities. RESULTS: There were 1288 (9.92%) COPD and 11,696 non-COPD patients who underwent ABR. Meanwhile, 1742 (9.70%) COPD and 16,221 non-COPD patients underwent IBR. In both ABR and IBR, patients with COPD had higher rates of seroma (ABR, aOR = 1.863, 95% CI = 1.022-3.397, and p = 0.04; IBR, aOR = 1.524, 95% CI = 1.014-2.291, and p = 0.04), infection (ABR, aOR = 1.863, 95% CI = 1.022-3.397, and p = 0.04; IBR, aOR = 1.956, 95% CI = 1.205-3.176, and p = 0.01), and prolonged LOS (p < 0.01). Specifically, patients with COPD in ABR had higher risks of respiratory complications (aOR = 1.991, 95% CI = 1.291-3.071, and p < 0.01) and incurred higher total hospital charges (p < 0.01). Meanwhile, patients with COPD undergoing IBR had elevated risks of renal complications (aOR = 3.421, 95% CI = 2.108-5.55, and p < 0.01), deep wound complications (aOR = 3.191, 95% CI = 1.423-7.153, and p < 0.01), and a higher rate of transfers out (aOR = 1.815, 95% CI = 1.081-3.05, and p = 0.02). CONCLUSION: COPD is an independent risk factor associated with distinct adverse outcomes in ABR and IBR. These findings can be valuable for preoperative risk stratification, determining surgical candidacy, and planning postoperative management in patients with COPD.
Asunto(s)
Mamoplastia , Complicaciones Posoperatorias , Enfermedad Pulmonar Obstructiva Crónica , Humanos , Enfermedad Pulmonar Obstructiva Crónica/cirugía , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Enfermedad Pulmonar Obstructiva Crónica/epidemiología , Femenino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Mamoplastia/métodos , Mamoplastia/efectos adversos , Adulto , Anciano , Neoplasias de la Mama/cirugía , Implantación de Mama/métodos , Implantación de Mama/efectos adversos , Estudios Retrospectivos , Implantes de Mama/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND: Breast reconstruction encompasses autologous (ABR) and implant-based breast reconstruction (IBR) each with its own sets of potential complications. Diabetes mellitus (DM) is associated with breast reconstruction complications, although most of the studies did not differentiate between the reconstruction procedures. This study conducted a population-based study examining impact of DM on inhospital outcomes in ABR and IBR. METHODS: Patients underwent ABR or IBR were identified in National Inpatient Sample from Q4 2015 to 2020. A 1:2 propensity score matching was used to address differences in demographics, hospital characteristics, primary payer status, comorbidities, and reconstruction staging between DM and non-DM patients. In hospital outcomes were assessed separately in ABR and IBR. RESULTS: There were 997 (7.68%) DM and 11,987 (92.32%) non-DM patients in ABR. Meanwhile, 1325 (7.38%) DM and 16,638 (92.62%) non-DM patients underwent IBR. DM cohorts in ABR and IBR were matched to 1930 and 2558 non-DM patients, respectively. After matching, DM patients in both ABR and IBR had higher risks of renal complications (ABR, 3.73% vs. 1.76%, p < 0.01; IBR, 1.83% vs. 0.78%, p = 0.01) and longer length of stay (ABR, p = 0.01; IBR, p = 0.04). In ABR, DM patients had higher respiratory complications (2.82% vs. 1.19%, p < 0.01), excessive scarring (2.72% vs. 1.55%, p = 0.03), and infection (2.42% vs. 1.14%, p = 0.01), while in IBR, DM patients had higher hemorrhage/hematoma (5.40% vs. 3.40%, p < 0.01) and transfer out (1.52% vs. 0.78%, p = 0.04). CONCLUSION: DM was associated with distinct sets of inhospital complications in ABR and IBR, which can be valuable for preoperative risk stratification and informing clinical decision-making for DM patients.
