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Multiple studies have used administrative datasets to examine the epidemiology of sepsis in general, but the entity of postoperative sepsis has been studied less intensively. Therefore, we undertook an analysis of the epidemiology of postoperative sepsis using the Nationwide Inpatient Sample, the largest in-patient dataset available in the United States.Elective admissions of patients aged 18 yr or older with a length of stay more than 3 days for any 1 of the 20 most common elective operative procedures were extracted from the dataset for the years 1997-2006. Postoperative sepsis was defined using the appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes; severe sepsis was defined as sepsis along with organ dysfunction. Logistic regression was used to assess the significance of temporal trends after adjusting for relevant demographic characteristics, operative procedure, and comorbid conditions.We identified 2,039,776 admissions for analysis. The rate of severe sepsis increased from 0.3% in 1997 to 0.9% in 2006. This trend persisted after adjusting for relevant covariables-the adjusted odds ratio of severe sepsis per year increase in the study period was 1.12 (95% CI, 1.11-1.13; P0.001). The in-hospital mortality rate for patients with severe postoperative sepsis declined from 44.4% in 1997 to 34.0% in 2006; this trend also persisted after adjustment for relevant covariables-the adjusted odds ratio per year was 0.94 (95% CI, 0.93-0.95; P0.001).During the 10-yr period that we studied, there was a marked increase in the rate of severe postoperative sepsis but a concomitant decrease in the in-hospital mortality rate in severe sepsis.

In this study, we sought to (1) define trends in the incidence of postpartum hemorrhage (PPH), and (2) elucidate the contemporary epidemiology of PPH focusing on risk factors and maternal outcomes related to this delivery complication.Hospital admissions for delivery were extracted from the Nationwide Inpatient Sample, the largest discharge dataset in the United States. Using International Classification of Diseases, Clinical Modification (ninth revision) codes, deliveries complicated by PPH were identified, as were comorbid conditions that may be risk factors for PPH. Temporal trends in the incidence of PPH from 1995 to 2004 were assessed. Logistic regression was used to identify risk factors for the most common etiology of PPH-uterine atony.In 2004, PPH complicated 2.9% of all deliveries; uterine atony accounted for 79% of the cases of PPH. PPH was associated with 19.1% of all in-hospital deaths after delivery. The overall rate of PPH increased 27.5% from 1995 to 2004, primarily because of an increase in the incidence of uterine atony; the rates of PPH from other causes including retained placenta and coagulopathy remained relatively stable during the study period. Logistic regression modeling identified age20 oror =40 years, cesarean delivery, hypertensive diseases of pregnancy, polyhydramnios, chorioamnionitis, multiple gestation, retained placenta, and antepartum hemorrhage as independent risk factors for PPH from uterine atony that resulted in transfusion. Excluding maternal age and cesarean delivery, one or more of these risk factors were present in only 38.8% of these patients.PPH is a relatively common complication of delivery and is associated with substantial maternal morbidity and mortality. It is increasing in frequency in the United States. PPH caused by uterine atony resulting in transfusion often occurs in the absence of recognized risk factors.

Perioperative acute ischemic stroke (AIS) is a recognized complication of noncardiac, nonvascular surgery, but few data are available regarding incidence and effect on outcome. This study examines the epidemiology of perioperative AIS in three common surgeries: hemicolectomy, total hip replacement, and lobectomy/segmental lung resection.Discharges for patients aged 18 yr or older who underwent any of the surgical procedures listed above were extracted from the Nationwide Inpatient Sample, an administrative database that contains 20% of all discharges from non-Federal hospitals each year, for years 2000 to 2004. Using appropriate International Classification of Diseases, 9th revision, Clinical Modification codes, patients with perioperative AIS were identified, as were comorbid conditions that may be risk factors for perioperative AIS. Multivariate logistic regression was performed to identify independent predictors of perioperative AIS and to ascertain the effect of AIS on outcome.A total of 0.7% of 131,067 hemicolectomy patients, 0.2% of 201,235 total hip replacement patients, and 0.6% of 39,339 lobectomy/segmental lung resection patients developed perioperative AIS. For patients older than 65 yr, AIS rose to 1.0% for hemicolectomy, 0.3% for hip replacement, and 0.8% for pulmonary resection. Multivariate logistic regression analysis revealed renal disease (odds ratio, 3.0), atrial fibrillation (odds ratio, 2.0), history of stroke (odds ratio, 1.6), and cardiac valvular disease (odds ratio, 1.5) to be the most significant risk factors for perioperative AIS.Perioperative AIS is an important source of morbidity and mortality associated with noncardiac, nonvascular surgery, particularly in elderly patients and patients with atrial fibrillation, valvular disease, renal disease, or previous stroke.

