Temporal variability of readmission determinants in postoperative vascular surgery patients.

INTRODUCTION: Clinical information continues to be limited regarding changes in the temporal risk profile for readmissions during the initial postoperative year in vascular surgery patients. We set out to describe the associations between demographics, clinical outcomes, comorbidity indices, and hospital readmissions in a sample of patients undergoing common extremity revascularization or dialysis access (ERDA) procedures. We hypothesized that factors independently associated with readmission will evolve from "short-term" to "long-term" determinants at 30-, 180-, and 360-day postoperative cutoff points. METHODS: Following IRB approval, medical records of patients who underwent ERDA at two institutions were retrospectively reviewed between 2008 and 2014. Abstracted data included patient demographics, procedural characteristics, the American Society of Anesthesiologists score, Goldman Criteria for perioperative cardiac assessment, the Charlson comorbidity index, morbidity, mortality, and readmission (at 30-, 180-, and 360-days). Univariate analyses were performed for readmissions at each specified time point. Variables reaching statistical significance of P< 0.20 were included in multivariate analyses for factors independently associated with readmission. RESULTS: A total of 450 of 744 patients who underwent ERDA with complete medical records were included. Patients underwent either an extremity revascularization (e.g. bypass or endarterectomy, 406/450) or a noncatheter dialysis access procedure (44/450). Sample characteristics included 262 (58.2%) females, mean age 61.4 ± 12.9 years, 63 (14%) emergent procedures, and median operative time 164 min. Median hospital length of stay (index admission) was 4 days. Cumulative readmission rates at 30-, 180-, and 360-day were 12%, 27%, and 35%, respectively. Corresponding mortality rates were 3%, 7%, and 9%. Key factors independently associated with 30-, 180-, and 360-day readmissions evolved over the study period from comorbidity and morbidity-related issues in the short-term to cardiovascular and graft patency issues in the long-term. Any earlier readmission elevated the risk of subsequent readmission. CONCLUSIONS: We noted important patterns in the temporal behavior of hospital readmission risk in patients undergoing ERDA. Although factors independently associated with readmission were not surprising (e.g. comorbidity profile, cardiovascular status, and graft patency), the knowledge of temporal trends described in this study may help determine clinical risk profiles for individual patients and guide readmission reduction strategies. These considerations will be increasingly important in the evolving paradigm of value-based healthcare.

Spontaneous renal artery dissection: three cases and clinical algorithms.

Spontaneous renal artery dissection (SRAD) is rare. Clinical manifestations vary from minimal symptoms to life-threatening hypertension. We analysed three cases from our institution and conducted a literature review in order to design diagnostic and treatment algorithms for SRAD.

The influence of ultraviolet irradiation on the blood transfusion effect.

Reports of improved survival of allografts in recipients of donor-specific blood prompted an attempt to determine the relationship of the antigenic composition of the blood product transfused to the development of immunologic unresponsiveness in rats. Cardiac allografts were transplanted from Fischer, Brown-Norway (BN), and Lewis (L) X BN (LBN) f1 hybrids to recipients treated with three weekly transfusions of 1 ml of donor-specific whole blood, erythrocytes, or ultraviolet-irradiated whole blood. Despite moderate improvement in survival with whole blood alone in the LBN- greater than L group (11.6 +/- 1.0 days), it was only with the ultraviolet-irradiated whole blood that marked prolongation was seen in all three strain combinations: Fischer- greater than L: 25.5 +/- 5.2, LBN- greater than L: 17.3 +/- 1.2, and BN- greater than L: 11.1 +/- 0.4 days compared with respective controls: 10.3 +/- 1.2, 7.3 +/- 0.5, and 7.4 +/- 0.6 days. Unlike reports for renal allografts, erythrocyte suspensions provided minimal protection for the cardiac allografts (14.2 +/- 0.8, 9.0 +/- 1.1, and 11.0 +/- 0.4 days, respectively), and adjunctive treatment with antilymphocyte serum had a similar small effect (16.3 +/- 1.4, 13.4 +/- 1.9, and 8.3 +/- 0.8 days, respectively). The elimination or inactivation of functional class 2 major histocompatibility complex antigens from the blood used for donor-specific blood transfusion may be an effective means of prolonging allograft survivals over those seen with whole blood alone; however, the degree of resultant unresponsiveness is still clearly influenced by dosage schedule, the organ transplanted, histocompatibility barrier, and adjunctive immunosuppression.

The use of arm veins for infrainguinal bypass in end-stage peripheral vascular disease.

Thirty-six infrainguinal bypass grafts were performed in 33 patients with the use of autologous arm vein. Indications for operation were ischemic rest pain or tissue loss in all patients. The average age of the patients was 70.0 years-27% were diabetic and 66% were smokers. Sixty-five percent of the grafts were performed as secondary reconstructions. Follow-up ranged from three weeks to six years, with a mean of 12.1 months. Life-table primary and secondary patencies for all grafts are 73% and 82% at one year, respectively. Simple (noncomposite) arm vein grafts had primary and secondary patencies of 75% and 85%, respectively. The limb salvage rate was 86%. No grafts required thrombectomy for early occlusion (less than 30 days), and no graft failures have occurred beyond nine months (n = 18). Arm vein bypass grafts demonstrate excellent patency rates and provide the preferred conduit in the absence of autologous saphenous vein.

Slip knot for tying monofilament nylon sutures.

The integrity of the suture and the knot is important during the early phase of laparotomy wound healing. When monofilament suture is used, the initial anchoring knot can have varying configuration. We present a simple and rapid technique of placing this anchoring knot with a modified "slip knot."

Complications of caval interruption by Greenfield filter in quadriplegics.

Patients with acutely injured spinal cords are thought to be at increased risk for thromboembolic disease and often have contraindications to anticoagulation therapy. From 1981 to 1986, 13 patients with quadriplegia at the New England Regional Model Spinal Cord Injury Center had caval interruption with a Greenfield filter. Twelve patients had deep venous thrombosis documented by venogram results and one had pulmonary embolism documented by arteriogram results. "Quad cough" chest physical therapy was required for mobilization of pulmonary secretions in nine patients. Follow-up abdominal x-ray results revealed significant abnormalities referrable to the filter in five patients having undergone "quad cough" therapy. Four patients had distal migration of the filter; three of the four had deformation of the filter. Laparotomy for bowel perforation was required in two of these patients. Quadriplegia requiring vigorous chest physical therapy ("quad cough") for pulmonary toilet may be a contraindication to caval interruption by Greenfield filter. Alternative techniques in the management of patients with quadriplegia and pulmonary compromise must be considered.