A longitudinal analysis of the relationship between in-hospital mortality in New York State and the volume of abdominal aortic aneurysm surgeries performed.

This study uses New York State hospital discharge data to examine the relationship between in-hospital mortality for a patient receiving an abdominal aortic aneurysm resection and the volume of aneurysm operations performed in the previous year at the hospital where the operation took place and by the surgeon performing the operation. Previous research on this topic is extended in several respects: (1) A three-year data base is used to examine the manner in which hospital and surgeon volume jointly affect mortality rate and to examine ruptured and unruptured aneurysms separately; (2) a six-year data base is used to study the "practice makes perfect" hypothesis and the "selective referral" hypothesis; and (3) the degree of specialization of high-volume surgeons is contrasted with that of other surgeons. The results demonstrate a significant inverse relationship between hospital volume and mortality rate for unruptured aneurysms. Further, very few surgeons substantially increased their aneurysm surgery volumes in the six-year study period. Weak selective referral effects were found for both surgeons and hospitals, and higher-volume aneurysm surgeons tended to have much higher specialization rates.     

Combined coronary artery bypass surgery and abdominal aortic aneurysm repair.

The proper management of patients with asymptomatic abdominal aortic aneurysms and significant coexistent coronary artery disease is still debatable. The most common approach has been to perform the coronary artery bypass surgery some weeks before the abdominal aortic aneurysm repair in the hope of reducing the cardiac morbidity and mortality. We report our initial experience of three consecutive elective cases where the coronary artery bypass surgery and the abdominal aortic aneurysm repair were performed at one operation by the same operating surgeon.     

Elective surgery for aortic abdominal aneurysm: comparison of English outcomes with those elsewhere

INTRODUCTION: The aim of this study was to quantify mortality after elective repair of abdominal aortic aneurysm (AAA) in England, and to compare English case fatality rates (CFRs) with those reported in the literature. PATIENTS AND METHODS: English Hospital Episode Statistics (HES) for the financial years 1998/9 to 2001/2, linked to death data, were analysed. A systematic literature search was undertaken to identify studies reporting CFRs after elective AAA surgery. The CFR in England was compared with these studies by using confidence intervals on the CFRs and funnel plot techniques. RESULTS: In the English study, elective repair of AAA was performed on 11,338 patients of whom 771 died within 30 days after surgery (6.8%). The literature search found 66 studies: 34 reported mortality rates that were within the 99% confidence limits of the English rates, 31 below, and one study above. DISCUSSION: The CFR after elective surgical repair in England within 30 days of operation (6.8%) was higher than expected from the literature. Differences between England and other countries in quality of care is one possible explanation for the findings, but other explanations are possible and are discussed.     

The surgical treatment of aneurysms of the descending thoracic aorta

Between June 1983 and December 1987, 52 patients underwent resection of a thoracic descending aortic aneurysm. Thirty-day mortality was 11.5%; 4.8% for elective cases and 36.5% for patients operated upon in emergency. Spinal cord injury was present in two patients (4%). One patient was paraplegic, the other showed mild paraparesis, which was completely resolved. Both patients were operated for ruptured aneurysms. Severe postoperative renal dysfunction was present in 4 patients (7.5%) and was strongly related to intraoperative hypotension. The cumulative proportional survival rate was 81% at one year and 66% at two years of the total group, 85% at one year and 72% at two years for the patients presenting with nonruptured aneurysms. Aneurysms of the thoracic descending aorta can be resected with an acceptable mortality and morbidity. Just as in abdominal aneurysms, surgery definitely improves the outcome for these patients, who have a rather poor prognosis if left untreated.     

