Search

Richard E Hughes,1,2 Brian R Hallstrom,1,2 Mark E Cowen,1,3 Rochelle M Igrisan,1,2 Bonita M Singal,1,3 David A Share,2,4 1Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI), Ann Arbor, MI, USA; 2Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA; 3Quality Institute, St Joseph Mercy Hospital, Ann Arbor, MI, USA; 4Blue Cross and Blue Shield of Michigan, Detroit, MI, USA Background: The United States has been a difficult environment in which to develop arthroplasty registries, largely because of the absence of a national health system. The purpose of this paper is to describe the development of a statewide registry-based quality improvement collaborative in Michigan. Methods: The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) was started in 2011 to improve the quality of care for total hip and knee replacement patients in Michigan. It is funded by Blue Cross and Blue Shield of Michigan/Blue Care Network as part of their Collaborative Quality Initiative (CQI) program. The CQI concept depends on capturing high-quality data (clinical status, process, and outcome), rigorously developing risk-adjustment models, and presenting risk-adjusted data to collaborative members at four face-to-face meetings a year. Results: MARCQI has grown to include 44 hospitals and 377 orthopedic surgeons. The registry contains 54,848 cases (18,421 hips and 36,427 knees). Four collaborative-wide quality improvement activities have been initiated: 1) transfusion reduction, 2) deep vein thrombosis and pulmonary emboli prevention, 3) infection prevention, and 4) readmission prevention. Conclusion: The CQI model developed by Blue Cross and Blue Shield of Michigan/Blue Care Network can be adapted to hip and knee arthroplasty, which demonstrates that private payers can play a role in the development and promotion of arthroplasty registries in the United States. Keywords: registry, arthroplasty, hip, knee, quality, collaboration

PURPOSE: To evaluate the effect of preference assessment method on treatment recommended by an individualized decision-analytic model for early prostate cancer. METHODS: Health state preferences were elicited by time tradeoff, rating scale, and a power transformation of the rating scale from 63 men ages 55 to 75. The authors used these values in a Markov model to determine whether radical prostatectomy or watchful waiting yielded the greater quality-adjusted life expectancy. RESULTS: Time tradeoff and transformed rating scale recommendations differed widely. Time tradeoff and transformed rating scale utilities differed in their treatment recommendation for 21% to 52% of men, and the mean difference in quality-adjusted life years varied from less than 0.5 to greater than 1.0. CONCLUSIONS: Treatment recommendations from the prostate cancer decision model were sensitive to the method of preference assessment. If decision analysis is used to counsel individual patients, careful consideration must be given to the method of preference elicitation. [ABSTRACT FROM AUTHOR]

This case report describes an unusual cardiac complication in a 22 year old, female injecting drug user. The retention of two fractured injection needles at the site of intravenous injection in the groin, and the subsequent embolisation of one to the right ventricle, predisposed to recurrent local and systemic infections, and endocarditis. Two years later, the needle was completely embedded in the wall of the right ventricle and not suitable for transvenous removal. Removal of the retained and/or embolised needle at an earlier stage would have precluded these complications. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to assess variations in surgical stage distribution in 2 centres within the same UK region. One centre was covered by an active screening program started in November 2018 and the other was not covered by screening., Methods: Retrospective analysis of 1895 patients undergoing lung resections (2018-2022) in 2 centres. Temporal distribution was tested using Chi-squared for trends. A lowess curve was used to plot the proportion of stage 1A patients amongst those operated over the years., Results: The surgical populations in the 2 centres were similar. In the screening unit (SU), we observed a 18% increase in the proportion of patients with clinical stage IA in the recent phase compared to the early phase (59% vs 50%, P = 0.004), whilst this increase was not seen in the unit without screening. This difference was attributable to an increase of cT1aN0 patients in the SU (16% vs 11%, P = 0.035) which was not observed in the other unit (10% vs 8.2%, P = 0.41). In the SU, there was also a three-fold increase in the proportion of sublobar resections performed in the recent phase compared to the early one (35% vs 12%, P < 0.001). This finding was not evident in the unit without screening., Conclusions: Lung cancer screening is associated with a higher proportion of lung cancers being detected at an earlier stage with a consequent increased practice of sublobar resections., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-754/coif). The authors have no conflicts of interest to declare.

Background: The Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR) and Knee Injury and Osteoarthritis Outcome Score Joint Replacement (KOOS JR) scores represent pain and dysfunction as a single number ranging from 0 (extreme pain and dysfunction) to 100 (no pain or functional limitations). However, scores between 0 and 100 lack a simple interpretation because they reflect varying combinations of pain levels and dysfunction. Given that most adverse events and improvement occur within the first 90 days after surgery, a deeper understanding of the level of pain and dysfunction may reveal missed opportunities for patient care., Questions/purposes: (1) What does a given preoperative or postoperative HOOS JR and KOOS JR score indicate about pain and ability to perform daily activities? (2) How much of a change in score (that is, delta) is needed to indicate significant improvement in pain control and daily functioning?, Methods: The Michigan Arthroplasty Registry Collaborative Quality Initiative contains more than 95% of THAs and TKAs performed in Michigan. Between January 2017 and March 2019, 84,175 people in the registry underwent primary THA or TKA and were potentially eligible for this retrospective, comparative study of the first 90 postoperative days. Eighty-four percent (70,608 of 84,175) were excluded because their surgeons did not attain a target survey collection proportion of 70% and another 6% (5042) were missing covariate information or surveys, leaving 10% (8525) for analysis. The mean age and percentage of women were 65 ± 11 years and 55% (2060 of 3716), respectively, for patients undergoing THA and 67 ± 9 years and 61% (2936 of 4809), respectively, for those undergoing TKA. There were no clinically meaningful differences between patients who were analyzed and those who were excluded except for lower representation of non-White patients in the analyzed group. For interpretation, patient responses to Question 7 (pain) and Question 6 (function) from the Patient-Reported Outcomes Measurement Information System global items (PROMIS-10) were dichotomized into "much pain" (rating of pain 4 to 10 of 10) versus "less pain" (rating of ≤ 3) and "good function" (able to perform most activities) versus "poor function" (not able to perform most activities) and combined into four pain-function categories. We examined the mean preoperative and postoperative HOOS JR and KOOS JR scores for each pain-function category, adjusted for patient characteristics. We calculated the size of the delta associated with an increase to a more favorable category postoperatively (versus staying in the same or worse category) via multivariable logistic regression that controlled for patient characteristics., Results: Patients in the least favorable "much pain, poor function" category preoperatively had adjusted mean scores of 40 (95% confidence interval 39 to 41) for both the HOOS JR and KOOS JR. Those with mixed levels of pain and function had mean scores between 46 and 55. Those in the most favorable "less pain, good function" category had means of 60 (95% CI 58 to 62) and 59 (95% CI 58 to 61) for the HOOS JR and KOOS JR, respectively. The adjusted delta to achieve a pain level of ≤ 3 or the ability to perform most activities was 30 (95% CI 26 to 36) on the HOOS JR and 27 (95% CI 22 to 29) on the KOOS JR scales., Conclusion: These adjusted means of the HOOS JR and KOOS JR provide context for understanding the levels of pain and dysfunction for individuals as well for patients reported in other studies. Potential quality improvement efforts could include tracking the proportion of patients with THA or TKA who achieved a sufficient delta to attain pain levels of ≤ 3 or the ability to perform most activities. Future studies are needed to understand pain and function represented by the HOOS JR and KOOS JR at 1 to 2 years, how these may differ by patient subgroups, and whether scores can be improved through quality improvement efforts., Level of Evidence: Level III, therapeutic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 by the Association of Bone and Joint Surgeons.)