Names with eponym status in present-day anesthesia include Apgar, Bier, Bovie, Esmarch, Fick, Foley, Ganz, Hofmann, Huber, Joule, Luer, Macintosh, Magill, Mallampati, Miller, Ovassapian, Pascal, Ringer, Seldinger, Sellick, Swan, Trendelenburg, Tuohy, Valsalva, and Yankauer. A discussion of the people behind the eponyms, which may make these commonly used terms more interesting and provides a sense of the history of the specialty of anesthesia, is presented.

Background Based on 2 small randomized controlled trials (RCTs) from the 1990s, β-blockers were promoted to prevent perioperative cardiac events in patients undergoing noncardiac surgery. In 2008, a large RCT (POISE trial) showed an increased mortality risk associated with perioperative β-blockade, raising concerns about an extensive β-Blocker use. Objectives The objective of the study is to examine patterns of β-Blocker initiation among patients undergoing noncardiac elective surgery in the US. Methods From a large, nationwide US health care insurer, we identified patients ≥18 years old who underwent moderate- to high-risk noncardiac elective surgery between 2003 and 2012 and initiated a β-Blocker within 30 days before surgery. We evaluated temporal trends and assessed the impact of the POISE trial on perioperative β-Blocker initiation. We also evaluated patient characteristics and examined the effect of temporal proximity to surgery on the likelihood of β-Blocker initiation. Results Of 499,752 patients undergoing surgery, 9,014 (18 per 1,000 patients) initiated a β-Blocker. β-Blocker initiation increased from 12 per 1,000 patients in 2003 to 23 before POISE, after which it decreased to 14 by December 2012 ( P = .0001). β-Blocker initiation remained relatively high among patients undergoing vascular surgery or with Revised Cardiac Risk Index score ≥ 2. Proximity to surgery was highly predictive of β-Blocker initiation (odds ratio 3.34, 95% CI 3.17-3.51). Conclusions After a period of a rapidly increasing trend, perioperative β-Blocker initiation decreased sharply in the second half of 2008 and continued to decrease afterwards. β-Blocker initiation remained relatively high in patients with Revised Cardiac Risk Index score ≥2 and in those undergoing major vascular surgery.

Importance Between 0.3% and 0.5% of all pregnancies occur among women with epilepsy. Evidence suggests an increase in perinatal morbidity and mortality among women with epilepsy. However, these risks have not been quantified in large population-based samples. Objective To report on the risk for death and adverse outcomes at the time of delivery for women with epilepsy in the United States. Design, Setting, and Participants Retrospective cohort study of pregnant women identified through delivery hospitalization records from the 2007-2011 Nationwide Inpatient Sample. From this representative sample of 20% of all US hospitals, we obtained a weighted sample of delivery hospitalizations from 69 385 women with epilepsy and 20 449 532 women without epilepsy. Main Outcomes and Measures Obstetrical outcomes including maternal death, cesarean delivery, length of stay, preeclampsia, preterm labor, and stillbirth. Results Women with epilepsy had a risk of death during delivery hospitalization of 80 deaths per 100 000 pregnancies, significantly higher than the 6 deaths per 100 000 pregnancies found among women without epilepsy (adjusted odds ratio [OR], 11.46 [95% CI, 8.64-15.19]). Women with epilepsy were also at a heightened risk for other adverse outcomes, including preeclampsia (adjusted OR, 1.59 [95% CI, 1.54-1.63]), preterm labor (adjusted OR, 1.54 [95% CI, 1.50-1.57]), and stillbirth (adjusted OR, 1.27 [95% CI, 1.17-1.38]), and had increased health care utilization, including an increased risk of cesarean delivery (adjusted OR, 1.40 [95% CI, 1.38-1.42]) and prolonged length of hospital stay (>6 days) among both women with cesarean deliveries (adjusted OR, 2.13 [95% CI, 2.03-2.23]) and women with vaginal deliveries (adjusted OR, 2.60 [95% CI, 2.41-2.80]). Conclusions and Relevance Findings suggest that women with epilepsy are at considerably heightened risk for many adverse outcomes during their delivery hospitalization, including a more than 10-fold increased risk of death, and that increased clinical attention is imperative for these pregnancies.

