Prognosis of primary percutaneous coronary intervention in elderly patients with ST-elevation myocardial infarction

Objective

To evaluate the prognosis of primary percutaneous coronary intervention (PPCI) and medical therapy (MT) in elderly patients presenting with ST-elevation myocardial infarction (STEMI).

Methods

A total of 238 STEMI patients aged above 80 and treated with PPCI (n = 186) and MT (n = 52) at Harefield Hospital, London were included in this study. Patients who did not have true STEMI based on non-diagnostic electrocardiogram (ECG) for STEMI and negative troponin, who presented with left bundle branch block (LBBB) and had normal coronaries were excluded from this study. Primary PCI was defined as any use of a guidewire for more than diagnostic purposes in patients with STEMI, whereas conventional MT was defined as treatment of patients with anti-platelets and anti-thrombotic medications without thrombolysis.

Results

The survival rate of PPCI patients was 86% (n = 160) at month 1 followed by 83.9% (n = 156) at month 6, and 81.2% (n = 151) at month 12. The survival rate of MT patients was 44.2% (n = 23) at month 1 followed by 36.5% (n = 19) at month 6, and 34.6% (n = 18) at month 12. Compared to MT, significantly fewer comorbidities were found in the PPCI group. Ventricular fibrillation (VF) (4.8%) and consequent admission to intensive care unit (7%) were the major complications of the PPCI group.

Conclusion

PPCI has a higher survival rate and, compared to MT, fewer comorbidities were observed in the PPCI group of elderly patients presenting with STEMI.     

Comparison of Modified Blumgart pancreaticojejunostomy and pancreaticogastrostomy after pancreaticoduodenectomy

Background

The aim of this study was to compare perioperative outcomes after Blumgart pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) for pancreatic-enteric reconstruction following pancreaticoduodenectomy.

Methods

Data of patients undergoing Blumgart PJ and PG were retrieved from prospectively-collected database. Matched patients in each surgical groups were included based on the Callery risk scoring system for clinically relevant postoperative pancreatic fistula (CR-POPF) (grades B and C). Surgical parameters and risks were compared between these two groups.

Results

A total of 206 patients undergoing PD were included. Blumgart PJ was associated with shorter postoperative hospital stay (median (range) 25 (10–99) vs. 27 (10–97) days, P = 0.022). There was no surgical mortality in the Blumgart PJ group, but a 4.9% perioperative mortality in the PG, P = 0.030. The CR-POPF by Blumgrt PG is significantly lower than that by PG for overall patients (7% vs. 20%, P = 0.007), especially for those in intermediate fistula risk zone (6% vs. 21%, P = 0.048) and high fistula risk zone (14% vs. 47%, P = 0.038).

Conclusions

Blumgart PJ is superior to PG in terms of pancreatic leakage and surgical mortality. Blumgart PJ can be recommended for pancreatic reconstruction after PD for all pancreatic remnant subtypes.     

The Effectiveness of a Physician-Only and Physician–Patient Intervention on Colorectal Cancer Screening Discussions Between Providers and African American and Latino Patients

BACKGROUND

Physician recommendation of colorectal cancer (CRC) screening is a critical facilitator of screening completion. Providing patients a choice of screening options may increase CRC screening completion, particularly among racial and ethnic minorities.

OBJECTIVE

Our purpose was to assess the effectiveness of physician-only and physician–patient interventions on increasing rates of CRC screening discussions as compared to usual care.

DESIGN

This study was quasi-experimental. Clinics were allocated to intervention or usual care; patients in intervention clinics were randomized to receipt of patient intervention.

PARTICIPANTS

Patients aged 50 to 75 years, due for CRC screening, receiving care at either a federally qualified health care center or an academic health center participated in the study.

INTERVENTION

Intervention physicians received continuous quality improvement and communication skills training. Intervention patients watched an educational video immediately before their appointment.

MAIN MEASURES

Rates of patient-reported 1) CRC screening discussions, and 2) discussions of more than one screening test.

