Critical Outcomes in Nonrobotic vs Robotic-Assisted Cardiac Surgery.
Yanagawa Franz,Perez Martin,Bell Ted,Grim Rod,Martin Jennifer,Ahuja Vanita
JAMA surgery
IMPORTANCE:As robotic-assisted cardiac surgical procedures increase nationwide, surgeons need to be educated on the safety of the new modality compared with that of open technique. OBJECTIVE:To compare complications, length of stay (LOS), actual cost, and mortality between nonrobotic and robotic-assisted cardiac surgical procedures. DESIGN, SETTING, AND PARTICIPANTS:Weighted data on cardiac patients who had undergone operations involving the valves or septa and vessels, as well as other heart and pericardium procedures, from January 1, 2008, to December 31, 2011, were obtained from the Nationwide Inpatient Sample via the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. Propensity score matching was used to match each robotic-assisted case to 2 nonrobotic cases on 14 characteristics. MAIN OUTCOMES AND MEASURES:Complications, median LOS, actual cost, and mortality. RESULTS:Exploratory analysis found a total of 1,374,653 cardiac cases (1,369,454 [99.6%] nonrobotic and 5199 [0.4%] robotic-assisted cases). After propensity score matching, there were 10,331 (66.5%) nonrobotic cases and 5199 (33.5%) robotic-assisted cases. Cardiac operations included 1630 (10.5%) involving the valves or septa, 6616 (42.6%) involving the vessels, and 7284 (46.9%) other heart and pericardium procedures. Robotic-assisted compared with nonrobotic surgery had a higher median cost ($39,030 vs $36,340; P < .001) but lower LOS (5 vs 6 days; P < .001) and lower mortality (1.0% vs 1.9%; P < .001). Robotic-assisted surgery had significantly fewer complications for all operation types (30.3% vs 27.2%; P < .001). CONCLUSIONS AND RELEVANCE:Overall, robotic-assisted surgery has significantly reduced median LOS, complications, and mortality compared with nonrobotic surgery. Results of this study support the contention that robotic-assisted surgery is as safe as nonrobotic surgery and offers the surgeon an additional technique for performing cardiac surgery.
10.1001/jamasurg.2015.1098
Empirical Antibiotic Treatment Does Not Improve Outcomes in Catheter-Associated Urinary Tract Infection: Prospective Cohort Study.
Babich Tanya,Zusman Oren,Elbaz Michal,Ben-Zvi Haim,Paul Mical,Leibovici Leonard,Avni Tomer
Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
BACKGROUND:Catheter associated urinary tract infection (CAUTI) is the most common healthcare-associated acquired infection. We aimed to describe the short- and long-term survival of patients with CAUTI and the impact of the empirical antibiotic treatment on survival rates. METHODS:In this prospective observational study we included consecutive adult patients with a chronic indwelling catheter-associated UTI and sepsis hospitalized in medical departments. The primary outcomes were 30-days all-cause mortality and long-term survival at end of the follow-up. A multivariate analysis using logistic regression and Cox proportional hazard model was performed to identify independent risk factors for an adverse outcome. A propensity-score model for receiving appropriate empirical antibiotic therapy was constructed and used to match patients. RESULTS:Overall, 315 consecutive patients with CAUTI were enrolled. The cohort consisted of elderly to very old patients (mean age 79.2 ± 11.5). The crude 30-day all-cause mortality rate was 30.8% (97/315). The median survival time was 82 days (interquartile range [IQR] 22-638). Appropriate early empirical treatment had no statistically significant association with 30-day mortality, propensity score-matched odds ratio (OR) 1.39 (0.76-2.55). Similarly, in the propensity-matched cohort, appropriate empirical treatment was not statistically associated with long-term survival (hazard ratio [HR] = 0.99, 95% confidence interval [CI] 0.75-1.3). CONCLUSIONS:In our setting, patients with CAUTI had poor short- and long-term prognosis regardless of appropriate empirical antibiotic treatment. Avoiding empirical antibiotics for CAUTI might be an important antibiotic stewardship intervention in hospitals.
10.1093/cid/cix680
Use of Elderly Donors in Liver Transplantation: A Paired-match Analysis at a Single Center.