From the Cochrane Library: ultrasonographic screening for abdominal aortic aneurysm in men aged 65 years and older: low risk of fatal aneurysm rupture

Abdominal aortic aneurysm (AAA) is present in 5-10% of men aged 65-79 years and is often asymptomatic. The major complication is rupture, which requires emergency surgery. The mortality rate after rupture is high: about 80% of those who reach the hospital and 50% of those undergoing emergency surgery will die. Elective surgical repair of AAA aims to prevent death from rupture; the 30-day surgical mortality rate for open surgery is approximately 5%. Currently elective surgical repair is recommended for aneurysms larger than 5-5 cm to prevent rupture. There is interest in population screening to detect, monitor and repair AAA before rupture. A Cochrane systematic review of 4 randomised studies involving 127,891 men and 9,342 women revealed a significant reduction in mortality from AAA in men aged 65-79 years who underwent ultrasonographic screening (odds ratio (OR): 0.60; 95% CI: 0.47-0.78). There was insufficient evidence to demonstrate a benefit in women. Men who had been screened underwent more surgery for AAA (OR: 2.03; 95% CI: 1.59-2.59). These findings should be considered carefully when determining whether a coordinated population-based screening programme should be introduced. A gap in the current research is the balance of benefits and risks in women. Furthermore, detailed studies are needed on how to best provide information on the potential benefits and risks to individuals who are offered screening, and on the psychological effects of screening on patients and their partners.     

Prevalence of aortic aneurysms in the Twin Cities metropolitan area, 1979-84.

The discharge summaries for Minneapolis-St. Paul metropolitan area residents hospitalized during 1979-84 were reviewed for diagnoses of aortic aneurysms. Annual age-specific and age-adjusted sex-specific hospital discharge diagnosis rates were calculated for all aortic aneurysms, dissecting aortic aneurysms, thoracic aortic aneurysms (nondissecting), and abdominal aortic aneurysms (nondissecting). For each aortic aneurysm type, hospital discharge diagnosis rates were found to increase with age for both men and women. Abdominal aortic aneurysms were the most common type reported (age-adjusted annual rates for men varied between 40.6 and 49.3 per 100,000 population; for women, between 6.8 and 12.0 per 100,000 population). Men were noted to have higher rates for each aneurysm type. An increasing temporal trend was observed for all aortic aneurysms and abdominal aortic aneurysms among men. These findings are reviewed in light of recent data on mortality from aortic aneurysms in the United States.     

Monocyte chemoattractant protein-1 mRNA in human intracranial aneurysm walls

OBJECTIVE: To investigate the pathological course in intracranial aneurysms. METHODS: Normal intracranial artery tissue (cortex fistulization) from 1 case, ruptured aneurysms tissuses from 11 cases, unruptured aneurysm tissues from 2 cases were obtained by neurosurgical excision. Routine HE staining was used to observe histological characteristics. In situ hybridization was used to observe the expression of the monocyte chemoattractant protein-1 (MCP-1) mRNA in the walls of the normal artery and aneurysms. RESULTS: By the HE staining showed that the wall of the ruptured aneurysms (10 cases) and unruptured ones (2 cases) had increased intima and connectivum extima. The fibroblast in the intima was arrayed in the disorder. Monocyte-like cells can be seen in the whole aneurysm wall. In one case aneurysms wall (ruptured) glass-like fiber structure was left over, few cells could be seen. In 9 cases, mural thrombus was found. The thrombus represented with organization. In situ hybridization, MCP-1 mRNA was not detectable in the normal artery. The hybridization signal could be observed in the ruptured aneurysms (10 cases) and unruptured ones (2 cases) often in the intima. MCP-1 mRNA appeared to be expressed by fibroblast cells in its cytoplasm. Monocyte-like cells had little cytoplasm, and the signal was seldom seen. The hybridization signal was discontinuous in the intima, MCP-1 mRNA expressed where fibroblast and monocyte-like cells assembled. One ruptured aneurysm had no signal because there were no cells only glass-like fiber. Mural thrombus showed upregulated hybridization signal in the cytoplasm of fibroblasts, phlogocytes and endotheliocytes of its micrangium. CONCLUSION: The pathological representation of the ruptured and unruptured aneurysms and the upregulated expresion of MCP-1 in the aneurysm wall suggest that the development of aneurysm may be a course of chronic inflammation in which main inflammatory cells are monocyte-like cells.     

Abdominal aortic aneurysms surgery in over 75 years old patients. Experience in 142 cases treated between 1980-1989

The paper describes the Authors' experience of abdominal aortic aneurysm surgery in over 75-year-old patients. One hundred and forty-two cases were operated over a 10-year period (1980-89). Seventy-two patients were treated electively and 70 underwent emergency surgery following rupture of the aneurysm. Operative mortality during elective surgery was comparable to that in younger patients, whereas the mortality rate during emergency surgery was notably higher than that in under 75-year-old patients. Follow-up confirmed that the life expectancy of operated patients is significantly better than that of patients with untreated abdominal aortic aneurysms.     