KEY RESULTS

The physician–patient intervention (n = 167) resulted in higher rates of CRC screening discussions compared to both physician-only intervention (n = 183; 61.1 % vs.50.3 %, p = 0.008) and usual care (n = 153; 61.1 % vs. 34.0 % p = 0.03). More discussions of specific CRC screening tests and discussions of more than one test occurred in the intervention arms than in usual care (44.6 % vs. 22.9 %,p = 0.03) and (5.1 % vs. 2.0 %, p = 0.036), respectively, but discussion of more than one test was uncommon. Across all arms, 143 patients (28.4 %) reported discussion of colonoscopy only; 21 (4.2 %) reported discussion of both colonoscopy and stool tests.

CONCLUSIONS

Compared to usual care and a physician-only intervention, a physician–patient intervention increased rates of CRC screening discussions, yet discussions overwhelmingly focused solely on colonoscopy. In underserved patient populations where access to colonoscopy may be limited, interventions encouraging discussions of both stool tests and colonoscopy may be needed.KEY WORDS: colorectal cancer screening, health literacy, randomized trial, physician communication of preventive care     

Minimally invasive versus the conventional open surgical approach of a radical cholecystectomy for gallbladder cancer: a retrospective comparative study

Background

Laparoscopic surgery has traditionally been contraindicated for the management of gall bladder cancer (GBC). This study was undertaken to determine the safety and feasibility of a laparoscopic radical cholecystectomy (LRC) for GBC and compare it with an open radical cholecystectomy (ORC).

Methods

Retrospective analysis of primary GBC patients (with limited liver infiltration) and incidental GBC (IGBC) patients (detected after a laparoscopic cholecystectomy) who underwent LRC between June 2011 and October 2013. Patients who fulfilled the study criteria and underwent ORC during the same period formed the control group.

Results

During the study period, 147 patients with GBC underwent a radical cholecystectomy. Of these, 24 patients (primary GBC– 20, IGBC – 4) who underwent a LRC formed the study group (Group A). Of the remaining 123 patients who underwent ORC, 46 matched patients formed the control group (Group B). The median operating time was higher in Group A (270 versus 240 mins, P = 0.021) and the median blood loss (ml) was lower (200 versus 275 ml, P = 0.034). The post-operative morbidity and mortality were similar (P = 1.0). The pathological stage of the tumour in Group A was T_1b (n = 1), T₂ (n = 11) and T₃ (n = 8), respectively. The median lymph node yield was 10 (4–31) and was comparable between the two groups (P = 0.642). During a median follow-up of 18 (6–34) months, 1 patient in Group A and 3 in Group B developed recurrence. No patient developed a recurrence at a port site.

Conclusion

LRC is safe and feasible in selected patients with GBC, and the results were comparable to ORC in this retrospective comparison.     

Dialysis Modality and Mortality in the Elderly: A Meta-Analysis

Background and objectives

Identifying the appropriate choice between hemodialysis (HD) and peritoneal dialysis (PD) is an unresolved issue in elderly patients with ESRD, who are at high risk for death but have a low chance of receiving kidney transplantation.

Design, setting, participants, & measurements

Data on 13,065 incident dialysis Korean patients (age≥65 years) receiving HD (n=10,675) or PD (n=2390) were obtained from the Korean Health Insurance dataset. Multiple statistical approaches, including the multivariate Cox model, were used to compare mortality between Korean patients receiving PD and those receiving HD. Subsequently, meta-analysis of previous comparison studies (published since the year 2000; population-based studies) and the Korean dataset was performed.

Results

During a mean duration of 1.8±1.3 years (maximum of 5 years), the Korean PD group had a higher mortality rate than the Korean HD group (hazard ratio [HR], 1.20 [95% confidence interval (95% CI), 1.13 to 1.28]; P<0.001 by multivariate Cox model). The discrepancy between the two modalities was greater in the presence of certain conditions, such as diabetes mellitus or longer dialysis duration. In the meta-analysis, 15 studies involving >631,421 elderly patients were reviewed. Compared with HD, the pooled HR with PD was 1.10 (95% CI, 1.01 to 1.20). When the meta-analysis was stratified by confounding factors, the survival benefit from HD was particularly strong in subgroups that had diabetes mellitus, had long dialysis duration (>1 year), or contained cohorts starting dialysis in the 1990s.

