Patient outcomes in the assessment of myocardial injury following cardiac surgery.

In the absence of online methods for the intraoperative assessment of the adequacy of myocardial protection, patient outcomes remain the gold standard for determining whether a patient has sustained injury in the course of a cardiac operation. Properly risk-adjusted 30-day postoperative mortality and myocardial infarction are the most definitive indicators of perioperative injury. The definition and clinical assessment of irreversible ischemic myocardial injury continues to be problematic postoperatively. In most instances, deterioration in postoperative cardiac function and performance is indicative of intraoperative injury. Late postoperative mortality and long-term survival may be affected by intraoperative myocardial injury. Likewise, long-term graft patency may be affected by intraoperative injury to the conduit vascular endothelium. Proper assessment of outcomes, although it may not change the intraoperative course of an operation, can be useful in the comparative assessment of the efficacy of various operations, methods, and techniques.     

Patient outcomes following wrist ganglion excision surgery

We present patient outcomes following surgical excision of primary wrist ganglia over a 5 year period. Patients (48 of 59; 81%) responded to a questionnaire by post or telephone, with a mean time to follow-up of 44 (range 21-77) months. There was a statistically significant reduction in all reported symptoms, including pain, paraesthesia, weakness, stiffness, and cosmesis. The recurrence rate was 8%. In total, 98% of patients were satisfied or very satisfied with treatment. Surgical excision of primary wrist ganglia may have advantages over aspiration and reassurance alone, particularly in reducing recurrence and hastening resolution of symptoms.     

SMAS facelift techniques to minimize stigmata of surgery

Patients seeking facial rejuvenation surgery are commonly concerned about their postoperative appearance. Their anxiety is expressed in the form of general statements about looking too different, not themselves, or being recognized for having had "something done." Typically, these reservations are the result of scars or deformities seen in a public figure, relative, or passerby. The more recognizable stigmata of facial rejuvenation surgery include unnatural hairlines, tragal distortions, ear lobule deformities, irregular neck contours, and an overall look of being lifted. The specific techniques and philosophy to prevent these stigmata are presented herein in a problem-specific format.     

Developing tools to predict outcomes following cardiovascular surgery

Background: Surgical decision‐making tools may help surgeons achieve better outcomes by providing more personally relevant information to patients. This paper describes approaches to developing statistical tools capable of estimating the probability of morbidity and mortality after cardiovascular surgery. Our aim is to inform surgeons about the important stages that contribute to the development of decision tools. Methods: The key elements described include study design (data quality, cohort size, etc.) and statistical methodology for developing and testing decision tools. Mention is made of the delivery of decision tools, simplicity of use, ease of interpretation of results and accessibility. Information specific to cardiac and vascular surgery is included. Results: Development of useful and effective decision tools is dependent on robust and reliable data, unambiguous outcome requirements and considerable statistical expertise. Decision tools must also be extensively tested for validity and reliability, both internally and with external data. Conclusion: Understanding the development and assumptions that underlie surgical decision tool development will help cardiovascular surgeons appreciate the value of applying such techniques at a clinical level.     

Effect of training on outcomes following coronary artery bypass graft surgery.

OBJECTIVE: We examined our coronary artery bypass surgery (CABG) experience to assess the effect of training on mortality and morbidity outcomes. METHODS: Between April 1997 and September 2002, 5678 consecutive patients underwent isolated CABG. Five hundred and fifty-five (9.9%) were performed by trainee surgeons. Multivariate logistic regression was used to assess the effect of training on adverse outcomes, while adjusting for patient and disease characteristics (treatment selection bias). Cox proportional hazards analysis was used to adjust Kaplan-Meier survival curves. Treatment selection bias was controlled for by constructing a propensity score from core patient characteristics including the additive EuroSCORE. The propensity score was the probability of CABG performed by trainee, with a C-statistic of 0.79, and was included along with the comparison variable (trainee vs Consultant) in a multivariable analysis of outcome. The propensity score is used as the sole variable for adjustment due to the low number of events, providing a more complete risk adjustment. RESULTS: CABG procedures performed by trainee surgeons were less likely to be female, hypertensive, obese, triple-vessel disease, redo and emergency cases. Also, trainee surgeons were less likely to operate on patients with cerebrovascular disease, renal dysfunction, and previous myocardial infarctions, prior gastrointestinal surgery, and poor left ventricular ejection fraction. The additive EuroSCORE was 2.9 in trainee cases compared to 3.5 in Consultant led cases (P<0.001) Crude outcomes were significantly better in trainee CABGs due to selection bias. In-hospital results were no longer significantly different between both groups after adjusting for the propensity score. The adjusted freedom from death in the trainee cases at 30 days, 1, 2, 3, and 4 years was 98.1, 96.2, 94.7, 93.2 and 91.8%, respectively, compared to 97.9, 95.7, 94.1, 92.3 and 90.8% for the Consultant led cases (P=0.53). CONCLUSIONS: After adjusting for case-mix, with careful case selection, training does not adversely affect the early and mid-term outcomes of CABG.     