OBJECTIVE: Uterine atony is a leading cause of postpartum hemorrhage. Although most cases of postpartum hemorrhage respond to first-line therapy with uterine massage and oxytocin administration, second-line uterotonics including methylergonovine and carboprost are integral for the management of refractory uterine atony. Despite their ubiquitous use, it is uncertain whether the risk of hemorrhagerelated morbidity differs in women exposed to methylergonovine or carboprost at cesarean delivery. STUDY DESIGN: We performed a secondary analysis using the Maternal-Fetal Medicine Units Network Cesarean Registry. We identified women who underwent cesarean delivery and received either methylergonovine or carboprost for refractory uterine atony. The primary outcome was hemorrhage-related morbidity defined as intraoperative or postoperative red blood cell transfusion or the need for additional surgical interventions including uterine artery ligation, hypogastric artery ligation, or peripartum hysterectomy for atony. We compared the risk of hemorrhagerelated morbidity in those exposed to methylergonovine vs carboprost. Propensity-score matching was used to account for potential confounders. RESULTS:Thestudycohortcomprised1335women;870(65.2%)women received methylergonovine and 465 (34.8%) women received carboprost. After accounting for potential confounders, the risk of hemorrhage-related morbidity was higher in the carboprost group than the methylergonovine group (relative risk, 1.7; 95% confidence interval, 1.2e2.6). CONCLUSION: In this propensity scoreematched analysis, methylergonovine was associated with reduced risk of hemorrhage-related morbidity during cesarean delivery compared to carboprost. Based on these results, methylergonovine may be a more effective secondline uterotonic.

Objective Chronic hypertension is a common medical condition in pregnancy. The purpose of the study was to examine the association between maternal chronic hypertension and the risk of congenital malformations in the offspring. Study Design We defined a cohort of 878,126 completed pregnancies linked to infant medical records using the Medicaid Analytic Extract. The risk of congenital malformations was compared between normotensive controls and those with treated and untreated chronic hypertension. Confounding was addressed using propensity score matching. Results After matching, compared with normotensive controls, pregnancies complicated by treated chronic hypertension were at increased risk of congenital malformations (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.2–1.5), as were pregnancies with untreated chronic hypertension (OR 1.2; 95% CI, 1.1–1.3). In our analysis of organ-specific malformations, both treated and untreated chronic hypertension was associated with a significant increase in the risk of cardiac malformations (OR, 1.6; 95% CI, 1.4–1.9 and OR, 1.5; 95% CI, 1.3–1.7, respectively). These associations persisted across a range of sensitivity analyses. Conclusion There is a similar increase in the risk of congenital malformations (particularly cardiac malformations) associated with treated and untreated chronic hypertension that is independent of measured confounders. Studies evaluating the teratogenic potential of antihypertensive medications must control for confounding by indication. Fetuses and neonates of mothers with chronic hypertension should be carefully evaluated for potential malformations, particularly cardiac defects.

Approximately 10% of Parkinson's disease (PD) patients have young-onset PD (YOPD). From a public health perspective, YOPD is an important subgroup of PD patients, because they are expected to remain active users of the health care system for many decades. Health care utilization and medical comorbidity during hospitalization have not been assessed in these patients. The objectives of this study were to compare YOPD patients to control patients in terms of (1) hospital utilization and outcomes, and (2) medical comorbidities during hospitalization. The Nationwide Inpatient Sample (NIS) provides yearly data on hospital admissions and discharges from approximately 1,000 hospitals. NIS data sets (1998–2003) were used to identify persons 18 to 40 years of age, including 714 PD patients and 2,007 randomly selected control patients (1:3 ratio). Hospital length of stay (P < 0.001) and number of discharge diagnoses (P < 0.001) were higher in PD than control patients. PD patients were more likely than controls to be discharged to a short-term hospital (odds ratio [OR], 2.23; 95% confidence interval [CI], 1.30–3.84; P = 0.004) or a skilled nursing facility (OR, 4.14; 95% CI, 3.06–5.61; P < 0.001); 20.4% required transfer to a short-term hospital or another facility. The most common discharge diagnosis-related group code in PD patients was psychosis (23% of patients), whereas pneumonia and hip or pelvic fractures were not associated with PD. YOPD patients had greater health care utilization and hospital morbidity than controls. Upon discharge, 1 in 5 required transfer to a short-term hospital or another facility. Psychosis was the most common comorbidity, whereas several comorbidities associated with older PD patients (e.g., fractures) were not common. © 2006 Movement Disorder Society