Ghinolfi Davide,Lai Quirino,Pezzati Daniele,De Simone Paolo,Rreka Erion,Filipponi Franco
Annals of surgery
OBJECTIVE:To evaluate the use of elderly donors in liver transplantation (LT) and identify risk factors associated with a worse outcome. SUMMARY BACKGROUND DATA:Use of livers from very old donors could expand the donor pool but is not universally implemented. METHODS:This is a retrospective, single-center medical record review. From January 2001 to December 2014, 1354 LTs were performed. After exclusion of donors <18 years, ABO-incompatible LT, re-LT and UNOS 1 status patients, LT recipients were stratified into 2 groups based on donor age: 18-69 (n=692) vs. ≥70 years (n=515) then matched using a propensity score approach. Two groups were finally matched (young group = 448 cases; old group = 515 cases). RESULTS:The median (interquartile range [IQR]) follow-up was 5.0 (2.0-8.4) years. Comparing the 2 identified groups, no differences were observed regarding early retransplants (1.8 vs. 2.9; P = 0.3), HCV-related death (7.6 vs. 8.7%; P = 0.6), vascular (5.8 vs. 5.0%; P = 0.7), and biliary complications (16.5 vs. 18.6%; P = 0.4). On multivariate analysis, independent risk factors for graft loss were: HCV-positive recipient (HR = 2.1; 95% CI = 1.6-2.7; P < 0.001), donor age (HR = 1.0; 95% CI = 1.0-1.0; P < 0.001), cold ischemia time (HR = 1.0; 95% CI = 1.0-1.0; P = 0.042), and donor history of diabetes mellitus (HR = 1.48; 95% CI = 1.03-2.13; P = 0.036). CONCLUSIONS:Use of elderly donors is not associated per se with an increased risk of vascular and biliary complications. In the presence of cold ischemia time and diabetes mellitus, appropriate donor-to-recipient matching is warranted.
10.1097/SLA.0000000000002305
Does Extracorporeal Membrane Oxygenation Improve Survival in Pediatric Acute Respiratory Failure?
American journal of respiratory and critical care medicine
RATIONALE:Extracorporeal membrane oxygenation (ECMO) has supported gas exchange in children with severe respiratory failure for more than 40 years, without ECMO efficacy studies. OBJECTIVES:To compare the mortality and functional status of children with severe acute respiratory failure supported with and without ECMO. METHODS:This cohort study compared ECMO-supported children to pair-matched non-ECMO-supported control subjects with severe acute respiratory distress syndrome (ARDS). Both individual case matching and propensity score matching were used. The study sample was selected from children enrolled in the cluster-randomized RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) clinical trial. Detailed demographic and daily physiologic data were used to match patients. The primary endpoint was in-hospital mortality. Secondary outcomes included hospital-free days, ventilator-free days, and change in functional status at hospital discharge. MEASUREMENTS AND MAIN RESULTS:Of 2,449 children in the RESTORE trial, 879 (35.9%) non-ECMO-supported patients with severe ARDS were eligible to match to 61 (2.5%) ECMO-supported children. When individual case matching was used (60 matched pairs), the in-hospital mortality rate at 90 days was 25% (15 of 60) for both the ECMO-supported and non-ECMO-supported children (P > 0.99). With propensity score matching (61 matched pairs), the ECMO-supported in-hospital mortality rate was 15 of 61 (25%), and the non-ECMO-supported hospital mortality rate was 18 of 61 (30%) (P = 0.70). There was no difference between ECMO-supported and non-ECMO-supported patients in any secondary outcomes. CONCLUSIONS:In children with severe ARDS, our results do not demonstrate that ECMO-supported children have superior outcomes compared with non-ECMO-supported children. Definitive answers will require a rigorous multisite randomized controlled trial.
10.1164/rccm.201709-1893OC
Survival benefit of liver resection for hepatocellular carcinoma associated with portal vein invasion.
Kokudo Takashi,Hasegawa Kiyoshi,Matsuyama Yutaka,Takayama Tadatoshi,Izumi Namiki,Kadoya Masumi,Kudo Masatoshi,Ku Yonson,Sakamoto Michiie,Nakashima Osamu,Kaneko Shuichi,Kokudo Norihiro,
Journal of hepatology
BACKGROUND & AIMS:The presence of portal vein tumor thrombosis (PVTT) in patients with hepatocellular carcinoma (HCC) is regarded as indicating an advanced stage, and liver resection (LR) is not recommended. The aim of this study was to evaluate the survival benefit of LR for HCC patients with PVTT through the analysis of the data from a Japanese nationwide survey. METHODS:We analyzed data for 6474 HCC patients with PVTT registered between 2000 and 2007. Of these patients, 2093 patients who underwent LR and 4381 patients who received other treatments were compared. The propensity scores were calculated and we successfully matched 1058 patients (66.1% of the LR group). RESULTS:In the Child-Pugh A patients, the median survival time (MST) in the LR group was 1.77years longer than that in the non-LR group (2.87years vs. 1.10years; p<0.001) and 0.88years longer than that in the non-LR group (2.45years vs. 1.57years; p<0.001) in a propensity score-matched cohort. A subgroup analysis revealed that LR provides a survival benefit regardless of age, etiology of HCC, tumor marker elevation, and tumor number. The survival benefit was not statistically significant only in patients with PVTT invading the main trunk or contralateral branch. In the LR group, the postoperative 90-day mortality rate was 3.7% (68 patients). CONCLUSIONS:As long as the PVTT is limited to the first-order branch, LR is associated with a longer survival outcome than non-surgical treatment. LAY SUMMARY:The presence of portal vein tumor thrombosis in patients with hepatocellular carcinoma is regarded as indicating an advanced stage, and liver resection is not recommended. We performed a multicenter, nationwide study to assess the survival benefit of liver resection in hepatocellular carcinoma patients with portal vein tumor thrombosis using propensity score-based matching. As long as the portal vein tumor thrombosis is limited to the first-order branch, liver resection is associated with a longer survival outcome than non-surgical treatment.
