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51.
Caitlin W. Hicks Husain N. Alshaikh Devin Zarkowsky Ian C. Bostock Besma Nejim Mahmoud B. Malas 《Journal of vascular surgery》2018,67(4):1091-1101.e4
Background
A large proportion of endovascular aortic aneurysm repair (EVAR) patients are routinely admitted to the intensive care unit (ICU) for postoperative observation. In this study, we aimed to describe the factors associated with ICU admission after EVAR and to compare the outcomes and costs associated with ICU vs non-ICU observation.Methods
All patients undergoing elective infrarenal EVAR in the Premier database (2009-2015) were included. Patients were stratified as ICU vs non-ICU admission according to location on postoperative day 0. Both patient-level (sociodemographics, comorbidities) and hospital-level (teaching status, hospital size, geographic location) factors were analyzed using univariate and multivariable logistic regression to determine factors associated with ICU vs non-ICU admission. Overall outcomes and hospital costs were compared between groups.Results
Overall, 8359 patients underwent elective EVAR during the study period, including 4791 (57.3%) ICU and 3568 (42.7%) non-ICU admissions. Patients admitted to ICU were more frequently nonwhite and had more comorbidities, including congestive heart failure, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, diabetes, and hypertension, than non-ICU patients (all, P < .03). ICU admissions were more common in small (<300 beds), urban, and nonteaching hospitals and varied greatly depending on surgeon specialty and geographic region (P < .001). A pattern emerged when admission location was clustered by hospital; ICU patients were treated at hospitals where 96.7% (interquartile range, 84.5%-98.9%) of patients were admitted to ICU after EVAR, whereas non-ICU patients were treated at hospitals where only 7.5% (interquartile range, 4.9%-25.8%) were admitted to ICU after EVAR. A multivariable logistic regression model accounting for patient-, operative-, and hospital-level differences had a significantly lower area under the curve for predicting ICU admission after EVAR than a model accounting only for hospital factors (area under the curve, 0.76 vs 0.95; P < .001). The overall rate of adverse events was higher for ICU vs non-ICU patients (16.3% vs 13.7%; P < .001). Failure to rescue (2.9% vs 3.9%; P = .42) and in-hospital mortality (0.4% vs 0.4%; P = .81) were similar between groups. After adjusting for patient and hospital factors as well as for postoperative adverse events, ICU admission after EVAR cost $1475 (95% confidence interval, $768-2183) more than non-ICU admission (P < .001).Conclusions
Among patients undergoing elective EVAR, postoperative ICU admission is more closely associated with hospital practice patterns than with individual patient risk. Routine ICU admission after EVAR adds significant cost without reducing failure to rescue or in-hospital mortality. 相似文献52.
Isibor J. Arhuidese Besma Nejim Susruth Chavali Satinderjit Locham Tammam Obeid Caitlin W. Hicks Mahmoud B. Malas 《Journal of vascular surgery》2017,65(5):1418-1428
Objective
In-stent restenosis is a recognized complication of carotid angioplasty and stenting (CAS), and it is associated with an increased risk of stroke. Few case series have reported outcomes separately following carotid endarterectomy (CEA) and CAS for the treatment of in-stent restenosis. In this study, we perform an evaluation of redo-CAS vs CEA in a large contemporary cohort of patients who underwent prior ipsilateral CAS.Methods
We studied all patients in the Vascular Quality Initiative (VQI) database, who underwent CEA or CAS between January 1, 2003, and April 30, 2016, after prior ipsilateral CAS. Univariate methods (χ2, t-test), Kaplan-Meier, logistic, and Cox regression analyses adjusting for patient characteristics were employed to evaluate stroke, death, myocardial infarction (MI), stroke/death, and stroke/death/MI within 30 days and up to 1 year following the procedure.Results
There were 645 carotid interventions (CEA, 134 [21%] and redo-CAS, 511 [79%]) performed in this cohort of patients with prior ipsilateral CAS. Postoperative stroke within 30 days comparing CEA vs CAS was 0% vs 0.3% (P = .61) for asymptomatic patients and 4.4% vs 3.5% (P = .79) for symptomatic patients for an overall stroke rate of 1.5% vs 1.4%. MI was 2.3% vs 1.2% (P = .35), 30-day mortality was 3.7% vs 0.9% (P = .02) following CEA vs CAS, whereas the composite of perioperative stroke/death was 4.5% vs 1.9% (P = .09). Freedom from stroke/death at 1 year was 91% for CEA and 92% for redo-CAS (P = .76). After risk adjustment, there was no significant difference in 30-day stroke (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.15-4.48; P = .82), mortality (OR, 2.21; 95% CI, 0.54-9.11; P = .27), or stroke/death (OR, 0.99; 95% CI, 0.26-3.84; P = .99) as well as 1-year stroke (hazard ratio [HR], 0.60; 95% CI, 0.13-2.85; P = .52), mortality (HR, 0.83; 95% CI, 0.42-1.65; P = .60), or stroke/death (HR, 0.80; 95% CI, 0.43-1.49; P = .48) comparing CEA with CAS. The significant predictors of perioperative stroke/death were older age, diabetes, active smoking, and preoperative American Society of Anesthesiologists class IV status (all P < .05).Conclusions
We have reported adverse event rates for CEA and CAS after prior CAS and shown no significant difference in perioperative and 1-year outcomes between both groups. However, CEA is offered to patients who are more severely ill than redo-CAS, resulting in significantly higher absolute mortality. We recommend avoidance of CEA especially in asymptomatic patients with serious systemic disease. Tight management of diabetes and smoking cessation remain potent targets for outcomes improvement in redo-CAS patients. 相似文献53.