Background: Uncertainty remains surrounding the use of aspirin as a sole chemoprophylactic agent to reduce the risk of venous thromboembolism (deep vein thrombosis or pulmonary embolism) and bleeding after primary total hip arthroplasty., Methods: We performed a non-inferiority analysis of a retrospective cohort of patients undergoing total hip arthroplasty from April 1, 2013 to December 31, 2018. Cases were retrieved from the Michigan Arthroplasty Registry Collaborative Quality Initiative database and performed by 355 surgeons at 61 hospitals throughout Michigan. Surgical setting ranged from small community hospitals to large academic and non-academic centers. The primary outcomes were post-operative venous thromboembolism event or death and bleeding event., Results: Of the 59,747 patients included, 32,878 (55.03%) were female, and the mean age was 64.5. A total of 462 (0.77%) composite venous thromboembolism events occurred. There were 221 (0.71%) and 129 (0.80%) venous thromboembolism events in patients receiving aspirin only and anticoagulants only, respectively. Aspirin was non-inferior to anticoagulants for composite venous thromboembolism events (odds ratio 0.99, 95% confidence interval 0.79-1.26, P < .001). Bleeding events occurred in 767 (1.28%) patients, with 304 (0.97%) and 281 (1.74%) bleeding events in patients receiving aspirin only and anticoagulants only, respectively. Aspirin was non-inferior to anticoagulants for bleeding events (odds ratio 0.62, 95% confidence interval 0.52-0.74, P < .001)., Conclusion: Aspirin is not inferior to other anticoagulants as pharmacologic venous thromboembolism prophylaxis with regards to post-operative risk of venous thromboembolism or bleeding. Sole use of aspirin for venous thromboembolism prophylaxis after total hip arthroplasty should be considered in the appropriate patient., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Although mortality prediction tools are the subject of significant interest as components of comprehensive hip fracture protocols, few have been applied or validated to prospectively inform ongoing patient management. Five regional hospitals are currently generating real-time mortality risk scores for all adults at the time of admission using available laboratory and comorbidity data (Cowen et al. J Hosp Med 9(11):720-726, 2014). Although results for aggregated conditions have been published, the primary aim of this study is to determine how well prospectively calculated scores predict mortality for hip fracture patients specifically., Methods: Using a five-hospital database, 1376 patients who were prospectively scored on admission were identified from January 2013 to April 2017, cross-referencing ICD9/10 diagnosis and procedure codes for AO/OTA 31A1 through 31B3 fractures. Prospective mortality scores have been previously divided into 5 risk categories to facilitate ease of clinical use. Vital status was determined from hospital data, Social Security and Michigan Death Indices., Results: Prospective scores demonstrated good mortality prediction, with AUCs of 0.80, 0.73, 0.74 and 0.74 for in hospital, 30-, 60- and 90-day mortality, respectively. Patients in the top 2 mortality risk categories represented 30% (410/1376) of the cohort and accounted for 78% (25/32) of the inpatient and 59% (57/97) of the 30 day deaths., Conclusions: Implementation of this real-time mortality risk tool is feasible and valid for the prediction of short- to medium-term mortality risk for hip fracture patients, and potentially offers valuable information to guide ongoing patient management decisions such as admitting service or level of care.

The care of patients with multiple chronic conditions and those near the end-of-life is often compromised by miscommunications among the healthcare teams. These might be improved by using common risk strata for both hospital and ambulatory settings. We developed, validated, and implemented an all-payer ambulatory risk stratification based on the patients' predicted probability of dying within 30 days, for a large multispecialty practice. Strata had comparable 30-day mortality rates to hospital strata already in use. The high-risk ambulatory strata contained less than 20% of the ambulatory population yet captured 85% of those with 3 or more comorbidities, more than 80% of those who would die 30 or 180 days from the date of scoring, and two-thirds of those with a nonsurgical hospitalization within the next 30 days. We provide examples how the practice and partner hospital have begun to use this common framework for their clinical care model.

Objective: Myocardial management during on-pump coronary artery bypass grafting (CABG) surgery includes aortic cross-clamping followed by fibrillation (XCF) and aortic cross-clamping followed by diastolic cardioplegia (cardioplegia). The authors wished to compare in-hospital and survival outcomes between these procedures., Design: A retrospective observational study utilizing propensity matching., Setting: Tertiary Referral Centre for Heart Surgery., Participants: A total of 8,875 consecutive patients undergoing CABG surgery between August 1999 and February 2018., Interventions: After 1:1 matching, the authors had 3,340 patients in the cardioplegia group and 3,340 in the XCF group., Measurements and Main Results: Baseline characteristics were not significant between the matched cardioplegia and XCF groups. The XCF group had shorter pump times (61.8 minutes +/-26.8 v 74.7 minutes +/-29.5, p < 0.0001) and shorter cross-clamp times (27.80 minutes +/-10.5 v 44.44 minutes +/-18.0, p < 0.0001) compared with the cardioplegia group despite a similar median number of distal anastomoses (3 v 3, p = 0.08). After surgery, atrial arrhythmias (32% v 36%, p = 0.01) and inotropic requirement (25% v 28%, p = 0.006) were less in the XCF group compared with the cardioplegia group, respectively. Other postoperative outcomes (such as mortality and cerebrovascular events) were not statistically different. There was a mean survival advantage in using cardioplegia compared with XCF (15.4 years versus 14.7 years, log-rank, p = 0.014; 10-year survival 64% v 61% and 18-year survival 38% v 34%)., Conclusion: This is the largest analysis of XCF. XCF does not adversely affect in-hospital outcomes. Long-term results demonstrate cardioplegic arrest may convey a survival advantage that would preclude routine XCF in the modern era., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The decision of whether to admit a patient to a critical care unit is a crucial operational problem that has significant influence on both hospital performance and patient outcomes. Hospitals currently lack a methodology to selectively admit patients to these units in a way that patient health risk metrics can be incorporated while considering the congestion that will occur. The hospital is modeled as a complex loss queueing network with a stochastic model of how long risk-stratified patients spend time in particular units and how they transition between units. A Mixed Integer Programming model approximates an optimal admission control policy for the network of units. While enforcing low levels of patient blocking, we optimize a monotonic dual-threshold admission policy. A hospital network including Intermediate Care Units (IMCs) and Intensive Care Units (ICUs) was considered for validation. The optimized model indicated a reduction in the risk levels required for admission, and weekly average admissions to ICUs and IMCs increased by 37% and 12%, respectively, with minimal blocking. Our methodology captures utilization and accessibility in a network model of care pathways while supporting the personalized allocation of scarce care resources to the neediest patients. The interesting benefits of admission thresholds that vary by day of week are studied.