Asunto(s)
Implantes de Mama , Neoplasias de la Mama , Diabetes Mellitus , Mamoplastia , Humanos , Femenino , Mastectomía/métodos , Pacientes Internos , Mamoplastia/métodos , Hospitales , Diabetes Mellitus/epidemiología , Diabetes Mellitus/etiología , Neoplasias de la Mama/complicaciones , Neoplasias de la Mama/cirugía , Estudios RetrospectivosRESUMEN
BACKGROUND: Incisional complications of groin after inflow or infrainguinal bypasses with prosthetic conduits can result in major morbidities that require reoperation, infected graft removal, and limb loss. Muscle flaps are typically performed to treat groin wound complications, but they are also done prophylactically at the time of index procedures in certain high-risk-for-poor-healing patients to mitigate anticipated groin wound complications. We used a nationwide multi-institutional database to investigate outcomes of prophylactic muscle flaps in high-risk patients who underwent prosthetic bypasses involving femoral anastomosis. METHODS: We utilized ACS-NSQIP database 2005-2021 to identify all elective inflow and infrainguinal bypasses that involve femoral anastomoses. Only high-risk patients for poor incisional healing who underwent prosthetic conduit bypasses were selected. A 1:3 propensity-matching was performed to obtain two comparable studied groups between those with (FLAP) and without prophylactic muscle flaps (NOFLAP) based on demographics and comorbidities. 30-day postoperative outcomes were compared. RESULTS: Among 35,011 NOFLAP, 990 of them were propensity-matched to 330 FLAP. There was no significant difference in 30-day mortality, MACE, pulmonary, or renal complications. FLAP was associated with higher bleeding requiring transfusion, longer operative time, and longer hospital stay. FLAP also had higher overall wound complications (15.2% vs. 10.6%; p = 0.03), especially deep incisional infection (4.9% vs. 2.4%; p = 0.04). CONCLUSION: Prophylactic muscle flap for prosthetic bypasses involving femoral anastomosis in high-risk-for-poor-healing patients does not appear to mitigate 30-day wound complications. Caution should be exercised with this practice and more long-term data should be obtained to determine whether prophylactic flaps decrease the incidence of graft infection.
RESUMEN
BACKGROUND: Frailty is an age-related, clinically recognizable state marked by increased susceptibility. The 5-item Modified Frailty Index (mFI-5) offers a concise assessment of frailty and has demonstrated its efficacy in various surgical fields. While the mFI-5 has been validated for endovascular aneurysm repair for abdominal aortic aneurysm (AAA), its applicability in open surgical repair (OSR) for AAA remains largely unexplored. This study sought to evaluate the utility of mFI-5 in predicting 30-day outcomes following OSR for AAA. METHODS: Patients underwent OSR for AAA were identified in American College of Surgeons National Surgical Quality Improvement Program-targeted database from 2012 to 2021. Patients were stratified into 3 cohorts: mFI-5 score of 0 (control), 1, and 2+. Multivariable logistic regression was used to compare 30-day perioperative outcomes between frail patients and controls adjusting preoperative variables with P value <0.1. RESULTS: Of the 5,249 patients who underwent OSR for AAA, 1,043 were controls, 2,938 had an mFI-5 score of 1 and 1,268 had an mFI-5 score of 2+. When compared to the control group, patients with an mFI-5 = 1 were more likely to have pulmonary events (adjusted odds ratio (aOR) = 1.452, P < 0.01), bleeding events (aOR = 1.33, P < 0.01), wound complications (aOR = 2.214, P < 0.01), ischemic colitis (aOR = 1.616, P = 0.01), and unplanned reoperation (aOR = 1.292, P = 0.04). Those with an mFI-5 = 2+ demonstrated higher risks of mortality (aOR = 1.709, P < 0.01), major adverse cardiovascular events (aOR = 1.347, P = 0.04), pulmonary events (aOR = 2.045, P < 0.01), renal dysfunction (aOR = 1.568, P < 0.01), sepsis (aOR = 1.587, P = 0.01), bleeding events (aOR = 1.429, P < 0.01), wound complications (aOR = 2.338, P < 0.01), ischemic colitis (aOR = 1.775, P = 0.01), unplanned reoperation (aOR = 1.445, P = 0.01), operation over 4 hours (aOR = 1.34, P < 0.01), length of stay over 7 days (aOR = 1.324, <0.01), discharge not to home (aOR = 1.547, P < 0.01), 30-day readmission (aOR = 1.657, P = 0.01). CONCLUSIONS: The mFI-5 emerges as a succinct yet effective indicator of frailty for patients undergoing OSR for AAA. Especially, an mFI-5 score of 2+ is linked with increased 30-day mortality and complications. As such, mFI-5 can be used as a valuable screening tool for frailty in patients undergoing OSR for AAA.