Introduction Restoration of blood flow following ischemic stroke can be achieved by means of thrombolysis or mechanical recanalization. However, for some patients, reperfusion may exacerbate the injury initially caused by ischemia, producing a so-called “cerebral reperfusion injury”. Multiple pathological processes are involved in this injury, including leukocyte infiltration, platelet and complement activation, postischemic hyperperfusion, and breakdown of the blood–brain barrier. Methods/results and conclusions Magnetic resonance imaging (MRI) can provide extensive information on this process of injury, and may have a role in the future in stratifying patients’ risk for reperfusion injury following recanalization. Moreover, different MRI modalities can be used to investigate the various mechanisms of reperfusion injury. Antileukocyte antibodies, brain cooling and conditioned blood reperfusion are potential therapeutic strategies for lessening or eliminating reperfusion injury, and interventionalists may play a role in the future in using some of these therapies in combination with thrombolysis or embolectomy. The present review summarizes the mechanisms of reperfusion injury and focuses on the way each of those mechanisms can be evaluated by different MRI modalities. The potential therapeutic strategies are also discussed.

Background and Purpose— The prospective trials evaluating the safety and efficacy of intravenous tissue plasminogen activator have generally been conducted at academic medical centers and community hospitals with an institutional commitment to stroke care. Relatively little is known about the safety of this therapy as it is used in the community. We therefore examined outcomes in acute stroke patients treated with thrombolysis using the largest discharge database available in the United States for the years 1999 to 2002. Methods— Data were derived from the Nationwide Inpatient Sample for the years 1999 to 2002. Using the appropriate International Classification of Disease—Clinical Modification, 9th revision , codes, patients admitted through the emergency room with a primary diagnosis of acute ischemic stroke were selected for analysis. From these patients, those coded as receiving thrombolysis were identified. Multivariate logistic regression was performed on the thrombolysis and nonthrombolysis cohorts to identify independent predictors of in-hospital mortality from among those clinical elements available in the database. Results— We identified 2594 patients treated with thrombolysis from a group of 248 964 patients admitted through the emergency room with a primary diagnosis of acute ischemic stroke. The thrombolysis cohort had a higher in-hospital mortality rate compared with the nonthrombolysis patients (11.4% versus 6.8%). The rate of intracerebral hemorrhage was 4.4% for the thrombolysis cohort and 0.4% for nonthrombolysis patients. Multivariate logistic regression showed advanced age, Asian/Pacific Islander race, congestive heart failure, and atrial fibrillation/flutter to be independent predictors of in-hospital mortality after thrombolysis. Thrombolysis volume, overall ischemic stroke volume, and teaching status were not significant predictors of in-hospital mortality after thrombolysis. Conclusions— Thrombolysis, as it is used in the community, has a safety profile that is similar to that observed in the large, prospective clinical trials.

Background and Purpose— To assess the outcome in acute ischemic stroke patients not eligible for systemic thrombolysis (outside the 3-hour time window, after surgery, or on anticoagulant) undergoing endovascular recanalization therapy (ERT) at the Columbia University Medical Center (CUMC) and to determine US nationwide usage and outcome of ERT in acute ischemic stroke. Methods— Patients treated at CUMC from 2001 to 2004 and the Nationwide Inpatient Sample (NIS) comprising 20% of all admissions in the United States from 1999 to 2002 were analyzed retrospectively. Results— Thirty-one patients underwent ERT. Mean age was 68±14 years, 68% were female, and 45% nonwhite (occlusion sites: internal carotid artery 29%; middle cerebral artery 39%; posterior circulation 32%). Pharmacological or mechanical ERT was initiated beyond 3 hours after symptom onset (median time 4.4 hours) in 61%, 29% had surgery, and 39% were on anticoagulant medication. At discharge, 32% had modified Rankin Scale scores of 0 to 2 (52% discharged home or to rehabilitation facilities); overall mortality was 29%, of which 19% were fatal intracerebral hemorrhages. From the NIS cohort, 477 patients (0.17% of all strokes and 14% of all thrombolysis cases) underwent ERT. Fifteen percent died, and ≈50% were discharged home or to rehabilitation facilities. Intracerebral hemorrhage occurred in 6%. Fewer good outcomes of the CUMC cohort may be explained by more unfavorable premorbid patient characteristics compared with the NIS cohort. Conclusion— Despite significant variability in patient characteristics and treatment methods among 2 sources of data analyzed, ERT in stroke patients not eligible for intravenous thrombolysis appears to be a relatively safe and effective treatment alternative that is being used increasingly nationwide.