Objectives: With an ageing population, increasing numbers of octogenarians are undergoing high-risk cardiac surgery. We examine the changing characteristics and in-hospital outcomes for octogenarians over an 18-year period., Methods: Clinical data from our prospective database for all octogenarians who had cardiac surgery from March 1999 through May 2016 were reviewed. We examined trends, risk profiles and in-hospital outcomes over 3 eras, namely early (1999-2004), middle (2005-2010) and late (2011-2016). A multivariable analysis was performed to identify independent predictors for adverse outcomes., Results: There were 1022 patients aged 80-94 years in our study cohort. The octogenarian population increased progressively from early to late eras (4.5%, n = 255 vs 7.1%, n = 321 vs 9.3%, n = 446), as the average logistic EuroSCORE predicted mortality (9% vs 9.7% vs 10.1%, P < 0.01). On the contrary, observed mortality declined substantially (9.4% vs 7.8% vs 4.7%, P = 0.04) over this period. While cardiac morbidity and respiratory comorbidities were more prevalent in the late era, chronic renal failure was more frequent in the early era. Over time, more procedures were performed electively (P = 0.05). Common operations across all eras were coronary artery bypass grafting (CABG), aortic valve replacement and CABG + aortic valve replacement. Emergency operation [odds ratio (OR) 4.96, 95% confidence interval (CI) 1.51-16.35; P < 0.01], poor ejection fraction (OR 3.38, 95% CI 1.80-6.32; P < 0.01) and bypass time (OR 1.01, 95% CI 1.00-1.02; P < 0.01) were predictors of in-hospital mortality. The late era of surgery (OR 0.41, 95% CI 0.23-0.73; P < 0.01) was associated with reduced mortality risk., Conclusions: The operative outcome in this growing surgical population is steadily improving despite the increasing prevalence of comorbidities, and surgery should be performed electively as much as possible., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Importance: There has been significant debate in the surgical and medical communities regarding the appropriateness of using aspirin alone for venous thromboembolism (VTE) prophylaxis following total knee arthroplasty (TKA)., Objective: To determine the acceptability of aspirin alone vs anticoagulant prophylaxis for reducing the risk of postoperative VTE in patients undergoing TKA., Design, Setting, and Participants: Noninferiority study of a retrospective cohort of TKA cases submitted to the Michigan Arthroplasty Registry Collaborative Quality Initiative at 29 member hospitals, ranging from small community hospitals to large academic and nonacademic medical centers in Michigan. The study included 41 537 patients who underwent primary TKA between April 1, 2013, and October 31, 2015. Clinical events were monitored for 90 days after surgery. Data were analyzed between September and October 2016., Exposures: The method of pharmacologic prophylaxis: neither aspirin nor anticoagulants for 668 patients (1.6%), aspirin only for 12 831 patients (30.9%), anticoagulant only (eg, low-molecular-weight heparin, warfarin, and Xa inhibitors) for 22 620 patients (54.5%), and both aspirin/anticoagulant for 5418 patients (13.0%). Most patients were also using intermittent pneumatic compression stockings., Main Outcome and Measures: The primary composite outcome was the first occurrence of VTE or death. The noninferiority margin was specified as 0.3. The secondary outcome was bleeding events., Results: Of the 41 537 patients, 14 966 were men (36%), and the mean age was 65.8 years. A VTE event occurred in 573 of 41 537 patients (1.38%); 32 of 668 (4.79%) who received no pharmacologic prophylaxis, 149 of 12 831 (1.16%) treated with aspirin alone, 321 of 22 620 (1.42%) with anticoagulation alone, and 71 of 5418 (1.31%) prescribed both aspirin and anticoagulation. Aspirin only was noninferior for the composite VTE outcome compared with those receiving other chemoprophylaxis (adjusted odds ratio, 0.85; 95% CI, 0.68-1.07, P for inferiority = .007). Bleeding occurred in 457 of 41 537 patients (1.10%), 10 of 668 (1.50%) without prophylaxis, 116 of 12 831 (0.90%) in the aspirin group, 258 of 22 620 (1.14%) with anticoagulation, and 73 of 5418 (1.35%) of those receiving both. Aspirin alone was also noninferior for bleeding complications (adjusted odds ratio, 0.80; 95% CI, 0.63-1.00, P for inferiority <.001)., Conclusions and Relevance: In this study of patients undergoing TKA, aspirin was not inferior to other anticoagulants in the postoperative rate of VTE or death. Aspirin alone may provide similar protection from postoperative VTE compared with other anticoagulation treatments.

The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) is a regional quality improvement effort that is focused on hip and knee arthroplasty. From its inception in 2012, MARCQI has grown to include data from 66 hospitals and surgery centers, and contains over 209,000 fully abstracted cases in its database. Using high-quality risk-standardized outcomes data, MARCQI drives quality improvement through a collaborative and nonpunitive structure. Quality improvement initiatives have included transfusion reduction, infection prevention, venous thromboembolism reduction, and reduction of discharge to nursing homes. In addition, MARCQI focuses on postmarket surveillance of implants by computing revision-risk estimates based on the cases that were registered prior to the end of 2016. This paper describes the impact of MARCQI on the quality of hip and knee arthroplasty care in the state of Michigan since its inception in 2012, and it briefly summarizes the recently released 5-year report.

Objectives: Conventional cardiopulmonary bypass is the most commonly used means of artificial circulation in cardiac surgery. However, it suffers from the effects of haemodilution and activation of inflammatory/coagulation cascades. Prime displacement (PD) can offset haemodilution and mini-extracorporeal technology (MIECT) can offset both. So far, no study has compared all of these modalities together; hence, we compared the outcomes of these 3 modalities at our institution., Methods: This was a retrospective analysis of our cardiac surgical database. A total of 9626 patients underwent conventional bypass (CB), 3125 patients underwent a modification of CB, called PD, and 904 underwent MIECT. A 1:1 propensity-matching algorithm was employed using IBM SPSS 24 to match (i) 813 MIECT patients with 813 CB patients and (ii) 717 MIECT patients with 717 PD patients. The patients included coronary artery bypass grafting and valve surgery., Results: MIECT had significantly (P < 0.05) longer bypass and cross-clamp times compared to CB and PD. MIECT had significantly higher rates of postoperative atrial fibrillation associated with it compared to CB. The mean red cell blood transfusion was significantly lower in the MIECT group compared to the CB group as was the mean platelet transfusion and fresh frozen plasma transfusion. The overall 5-year survival was higher in the MIECT group compared to the CB group (log-rank, P = 0.018). Between the MIECT and the PD groups, we found the incidence of renal failure and gastrointestinal complications to be significantly higher in the PD group compared to the MIECT group., Conclusions: MIECT has short-term advantages over CB and PD. However, due to the retrospective limitations of the study, including calendar time bias, a multicentre randomized controlled trial comparing all 3 modalities will be beneficial for the larger cardiac community.