Conclusions

A meta-analysis that included results in Korean patients suggests a higher risk for death in elderly patients receiving PD than in those receiving HD.     

Enhanced recovery following liver surgery: a systematic review and meta-analysis

Background

Enhanced recovery after surgery (ERAS) programmes aim to improve postoperative outcomes. They are being utilized increasingly in hepatic surgery. This review aims to evaluate the impact of ERAS programmes on outcomes following liver surgery.

Methods

EMBASE, MEDLINE, PubMed and the Cochrane Database were searched for trials comparing outcomes in patients undergoing liver surgery utilizing ERAS principles with those in patients receiving conventional care. The primary outcome was occurrence of postoperative complications within 30 days. Secondary outcomes included length of stay (LoS), functional recovery and adherence to ERAS protocols.

Results

Nine articles were included in the review, of which two were randomized controlled trials (RCTs). Overall complication rates were 25.0% (range: 11.5–46.4%) in ERAS patients, and 31.0% (range: 11.8–46.2%) in conventional care patients. Significantly reduced overall complication rates following ERAS care were demonstrated by a meta-analysis of the data reported in the two RCTs (odds ratio: 0.49, 95% confidence interval 0.28–0.84; P = 0.01) The median LoS reported by the studies was 5.0 days (range: 2.5–7.0 days) in ERAS patients, and 7.5 days (range: 3.0–11.0 days) in non-ERAS patients. Recovery milestones, when reported, were improved following ERAS care.

Conclusions

The adoption of ERAS protocols improves morbidity and LoS following liver surgery. Future ERAS programmes should accommodate the unique requirements of liver surgery in order to optimize postoperative outcomes.     

The role of three-dimensional imaging in optimizing diagnosis,classification and surgical treatment of hepatocellular carcinoma with portal vein tumor thrombus

Background

Accurate assessment of characteristics of tumor and portal vein tumor thrombus is crucial in the management of hepatocellular carcinoma.

Aims

Comparison of the three-dimensional imaging with multiple-slice computed tomography in the diagnosis and treatment of hepatocellular carcinoma with portal vein tumor thrombus.

Method

Patients eligible for surgical resection were divided into the three-dimensional imaging group or the multiple-slice computed tomography group according to the type of preoperative assessment. The clinical data were collected and compared.

Results

74 patients were enrolled into this study. The weighted κ values for comparison between the thrombus type based on preoperative evaluation and intraoperative findings were 0.87 for the three-dimensional reconstruction group (n = 31) and 0.78 for the control group (n = 43). Three-dimensional reconstruction was significantly associated with a higher rate of en-bloc resection of tumor and thrombus (P = 0.025). Using three-dimensional reconstruction, significant correlation existed between the predicted and actual volumes of the resected specimens (r = 0.82, P < 0.01), as well as the predicted and actual resection margins (r = 0.97, P < 0.01). Preoperative three-dimensional reconstruction significantly decreased tumor recurrence and tumor-related death, with hazard ratios of 0.49 (95% confidential interval, 0.27–0.90) and 0.41 (95% confidential interval, 0.21–0.78), respectively.

Conclusion

For hepatocellular carcinoma with portal vein tumor thrombus, three-dimensional imaging was efficient in facilitating surgical treatment and benefiting postoperative survivals.     

Value of E-PASS models for predicting postoperative morbidity and mortality in resection of perihilar cholangiocarcinoma and gallbladder carcinoma

Background

It has previously been reported that a general risk model, Estimation of Physiologic Ability and Surgical Stress (E-PASS), and its modified version, mE-PASS, had a high predictive power for postoperative mortality and morbidity in a variety of gastrointestinal surgeries. This study evaluated their utilities in proximal biliary carcinoma resection.

Methods

E-PASS variables were collected in patients undergoing resection of perihilar cholangiocarcinoma and gallbladder carcinoma in Japanese referral hospitals.