Asunto(s)
Aneurisma de la Aorta Abdominal , Bases de Datos Factuales , Anciano Frágil , Fragilidad , Complicaciones Posoperatorias , Valor Predictivo de las Pruebas , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Femenino , Fragilidad/diagnóstico , Fragilidad/complicaciones , Fragilidad/mortalidad , Masculino , Anciano , Factores de Riesgo , Medición de Riesgo , Resultado del Tratamiento , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Factores de Tiempo , Estudios Retrospectivos , Anciano de 80 o más Años , Persona de Mediana Edad , Estados Unidos , Evaluación Geriátrica , Técnicas de Apoyo para la Decisión , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidadRESUMEN
OBJECTIVES: Although general anesthesia is the primary anesthesia in endovascular aneurysm repair (EVAR), some studies suggest locoregional anesthesia could be a feasible alternative for eligible patients. However, most evidence was from retrospective studies and was subjected to an inherent selection bias that general anesthesia is often chosen for more complex and prolonged cases. To mitigate this selection bias, this study aimed to compare 30-day outcomes of prolonged, nonemergent, intact, infrarenal EVAR in patients undergoing locoregional or general anesthesia. In addition, risk factors associated with prolonged operative time in EVAR were identified. DESIGN: Retrospective large-scale national registry study. SETTING: American College of Surgeons National Surgical Quality Improvement Program targeted database from 2012 to 2022. PARTICIPANTS: A total of 4,075 out of 16,438 patients (24.79%) had prolonged EVAR. Among patients with prolonged EVAR, 324 patients (7.95%) were under locoregional anesthesia. There were 3,751 patients (92.05%) under general anesthesia, and 955 of them were matched to the locoregional anesthesia cohort. INTERVENTIONS: Patients undergoing infrarenal EVAR were included. Exclusion criteria included age <18 years, emergency cases, ruptured abdominal aortic aneurysm, and acute intraoperative conversion to open. Only cases with prolonged operative times (>157 minutes) were selected. A 1:3 propensity-score matching was used to address demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, and concomitant procedures between patients under locoregional and general anesthesia. Thirty-day postoperative outcomes were assessed. Moreover, factors associated with prolonged EVAR were identified by multivariate logistic regression. MEASUREMENTS AND MAIN RESULTS: Except for general anesthesia contraindications, patients undergoing locoregional or general anesthesia exhibited largely similar preoperative characteristics. After propensity-score matching, patients under locoregional and general anesthesia had a lower risk of myocardial infarction (0.93% v 2.83%, p = 0.04), but comparable 30-day mortality (3.72% v 2.72%, p = 0.35) and other complications. Specific concomitant procedures, aneurysm anatomy, and comorbidities associated with prolonged EVAR were identified. CONCLUSIONS: Locoregional anesthesia can be a safe and effective alternative to general anesthesia, particularly in EVAR cases with anticipated complexity and prolonged operative times, as it offers the potential benefit of reduced cardiac complications. Risk factors associated with prolonged EVAR can aid in preoperative risk stratification and inform the decision-making process regarding anesthesia choice.
