Toward prospective identification of high-risk surgical patients

The purpose of this study was to explore the feasibility of prospectively identifying patients at high risk for surgical complications using automatable methods focused on patient characteristics. We used data from the Michigan Surgical Quality Collaborative (60,411 elective surgeries) performed between 2003 and 2008. Regression models for postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection complications were developed using preoperative patient and planned procedure data. Risk was categorized by quartiles of predicted probability: "low" risk corresponding to the bottom quartile, "average" to the middle two quartiles, and "high" to the top quartile. C-indices were calculated to measure discrimination; model validity was assessed by cross-validation. Models were repeated using only patient characteristics. Risk category was closely related to event rates; 80 to 90 per cent of mortality and cardiac, renal, and pulmonary complications occurred among the 25 per cent of "high-risk" patients. Although thromboembolisms and surgical site infections were less predictable, 60 to 70 per cent of events occurred among high-risk patients. Cross-validation results were consistent and only slightly attenuated when predictors were restricted to patient characteristics alone. Adverse postoperative events are concentrated among patients identifiable preoperatively as high risk. Preoperative risk assessment could allow for efficient interventions targeted to high-risk patients.     

Predictive ability of preoperative indices for esophagectomy

Esophageal resection remains the mainstay of treatment for early-stage cancer. In spite of recent advances, these mortality rates remain significant when compared with other major surgical procedures. Several risk scores have been reported, but few have been put to the test with adequate and objective validation studies in high volume centers. Others already in use have poor discriminatory power.     

Predictive ability of preoperative indices for major pulmonary surgery

In the last years a number of significant improvements have been achieved in risk stratification for lung cancer patients who undergo lung resection. Nevertheless, future improvements should be based in prospective cooperative studies including a large number of comparable cases. First limitations of available published evidence come from the fact that FEV1 and ppo-FEV1 are pivotal in patient classification. Besides, ppoFEV1 is not a reliable predictor of complications in patients with COPD, since their functional behavior is different compared with non-COPD patients after lung resection and, although current calculation methods may be accurate in estimating the residual definitive FEVI at 3 to 6 months after surgery, they tend to overestimate the actual FEV1 in the first postoperative days, when most of the complications occur. The assumption that FEV1 and DLCO are highly correlated is the reason why ppoDLCO estimation is not recommended in all patients, limiting the predictive ability of this test. Finally, the predictive ability of exercise testing has not been proven since it is not systematically recommended in all patients before lung resection.     

Penetrating extremity trauma: identification of patients at high-risk requiring arteriography

Indications for arteriography in patients with penetrating trauma to the extremities remain controversial. Some clinicians have recommended universal use of arteriography, whereas others prefer to rely on physical findings alone. To better define our indications for contrast studies, we reviewed clinical data on 306 patients (349 extremities) with penetrating trauma who were admitted during a prior 2-year period (1985 to 1987). Injuries were caused by stab wounds in 50 (14.3%) extremities and by gunshot wounds in 299 (85.7%) extremities. Twenty-seven of the 50 stab wounds (54%) required urgent exploration based on physical findings, whereas 23 underwent arteriography. None of these studies showed unsuspected arterial injury. Twenty-nine of 299 gunshot wounds (9.7%) underwent mandatory exploration, and arteriograms were performed on 270 extremities; findings in 30 studies (11.1%) were positive for unsuspected arterial injuries. Gunshot wounds were categorized according to location and number of arteriograms with positive results. Arteriograms of lateral thigh and upper arm injuries resulted in no positive outcomes. Positive study results were recorded in 22.9% of calf injuries, 20% of forearm and antecubital injuries, 9.5% of popliteal fossa injuries, 9.0% of medial and posterior thigh injuries, and 8.3% of medial and posterior upper arm injuries. We recommend arteriography for penetrating injuries to these high-risk areas. However, clinical evaluation alone is accurate for identification of arterial trauma with lateral thigh or upper arm wounds and stab wounds to the extremities.     

高危患者肾移植体会

通过对１３例６０岁以上的高龄患者，１０例传染性肝炎患者，６例糖尿病患者和７例多囊肾患者行肾异体移植的临床资料的总结，发现移植后的并发症是导致高危患者移植失败的主要原因。认为在移植前后积极治疗导致高危的原发病，合理应用免疫抑制剂，密切的临床观察和实验室监测是提高高危患者肾移植存活率的关键。     

Methicillin-resistant Staphylococcus aureus in surgical patients: identification of high-risk populations for the development of targeted screening programmes

INTRODUCTION

Methicillin-resistant Staphylococcus aureus (MRSA)-related hospital-acquired infection (HAI) in surgical patients is associated with high morbidity, mortality and financial cost. The identification and characterisation of populations of patients who are at high risk of developing MRSA infection or colonisation could inform the design of more effective strategies to prevent HAIs and reduce transmission of MRSA.

PATIENTS AND METHODS

An analysis of historical discharge data for the whole of 2005 (7145 surgical in-patients) was performed, for all patients admitted to general surgery at the Royal Infirmary of Edinburgh. Analysis specifically focused on MRSA laboratory data and coding data for patient demographics, medical co-morbidities, and progress of in-patient stay.

RESULTS

A total of 134 (1.88%) individual patients with colonisation or infection by MRSA were identified from indicated laboratory testing. Univariate analysis identified a significant association of concurrent MRSA-positive status with patients aged over 60 years (P < 0.01), a duration of inpatient stay > 7 days (P < 0.01), presence of a malignant neoplasm (P < 0.01), circulatory disease (P < 0.01), respiratory disease (P < 0.01), central nervous system disease (P < 0.01), renal failure (P < 0.01), and concurrent admission to ITU/HDU (P < 0.01). Multivariate analysis suggested MRSA colonisation or infection was strongest in those with co-morbid malignancy (P < 0.0001) or admission to ITU/HDU (P < 0.0001).