Results

Analysis of 125 patients with gallbladder cancer and 97 patients with perihilar cholangiocarcinoma (n = 222). Fifty-six patients (25%) underwent liver resection with either hemihepatectomy or extended hemihepatectomy. The E-PASS models showed a high discrimination power to predict in-hospital mortality; areas under the receiver operating characteristic curve (95% confidence intervals) were 0.85 (0.76–0.94) for E-PASS and 0.82 (0.73–0.91) for mE-PASS. The predicted mortality rates correlated with the severity of postoperative complications (Spearman''s rank correlation coefficient: ρ = 0.51, P < 0.001 for E-PASS; ρ = 0.47, P < 0.001 for mE-PASS).

Conclusions

The E-PASS models examined herein may accurately predict postoperative morbidity and mortality in proximal biliary carcinoma resection. These models will be useful for surgical decision-making, informed consent, and risk adjustments in surgical audits.     

Effectiveness of a Physical Activity and Weight Loss Intervention for Middle-Aged Women: Healthy Bodies,Healthy Hearts Randomized Trial

BACKGROUND

Physical inactivity is a significant risk factor for cardiovascular disease and remains highly prevalent in middle-aged women.

OBJECTIVE

We hypothesized that an interventionist-led (IL), primary-care–based physical activity (PA) and weight loss intervention would increase PA levels and decrease weight to a greater degree than a self-guided (SG) program.

DESIGN

We conducted a randomized trial.

PARTICIPANTS

Ninety-nine inactive women aged 45–65 years and with BMI ≥ 25 kg/m² were recruited from three primary care clinics.

INTERVENTIONS

The interventionist-led (IL) group (n = 49) had 12 weekly sessions of 30 min discussions with 30 min of moderate-intensity PA. The self-guided (SG) group (n = 50) received a manual for independent use.

MAIN MEASURES

Assessments were conducted at 0, 3, and 12 months; PA and weight were primary outcomes. Weight was measured with a standardized protocol. Leisure PA levels were assessed using the Modifiable Activity Questionnaire. Differences in changes by group were analyzed with a t-test or Wilcoxon rank-sum test. Mixed models were used to analyze differences in changes of outcomes by group, using an intention-to-treat principle.

KEY RESULTS

Data from 98 women were available for analysis. At baseline, mean (SD) age was 53.9 (5.4) years and 37 % were black. Mean weight was 92.3 (17.7) kg and mean BMI was 34.7 (5.9) kg/m². Median PA level was 2.8 metabolic equivalent hours per week (MET-hour/week) (IQR 0.0, 12.0). At 3 months, IL women had a significantly greater increase in PA levels (7.5 vs. 1.9 MET-hour/week; p = 0.02) than SG women; there was no significant difference in weight change. At 12 months, the difference between groups was no longer significant (4.7 vs. 0.7 MET-hour/week; p = 0.38). Mixed model analysis showed a significant (p = 0.048) difference in PA change between groups at 3 months only.

CONCLUSIONS

The IL intervention was successful in increasing the physical activity levels of obese, inactive middle-aged women in the short-term. No significant changes in weight were observed.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-3077-5) contains supplementary material, which is available to authorized users.KEY WORDS: physical activity, exercise, clinical trial, intervention     

Elevated oxidative stress among coronary artery disease patients on statin therapy: A cross sectional study

Background

Statins are a major group of drugs that reduces LDL-C levels, which are proven to have other beneficial effects such as preventing coronary events. The objective of this study was to evaluate oxidative stress and select novel coronary artery disease risk factors among coronary artery disease patients on statins.

Methods

In this observational, cross-sectional study, we compared total cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol, apolipoprotein B, lipoprotein (a), homocysteine, reduced glutathione, glutathione peroxidase, superoxide dismutase, ascorbic acid, malondialdehyde and oxidized LDL among male coronary artery disease patients on statin therapy (group 2, n = 151) with sex-matched, diabetic patients (group 3, n = 80) as well as healthy controls (group 1, n = 84).

Results

Total cholesterol, triglycerides, HDL-cholesterol and LDL-cholesterol were significantly lower among subjects of group 2 compared to other two groups. The novel risk factors studied did not differ significantly between groups, except for a higher homocysteine level among group 2 subjects compared to the other two groups. Elevated oxidative stress, indicated by lower reduced glutathione, glutathione peroxidase, and ascorbic acid as well as higher malondialdehyde and oxidized LDL was observed among group 2 subjects. Triglycerides, HDL-cholesterol, ascorbic acid and malondialdehyde were found to be independent predictors for coronary artery disease among this study population.