Asunto(s)
Anestesia de Conducción , Anestesia General , Aneurisma de la Aorta Abdominal , Procedimientos Endovasculares , Complicaciones Posoperatorias , Sistema de Registros , Humanos , Aneurisma de la Aorta Abdominal/cirugía , Procedimientos Endovasculares/métodos , Procedimientos Endovasculares/efectos adversos , Anestesia General/efectos adversos , Anestesia General/métodos , Femenino , Masculino , Estudios Retrospectivos , Anciano , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Anestesia de Conducción/métodos , Anestesia de Conducción/efectos adversos , Factores de Riesgo , Anciano de 80 o más Años , Persona de Mediana Edad , Cardiopatías/epidemiología , Cardiopatías/etiología , Tempo OperativoRESUMEN
BACKGROUND: Type A aortic dissection (TAAD) is an emergent condition that warrants immediate intervention. Peripheral artery disease (PAD) is a prevalent disease associated with worse outcomes in various cardiovascular procedures. However, it remains unclear whether PAD influences outcomes of TAAD repair. This study aimed to undertake a population-based analysis to assess impact of PAD on in-hospital outcomes following TAAD repair. METHODS: Patients underwent TAAD repair were identified in National Inpatient Sample from Q4 2015 to 2020. Multivariable logistic regressions were used to compare in-hospital outcomes between patients with and without PAD, adjusted for demographics, socioeconomic status, primary payer status, hospital characteristics, comorbidities, and transfer/admission status. RESULTS: 1525 patients with PAD and 2757 non-PAD patients underwent TAAD. PAD patients had higher mortality (18.62% vs 13.17%, aOR = 1.287, p = .01), AKI (51.41% vs 47.48%, aOR = 1.222, p < .01), infection (10.69% vs 8.02%, aOR = 1.269, p = .03), and vascular complication (7.28% vs 3.77%, aOR = 1.846, p < .01) but lower risks of pericardial complications (15.21% vs 19.95%, aOR = 0.696, p < .01). In addition, patients with PAD had longer time from admission to operation (1.29 ± 3.95 vs 0.70 ± 2.09 days, p < .01), longer LOS (14.92 ± 13.98 vs 13.41 ± 11.66 days, p = .01), and higher hospital charge (499,064 ± 519,405 vs 409,754 ± 405,663 US dollars, p < .01). CONCLUSION: PAD was independently associated with worse outcome after TAAD repair. The elevated mortality rate could be attributed to the delay in surgery, which may be related to preoperative peripheral malperfusion syndrome that is common in PAD patients. A balance between preoperative management and immediate TAAD repair might be essential to prevent the increased mortality risk from treatment delays among PAD patients.
RESUMEN
BACKGROUND: Prior abdominal surgery (PAS) has the potential to affect outcomes of abdominal aortic aneurysm (AAA) repair. Recently, endovascular aneurysm repair (EVAR) has been expanded among patients with complex AAA, which involves visceral branches in the upper abdominal aortic. However, outcomes of EVAR for complex AAA in patients with PAS have not been examined. This study aimed to investigate the impact of PAS on 30-day outcomes in EVAR for complex AAA. METHODS: Patients who underwent EVAR for complex AAA were identified in ACS-NSQIP targeted database from 2012 to 2022. Complex AAA was defined as juxtarenal, suprarenal, or pararenal proximal extent, Type IV thoracoabdominal aneurysm, or aneurysms treated with Zenith Fenestrated endograft. Patients with age less than 18 years, ruptured AAA with or without hypotension, acute intraoperative conversion to open, and emergency presentation were excluded. Multivariable logistic regression was used to compare 30-day postoperative outcomes of patients with and without PAS. Demographics, baseline characteristics, aneurysm diameter, indication for surgery, proximal and distant aneurysm extent, anesthesia, and concomitant procedures were adjusted. RESULTS: There were 515 (28.34%) and 1302 (71.66%) patients with and without PAS, respectively, who underwent EVAR for complex AAA. Patients with and without PAS had comparable 30-day mortality (3.11% vs 3.00%, aOR = 0.766, 95 CI = 0.407-1.442, p = .41). Organ system complications including cardiac complications, stroke, pulmonary complications, and renal complications were comparable between patients with and without PAS. All other 30-day outcomes were similar between groups. However, patients with PAS had higher 30-day readmission rate (11.65% vs 7.14%, aOR = 1.634, 95 CI = 1.145-2.331, p = .01). CONCLUSION: While PAS has high prevalence among patients undergoing EVAR for complex AAA, it does not impact 30-day mortality and morbidities. Thus, EVAR for complex AAA can be considered safe for patients with PAS in terms of short-term outcomes, despite the long-term prognosis in these patients being needed in further studies.