Background: The efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion requirements in total hip and knee arthroplasty has been well established in small controlled clinical trials and meta-analyses. The purpose of the current study was to determine the risks and benefits of TXA use in routine orthopaedic surgical practice on the basis of data from a large, statewide arthroplasty registry., Methods: From April 18, 2013, to September 30, 2014, there were 23,236 primary total knee arthroplasty cases and 11,489 primary total hip arthroplasty cases completed and registered in the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI). We evaluated the association between TXA use and hemoglobin drop, transfusion, length of stay (LOS), venous thromboembolism (VTE), readmission, and cardiovascular events by fitting mixed-effects generalized linear and mixed-effects Cox models. We used inverse probability of treatment weighting to enhance causal inference., Results: For total hip arthroplasty, TXA use was associated with a smaller drop in hemoglobin (mean difference = -0.65 g/dL; 95% confidence interval [CI] = -0.60 to -0.71 g/dL), decreased odds of blood transfusion (odds ratio [OR] = 0.72; 95% CI = 0.60 to 0.86), and decreased readmissions (OR = 0.77; 95% CI = 0.64 to 0.93) compared with no TXA use. There was no effect on VTE (hazard ratio [HR] = 0.91; 95% CI = 0.62 to 1.33), LOS (incident rate ratio [IRR] = 1.00; 95% CI = 0.97 to 1.03), or cardiovascular events (OR = 0.85; 95% CI = 0.47 to 1.52). For total knee arthroplasty, TXA was associated with a smaller drop in hemoglobin (mean difference = -0.68 g/dL; 95% CI = -0.64 to -0.71 g/dL) and one-fourth the odds of blood transfusion (OR = 0.26; 95% CI = 0.21 to 0.31). There was an association with decreased risk of VTE within 90 days after surgery (HR = 0.56; 95% CI = 0.42 to 0.73), slightly decreased LOS (IRR = 0.93; 95% CI = 0.92 to 0.95), and no association with readmissions (OR = 0.90; 95% CI = 0.79 to 1.04) or cardiovascular events (OR = 1.12; 95% CI = 0.74 to 1.71)., Conclusions: In routine orthopaedic surgery practice, TXA use was associated with decreased blood loss and transfusion risk for both total knee and total hip arthroplasty, without evidence of increased risk of complications. TXA use was also associated with reduced risk of readmission among total hip arthroplasty patients and reduced risk of VTE among total knee arthroplasty patients, and did not have an adverse effect on cardiovascular complications in either group., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Studies have shown an association between the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) scores and clinical quality. The mortality risk on admission predicts adverse events. It is not known if this risk also portends a suboptimal patient experience., Objective: To determine if the admission mortality risk identifies an experience of care risk., Design: A retrospectively assembled cohort in which individual HCAHPS survey responses were linked to the admission risk of dying., Setting: Five community hospitals of various sizes in Michigan., Patients: There were 17,509 HCAHPS medical and surgical respondents; 2513 (14.4%) were at high risk of dying., Measurements: Odds ratio (OR) (high-risk patients to low-risk patients) for providing a top box score for HCAHPS dimensions, controlling for hospital and the standard HCAHPS patient mix adjustment factors., Results: High-risk respondents were less likely to provide the most favorable response (unadjusted) for all HCAHPS domains, although the difference was not significant (P = 0.09) for discharge information. Multivariable analyses indicated that high-risk patients were less likely to report a top box experience for doctor communication (OR: 0.85; 95% confidence interval [CI]: 0.77-0.94) and responsiveness of hospital staff (OR: 0.77; 95% CI: 0.69-0.85), but were more likely to have received adequate discharge information (OR: 1.30, 95% CI: 1.14-1.48)., Conclusions: Patients at high risk of dying who completed surveys were less likely to report favorable physician communication and staff responsiveness. Further understanding of these relationships may help design a care model to improve both outcomes and experience. Journal of Hospital Medicine 2016;11:628-635. © 2016 Society of Hospital Medicine., (© 2016 Society of Hospital Medicine.)

Background: Surgery is the most important therapeutic modality for lung cancer. Surgical outcomes are normally reported as 30-day or 90-day mortality or 5-year survival; 10-year survival is rarely mentioned in national data or international studies., Methods: Three hundred and six patients (79% male) underwent pneumonectomy, mainly for lung cancer, from January 1998 to February 2013. Their short- and long-term outcomes up to September 2014 were analyzed retrospectively. The mean age was 64 years (range 22-82 years) and 24% were aged ≥70 years. Thoracoscore was used to calculate the risk of hospital mortality., Results: Operative mortality was 4.5% whereas predicted mortality was 8%. The operative mortality for cancer patients was 3.3%; the national mortality for lung cancer is 6.5%. Only 2 patients died in hospital after a pneumonectomy in the last 5 years. Half of the patients who died in hospital were ≥70 years old; 29% (4 patients) died after urgent operations for nonmalignant disease. Overall 5- and 10-year survival was 32% and 20%. Median and mean survival was 26 and 57 months, respectively. Long-term survival was better in females aged <70 years, in left pneumonectomy patients, and in those with squamous cell lung cancer., Conclusion: Our mortality for pneumonectomy was 50% less than the national mortality rate and significantly lower than that predicted by the Thoracoscore for lung cancer. This confirms that pneumonectomy is still an effective modality for the treatment of lung cancer, with low operative mortality and good long-term survival, especially in younger patients., (© The Author(s) 2016.)

Objectives: Bowel ischaemia following cardiac surgery is associated with a high postoperative mortality. No scoring system exists as yet to predict this complication following surgery. In addition, the long-term survival is not known. We sought to evaluate in-hospital outcomes and long-term outcomes in bowel ischaemia following cardiac surgery. We also sought to devise a simple risk prediction model for this catastrophic entity., Methods: This was a retrospective study of data entered prospectively into our cardiac surgical database between July 1999 and May 2014. We compared the short- and long-term outcomes of patients who developed bowel ischaemia following cardiac surgery with those who did not develop bowel ischaemia using propensity-matched analysis. We developed a prediction model for bowel ischaemia from logistic regression., Results: In total, 13 853 patients underwent cardiac surgery. Of these, 85 had confirmed bowel ischaemia following surgery. The in-hospital mortality rate for those with bowel ischaemia was 60%, while in those without bowel ischaemia, the mortality rate was 3% (P < 0.0001). In those bowel ischaemia patients who had a laparotomy for corrective surgery, the in-hospital mortality was significantly less compared with those who did not have a laparotomy (39.2 vs 91.2%, P < 0.0001). The long-term survival for bowel ischaemia at 2, 6 and 10 years was 35% (±5), 31% (±5) and 26% (+/6), respectively. Multivariable analysis revealed that advanced age at surgery, peripheral vascular disease, intra-aortic balloon pump usage, NYHA IV and postoperative atrial fibrillation were the significant (P < 0.005) determinants of developing postoperative bowel ischaemia. We developed a model to predict bowel ischaemia and validated it within our population (c-index = 0.781)., Conclusions: We have shown that whilst bowel ischaemia carries a higher short-term mortality, the long-term mortality is not significantly greater for those few who survive to discharge. We have developed a simple prediction model to identify those at high risk of developing bowel ischaemia following cardiac surgery in order to optimize perioperative strategies in future., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: A previously published, retrospectively derived prediction rule for death within 30 days of hospital admission has the potential to launch parallel interdisciplinary team activities. Whether or not patient care improves will depend on the validity of prospectively generated predictions, and the feasibility of generating them on demand for a critical proportion of inpatients., Objective: To determine the feasibility of generating mortality predictions on admission and to validate their accuracy using the scoring weights of the retrospective rule., Design: Prospective, sequential cohort., Setting: Large, tertiary care, community hospital in the Midwestern United States, Patients: Adult patients admitted from the emergency department or scheduled for elective surgery, Results: Mortality predictions were generated on demand at the beginning of the hospitalization for 9312 (92.9%) out of a possible 10,027 cases. The area under the receiver operating curve for 30-day mortality was 0.850 (95% confidence interval: 0.833-0.866), indicating very good to excellent discrimination. The prospectively generated 30-day mortality risk had a strong association with the receipt of palliative care by hospital discharge, in-hospital mortality, and 180-day mortality, a fair association with the risk for 30-day readmissions and unplanned transfers to intensive care, and weak associations with receipt of intensive unit care ever within the hospitalization or the development of a new diagnosis that was not present on admission (ie, complication)., Conclusions: Important prognostic information is feasible to obtain in a real-time, single-assessment process for a sizeable proportion of hospitalized patients., (© 2014 Society of Hospital Medicine.)