OBJECTIVE: Morbidity and mortality rates reported for meningioma resection in the elderly vary widely. Thus, it is difficult for neurosurgeons to compare the risks and benefits of operating on elderly patients against opting for radiosurgery or watchful waiting. To address this issue, we studied the effect of advanced age on outcome after meningioma resection using the Nationwide Inpatient Sample. METHODS: We identified all patients over the age of 20 in the Nationwide Inpatient Sample database who underwent surgical resection of a meningioma between 1998 and 2002 and were admitted from home. Primary outcomes were in-hospital mortality, adverse outcome (defined as death or discharge to a facility other than home), and length of hospitalization. Multivariate models were constructed to assess the effect of elderly age on the primary outcomes, adjusting for patient demographics, comorbid medical conditions, and hospital surgical volume. RESULTS: There were 8861 patients in the Nationwide Inpatient Sample database who underwent resection of meningioma during the study period; 26.0% were age 70 or older. Each of the primary outcomes demonstrated a marked effect of advancing age. The in-hospital mortality rate was higher in the elderly than in the nonelderly (4.0% versus 1.1%, P < 0.001), as was the rate of discharge to a facility other than home (53.2% versus 16.6%, P < 0.001). Elderly patients also had a longer mean length of stay (7.2 versus 5.1 d P < 0.001). CONCLUSION: The association between elderly age and adverse outcome after meningioma resection suggests a note of caution before proceeding to surgery with these patients.

Objective The purpose of this study was to assess the effect of maternal age on the rate of stillbirth in a large, nationwide sample of deliveries in the United States. Study design Data were derived from the Nationwide Inpatient Sample for the years 1995 through 2002. With the use of ICD-9 codes, the rate of stillbirth was determined as a function of maternal age. Multivariate regression analysis was used to assess the effect of maternal age on the odds of stillbirth, with adjustment for multiple known risk factors for stillbirth. Results There were 5,874,203 deliveries that were identified for analysis. The unadjusted rate of stillbirth was elevated for teenagers and for women aged ≥35 years. In the multivariate analysis, compared with women 20 to 34 years old, women who were ≤19 years old were more likely to have a pregnancy outcome of stillbirth (odds ratio, 1.11; 95% CI, 1.08-1.14), as were women who were 35 to 39 years old (odds ratio, 1.28; 95% CI, 1.24-1.32) and women who were ≥40 years old (odds ratio, 1.72; 95% CI, 1.63-1.81). Conclusion The extremes of maternal age are associated with an increased risk for stillbirth, even after adjustment for a large number of known predisposing conditions.

This review examines the possible role for definitive embolization as a primary therapy for intracranial meningiomas. Surgery or radiosurgery are currently considered the standard of care for most benign meningiomas. However, each of these carries substantial risks. The perioperative mortality for surgical resection, as reported in large series, is between 3.7–9.4%; these studies report a similarly high rate of new neurological deficits following surgery. The rate of complications from radiosurgery is reported between 2–16% and it may take months to years before improvement in symptoms occurs following this therapy. There are a few reports of treating meningiomas by embolization without subsequent surgery. While these studies include small numbers of patients and have limited follow-up, the initial results are very promising. Given the risks and limitations of surgery and radiosurgery, prospective trials are now needed to determine the safety and efficacy of definitive embolization.

BACKGROUND Subarachnoid hemorrhage (SAH) in pregnancy occurs because of a variety of etiologies, which range from ruptured aneurysms to benign venous bleeding. The more malignant etiologies represent an important cause of maternal morbidity and mortality. We sought to investigate the epidemiology and mechanisms of pregnancy-related SAH. METHODS Using the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, we extracted pregnancy-related admissions for women ages 15-44 from 1995-2008 and identified admissions complicated by SAH. Logistic regression identified independent predictors of SAH. Outcomes and risk factors were then compared with age-matched, nonpregnant women with SAH. We also analyzed our institution's experience with pregnancy-related SAH. RESULTS There were 639 cases (5.8 per 100,000 deliveries) of pregnancy-related SAH in the cohort during the study period; SAH was associated with 4.1% of all pregnancy-related in-hospital deaths. More than half of the SAH cases occurred postpartum. Advancing age, African-American race, Hispanic ethnicity, hypertensive disorders, coagulopathy, tobacco, drug or alcohol abuse, intracranial venous thrombosis, sickle cell disease, and hypercoagulability were independent risk factors for pregnancy-related SAH. Compared with SAH in nonpregnant controls, pregnancy-related SAH had lower clipping/coiling rates (12.7% vs. 44.5%, P < 0.001). We identified 12 cases of pregnancy-related SAH in our hospital, the majority of which presented postpartum and with severe headache. CONCLUSION SAH during pregnancy results from a range of etiologies, and is less likely to be because of a cerebral aneurysm than SAH occurring in the nonpregnant patient. Peripartum SAH frequently occurs in the setting of hypertensive disorders.