The diagnosis and management of splenic artery aneurysms.

The presentation and course of 7 patients with splenic artery aneurysms is reviewed. Three presented with abdominal pain, 2 with collapse and rupture and in 2 it was an incidental finding. Four patients had elective ligation-excision of the aneurysm with splenectomy as had one patient operated on as an emergency, with no operative mortality. The aneurysm size ranged from 20 to 45 mm (mean 30 mm) and histology confirmed atheroma. One patient was managed as a myocardial infarct for 8 hours after admission and a ruptured splenic aneurysm was diagnosed at autopsy, an overall mortality of 14%. A 66-year-old woman in poor general health was managed expectantly and was asymptomatic when lost to follow-up after 2 years.     

Life-style factors and risk for abdominal aortic aneurysm in a cohort of Finnish male smokers

Prospective studies evaluating risk factors for abdominal aortic aneurysm are few. We studied the association of life-style factors with risk for abdominal aortic aneurysm among 29,133 male smokers 50-69 years of age, participants in the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study. During a mean follow-up of 5.8 years, 181 were diagnosed with ruptured abdominal aortic aneurysm or nonruptured abdominal aortic aneurysm plus aneurysmectomy. Risk for abdominal aortic aneurysm was positively associated with age [relative risk (RR) = 4.56, 95% confidence interval (CI) = 2.42-8.61 for > 65 vs < or = 55 years], smoking years (RR = 2.25, 95% CI = 1.33-3.81 for > 40 vs < or = 32 years), systolic blood pressure (RR = 1.92, 95% CI = 1.13-3.25 for > 160 vs < or = 130 mmHg), diastolic blood pressure (RR = 1.80, 95% CI = 1.05-3.08 for > 100 vs < or = 85 mmHg), and serum total cholesterol (RR = 1.85, 95% CI = 1.09-3.12 for > 6.5 vs < or = 5.0 mmol/liter). High-density lipoprotein cholesterol showed a strong inverse association with risk for aortic aneurysm (RR = 0.16, 95% CI = 0.08-0.32 for > 1.5 vs < or = 0.9 mmol/liter). High energy intake was associated with lower risk for aortic aneurysm (RR = 0.59, 95% CI = 0.38-0.94 for the highest quartile vs the lowest), whereas no associations with nutrients were evident. We conclude that classical risk factors for atherosclerotic diseases seem to be important in pathogenesis of large abdominal aortic aneurysms.     

Nosocomial infection, indices of intrinsic infection risk, and in-hospital mortality in general surgery

The objectives of this paper are to assess whether two indices of intrinsic infection risk (the SENIC and the NNIS index) predict in-hospital mortality and the attributable in-hospital mortality due to nosocomial infection in surgical patients. A prospective study on 4714 patients admitted to three hospitals has been carried out. The relative risk and its 95% confidence interval (CI) were estimated. Multiple-risk factors adjusted for odds ratios (OR) were yielded by logistic regression analysis. Overall, 119 patients (2.5%) died before hospital discharge. Both the SENIC and the NNIS indices were related to in-hospital mortality in crude data. After controlling for several variables (age, sex, ASA score, cancer, renal failure, diabetes mellitus, stay at the ICU), the SENIC index did not show any significant trend with mortality (P = 0.252), whereas the trend was significant for the NNIS index (P < 0.001). Risk of death in patients with one nosocomial infection was 7.5%, and in patients developing more than one nosocomial infection was 17.1%. After adjusting for several confounding variables, the development of an organ/space surgical site infection was significantly related to mortality (OR = 4.5, 95% CI 1.5-15.6) as was blood infection (OR = 17.3, 95% CI 3.5-87.0). The association of a surgical site infection and either a respiratory tract infection or a blood infection also increased significantly the risk of in-hospital mortality (OR = 3.3, 95% CI 1.2-8.7). In conclusion, the NNIS index is a good predictor of in-hospital mortality. Patients developing an organ/space surgical site infection and/or a blood infection have an increased risk of in-hospital mortality.     