RESUMEN
BACKGROUND: Infrainguinal bypass surgery is an effective treatment for peripheral artery disease (PAD). While chronic obstructive pulmonary disease (COPD) has been linked to heightened risks of mortality and morbidity in major surgery, a thorough investigation into COPD's impact on infrainguinal bypass outcomes remained underexplored. Thus, this study aimed to assess the 30-day outcomes for COPD patients undergoing infrainguinal bypass surgery. METHODS: COPD and non-COPD patients who underwent infrainguinal bypass were identified in American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011 to 2022. Patients of age<18 were excluded. A 1:1 propensity-score matching was used to match demographics, baseline characteristics, symptomatology, procedure, conduit, and anesthesia. Thirty postoperative outcomes were compared. RESULTS: There were 3,183 (12.64%) and 22,004 (87.36%) patients with and without COPD, respectively, who underwent infrainguinal bypass. COPD patients had a higher comorbid burden. After propensity-score matching, COPD patients had higher sepsis (3.55% vs 2.42%, p = 0.01), wound complications (18.94% vs 16.40%, p = 0.01), and 30-day readmission (18.00% vs 14.92%, p < 0.01). However, COPD and non-COPD patients had comparable 30-day mortality (2.54% vs 2.67%, p = 0.81), and organ system complications including cardiac (3.58% vs 3.99%, p = 0.43), pulmonary (3.96% vs 3.20%, p = 0.12), and renal complications (1.70% vs 1.82%, p = 0.78). Limb-specific outcomes including major amputation (2.95% vs 2.50%, p = 0.30), untreated loss of patency (1.85% vs 1.38%, p = 0.16), and patent graft (98.24% vs 98.65%, p = 0.27) were also comparable between the cohorts. CONCLUSION: While COPD might be associated with the development of PAD due to potentially shared pathophysiology, it may not be an independent risk factor for the major 30-day outcomes in infrainguinal bypass surgery.