10.1016/j.jhep.2016.05.044
Fondaparinux for the treatment of suspected heparin-induced thrombocytopenia: a propensity score-matched study.
Kang Matthew,Alahmadi Majed,Sawh Sonja,Kovacs Michael J,Lazo-Langner Alejandro
Blood
Current guidelines for heparin-induced thrombocytopenia (HIT) management recommend heparin cessation and switching to a nonheparin anticoagulant (ie, argatroban, danaparoid) upon clinical suspicion. Fondaparinux may be effective but information supporting its use is limited. We retrospectively evaluated 239 patients who received a nonheparin anticoagulant (fondaparinux = 133, danaparoid = 59, and argatroban = 47) for suspected or confirmed HIT. A propensity score was constructed based on age, gender, creatinine, 4T scores, and comorbidity index, and used to match 133 patients to 60 controls. Outcomes were thrombosis or thrombosis-related death and major bleeding. In the matched population there were 22 (16.5%) episodes of thromboses in the fondaparinux group and 13 (21.4%) in the control group (χ(2) P = .424). Bleeding was observed in 28 (21.1%) patients in the fondaparinux group compared with 12 (20%) in the control group (χ(2) P = .867). Survival analysis, and subgroup and unmatched analyses showed similar results. In the fondaparinux group, 60% of patients received prophylactic doses. Fondaparinux has similar effectiveness and safety as argatroban and danaparoid in patients with suspected HIT. Prophylactic fondaparinux doses seem to be effective if no indication for full anticoagulation exists.
10.1182/blood-2014-09-599498
Obesity Paradox in Peripheral Arterial Disease: Results of a Propensity Match Analysis from the National Inpatient Sample.
Ludhwani Dipesh,Wu Joyce
Cureus
Introduction The role of obesity in cardiovascular mortality is controversial. The obesity paradox has been widely attributed to smoking in the underweight. Large-scale studies analyzing the outcomes of peripheral arterial disease (PAD) in patients with a higher body mass index (BMI) while accounting for confounders such as smoking are lacking. Method The 2016 National Inpatient Sample (NIS) was used to identify all admissions with a primary discharge diagnosis of PAD. A secondary diagnosis of obesity or elevated BMI was used to segregate the admissions into two groups. Propensity scores were calculated to match and control both groups for age, smoking, and diabetes, amongst other confounders. A multivariate logistic and linear regression analysis was performed to calculate the odds ratio for in-hospital mortality, amputation, need for intervention (angioplasty or bypass), acute kidney injury, hospital charges, and length of stay. Non-obesity-related PAD admissions were selected as the reference groups. Results Among 248,288 PAD-related admissions, 41,618 had a secondary diagnosis of obesity. After calculating propensity scores for 1-1 matching, 41,589 admissions in the PAD and obesity group were compared to a similar number of admissions in the reference population. Patients with a concomitant diagnosis of obesity had lower odds of amputation (OR=0.90, 95% CI=0.84-0.95, p<0.001), need for intervention (OR=0.66, 95% CI=0.62-0.69, p<0.0001), and in-hospital mortality (OR=0.81, 95% CI=0.74-0.87, p<0.0001). On the contrary, the odds of having acute kidney injury were higher with elevated BMI (OR=1.30, 95% CI=1.26-1.34, p<0.0001). Conclusion Despite increasing the risk of hypertension, diabetes, and hypertriglyceridemia, the obesity paradox continues to exist with a better short-term prognosis in patients with PAD. Future studies looking into the pathophysiology behind this phenomenon are needed.
10.7759/cureus.4704