Relationship between volume and quality of care for surgical interventions; results of a literature review

OBJECTIVE: To examine the relationship between the number of procedures performed per hospital or per surgeon and health care outcomes. DESIGN: Literature review. METHOD: Relevant literature was identified using recent systematic reviews from Germany, England, France and the United States. The Cochrane Library, Medline and Embase were also searched for recent studies (2000-2005) published in German, English, French, or Dutch using the combined search terms 'surgery' and 'volume'; included studies reported mortality or morbidity as measures of health care quality. RESULTS: 5 systematic reviews were found, which described the results of a total of 41 relevant articles. 8 original articles of sufficient quality published since 2000 were also identified. Most of these articles were also included in the reviews. Relationships between volume per hospital and per surgeon and case fatality (or survival) and morbidity were found for a number of surgical procedures. The strongest associations between volume and case fatality were found for pancreatic and oesophageal resection and, to a lesser degree, elective repair ofabdominal aortic aneurysm. For other procedures the relationship was relatively weak, absent, or not studied. CONCLUSION: Volume appears to be related to quality for some surgical procedures. The magnitude of the relationship differs depending on the procedure. For technically less complex procedures, organisation within the hospital appears to have a greater influence on the differences between hospitals than the performing surgeon.     

Treatment of abdominal aortic aneurysms

Three treatment options are available for an asymptomatic abdominal aortic aneurysm (AAA): an expectant approach with ultrasonographic check-ups, reconstruction of the abdominal aorta via the conventional ('open') approach and endovascular repair. For aneurysms less than 5.5 cm in diameter the annual rupture risk is less than 1%. For these patients a better alternative to the expectant approach does not seem to exist. The risk of rupture needs to be weighed up against the risks of a conventional operation. The operation mortality of patients with a non-ruptured AAA is about 7% while other serious complications occur in about 10%. The short to medium-term results of endovascular aneurysm repair are characterized by high reintervention rates, material fatigue and device failure. The three treatment options described are currently being investigated in several large-scale randomised studies for AAAs greater than 5.5 cm in diameter.     

A prospective study of tobacco smoking as a predictor of complications in general surgery.

OBJECTIVE: To analyze whether tobacco smoking is related to nosocomial infection, admission to the intensive care unit, in-hospital death, and length of stay. DESIGN: A prospective cohort study. SETTING: The Service of General Surgery of a tertiary-care hospital. PATIENTS: A consecutive series of patients admitted for more than 1 day (N = 2,989). RESULTS: Sixty-two (2.1%) patients died and 503 (16.8%) acquired a nosocomial infection, of which 378 (12.6%) were surgical site and 44 (1.5%) were lower respiratory tract. Smoking (mainly past smoking) was associated with a worse health status (eg, longer preoperative stay and higher American Society of Anesthesiologists score). A long history of smoking (> or = 51 pack-years) increased postoperative admission to the intensive care unit (adjusted odds ratio [OR] = 2.86; 95% confidence interval [CI95], 1.21 to 6.77) and in-hospital mortality (adjusted OR = 2.56; CI95, 1.10 to 5.97). There was no relationship between current smoking and surgical-site infection (adjusted OR = 0.99; CI95, 0.72 to 1.35), whereas a relationship was observed between past smoking and surgical-site infection (adjusted OR = 1.46; CI95, 1.02 to 2.09). Current smoking and, to a lesser degree, past smoking augmented the risk of lower respiratory tract infection (adjusted OR = 3.21; CI95, 1.21 to 8.51). Smokers did not undergo additional surgical procedures more frequently during hospitalization. In the multivariate analysis, length of stay was similar for smokers and nonsmokers. CONCLUSION: Smoking increases in-hospital mortality, admission to the intensive care unit, and lower respiratory tract infection, but not surgical-site infection. Deleterious effects of smoking are also observed in past smokers and they cannot be counteracted by hospital cessation programs.     