CONCLUSIONS

This large observational study has identified cancer patients as a UK surgical patient subpopulation which is at significantly higher risk of colonisation by MRSA. These data could inform the development of focused hospital in-patient screening protocols and provide a means to stratify patient risk.     

高危胆囊结石患者的围手术期处理

目的:探讨提高对高危胆囊结石患者治疗水平的经验.方法:回顾分析82例高危胆囊结石患者的临床资料.结果:高危胆囊结石患者并存心血管疾病50例(占61%),内分泌代谢性疾病32例(占39%),呼吸系统疾病11例(占13%),5例并存脑血管意外后遗症(偏瘫、失语等).80岁以上患者为9例.23例患者还同时并存多个系统多种疾病.按美国麻醉医师学会(American Society of Anesthesiologists,ASA)分级,其中ASA Ⅲ级、Ⅳ级患者并存疾病涉及2个系统以上的病例数和并存2种以上疾病的病例数均明显高于ASA Ⅱ级患者;ASA Ⅱ级患者住院时间明显短于ASA Ⅲ级和Ⅳ级患者(P<0.01),无术后并发症;ASA Ⅲ级和Ⅳ级患者中并发症发生率为16.7%;全组无死亡,均痊愈出院.结论:对合并多个系统多种疾病,储备功能差的胆囊结石患者,经过严格的术前准备,以及加强围手术期监护与治疗,可降低其术后并发症发生率和病死率,改善其预后.     

Predictive value of some biochemical indices in stone formers

Search is under way to develop reliable tests for the prediction of stone risk. Several indices and ratios on the basis of urinary excretions have been suggested. In the present study the applicability of some risk indices and ratios in slum dwellers of Dharavi area of Bombay was examined. No significant difference was observed in IAP (ionic activity product) and CORI (calcium oxalate risk index) between stone formers (SF) and normal subjects (NS). We have suggested two more adjuncts, PIR (promoter/inhibitor ratio) and COQ (calcium oxalate quotient), and found them to be quite useful in the detection of risk. Pre-existence of risk factor(s) in the majority of the normal population suggests that triggering of stone formation should be a transient phenomenon in this population. No consistent pattern of relationship between various urinary parameters was observed.     

Differences in the Predictive value of Elixhauser Comorbidity Index and the Charlson Comorbidity indices in patients with hand infections

PurposeHand infections are a common source of potentially debilitating morbidity, particularly in patients with comorbid disease. We hypothesize that there is a difference in predictive value between two commonly used comorbidity indices for the prognosis of hand infections, which may have clinical implications in the management of these conditions.MethodsThe Nationwide Inpatient Sample 2001–2013 database was queried for hand infections using International Classification of Diseases, Ninth Revision codes. The Elixhauser (ECI) and Charlson (CCI) comorbidity scores were calculated based on validated sets of ICD-9 codes. Primary outcomes included mortality, prolonged length of stay (LOS, defined as >95 percentile), discharge destination, and postoperative complications. Indices were compared using receiver operating characteristic (ROC) curves and the areas under the curve (AUC). If confidence intervals overlapped, significance was determined using the DeLong method for correlated ROC curves. This is a validated, non-parametric comparison used for the calculation of the difference between two AUCs.ResultsA weighted total of 1,511,057 patients were included in this study. The majority were Caucasian (57.1%) males (61.4%). Complication rates included 0.9% mortality, 5.3% prolonged length of stay, 25.3% discharges to non-home destinations, and 5.3% post-operative complications. The ECI and CCI each demonstrated good predictive value for mortality, but poor predictive value for non-routine discharge, prolonged LOS, and post-operative complications. There was a significantly increased likelihood of each complication with increasing comorbidity score for both indices, with the greatest odds ratio in the ECI ≥4 cohort.ConclusionsThe CCI was superior in predicting mortality while the ECI was superior in predicting non-routine discharge, prolonged length of stay, and postoperative complications, but these indices may not be clinically relevant. While both represent good predictive models, a score specifically designed for patients with hand infections may have superior prognostic value.Level of evidenceLevel IV.     

Treatment options for aneurysms in high-risk patients

The increasing prevalence of aneurysms in an aging population bears with it increasing numbers of patients who are less than optimal candidates for resection. It is likely that the majority of such patients can undergo standard resection, either by referral to a center where the management of the elderly chronically ill is commonplace or by providing intensive preoperative metabolic, cardiac, pulmonary, and nutritional resuscitation. Such preoperative preparation might well include coronary revascularization or carotid endarterectomy. For the occasional patient in whom medical comorbidity is advanced and fixed, or in whom rapid aneurysm expansion or worsening symptoms mandate immediate management, yet operative risk for standard aneurysm resection seems inordinately high, several nonresective options have been identified and tested. Among these options, aneurysm exclusion appears to have significantly better results (in terms of lower rates of operative mortality and subsequent aneurysm rupture) than distal aneurysm ligature. A more recent technique, aneurysm bypass, may have potential but has not been tested for a long enough period, or by an adequate number of surgeons, to have established itself as a nonresective option. Clinical judgment, technical expertise, and a willingness to seek assistance and consultation remain the hallmarks of the optimal management of the patient with an abdominal aortic aneurysm.