Background— Obtaining viable informed consent from stroke patients for participation in clinical trials of acute stroke therapies is often problematic because of patients’ neurological deficits. Furthermore, obtaining permission from surrogates is often not possible or not legally permissible. Summary of Review— In 1996 the Food and Drug Administration and Department of Health and Human Services published regulations that allow investigators to conduct emergency research without patient consent under a narrowly defined set of circumstances. We review requirements of these regulations, paying particular attention to how they may be applied in a clinical trial of an acute stroke therapy. Conclusions— Acute stroke researchers should consider conducting clinical trials with an exception from the informed consent requirement permitted by this law.

In response to Gupta’s letter,1 as we note in the discussion section in our paper,2 information on postoperative delirium is unfortunately not well captured in our …

Objective To evaluate the effect of anesthesia type on the risk of in-hospital mortality among adults undergoing hip fracture surgery in the United States. Design Retrospective cohort study. Setting Premier research database, United States. Participants 73 284 adults undergoing hip fracture surgery on hospital day 2 or greater between 2007 and 2011. Of those, 61 554 (84.0%) received general anesthesia, 6939 (9.5%) regional anesthesia, and 4791 (6.5%) combined general and regional anesthesia. Main outcome measure In-hospital all cause mortality. Results In-hospital deaths occurred in 1362 (2.2%) patients receiving general anesthesia, 144 (2.1%) receiving regional anesthesia, and 115 (2.4%) receiving combined anesthesia. In the multivariable adjusted analysis, when compared with general anesthesia the mortality risk did not differ significantly between regional anesthesia (risk ratio 0.93, 95% confidence interval 0.78 to 1.11) or combined anesthesia (1.00, 0.82 to 1.22). A mixed effects analysis accounting for differences between hospitals produced similar results: compared with general anesthesia the risk from regional anesthesia was 0.91 (0.75 to 1.10) and from combined anesthesia was 0.98 (0.79 to 1.21). Findings were also consistent in subgroup analyses. Conclusions In this large nationwide sample of hospital admissions, mortality risk did not differ significantly by anesthesia type among patients undergoing hip fracture surgery. Our results suggest that if the previously posited beneficial effect of regional anesthesia on short term mortality exists, it is likely to be more modest than previously reported.

The purpose of this study was to examine racial and ethnic disparities in severe maternal morbidity during delivery hospitalizations in the United States.We identified delivery hospitalizations from 2008-2010 in State Inpatient Databases from 7 states. We used International Classification of Diseases, 9th Revision, codes to create severe maternal morbidity indicators during delivery hospitalizations. We calculated the rates of severe maternal morbidity that were measured with and without blood transfusion for 5 racial/ethnic groups: non-Hispanic white, non-Hispanic black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women. Poisson regression models were fitted to explore the associations between race/ethnicity and severe maternal morbidity after we controlled for potential confounders.Overall, severe maternal morbidity rates that were measured with and without blood transfusion were 150.7 and 64.3 per 10,000 delivery hospitalizations, respectively. Non-Hispanic black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women had 2.1, 1.3, 1.2, and 1.7 times (all P.05), respectively, higher rates of severe morbidity that were measured with blood transfusion compared with non-Hispanic white women; similar increased rates were observed when severe morbidity was measured without blood transfusion. Other significant positive predictors of severe morbidity were age20 and ≥30 years, self-pay or Medicaid coverage for delivery, low socioeconomic status, and presence of chronic medical conditions.Severe maternal morbidity disproportionally affects racial/ethnic minority women, especially non-Hispanic black women. There is a need for a systematic review of severe maternal morbidities at the facility, state, and national levels to guide the development of quality improvement interventions to reduce the racial/ethnic disparities in severe maternal morbidity.