Background: The United States has established aortic supercenters, which have demonstrated clear improvements in the short-term and long-term outcomes after surgery on the thoracic aorta. This model of care does not exist in the United Kingdom. We have looked at our recent experience of emergency and elective thoracic aortic surgery and describe and compare our operative outcomes and 10-year survival with other regional centers and supercenters worldwide., Methods: This was a retrospective analysis of data collected prospectively from our cardiac database on patients who underwent surgery on the thoracic aorta (n=318) between November 1999 and November 2012. The outcome measures were adjusted operative mortality, postoperative complications, and long-term survival., Results: Type A dissection was carried out on 23.90% of the patients and 76.10% had surgery on the aortic root and thoracic aorta for nondissection. The mean age of the patients was 62.21±14.1 years. The mean logistic EuroSCORE was 26 in the dissection group and 19 in the nondissection group. Hospital mortality was significantly greater (P<.05) in the dissection group compared with the nondissection group (23.7% vs 12.8%). Survival after dissection and nondissection surgery was 66.3%±5.6% versus 77.4%±2.8%, respectively, at 3 years, 63.9%±5.9% versus 71.8%±3.2% at 5 years, and 53.7%±7.4% versus 47.1%±6.0% at 10 years., Conclusions: Our outcomes are comparable with other regional centers worldwide; however, they are not as good as those reported from the aortic supercenters. There should be continued impetus regarding the establishment of thoracic aortic surgery guidelines and specialist aortic centers in the United Kingdom., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Thoracoscore is incorporated in the new British Thoracic Society and National Institute of Health and clinical Excellence guidelines to evaluate the operative mortality risk of patients undergoing thoracic surgery. This study examines the accuracy of Thoracoscore in predicting postoperative mortality in patients undergoing pneumonectomy., Methods: All patients who underwent pneumonectomy from January 1998 to March 2008 were included. Thoracoscore was calculated based on the following variables: age, sex, American Society of Anaesthesiologists' class, performance status classification, dyspnoea score, priority of surgery, procedure class, Diagnosis group and comorbidities score., Results: Two hundred and forty-three patients with a mean age of 63 ± 9 years were included and 81% were male. The predicted postoperative mortality based on Thoracoscore was 8 ± 2.6% (95% confidence interval (CI) 4.56-11.43), while actual in-hospital mortality was 4.5% (11/243) (95% CI 1.87-7.12). 54% (6/11) of in-hospital mortality was of those who were >70 years old and 73% (8/11) of patients who died in hospital were male. Nine of 11 (82%) patients had pneumonectomy for malignancy. Thoracoscore was divided into four risk groups: low (0-3), moderate (3.1-5), high (5.1-8) and very high (>8). It underestimated mortality in low-risk group while overestimated in high-risk groups. The 30-day, 1-year, 2-year and 3-year observed mortalities were 5.3, 29, 43 and 55%, respectively., Conclusions: Although advanced age, the male sex and malignancy proved to be strong predictors of in-hospital mortality in our study, Thoracoscore failed to predict accurate risk of in-hospital mortality in pneumonectomy patients in this study. Further studies are required to validate the Thoracoscore in different subgroups of thoracic surgery.

Objective: Acute rises in pulmonary artery pressures following complex cardiac surgery are associated with high morbidity and mortality. We hypothesised that periods of deep hypothermia predispose to elevated pulmonary pressures upon rewarming. We investigated the effect of this hypothermic preconditioning on isolated human pulmonary arteries and isolated perfused lungs., Methods: Isometric tension was measured in human pulmonary artery rings (n=24). We assessed the constriction and dilation of these arteries at 37 °C and 17 °C. Isolated perfused human lung models consisted of lobes ventilated via a bronchial cannula and perfused with Krebs via a pulmonary artery cannula. Bronchial and pulmonary artery pressures were recorded. We investigated the effect of temperature using a heat exchanger., Results: Rewarming from 17 °C to 37 °C caused a 1.3 fold increase in resting tension (p<0.05). Arteries constricted 8.6 times greater to 30 nM KCl, constricted 17 times greater to 1 nM Endothelin-1 and dilated 30.3 times greater to 100 μM SNP at 37 °C than at 17 °C (p<0.005). No difference was observed in the responses of arteries originally maintained at 37 °C compared to those arteries maintained at 17 °C and rewarmed to 37 °C. Hypothermia blunted the increase in pulmonary artery pressures to stimulants such as potassium chloride as well as to H-R but did not precondition arteries to higher pulmonary artery pressures upon re-warming., Conclusions: Deep hypothermia reduces the responsiveness of human pulmonary arteries but does not, however, precondition an exaggerated response to vasoactive agents upon re-warming., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Favorable health outcomes are more likely to occur when the clinical team recognizes patients at risk and intervenes in consort. Prediction rules can identify high-risk subsets, but the availability of multiple rules for various conditions present implementation and assimilation challenges., Methods: A prediction rule for 30-day mortality at the beginning of the hospitalization was derived in a retrospective cohort of adult inpatients from a community hospital in the Midwestern United States from 2008 to 2009, using clinical laboratory values, past medical history, and diagnoses present on admission. It was validated using 2010 data from the same and from a different hospital. The calculated mortality risk was then used to predict unplanned transfers to intensive care units, resuscitation attempts for cardiopulmonary arrests, a condition not present on admission (complications), intensive care unit utilization, palliative care status, in-hospital death, rehospitalizations within 30 days, and 180-day mortality., Results: The predictions of 30-day mortality for the derivation and validation datasets had areas under the receiver operating characteristic curve of 0.88. The 30-day mortality risk was in turn a strong predictor for in-hospital death, palliative care status, 180-day mortality; a modest predictor for unplanned transfers and cardiopulmonary arrests; and a weaker predictor for the other events of interest., Conclusions: The probability of 30-day mortality provides health systems with an array of prognostic information that may provide a common reference point for organizing the clinical activities of the many health professionals involved in the care of the patient., (Copyright © 2012 Society of Hospital Medicine.)