Conclusions

Though coronary artery disease subjects had healthy lipid profile, oxidative stress, a recognized risk factor for coronary events, was still elevated among this patient group. Novel risk factors were not found to be major predictors for coronary artery disease among the study subjects.     

The LiMAx test: a new liver function test for predicting postoperative outcome in liver surgery

Background:

Liver failure has remained a major cause of mortality after hepatectomy, but it is difficult to predict preoperatively. This study describes the introduction into clinical practice of the new LiMAx test and provides an algorithm for its use in the clinical management of hepatic tumours.

Methods:

Patients with hepatic tumours and indications for hepatectomy were investigated perioperatively with the LiMAx test. In one patient, analysis of liver volume was carried out with preoperative three-dimensional virtual resection.

Results:

A total of 329 patients with hepatic tumours were evaluated for hepatectomy. Blinded preoperative LiMAx values were significantly higher before resection (n= 139; mean 351 µg/kg/h, range 285–451 µg/kg/h) than before refusal (n= 29; mean 299 µg/kg/h, range 223–376 µg/kg/h; P= 0.009). In-hospital mortality rates were 38.1% (8/21 patients), 10.5% (2/19 patients) and 1.0% (1/99 patients) for postoperative LiMAx of <80 µg/kg/h, 80–100 µg/kg/h and >100 µg/kg/h, respectively (P < 0.0001). A decision tree was developed to avoid critical values and its prospective preoperative application revealed a reduction in mortality from 9.4% to 3.4% (P= 0.019).

Discussion:

The LiMAx test can validly determine liver function capacity and is feasible in every clinical situation. Combination with virtual resection could enable the calculation of residual liver function. The LiMAx decision tree algorithm for hepatectomy might significantly improve preoperative evaluation and postoperative outcome in liver surgery.     

Acute Care Utilization by Patients After Graduation of Their Resident Primary Care Physicians

BACKGROUND

The disruption in provider continuity caused by medical resident graduation may result in adverse patient outcomes.

OBJECTIVE

Our aim was to investigate whether resident graduation was associated with increased acute care utilization by residents’ primary care patients.

DESIGN AND PARTICIPANTS

This was a retrospective cohort study of patients cared for by junior and senior residents finishing the academic year in 2010, 2011 and 2012.

MAIN MEASURES

We compared rates of clinic visits, emergency department (ED) visits, and hospitalizations between transitioning patients whose residents were graduating and non-transitioning patients whose residents were not graduating.

KEY RESULTS

Our study population comprised 90 residents, 4018 unique patients, and 5988 resident–patient dyads that transitioned (n = 3136) or did not transition (n = 2852). For transitioning patients, the clinic visit rate per 100 patients in the 4 months before and after graduation was 129 and 102, respectively; for non-transitioning patients, the clinic visit rate was 119 and 94, respectively (difference-in-differences, +2 per 100 patients; p = 0.12). For transitioning patients, the ED visit rate per 100 patients before and after graduation was 29 and 26, respectively; for non-transitioning patients, the ED visit rate was 28 and 25, respectively (difference-in-differences, 0; p = 0.49). For transitioning patients, the hospitalization rate per 100 patients before and after graduation was 14 and 13, respectively; for non-transitioning patients, the hospitalization rate was 15 and 12, respectively (difference-in-differences, −2; p = 0.20). In multivariable modeling there was no increased risk for transitioning patients for clinic visits (adjusted rate ratio [aRR], 1.03; 95 % confidence interval [CI], 0.97 to 1.10), ED visits (aRR, 1.05; 95 % CI, 0.92 to 1.20), or hospitalizations (aRR, 1.04; 95 % CI, 0.83 to 1.31).

CONCLUSIONS

Acute care utilization by residents’ patients did not increase or decrease after graduation. Acute care utilization was high before and after graduation. Interventions to decrease the need for acute care should be employed throughout the year.KEY WORDS: continuity of care, care transitions, medical education-systems based practice, medical education-graduate, ambulatory care, utilization     

Nurse-Led Behavioral Management of Diabetes and Hypertension in Community Practices: A Randomized Trial

Background

Several trials have demonstrated the efficacy of nurse telephone case management for diabetes (DM) and hypertension (HTN) in academic or vertically integrated systems. Little is known about the real-world potency of these interventions.