Depression and Geographic Status as Predictors for Coronary Artery Bypass Surgery Outcomes

Purpose: To examine the relationships between depression, geographic status, and clinical outcomes following a coronary artery bypass grafting (CABG) surgery.
Methods: Using the 2004 Nationwide Inpatient Sample database, we identified 63,061 discharge records of patients who underwent a primary CABG surgery (urban 57,247 and rural 5,814). We analyzed 7 demographic variables, 19 preoperative medical and psychiatric variables, and 2 outcome variables (ie, in-hospital mortality and length of stay). Logistic regression and multivariable regression analyses were used to assess urban-rural status and depression as independent predictors of in-hospital mortality and length of stay.
Findings: Rural patients were more likely to have a comorbid depression diagnosis compared to urban patients (urban = 19.4%, rural = 21.4%, P < .001). After adjusting for confounding factors, having a comorbid depression diagnosis ( B = 1.10, P < .001) and residing in a rural area ( B = .986, P < .05) were associated with an increased length of in-hospital stay following CABG surgery. Furthermore, having a depression diagnosis (OR = 1.63, 95% CI = 1.45-2.21) and residing in a rural area (OR = 1.43, 95% CI = .896-1.45) were associated with an increased likelihood of in-hospital mortality.
Conclusions: Rural patients were more likely than urban ones to have a depression diagnosis. Depression was a significant independent predictor of both in-hospital mortality and length of stay for patients receiving CABG surgery. Also, rural patients had increased lengths of in-hospital stay as well as in-hospital mortality rates compared to those who resided in urban areas.     

Risk Factors Correlated with Post-operative Mortality for Hip Fracture Surgery in the Elderly: A Population-based Approach

Objectives: To estimate the effect of waiting time for surgery and volume of surgical activity on mortality in patients with hip fracture and to compare risk-adjusted outcomes between hospitals providing surgery for such patients. Design: Retrospective cohort study. Setting: Friuli Venezia Giulia, Italy. Participants: A total of 6,629 elderly people who underwent surgery for hip fracture between 1st January 1996 and 31th December 2000. Main outcome measures: In-hospital, 6-month and 1-year mortality rate Results: In-hospital mortality rate was 5.4%. At six months, the mortality rate was 20.0%, and at 1 year 25.3%. Age, male sex, and comorbidity were significant predictors of mortality. Logistic regression analysis indicated that, after controlling for main patients risk factors and taking into account the hospital level variability, there was no significant association between increase in mortality rate and more than 1 day of waiting time for surgery (OR 0.90; 95% CI 0.58–1.40 for in-hospital mortality). One hospital had a significantly higher mortality rate than the others; high hospital volume for hip fracture surgery was associated with worse outcomes (OR 1.57; 95% CI 1.38–1.78 for in-hospital mortality). Mortality after hip fracture decreased significantly from 1996 to 2000 (OR 0.85; 95% CI 0.80–0.90). Conclusions: Longer waiting time for surgery was not associated with mortality after adjusting for patient risk factors, and taking into account hospital level variability. Hospital level variability was statistically significant, and was partially explained by the total volume of hospital surgical activity. The decrease in mortality between 1996 and 2000 was confirmed by multivariate models.     

Routinely Assessed Biochemical Markers Tested on Admission as Predictors of Adverse Outcomes in Hospitalized Elderly Patients