Objectives. Acute rises in pulmonary artery pressures following postinfarction ventricular septal defects present a challenge. We hypothesised that the abnormally high oxygen content exposure to the pulmonary arteries may be a factor. We investigated the contractile responses of human pulmonary arteries to changes in oxygen tension. Methods. Isometric tension was measured in large and medium sized pulmonary artery rings obtained from lung resections for patients with bronchial carcinoma (n = 30). Fresh rings were mounted in organ baths bubbled under basal conditions with hyperoxic or normoxic gas mixes and the gas tensions varied during the experiment. We studied whether voltage-gated calcium channels and nitric oxide signalling had any role in responses to oxygen changes. Results. Hypoxia caused a net mean relaxation of 18.1% ± 15.5 (P < 0.005) from hyperoxia. Subsequent hyperoxia caused a contraction of 19.2% ± 13.5 (P < 0.005). Arteries maintained in normoxia responded to hyperoxia with a mean constriction of 14.8% ± 3.9 (P < 0.005). Nifedipine inhibited the vasoconstrictive response (P < 0.05) whilst L-NAME had no effect on any hypoxic vasodilatory response. Conclusions. We demonstrate that hyperoxia leads to vasoconstriction in human pulmonary arteries. The mechanism appears to be dependent on voltage-gated calcium channels. Hyperoxic vasoconstriction may contribute to acute rises in pulmonary artery pressures.

Background: Although disease management programs for patients hospitalized with heart failure (HF) are effective, they are, however, often resource intensive, limiting their uptake. Peer support programs have led to improved outcomes among patients with other chronic conditions and may result in similar improvements for patients with HF., Methods and Results: In this randomized controlled trial, reciprocal peer support (RPS) arm patients participated in a HF nurse practitioner-led goal setting group session, received brief training in peer communication skills, and were paired with another participant in their cohort with whom they were encouraged to talk weekly using a telephone platform. Participants were also encouraged to attend 3 nurse practitioner-facilitated peer support group sessions. Patients in the nurse care management arm attended a nurse practitioner-led session to address their HF care questions and receive HF educational materials and information on how to access care management services. The median age of the patients was 69 years; 51% were female and 26% were racial/ethnic minorities. Only 55% of RPS patients participated in peer calls or group sessions. In intention-to-treat analyses, the RPS and nurse care management groups did not differ in time-to-first all-cause rehospitalization or death or in mean numbers of rehospitalizations or deaths. There were no differences in improvements in 6-month measures of HF-specific quality of life or social support. Conclusions- Among patients recently hospitalized for HF, more than half of RPS participants had no or minimal engagement with the RPS program, and the program did not improve outcomes compared with usual HF nurse care management., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. UNIQUE IDENTIFIER: NCT00508508.

Background: Patients who undergo coronary artery stent procedures are at risk for late atherothrombotic events, including stent thrombosis. The relationship between the duration during which evidence-based medical therapies are utilized after coronary artery stenting and the risk of late atherothrombotic events is not well characterized., Methods: In a retrospective cohort study linking a hospital-based percutaneous coronary intervention registry with a health maintenance organization claims dataset, we related the duration of medical therapy utilization during follow up to the hazard for death, myocardial infarction, unstable angina, transient ischemic attack or stroke following a coronary artery stent procedure. Multivariable Cox models were employed in which medical treatments were entered as time-varying covariates; data were stratified by stent type and time period., Results: The median [interquartile range, IQR] duration of follow up was 832 [460, 1420] days. During this time, 86 ischemic events occurred in 84 of 386 patients at a median [IQR] of 260 [110, 658] days. The incidence of atherothrombotic events following coronary artery stenting was highest during the first post-procedure year and declined substantially thereafter. Multivariable predictors of incident ischemic events included multivessel coronary artery disease (HR 2.01 [95% CI 1.30-3.11], p=0.0018) and longer duration angiotensin converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), beta blocker or statin therapy (HR 0.52 [95% CI 0.28-0.99], p=0.045)., Conclusions: The use of longer-term ACE inhibitor/ARB, beta blocker or statin therapy was associated with a significantly lower risk; these risk reductions were of greater magnitude than those associated with clopidogrel., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Intrathoracic epithelioid mesothelioma commonly presents as a diffuse tumor of the pleura. It rarely occurs as a localized tumor that might be surgically resectable. We report a case of one such localized mesothelioma in a 72-year-old woman, which arose from the wall of the esophagus and had all the presenting features of an esophageal tumor.