Objective

To assess the effectiveness of nurse behavioral management of DM and HTN in community practices among patients with both diseases.

Design

The study was designed as a patient-level randomized controlled trial.

Participants

Participants included adult patients with both type 2 DM and HTN who were receiving care at one of nine community fee-for-service practices. Subjects were required to have inadequately controlled DM (hemoglobin A1c [A1c] ≥ 7.5 %) but could have well-controlled HTN.

Interventions

All patients received a call from a nurse experienced in DM and HTN management once every two months over a period of two years, for a total of 12 calls. Intervention patients received tailored DM- and HTN- focused behavioral content; control patients received non-tailored, non-interactive information regarding health issues unrelated to DM and HTN (e.g., skin cancer prevention).

Main Outcomes and Measures

Systolic blood pressure (SBP) and A1c were co-primary outcomes, measured at 6, 12, and 24 months; 24 months was the primary time point.

Results

Three hundred seventy-seven subjects were enrolled; 193 were randomized to intervention, 184 to control. Subjects were 55 % female and 50 % white; the mean baseline A1c was 9.1 % (SD = 1 %) and mean SBP was 142 mmHg (SD = 20). Eighty-two percent of scheduled interviews were conducted; 69 % of intervention patients and 70 % of control patients reached the 24-month time point. Expressing model estimated differences as (intervention – control), at 24 months, intervention patients had similar A1c [diff = 0.1 %, 95 % CI (−0.3, 0.5), p = 0.51] and SBP [diff = −0.9 mmH g, 95% CI (−5.4, 3.5), p = 0.68] values compared to control patients. Likewise, DBP (diff = 0.4 mmHg, p = 0.76), weight (diff = 0.3 kg, p = 0.80), and physical activity levels (diff = 153 MET-min/week, p = 0.41) were similar between control and intervention patients. Results were also similar at the 6- and 12-month time points.

Conclusions

In nine community fee-for-service practices, telephonic nurse case management did not lead to improvement in A1c or SBP. Gains seen in telephonic behavioral self-management interventions in optimal settings may not translate to the wider range of primary care settings.KEY WORDS: Diabetes, Hypertension, Implementation     

Serum amylase on the night of surgery predicts clinically significant pancreatic fistula after pancreaticoduodenectomy

Objectives

Drainage after pancreaticoduodenectomy (PD) remains controversial because the risk for uncontrolled postoperative pancreatic fistula (POPF) must be balanced against the potential morbidity associated with prolonged and possibly unnecessary drainage. This study investigated the utility of the level of serum amylase on the night of surgery [postoperative day (PoD) 0 serum amylase] to predict POPF.

Methods

A total of 185 patients who underwent PD were studied. Occurrences of POPF were graded using the International Study Group on Pancreatic Fistula (ISGPF) classification. Receiver operating characteristic (ROC) analysis identified a threshold value of PoD 0 serum amylase associated with clinically significant POPF (ISGPF Grades B and C) in a test cohort (n = 45). The accuracy of this threshold value was then tested in a validation cohort (n = 140).

Results

Overall, 43 (23.2%) patients developed clinically significant POPF. The threshold value of PoD 0 serum amylase for the identification of clinically significant POPF was ≥130 IU/l (P = 0.003). Serum amylase of <130 IU/l had a negative predictive value of 88.8% for clinically significant POPF (P < 0.001). Serum amylase of ≥130 IU/l on PoD 0 and a soft pancreatic parenchyma were independent risk factors for clinically significant POPF.

Conclusions

Postoperative day 0 serum amylase of <130 IU/l allows for the early and accurate categorization of patients at least risk for clinically significant POPF and may identify patients suitable for early drain removal.     

Prediction of post-operative pancreatic fistula in pancreaticoduodenectomy patients using pre-operative MRI: a pilot study

Background:

Post-operative pancreatic fistula (POPF) is one of the most fearful complications which may occur after pancreaticoduodenectomy (PD). The methods used to predict POPF pre-operatively have not been studied in great detail. We analyzed correlation between various parameters related to PD including pre-operative magnetic resonance imaging (MRI) signal intensity (SI), pathology of pancreatic fibrosis and occurrence rates of POPF, and verified that MRI SI results could be the determining values for pre-operative prediction of POPF.