To explore the impact of a community-based dental care pathway on the dental care of children entering residential or foster care.The study used qualitative data collected during interviews with children who used the service, their carers and key professionals involved in the pathway, and routine quantitative data concerned with care entry and the dental service use.The dental pathway facilitated dental care access for children entering statutory care, met the dental needs of service users even when dental care provision proved challenging, and offered a consistent dental service regardless of care moves. Improved interagency integration and support was reported by key professionals as was better dissemination and documentation of dental assessments and outcomes.The dental care pathway had a beneficial impact on the dental access and experiences of children who used it, promoted better interagency working and facilitated record keeping. These findings call for extension of the service to a wider population to allow further evaluation of its impact and efficacy in different regional areas and contexts.

Background Acute kidney injury is a frequent postoperative complication that confers increased mortality, morbidity, and costs. The purpose of this study was to evaluate whether preoperative statin use is associated with a decreased risk of postoperative acute kidney injury. Methods We assembled a retrospective cohort of 98,939 patients who underwent a major open abdominal, cardiac, thoracic, or vascular procedure between 2000 and 2010. Statin users were pair-matched to nonusers on the basis of surgery type, baseline kidney function, days from admission until surgery, and propensity score based on demographics, comorbid conditions, and concomitant medications. Acute kidney injury was defined based on changes in serum creatinine measurements applying Acute Kidney Injury Network and Risk-Injury-Failure staging systems, and on the need for renal replacement therapy. Associations between statin use and acute kidney injury were estimated by conditional logistic regression. Results Across various acute kidney injury definitions, statin use was consistently associated with a decreased risk: adjusted odds ratios (95% confidence intervals) varied from 0.74 (0.58-0.95) to 0.80 (0.71-0.90). Associations were similar among diabetics and nondiabetics, and across strata of baseline kidney function. The protective association of statins was most pronounced among patients undergoing vascular surgery and least among patients undergoing cardiac surgery. Conclusions Preoperative statin use is associated with a decreased risk of postoperative acute kidney injury. Future randomized clinical trials are needed to determine causality.

Objective To determine whether use of intermediate acting neuromuscular blocking agents during general anesthesia increases the incidence of postoperative respiratory complications. Design Prospective, propensity score matched cohort study. Setting General teaching hospital in Boston, Massachusetts, United States, 2006-10. Participants 18 579 surgical patients who received intermediate acting neuromuscular blocking agents during surgery were matched by propensity score to 18 579 reference patients who did not receive such agents. Main outcome measures The main outcome measures were oxygen desaturation after extubation (hemoglobin oxygen saturation 3%) and reintubations requiring unplanned admission to an intensive care unit within seven days of surgery. We also evaluated effects on these outcome variables of qualitative monitoring of neuromuscular transmission (train-of-four ratio) and reversal of neuromuscular blockade with neostigmine to prevent residual postoperative neuromuscular blockade. Results The use of intermediate acting neuromuscular blocking agents was associated with an increased risk of postoperative desaturation less than 90% after extubation (odds ratio 1.36, 95% confidence interval 1.23 to 1.51) and reintubation requiring unplanned admission to an intensive care unit (1.40, 1.09 to 1.80). Qualitative monitoring of neuromuscular transmission did not decrease this risk and neostigmine reversal increased the risk of postoperative desaturation less than 90% (1.32, 1.20 to 1.46) and reintubation (1.76, 1.38 to 2.26). Conclusion The use of intermediate acting neuromuscular blocking agents during anesthesia was associated with an increased risk of clinically meaningful respiratory complications. Our data suggest that the strategies used in our trial to prevent residual postoperative neuromuscular blockade should be revisited.