Study Objective: We want to know whether a low B-type natriuretic peptide (BNP) level, obtained shortly after presentation and independent of information provided by other clinical findings and laboratory tests, would affect management decisions for emergency department (ED) patients with nondiagnostic troponin levels. Previous studies have generally been retrospective or inclusive of patients with heart failure., Methods: We prospectively studied patients evaluated for possible acute coronary syndromes who had nondiagnostic levels of serum troponin, nondiagnostic ECGs, and no clinical heart failure within 4 hours of presentation. BNP levels were obtained but results not provided to clinical staff. The primary outcome was the composite of acute myocardial infarction or death within 30 days. The secondary outcome was the composite of the primary outcome, percutaneous coronary intervention, or coronary artery bypass grafting., Results: Almost half of the patients screened for but excluded from the study had known heart failure or a history of heart failure. The resulting cohort was composed of 348 patients, with a median age of 64 years and 51% women. The primary outcome occurred in 16.1% of patients; the secondary outcome, in 27.6%. At a standard cutoff of BNP greater than or equal to 80 pg/mL, the negative predictive value for the primary outcome was 80% (95% confidence interval 73% to 86%). The negative predictive value for the secondary outcome was 69% (95% confidence interval 61% to 75%). Multivariable analyses supported these findings., Conclusion: A single, low BNP level obtained shortly after presentation to the ED could not identify patients at low risk for 30-day acute myocardial infarction or death., (Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Objective: Small coronary size and extensive atherosclerosis pose operative challenges during coronary artery bypass grafting. We investigated the influence of coronary characteristics on early operative outcome., Methods: Prospectively collected data for 5171 patients undergoing first-time coronary artery bypass grafting from April 1, 1999, to December 31, 2007, were analyzed. Coronary diameter estimated or probe-gauged intraoperatively was regarded as small if 1.25 mm or less. Coronary atherosclerosis was graded as none/mild or moderate/severe. Their influence on postoperative major adverse cardiac events, myocardial infarction or reintervention for graft failure, post-cardiotomy shock, and operative mortality, was investigated., Results: Of 14,019 coronary anastomoses, 4417 coronaries (31.5%) were small and 5895 coronaries (43.4%) had moderate/severe atherosclerosis. All grafted coronaries were small in 1091 patients (21.1%). Left anterior descending, circumflex, and right coronary arteries received grafts in 94.8% of patients (n = 4903), 74.3% of patients (n = 3842), and 72.5% of patients (n = 3751), with corresponding rates of 31.7%, 31.7%, and 32.6% for small-caliber arteries, 44.4%, 33.3%, and 47.2% for moderate/severe atherosclerosis, and 0.6%, 0.5%, and 3.4% for endarterectomy. Postoperative major adverse cardiac events occurred in 236 patients (4.6%). There was no clear evidence that small caliber of half or more distal anastomoses in a patient (odds ratio, 1.36; 95% confidence interval, 0.97-1.94; P = .07) increased the risk of a major adverse cardiac event, but incomplete revascularization (odds ratio, 1.87; 95% confidence interval, 1.03-3.39; P = .04) and moderate/severe atherosclerosis of the left anterior descending artery (odds ratio 1.37; 95% confidence interval, 1.01-1.87; P = .04) did increase the risk., Conclusion: Grafting small coronaries did not significantly increase the risk of an early postoperative major adverse cardiac event, but incomplete revascularization did increase the risk. Our findings support grafting small coronaries when technically feasible to prevent incomplete revascularization., (2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: Preoperative neurological event with functional impairment is high risk for operative morbidity and mortality after coronary artery bypass grafting (CABG). However, data regarding the influence of remote and reversible neurological events on early and late survival are lacking., Methods: The clinical profile and operative outcome of 5542 patients who underwent first-time CABG from 01 April 1999 through 30 June 2008 were analysed. Late survival data were 100% complete. The relationship between preoperative neurological event and survival (early and late) was investigated using multivariate logistic regression and survival analyses., Results: Mean age was 65.2+/-9.2 years, and 494 patients (8.9%) had remote reversible neurological events preoperatively. There were 129 (2.3%) operative and 595 (10.7%) late deaths after a mean follow-up of 4.9+/-2.7 years. Reversible neurological events had strong univariate (odds ratio (OR) 2.80, 95% confidence interval (CI) 1.82-4.33, p<0.0001) and multivariate associations (OR 2.14, 95% CI 1.34-3.41, p=0.001) with operative mortality. Although reversible neurological events exhibited a powerful univariate relationship with late deaths (hazard ratio (HR) 1.66, 95% CI 1.30-2.12, p<0.0001), this was not maintained after controlling for other factors in multivariable analysis (HR 1.24, 95% CI 0.97-1.59, p=0.08). Neurological complications, more frequent in patients with preoperative events, were implicated in 25% of operative deaths in patients with preoperative neurological events. The respective 5- and 10-year survival rates for patients with reversible neurological events (86% and 68%) were substantially lower than others (91% and 80%, p<0.0001)., Conclusions: Remote reversible neurological events increase the risk of fatal and non-fatal postoperative neurological complications. Rigorous measures to improve cerebral protection are warranted in these patients., (Copyright 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

In this paper, we propose a flexible "two-part" random effects model (Olsen and Schafer, 2001; Tooze et al., 2002) for correlated medical cost data. Typically, medical cost data are right-skewed, involve a substantial proportion of zero values, and may exhibit heteroscedasticity. In many cases, such data are also obtained in hierarchical form, e.g., on patients served by the same physician. The proposed model specification therefore consists of two generalized linear mixed models (GLMM), linked together by correlated random effects. Respectively, and conditionally on the random effects and covariates, we model the odds of cost being positive (Part I) using a GLMM with a logistic link and the mean cost (Part II) given that costs were actually incurred using a generalized gamma regression model with random effects and a scale parameter that is allowed to depend on covariates (cf., Manning et al., 2005). The class of generalized gamma distributions is very flexible and includes the lognormal, gamma, inverse gamma and Weibull distributions as special cases. We demonstrate how to carry out estimation using the Gaussian quadrature techniques conveniently implemented in SAS Proc NLMIXED. The proposed model is used to analyze pharmacy cost data on 56,245 adult patients clustered within 239 physicians in a mid-western U.S. managed care organization., (Copyright 2009 Elsevier B.V. All rights reserved.)

Background: Study objectives were to (1) report the clinical profile of and outcome for patients who experience a cardiorespiratory arrest after coronary artery bypass grafting or aortic valve replacement, and (2) identify factors associated with improved probability of survival., Methods: We identified 108 consecutive patients who had cardiorespiratory arrest after coronary artery bypass grafting or aortic valve replacement between April 1999 and June 2008. We studied the characteristics of arrests and survivors, and performed a multivariate logistic analysis to determine features associated with survival to hospital discharge., Results: Cardiac arrest (n = 86) was more common than respiratory arrest (n = 13; unknown cause, n = 9). Cardiorespiratory arrest occurred with decreasing frequency from the day of surgery. Ventricular fibrillation or tachycardia was the dominant mechanism of cardiac arrest (70% versus 17% for asystole versus 13% for pulseless electrical activity), and the principal causes were postoperative myocardial infarction (n = 46; 53%) and tamponade or bleeding (n = 21; 24%). Resternotomy was performed in 45 patients (52%), cardiopulmonary bypass reinstituted in 14 (16%), and additional grafts constructed in 5 (6%). The causes of respiratory arrest were mainly pulmonary (n = 8) and neurologic (n = 5). Survival to hospital discharge was better for respiratory arrest (69%) than for cardiac arrest (50%). Older age, ejection fraction less than 0.30, and postoperative myocardial infarction decreased the probability of survival., Conclusions: Ventricular fibrillation or tachycardia was the most common mechanism, and myocardial infarction, the predominant precipitating cause of cardiac arrest after coronary artery bypass grafting or aortic valve replacement. Despite aggressive resuscitation, outcome is poor. Young patients with good left ventricular function had a better probability of survival if they did not suffer a postoperative myocardial infarction.

Objective: Cardiac surgery is higher risk in the elderly. It has been suggested that preoperative left ventricular systolic dysfunction (LVSD) and cardiopulmonary bypass (CPB) affect elderly and young patients differently. This study investigates the predictive risk of preoperative LVSD and CPB time for operative mortality in the two groups of patients., Methods: We reviewed the data for 2616 consecutive patients aged >/=70 years and 4078 young patients who had coronary artery bypass grafting (CABG) and/or valve surgery between March 1998 and January 2007. Subgroups defined by severity of LVSD (ejection fraction >0.50 [mild], 0.31-0.50 [moderate] and

Objective: Studies of postoperative morbidity in diabetics have focussed on infection; however, autonomic and cardiovascular complications of diabetes potentially increase the risk for non-infective morbidity. We sought to investigate major non-infective early postoperative complications in diabetic patients., Methods: We identified diabetics who underwent CABG and/or valve operation from 1998 through 2007, and compared their clinical characteristics and outcome with a contemporaneous cohort of non-diabetic patients., Results: The demographic characteristics of 1145 diabetics were similar to 5534 non-diabetic patients (mean age 66+/-9 years vs 66+/-10 years, p=0.45, female 27.5% vs 26.7%, p=0.59, respectively). Class III/IV angina symptoms (43.9% vs 34.9%, p<0.0001), intravenous nitrates therapy (10.4% vs 6.6%, p<0.0001), heart failure (24.8% vs 20.4%, p=0.001), prior myocardial infarction (37% vs 31%, p<0.0001), ejection fraction