Methods:

From January 2005 to August 2006, we retrospectively examined 43 cases of PDs by reviewing abdominal MRI findings, degree of fibrosis of remnant pancreatic stump, and other surgery-related parameters.

Results:

POPF encountered in PD were 11 cases (25.6%). Operation time and degree of fibrosis of remnant pancreatic cut surface were related to POPF (P= 0.030, P= 0.010). The pancreas–liver SI ratio (PLSI) between fistula group and no fistula group was −0.0009 ± 0.2 and −0.1297 ± 0.2, respectively (P= 0.0004). The pancreas–spleen SI ratio (PSSI) in each group was 0.423 ± 0.25 and 0.288 ± 0.32, respectively (P= 0.014). Using quantitative analysis, the SI ratios were 1.27 and 0.66 in each group (P= 0.013).

Conclusions:

When analyzing the results of POPF in 43 patients who underwent PD, PLSI, PSSI and qualitative analysis, fistula group differed significantly from no fistula group. Using these results, it will be helpful for us to predict the occurrence of POPF pre-operatively using MRI in PD patients.     

Relationship between red blood cell distribution width and intermediate-term mortality in elderly patients after percutaneous coronary intervention

Background Large-scale clinical research on the relationship between red blood cell distribution width (RDW) and intermediate-term prognosis in elderly patients with coronary artery disease (CAD) is lacking. Thus, this study investigated the effects of RDW on the intermediate-term mortality of elderly patients who underwent elective percutaneous coronary intervention (PCI). Methods Data from 1891 patients ≥ 65 years old underwent elective PCI from July 2009 to September 2011 were collected. Based on preoperative median RDW (12.3%), the patients were divided into two groups. The low RDW group (RDW < 12.3%) had 899 cases; the high RDW group (RDW ≥ 12.3%) had 992 cases. The all-cause mortality rates of the two groups were compared. Results Patients in the high RDW group were more likely to be female and accompanied with diabetes, had lower hemoglobin level. The mean follow-up period was 527 days. During follow-up, 61 patients died (3.2%). The postoperative mortality of the high RDW group was significantly higher than that of the low RDW group (4.3% vs. 2.0%, P = 0.004). After adjusting other factors, multivariate Cox regression analysis revealed that preoperative high RDW was significantly associated with postoperative all-cause mortality (hazard ratio: 2.301, 95% confidence interval: 1.106–4.785, P = 0.026). Conclusions Increased RDW was an independent predictor of the increased intermediate-term all-cause mortality in elderly CAD patients after elective PCI.     

Hospital Strategy Uptake and Reductions in Unplanned Readmission Rates for Patients with Heart Failure: A Prospective Study

BACKGROUND

Despite recent reductions in national unplanned readmission rates, we have relatively little understanding of which hospital strategies are most associated with changes in risk-standardized readmission rates (RSRR).

OBJECTIVE

We examined associations between the change in hospital 30-day RSRR for patients with heart failure and the uptake of strategies over 12–18 months in a national sample of hospitals.

DESIGN

We conducted a prospective study of hospitals using a Web-based survey at baseline (November 2010–May 2011, n = 599, 91.0 % response rate) and 12–18 months later (November 2011–October 2012, n = 501, 83.6 % response rate), with RSRR measured at the same time points. The final analytic sample included 478 hospitals.

PARTICIPANTS

The study included hospitals participating in the Hospital-to-Home (H2H) and State Action on Avoidable Rehospitalizations (STAAR) initiatives.

MAIN MEASURES

We examined associations between change in hospital 30-day RSRR for patients with heart failure and the uptake of strategies previously demonstrated to have increased between baseline and follow-up, using unadjusted and adjusted linear regression.