RESUMEN
BACKGROUND: Anemia is a highly prevalent condition potentially linked to chronic inflammation. Preoperative anemia is an independent risk factor across many surgical fields. However, the relationship between anemia and abdominal aortic aneurysm (AAA) repair outcomes remains unclear. This study aimed to examine the effects of preoperative anemia on 30-day outcomes of non-ruptured infrarenal AAA repair. METHODS: Patients who underwent open surgical repair (OSR) and endovascular aneurysm repair (EVAR) for infrarenal AAA were identified in National Surgical Quality Improvement Program (NSQIP) targeted databases from 2012 to 2021. Anemia was defined as preoperative hematocrit less than 39% in males and 36% in females. Multivariable logistic regression was used to compare 30-day perioperative outcomes between anemic and non-anemic patients, adjusting for demographics, comorbidities, indications, aneurysm extents, operation time, and surgical approaches. RESULTS: There were 408 (22.13%) anemic and 1436 (77.88%) non-anemic patients who underwent OSR for non-ruptured AAA, while 3586 (25.20%) patients with and 10,644 (74.80%) without anemia underwent EVAR. In both OSR and EVAR, anemic patients had higher risks of bleeding requiring transfusion (OSR, aOR = 2.446, p < .01; EVAR, aOR = 3.691, p < .01), discharge not to home (OSR, aOR = 1.385, p = .04; EVAR, aOR = 1.27, p < .01), and 30-day readmission (OSR, aOR = 1.99, p < .01; EVAR, aOR = 1.367, p < .01). Also, anemic patients undergoing OSR had higher pulmonary events (aOR = 2.192, p < .01), sepsis (aOR = 2.352, p < .01), and venous thromboembolism (aOR = 2.913, p = .01), while in EVAR, anemic patients had higher mortality (aOR = 1.646, p = .01), cardiac complications (aOR = 1.39, p = .04), renal dysfunction (aOR = 1.658, p = .02), and unplanned reoperation (aOR = 1.322, p = .01). Moreover, in both OSR and EVAR, anemic patients had longer hospital length of stay (p < .01). CONCLUSION: In OSR and EVAR, preoperative anemia was independently associated with worse 30-day outcomes. Preoperative anemia could be a useful marker for risk stratification for patients undergoing infrarenal AAA repair.
RESUMEN
BACKGROUND: Bottom gender affirmation surgery (GAS) involves the risks of bleeding and associated complications. Effective preoperative blood management is paramount across surgical disciplines with international normalized ratio (INR)≤1.5 advised prior to certain surgeries. This study aimed to examine the proportion of patients who were hypocoagulative before they underwent bottom GAS and assess the influence of hypocoagulability on their 30-day post-operative outcomes. METHOD: A retrospective study on female-to-male (FtM) and male-to-female (MtF) bottom GAS was performed based on American college of surgeons national surgical quality improvement program (ACS-NSQIP) database from 2005 to 2021. Patients with hypocoagulation were identified when PTT> 60 s, PT > 30 s, and/or INR> 2. Multivariable logistic regression was used to compare the 30-day perioperative outcomes between patients with hypocoagulation and controls. RESULTS: In this study, 380 patients (182 FtM, 198 MtF) with hypocoagulation and 1176 controls (886 FtM, 310 MtF) were included. Mortality and organ system complications were infrequent in both groups. Patients with hypocoagulation had higher wound complication rates (13.68% vs. 2.64%, aOR 2.858, p < 0.01), especially wound dehiscence (10.00% vs. 0.60%, aOR 4.424, p < 0.01) and organ space infection rates (2.11% vs. 0.26%, aOR 12.77, p < 0.01). Additionally, patients with hypocoagulation had higher sepsis (0.79% vs. 0.09%, aOR 15.508, p = 0.04) and readmission rates (4.74% vs. 2.47%, aOR 1.919, p = 0.03), but lower rates of discharge not to home (7.92% vs. 25.38%, aOR 0.324, p < 0.01). CONCLUSION: Preoperative hypocoagulative state is observed in approximately a quarter of the patients undergoing bottom GAS and is an independent risk factor for increased risks of 30-day wound complications and infections. Therefore, meticulous monitoring of preoperative hemostasis and implementing hemostasis control before surgery may be necessary. Thus, it may be advisable to discontinue oral anticoagulants before the surgery.