Background: Aggressive nonsurgical revascularization results in high-risk patients presenting for operation at a later stage of coronary artery disease (CAD). This study investigated the effect of temporal changes in operative characteristics on outcomes of surgical revascularization., Methods: We compared preoperative, intraoperative, and postoperative variables of 5633 patients who underwent surgical revascularization for CAD between April 1998 and January 2007, divided into early (1998 to 2002, n = 2746) and late (2004 to 2007, n = 2887) eras. End points were major adverse outcomes (postoperative myocardial infarction, stroke, new dialysis) and operative mortality., Results: Median age (66 vs 68 years, p < 0.0001), prevalence of left ventricular systolic dysfunction, left main stem disease, prior angioplasty, diabetes mellitus, concomitant valve operation, and aprotinin use increased steadily over time. Severe symptoms, nonelective operations, mean number of grafts, postoperative bleeding, reopening for bleeding, and blood transfusion declined. Major complications were evenly distributed between the eras. Operative mortality for isolated coronary artery bypass grafting did not change (2.0% vs 1.8% p = 0.62) despite increasing operative risk (p < 0.0001); there was a 100% reduction in the absolute risk (110% to 210%) over time. The markers for operative difficulties, such as longer bypass times, were determinants of operative mortality and, in addition to other predictors like age and left ventricular systolic dysfunction, were more prevalent in the late era., Conclusions: Coronary operations are increasingly performed in higher-risk patients; however, surgical revascularization is nearly twice as safe in current practice compared with a decade ago.

Background: Some recent multicenter series have questioned the safety of aprotinin in primary cardiac operations. We report a large, single-center experience with aprotinin therapy in primary cardiac operations and discuss the limitations and potential confounders of current treatment strategies., Methods: We compared myocardial infarction, neurologic events, renal insufficiency, and operative death after first-time coronary or valve procedures, or both, in 3334 patients treated with full-dose aprotinin with 3417 patients not treated with aprotinin who underwent operation between March 1998 and January 2007. Further analysis was performed for 341 propensity score-matched pairs., Results: There were substantial differences between the groups. Aprotinin patients were higher risk on account of older age, unstable symptoms, poor ejection fraction, preoperative hemodynamic support, emergency/urgent operations, and combined coronary/valve operations. Postoperative bleeding and blood product transfusion were considerably reduced in aprotinin patients, as was median duration of mechanical ventilation. Aprotinin was neither a predictor of postoperative myocardial infarction, renal insufficiency, neurologic dysfunction, or operative death. Achieving parity between the groups by propensity score matching eliminated the elevated rates of postoperative renal insufficiency, neurologic dysfunction, and operative death observed in aprotinin patients in the unmatched comparison. These adverse outcomes were evenly distributed between matched groups. Conversely, blood transfusion had univariate associations with all adverse outcome measures., Conclusions: Full-dose aprotinin use was not associated with myocardial infarction, neurologic dysfunction, renal insufficiency, or death after coronary or valve operations. We observed less postoperative bleeding and blood product transfusion, and early extubation with the use of aprotinin.

Objective: Early post-sternotomy tracheostomy is not infrequently considered in this era of percutaneous tracheostomy. There is, however, some controversy about its association with sternal wound infections., Methods: Consecutive patients who had percutaneous tracheostomy following median sternotomy for cardiac operation at our institution from March 1998 through January 2007 were studied, and compared to contemporaneous patients. We identified risk factors for tracheostomy, and investigated the association between percutaneous tracheostomy and deep sternal wound infection (mediastinitis) by multivariate analysis., Results: Of 7002 patients, 100 (1.4%) had percutaneous tracheostomy. The procedure-specific rates were: 8.6% for aortic surgery, 2.7% for mitral valve repair/replacement (MVR), 1.1% for aortic valve replacement (AVR), and 0.9% for coronary artery bypass grafting (CABG). Tracheostomy patients differed vastly from other patients on account of older age, severe symptoms, preoperative support, lower ejection fraction, more comorbidities, more non-elective and complex operations and higher EuroScore. Risk factors for tracheostomy were New York Heart Association class III/IV (OR 6.01, 95% CI 2.28-16.23, p<0.0001), chronic obstructive pulmonary disease (OR 1.84, 95% CI 1.01-3.37, p=0.05), preoperative renal failure (OR 3.57, 95% CI 1.41-9.01, p=0.007), prior stroke (OR 3.08, 95% CI 1.75-5.42, p<0.0001), ejection fraction<0.30% (OR 2.73, 95% CI 1.23-6.07, p=0.01), and bypass time (OR 1.008, 95% CI 1.004-1.012, p<0.0001). The incidences of deep (9% vs 0.7%, p<0.0001) and superficial sternal infections (31% vs 6.5%, p<0.0001) were significantly higher among tracheostomy patients. Multivariate analysis identified percutaneous tracheostomy as a predictor for deep sternal wound infection (OR 3.22, 95% CI 1.14-9.31, p<0.0001)., Conclusions: Tracheostomy, often performed in high-risk patients, may further complicate recovery with sternal wound infections, including mediastinitis, therefore, patients and timing should be carefully selected for post-sternotomy tracheostomy.

Background: Ischemic ventricular fibrillation/tachycardia (VF/VT) treated by myocardial revascularization, often with an implanted cardioverter defibrillator, prevents sudden cardiac death. Early series have suggested that recurrent VF/VT threatens survival even after treatment. As late outcome is unknown, we sought to determine if the early survival benefit is sustained., Methods: From January 1999 through January 2007, 93 consecutive patients (75 male, 81%) presented with ischemic VF/VT; 21% survived cardiac arrest and underwent coronary artery bypass graft surgery at our institution. We analyzed their early and late survival., Results: Median age was 66 years (range, 44 to 88). Clinical presentation included class III/IV angina (46%), controlled heart failure (43%), prior myocardial infarction (68%), left ventricular ejection fraction less than 0.30 (23%) and 0.30 to 0.50 (35%), left main stem disease (24%), and triple-vessel disease (67%). Surgical revascularization, mostly nonelective (urgent 73%, emergency 7%), was combined with aortic valve replacement in 5 patients and left ventricular pseudoaneurysm repair in 3. Ischemic territories and mean number of diseased coronaries (2.6) corresponded to the grafted territories and average number of grafts (2.5). Operative mortality was 6.5% (n = 6, median EuroSCORE [European System for Cardiac Operative Risk Evaluation] predicted mortality 9). Recurrent VF/VT occurred early postoperatively in 21 patients (24%). All patients had electrophysiologic studies postoperatively and 40% received an implanted cardioverter defibrillator. Of 12 late deaths (16%) at follow-up extending to 8 years, 4 (33%) were due to cardiac causes. Five-year survival was 88%, equivalent to that (83% to 85%) reported for patients with sinus rhythm preoperatively., Conclusions: Complete myocardial revascularization for ischemic VF/VT yields excellent early and late results; 5-year survival is comparable to that of patients with preoperative sinus rhythm.