Abstract

Aim: To explore whether routinely assessed biochemical markers tested on admission will predict 3 predefined adverse outcomes for hospitalized elderly patients: discharge to a long-term care facility, in-hospital mortality, and prolonged hospital length of stay (> 14 days). Methods: A prospective observational study of elderly patients (aged ≥ 75 years) admitted to an acute-care geriatric ward over a 6-month period. Patients were assessed on admission and baseline characteristics were collected. Activities of daily living were assessed by the Barthel Index and cognitive function by the abbreviated mental test. Results from biochemical markers tested on admission were downloaded from the pathology laboratory database using patient details. Patients were folio wed-up with until discharge or in-hospital mortality. Results: A total of 392 patients formed the study population. Mean (standard deviation) age was 83.2 (± 5.5) years and 283 (72%) patients were men. Thirty-eight (10%) patients were discharged to a long-term care facility, 134 (34%) had a prolonged hospital length of stay, and 33 (8%) died in the hospital. Results from testing 5 biochemical markers independently predicted in-hospital mortality: hypoalbuminemia (adjusted odds ratio [OR], 2.5; 95% CI, 0.9–6.7; P = 0.04), low total cholesterol level (adjusted OR, 2.9; 95% CI, 1.3–6.3; P = 0.01), hyperglycemia (adjusted OR, 2.9; 95% CI, 1.2–7.4; P = 0.02), high C-reactive protein level (adjusted OR, 4.2; 95% CI, 1.3–13.4; P = 0.01), and renal impairment (adjusted OR, 3.8; 95% CI, 1.7–8.7; P = 0.002). High C-reactive protein level independently predicted prolonged hospital length of stay (OR, 1.7; 95% CI, 1.1–2.9; P = 0.03). Hypoalbuminemia predicted discharge to a long-term care facility independent of confounding factors except for physical dysfunction (OR, 2.4; 95% CI, 1.1–5.1; P = 0.03). Significance was reduced after adjustment for Barthel Index score (OR, 1.9; 95% CI, 0.9–4.1; P = 0.08). Conclusion: Testing of routinely assessed biochemical markers on admission predicted adverse hospital outcomes for elderly patients. Their inclusion in a standardized prediction tool may help to create interventions to improve such outcomes.     

Early surgery versus conservative management of dissecting aneurysms of the descending thoracic aorta.

BACKGROUND: Optimal management for patients who present acutely with uncomplicated type III dissections of the descending thoracic aorta remains controversial. Patients with dissecting aneurysms represent a subgroup at high risk of rupture who may benefit from early elective surgery as an alternative to standard medical therapy. METHODS. The authors constructed a Markov decision model to compare the following clinical strategies: 1) early elective surgery immediately after diagnosis (EARLY SURGERY), 2) medical therapy with periodic computed tomography and with elective surgery when aortic diameter is projected to reach 6 cm (CT FOLLOW-UP), and 3) medical therapy with urgent surgery for dissection-related complications (WATCHFUL WAITING). Data sources included Medline (1966-1995) and a case series of patients with type III dissecting aneurysms who received medical therapy with radiographic follow-up. RESULTS: For a typical 60-year-old patient with an acute, uncomplicated 5-cm dissecting aneurysm of the descending thoracic aorta and an operative 30-day mortality rate of 14% for EARLY SURGERY, the model predicts that EARLY SURGERY improves survival compared with CT FOLLOW-UP (9.91 vs 9.44 QALYs). Conservative management may be preferred for patients who have maximum aneurysm diameters < or = 4 cm, are elderly (> or = 75 years), or have higher-than-expected risk of operative mortality. CONCLUSIONS: The choice between early surgery and medical therapy for uncomplicated dissecting aneurysm of the descending thoracic aorta should be tailored to the individual patient's operative risk, risk of dissection-related events, and age. Early surgery may be a reasonable alternative to medical therapy for carefully selected patients at centers with favorable perioperative mortality rates.     

A population-based study of the prevalence of abdominal aortic aneurysms in relation to bone mineral density: the Tromsø study

In a population-based study of 2,586 men and 2,806 postmenopausal women aged 55-74 years in Troms?, Norway, in 1994-1995, associations between the prevalence of abdominal aortic aneurysms and bone mineral density were examined. The presence of an abdominal aortic aneurysm was assessed by ultrasonography. The bone mineral density of the forearm was measured by single X-ray absorptiometry. In postmenopausal women aged 55-64 years (nine cases of aneurysm), the adjusted odds ratio for abdominal aortic aneurysm was 0.42 (95% confidence interval: 0.19, 0.95) for each standard-deviation increase in bone mineral density. In other age groups (65-69 years and 70-74 years) including a total of 50 cases, the corresponding odds ratios for abdominal aortic aneurysm were 1.17 and 0.70, respectively. In men aged 55-59 years, based on 45 cases, the odds ratio for abdominal aortic aneurysm was 0.72 (95% confidence interval: 0.50, 1.03). In other age groups (60-64, 65-69, and 70-74 years) including a total of 206 cases, the odds ratios ranged from 1.00 to 1.10. The associations among men (in any age group) and among women older than 64 years were not statistically significant. The authors' main conclusion is that abdominal aortic aneurysms and bone mineral density are not related. However, an association in younger subjects cannot be ruled out.