Asunto(s)
Complicaciones Posoperatorias , Cirugía de Reasignación de Sexo , Humanos , Masculino , Femenino , Estudios Retrospectivos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Alta del Paciente , Cirugía de Reasignación de Sexo/efectos adversos , Factores de Riesgo , Infección de la Herida Quirúrgica/etiologíaRESUMEN
Small bowel obstruction (SBO) is one of the most frequent causes of general emergency surgery. The 30-day mortality rate post-surgery ranges widely from 2 to 30%, contingent upon the patient population, which renders risk assessment tools helpful. this study aimed to develop a 30-day point-scoring risk calculator designed for patients undergoing SBO surgery. Patients who underwent SBO surgery were identified in the ACS-NSQIP database from 2005 to 2021. Patients were randomly sampled into an experimental (2/3) and a validation (1/3) group. A weighted point scoring system was developed for the risk of 30-day mortality, utilizing multivariable regression on preoperative risk variables based on Sullivan's method. The risk scores underwent both internal and external validation. Furthermore, the efficacy of the risk score was evaluated in 30-day major surgical complications. A total of 93,517 patients were identified, with 63,521 and 29,996 assigned to the experimental and validation groups, respectively. The risk calculator is structured to assign points based on age (> 85 years, 4 points; 75-85 years, 3 points; 65-75 years, 2 points; 55-65 years, 1 point), disseminated cancer (2 points), American Society of Anesthesiology (ASA) score of 4 or 5 (1 point), preoperative sepsis (1 point), hypoalbuminemia (1 point), and fully dependent functional status (1 point). The risk calculator showed strong discrimination (c-statistic = 0.825, 95% CI 0.818-0.831) and good calibration (Brier score = 0.043) in the experimental group. The point scoring system was successfully translated from individual preoperative variables (c-statistic = 0.840, 95% CI 0.834-0.847) and was externally validated in ACS-NSQIP (c-statistic = 0.827, 95% = CI 0.834-0.847, Brier score = 0.043). The SBO risk score can effectively discriminate major surgical complications including major adverse cardiovascular events (c-statistic = 0.734), cardiac complications (c-statistic = 0.732), stroke (c-statistic = 0.725), pulmonary complications (c-statistic = 0.727), renal complications (c-statistic = 0.692), bleeding (c-statistic 0.674), sepsis (c-statistic = 0.670), with high predictive accuracy (all Brier scores < 0.1). This study developed and validated a concise yet robust 10-point risk scoring system for patients undergoing SBO surgery. It can be informative to determine treatment plans and to prepare for potential perioperative complications in patients undergoing SBO surgery.
RESUMEN
OBJECTIVES: Colonic volvulus is a common cause of bowel obstructions and surgery is the definitive treatment. Functional status is often associated with adverse postoperative outcomes but its effect on colectomy for volvulus remained under-explored. This study sought to analyze the effect of functional status on the 30-day outcomes of colectomy for volvulus. MATERIALS AND METHOD: National Surgical Quality Improvement Program (NSQIP) targeted colectomy database from 2012 to 2022 was utilized. Only patients with volvulus as the primary indication for colectomy were included. Thirty-day postoperative outcomes were compared between patients with dependent functional status (DFS) and independent functional status (IFS), adjusted for demographics, baseline characteristics, preoperative preparation, indication for surgery, and operative approaches by multivariable logistic regression. RESULTS: There were 1,476 patients with DFS (945 partially DFS and 531 fully DFS) and 8,824 (85.67 %) IFS patients who underwent colectomy for volvulus. After multivariable analysis, DFS patients had higher risks of mortality (aOR=1.671, 95 CI=1.37-2.038, p < 0.01), pulmonary complications (aOR=2.166, 95 CI=1.85-2.536, p < 0.01), sepsis (aOR=1.31, 95 CI=1.107-1.551, p < 0.01), prolonged postoperative nothing by mouth (NPO) or nasogastric tube (NGT) use (aOR=1.436, 95 CI=1.269-1.626, p < 0.01), discharge not to home (aOR=3.774, 95 CI=3.23-4.411, p < 0.01), and 30-day readmission (aOR=1.196, 95 CI=1.007-1.42, p = 0.04). Moreover, DFS patients had a longer length of stay (p = 0.01). CONCLUSION: DFS was identified as an independent risk factor for increased mortality and complications after colectomy for volvulus. Given the substantial overlap between DFS patients and those who have colonic volvulus, these insights can contribute to preoperative risk assessments and postoperative care in these patients.