KEY RESULTS

The average number of strategies taken up from baseline to follow-up was 1.6 (SE = 0.06); approximately one-quarter (25.3 %) of hospitals took up at least three new strategies. Hospitals that adopted the strategy of routinely discharging patients with a follow-up appointment already scheduled experienced significant reductions in RSRR (reduction of 0.63 percentage point, p value < 0.05). Hospitals that took up three or more strategies had significantly greater reductions in RSRR compared to hospitals that took up only zero to two strategies (reduction of 1.29 versus 0.57 percentage point, p value < 0.05). Among the 117 hospitals that took up three or more strategies, 93 unique combinations of strategies were used.

CONCLUSIONS

Although most individual strategies were not associated with RSRR reduction, hospitals that took up any three or more strategies showed significantly greater reduction in RSRR compared to hospitals that took up fewer than three strategies.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-3105-5) contains supplementary material, which is available to authorized users.KEY WORDS: readmissions, quality improvement, heart failure, discharge     

Do circulating blood cell types correlate with modifiable risk factors and outcomes in patients with acute coronary syndrome (ACS)?

Aims

Atherosclerosis is an inflammatory process with different cardiovascular risk factors (CVRFs) contributing to its pathogenesis. We aimed to evaluate the specific relationship between circulating blood leukocytes, troponin I and CVRFs.

Methods

We prospectively enrolled 959 patients with evidence of acute coronary syndrome either in form of unstable angina or STEMI or NSTEMI. Details demographic characteristics, CVRF and biochemical parameters such as total white blood cells (WBC), neutrophil, lymphocytes, platelet, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and troponin I were collected.

Results

The results indicated that patients having either hypertension, diabetes or smoking habit had significantly higher levels of total WBC (p = 0.013), neutrophil (p = 0.029), NLR (p = 0.029) and PLR (p = 0.009). The level of troponin I was unaffected by these risk factors. Significant association of hypertension was found with total WBC (p = 0.0392), lymphocytes (p = 0.0384) and PLR (p = 0.0027), whereas in diabetes and females all other leukocyte subtypes were significantly altered except for platelet and troponin I. Smokers had higher level of total WBC count (p = 0.0033) and PLR (p = 0.0464). No relationship between CVRFs and leukocytes was observed in males. The age independent effect was observed with PLR, whereas association with total WBC, lymphocytes, NLR, platelet was specific in older population. In younger patients NLR (p = 0.0453) is more likely to be elevated. Mortality was significantly associated with changes in the leukocytes but not with the CVRF presence.

Conclusion

We demonstrate that the neutrophils, lymphocytes and total WBC along with its ratios predict mortality and are more likely to be elevated in presence of CVRFs.     

Identification of risk categories for in pancreaticoduodenectomy based on diagnosis

Background

Studies of pancreaticoduodenectomy (PD) frequently overlook diagnosis as a variable when evaluating postoperative outcomes or generically group patients according to whether they have ‘benign’ or ‘malignant’ disease. Large multicentre studies comparing postoperative outcomes in PD stratified by diagnosis are lacking. The present study was conducted to verify the hypothesis that postoperative morbidity and length of stay (LoS) following PD vary by diagnosis and that patients may be grouped into low- and high-risk categories.

Methods

The database of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was reviewed for all PDs performed during 2005–2011. Diagnoses were identified using ICD-9 codes and grouped based on the incidence of major morbidity. Univariate and multivariate analyses were utilized to assess the impact of diagnosis on PD outcomes.

Results

Of 5537 patients, those with pancreas cancer (n = 3173) and chronic pancreatitis (n = 485) experienced similar incidences of major morbidity (P = 0.95) and were grouped as having low-risk diagnoses. Patients with bile duct and ampullary (n = 1181), duodenal (n = 558) and neuroendocrine (n = 140) disease experienced similar levels of major morbidity (P = 0.78) and were grouped as having high-risk diagnoses. A high-risk diagnosis was identified as an independent risk factor for a prolonged LoS [odds ratio (OR) 1.67], organ space infection (OR 2.57), sepsis or septic shock (OR 1.83), and major morbidity (OR 1.70). Diagnosis did not predict readmission.

Conclusions

The high-risk diagnosis is independently associated with postoperative morbidity and prolonged LoS. Patients with PD should be stratified by diagnosis to more accurately reflect their risk for postoperative complications and the complexity of care they will require.