Objective: To determine whether pregnant women with brain tumors have an elevated risk of adverse pregnancy outcomes. Background Diagnosis of a brain tumor during pregnancy presents complex management challenges, and relevant population-based studies are lacking. Design/Methods: We designed a retrospective cohort study using the Nationwide Inpatient Sample (NIS), a stratified sample of US hospitalizations, to investigate pregnancy outcomes in women with brain tumors. We constructed a logistic regression model for the outcomes of maternal mortality, preterm labor, Caesarean delivery, miscarriage, and elective abortion, controlling for age, medical comorbidities, and demographic and hospital characteristics. Results: We identified 379 malignant and 437 benign brain tumors among 19 million pregnancy-related admissions between 1988 and 2009. Malignant brain tumors were associated with maternal mortality (OR 143), miscarriage (OR 1.8), and elective abortion (OR 11.6). Caesarean delivery was more frequent for malignant (OR 5.3) and benign (OR 2.2) brain tumors. Admissions not resulting in a delivery were more common for malignant (OR 8.6) and benign (OR 4.3) brain tumors. As with non-pregnant adult brain tumor patients, seizures (16%) and hydrocephalus (6%) were the most common associated diagnoses. Hyperemesis gravidarum was more common for malignant (OR 2.2) and benign (OR 2.8) brain tumors, raising the suspicion that elevated intracranial pressure was responsible for symptoms thought to be pregnancy-related. 27% of all hospitalizations involved a neurosurgical procedure, but the likelihood of pregnancy complications was not significantly increased in these patients. All reported associations were statistically significant to a level of p Conclusions: Brain tumors are strongly associated with adverse pregnancy outcomes, but neurosurgery during pregnancy does not appear to enhance these risks. Brain tumors were associated with higher rates of Caesarean delivery, implying a conservative management strategy. Further research is needed to improve understanding of obstetric risk in this patient population and to assist with treatment, prenatal counseling, and monitoring during delivery. Supported by: Harvard Center for Neurofibromatosis and Allied Disorders. Disclosure: Dr. Terry has nothing to disclose. Dr. Barker has nothing to disclose. Dr. Leffert has nothing to disclose. Dr. Bateman has nothing to disclose. Dr. Souter has nothing to disclose. Dr. Plotkin has received research support from Pfizer.

N 80-yr-old man underwent hybrid thoracoabdominal aortic aneurysm repair using open and endovascular techniques. He had a cerebrospinal fluid (CSF) drain placed before the procedure for spinal cord protection by means of decreasing CSF pressure and promoting perfusion. It was removed on postoperative day 2, but replaced on postoperative day 3 because of lower extremity weakness. During both placements skin disinfection was achieved with povidone/iodine. Wide sterile fields were used and operators wore sterile gloves, hats, and masks. The CSF drain remained in place until the seventh postoperative day because as the lower extremity weakness recurred with trials of clamping. The patient became febrile to 102.7°F. He developed mental status changes and computed tomography of the head was obtained emergently. This revealed layering thick fluid in the occipital horns bilaterally with increased periventricular white matter hypoattenuation, indicating meningitis with pus in the ventricles. CSF analysis revealed abundant polynuclear cells and few gram-negative rods. The culture grew Klebsiella pneumoniae. The spinal drain was removed, and the patient was treated with broad- spectrum antibiotics. He slowly recovered and was eventually discharged to a rehabilitation facility with residual proximal leg weakness suggestive of mild anterior cord ischemia syndrome. Placement of CSF drains has been shown to decrease the incidence of paralysis after thoracoabdominal aneurysm repair. 1 Serious complications associated with CSF drains include intracranial hemorrhage 2 and retained catheter fragments. 3 Meningitis is a very rare complication of lumbar drains placed for spinal cord protection during aortic aneurysm repair. 3 Longer duration of drainage and repeated procedures might increase meningitis risk. This case demonstrates that meningitis should be considered in patients with CSF drains placed for spinal cord protection that develop fever and altered mental status. References

Background We aimed to define the frequency and predictors of successful external cephalic version in a nationally-representative cohort of women with breech presentations and to compare maternal outcomes associated with successful external cephalic version versus persistent breech presentation. Methods Using the Nationwide Inpatient Sample, a United States healthcare utilization database, we identified delivery admissions between 1998 and 2011 for women who had successful external cephalic version or persistent breech presentation (including unsuccessful or no external cephalic version attempt) at term. Multivariable logistic regression identified patient and hospital-level factors associated with successful external cephalic version. Maternal outcomes were compared between women who had successful external cephalic version versus persistent breech. Results Our study cohort comprised 1,079,576 delivery admissions with breech presentation; 56,409 (5.2 %) women underwent successful external cephalic version and 1,023,167 (94.8 %) women had persistent breech presentation at the time of delivery. The rate of cesarean delivery was lower among women who had successful external cephalic version compared to those with persistent breech (20.2 % vs. 94.9 %; p 7 days (aOR = 0.53, 95 % CI 0.40–0.70), but had a higher risk of chorioamnionitis (aOR = 1.83, 95 % CI 1.54–2.17). Conclusions Overall a low proportion of women with breech presentation undergo successful external cephalic version, and it is associated with significant reduction in the frequency of cesarean delivery and a number of measures of maternal morbidity. Increased external cephalic version use may be an important approach to mitigate the high rate of cesarean delivery observed in the United States.