Surgical site infection in the elderly following orthopaedic surgery. Risk factors and outcomes

BACKGROUND: Risk factor and outcomes data pertaining to surgical site infection in the elderly following orthopaedic operations are lacking. The aim of this study was to identify risk factors for surgical site infections and to quantify the impact of these infections on health outcomes in elderly patients following orthopaedic surgery. METHODS: A risk factor and outcomes study was performed at Duke University Medical Center, a tertiary care center, and seven community hospitals in North Carolina and Virginia between 1991 and 2002. The study included elderly patients in whom a surgical site infection had developed following orthopaedic surgery and elderly patients in whom a surgical site infection had not developed following orthopaedic surgery (controls). Outcome measures included mortality during the one-year postoperative period and the total length of the hospital stay (including readmissions during the ninety-day postoperative period). RESULTS: One hundred and sixty-nine patients with a surgical site infection were identified, and 171 controls were selected. The mean age of the patients was 74.7 years. The most frequent procedures were hip arthroplasty (n = 74, 22%) and open reduction of fractures (n = 55, 16%). The most common pathogen was Staphylococcus aureus (n = 95, 56%). A risk factor for surgical site infection, identified in the multivariate analysis, was admission from a health-care facility (odds ratio = 4.35; 95% confidence interval = 1.64, 11.11). Multivariate analysis also indicated that surgical site infection was a strong predictor of mortality (odds ratio = 3.80; 95% confidence interval = 1.49, 9.70) and an increased length of stay in the hospital (multiplicative effect = 2.49; 95% confidence interval = 2.10, 2.94; 9.31 mean attributable days per infection, 95% confidence interval = 6.88, 12.13). CONCLUSIONS: Measures for prevention of surgical site infection in elderly patients should target individuals who reside in health-care facilities prior to surgery. Future studies should be done to examine the effectiveness of such interventions in preventing infection and improving outcomes in elderly patients who undergo orthopaedic surgery.     

Correcting rotational deformity following femoral nailing

Introduction

The incidence of rotational malalignment after femoral nailing has been reported to be at least 20%. If the deformity is recognised early, it can be corrected by changing the distal locking screw and rotating the bone prior to fracture union. It is common practice to use the same distal locking screw of the nail if this surgery is performed, however, there is a risk of the new drill hole “cutting out” into the old screw hole. The degree of rotational deformity that needs to be corrected to use the same distal locking hole without cut out of the screw has not been defined.

Method

Ten femora, five from cadavera and five synthetic (“Synbone”), were stabilised in a vice and then fitted with one distal transverse screw. The screw was then removed and a second distal transverse screw was inserted at the same level after variable amounts of rotation. The bone bridge between the drill holes was then measured and any cut out was noted.

Results

Both of the femora cut out when rotated 10°, and one when rotated 15°. The size of the bone bridge between drill holes in femora rotated by 20° was 3 mm. This bone bridge was increased to 4 mm when the femora were rotated by 25°, and 8 and 9 mm when rotated by 30°.

Conclusion

The amount of rotational deformity that needs to be corrected in order to use the same distal locking hole in a femoral nail is significant. In our study, this equates to a correction of at least 25°, but this is not a definitive value in practice. Particular attention must be paid to the location and size of the distal locking screw when correcting malrotation after femoral nailing, to ensure an adequate bone bridge between the two holes.     

Costs and outcomes of acute kidney injury (AKI) following cardiac surgery.

BACKGROUND: Acute kidney injury (AKI) is a recognized complication of cardiac surgery; however, the variability in costs and outcomes reported are due, in part, to different criteria for diagnosing and classifying AKI. We determined costs, resource use and mortality rate of patients. We used the serum creatinine component of the RIFLE system to classify AKI. METHODS: A retrospective cohort study was conducted from the electronic data repository at the University of Pittsburgh Medical Center of patients who underwent cardiac surgery and had an elevation (>or=0.5 mg/dl) of serum creatinine postoperatively. Data were compared to age- and APACHE III-matched controls. Cost, mortality and resource use of AKI patients were determined postoperatively for each of the three RIFLE classes on the basis of changes in serum creatinine. RESULTS: Of the 3741 admissions, 258 (6.9%) had AKI and were classified as RIFLE-R 138 (3.7%), RIFLE-I 70 (1.9%) and RIFLE-F 50 (1.3%). Total and departmental level costs, length of stay (LOS) and requirement for renal replacement therapy (RRT) were higher in AKI patients compared to controls. Statistically significant differences in all costs, mortality rate and requirement for RRT were seen in the patients stratified into RIFLE-R, RIFLE-I and RIFLE-F. Even patients with the smallest change in serum creatinine, namely RIFLE-R, had a 2.2-fold greater mortality, a 1.6-fold increase in ICU LOS and 1.6-fold increase in total postoperative costs compared to controls. DISCUSSION: Costs, LOS and mortality are higher in postoperative cardiac surgery patients who develop AKI using RIFLE criteria, and these values increase as AKI severity worsens.     

Advanced age and sex as predictors of adverse outcomes following gastric bypass surgery.

OBJECTIVES: This study aimed to determine whether advanced age or sex was predictive of adverse outcomes after Roux-en-Y gastric bypass. METHODS: The Pennsylvania State Discharge Database was searched for records of morbidly obese patients who underwent Roux-en-Y gastric bypass. The SASs MIXED Procedure was used to test whether mortality alone or adverse outcomes (postoperative complications, nonroutine hospital transfer and mortality) were significantly related to sex or advanced age (>50 years). The presence of comorbidities was used as a blocking variable. RESULTS: Between 1999 and 2001, 4,685 patients underwent Roux-en-Y gastric bypass in Pennsylvania, of which 82% were female and 20% were older than 50 years of age. Comorbidities were present in 71% of patients. Twenty-eight deaths (0.6%) and 813 adverse outcomes (17.4%) occurred. Mortality was greater in males than in females (1.2% vs. 0.47%, P<0.05) without comorbid interaction. Mortality did not increase with age. Adverse outcomes were related to both sexes (24% male, 16% female, P<0.05) and age (< or = 50, 16% vs. > 50, 23%, P<0.05) with a small comorbid interaction. CONCLUSION: Adverse outcomes are more frequent among males and older patients and are influenced by comorbidities. Male patients have a higher mortality that was not affected by the presence of comorbidities.     

SMAS-platysma facelift. A bidirectional cervicofacial rhytidectomy

The technique of SMAS-platysma facelift has been reviewed. The deep layer lift with the SMAS-platysma myocutaneous flap of the anterior neck and lower face facilitates correction of submental deformities without the necessity of direct approach with a submental incision. Wide superficial undermining of the upper and mid-cheek skin which is pulled laterally for correction of the nasolabial fold achieves a bidirectional facelift. The author's experience over six years with 460 patients who had a SMAS-platysma facelift indicates that the operation can be performed safely with a low incidence of complications.     

Long-term survival outcomes following breast cancer surgery in Western Australia

BACKGROUND: Mortality rates from breast cancer are stabilizing or falling in many developed countries including Australia, however, survival outcomes are known to vary by social, demographic and treatment related factors. The aim of the present study was to investigate how hospital, social and demographic factors were associated with survival outcomes from surgically treated breast cancer for all women living in Western Australia. METHODS: The WA Data Linkage System was used to access hospital morbidity, death and cancer information for all women diagnosed with invasive breast cancer in Western Australia 1982-2000. Relative survival and Cox proportional hazards regression analyses were used to identify social, demographic and hospital factors associated with an increased risk of dying from breast cancer or dying from any cause. RESULTS: Survival outcomes improved in all women diagnosed in more recent calendar periods. However, a significantly increased risk of dying was observed for women who underwent initial surgical treatment in regional public hospitals outside of the state capital, Perth. Consistent with other reports, women aged greater than 80 years and younger than 35 years at diagnosis also had poorer survival outcomes. Residential location, socioeconomic status and race were not associated with survival after adjusting for treatment, health and hospital related factors. CONCLUSIONS: Despite overall improvements in survival of women diagnosed with breast cancer in Western Australia, initial surgical treatment in public hospitals outside of Perth was associated with significantly poorer outcomes.