Background: The association cancer and venous thrombosis is almost always an independent criterion of poor prognosis of cancer. Thus, venous thromboembolic disease is with infection and organ failure, one of the leading causes of death in patients with malignant disease. Aim: To identify the characteristics of the association between cancer and venous thrombosis in any patient with deep vein thrombosis of lower limbs seemingly unexplained. Methods: This is a retrospective study from January 1994 to December 2008, concerning 17 cases of patients with deep vein thrombosis of lower limbs associated with neoplasia, hospitalized in internal medicine department at Habib Thameur hospital between a total of 290 patients with deep vein thrombosis of lower limbs. Only patients hospitalized for deep vein thrombosis of lower limbs complicated or not by a pulmonary embolism were included. Results: Our study concerned 17 patients. There were 10 women and 7 men with a sex ratio (Female / Male) at 1, 42. The average age was 68.7 years, with extreme ages ranging from 40 to 90 years. Cancer has formed 6% of the causes of deep venous thrombosis of lower limbs. Eight of our patients were known to suffer from a cancerous disease. Six cases of cancers were discovered at an advanced stage of evolution with multiple metastases. In seven cases the etiological could not be achieved. Deep venous thrombosis was complicated by pulmonary embolism in four inaugural events, five patients had recurrent thrombosis, and two cases of bleeding complications were noted. Conclusion: Venous thromboembolism is common in cancer patients. It can be the first manifestation of cancer completely silent. The course and prognosis depend on the stage of cancer combined. 相似文献
54.
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56.
Hajer Ennafaa Mohamed Ben Amor Besma Yacoubi-Loueslati Hussein Khodjet El Khil Emili Gonzalez-Perez Pedro Moral 《Annals of human biology》2013,40(5-6):634-640
Jerba Island represents an interesting area because four distinct ethnic groups have been cohabiting there until now: Arabs, Berbers, dark-skinned people of sub-Saharan origin and Jews. Religious and cultural differences seem to have constituted an obstacle to their intermixing. Our aim is to provide further information on the genetic structure of the Arab and Berber groups for whom previous data based on haploid markers confirmed their reproductive isolation. Five polymorphic Alu markers (HS 4.69, Sb 19.3, TPA-25, ACE and APO-A1) were analysed in a sample of 43 Arabs and 48 Berbers of Jerba. The genetic relationships among these groups and several populations from North Africa, sub-Saharan Africa and Europe were analysed using genetic distances based on allele frequencies. The results showed a homogeneous distribution of Alu insertions in the two geographically close groups, reflecting ancient relationships between them. This study also revealed that Arabs from Jerba present close genetic distances to other North African populations, whilst Berbers of Jerba occupy an intermediate position among Mediterranean populations. 相似文献
57.
Hanaa N. Dakour Aridi Satinderjit Locham Besma Nejim Nasr S. Ghajar Husain Alshaikh Mahmoud B. Malas 《Journal of vascular surgery》2018,67(3):747-758.e7
Objective
Reducing readmissions is an important target for improving patient care and enhancing health care quality and cost-effectiveness. The aim of this study was to assess rates, risk factors, and indications of 30-day readmission after open aortic repair (OAR) and endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs).Methods
A retrospective analysis of the Premier Healthcare Database from 2009 to 2015 was performed. Indications for readmission after the index procedure, risk factors, and outcomes of the index admission and rehospitalization were evaluated. Multivariate logistic models were used to assess the association between 30-day readmission and different patient and hospital factors.Results
A total of 33,332 AAA repair procedures were identified: 27,483 (82.5%) EVAR and 5849 (17.5%) OAR. The overall rate of 30-day readmission was 8.1%, and it was greater after OAR (12.9% vs 7.1% in EVAR; P < .001). In general, the most common specific readmission diagnoses were infectious complications (16.1%), followed by respiratory and cardiac complications (11.8% and 11.3%, respectively). After multivariate adjustment, OAR was associated with higher 30-day readmission compared with EVAR (adjusted odds ratio, 1.11; 95% confidence interval, 1.0-1.2; P = .04). Other risk factors of 30-day readmission included female gender, emergency and urgent procedures, certain patient comorbidities (dyslipidemia, congestive heart failure, history of transient ischemic attack, previous cardiac surgery, chronic obstructive pulmonary disease, asthma, chronic kidney disease, peripheral vascular disease, and history of malignant disease), and hemorrhage/shock/bleeding occurring during the index admission as well as nonhome discharge. Readmitted patients had an overall in-hospital mortality of 3.6% and paid a median rehospitalization cost of $7757.Conclusions
Our study shows that around 8.1% of patients undergoing infrarenal AAA repair were readmitted within 30 days. Because many readmissions are unrelated to the index procedure or caused by factors that are nonmodifiable or nonidentifiable at discharge, efforts should focus on discharge planning and improving the decision process regarding discharge destination as well as postdischarge coordination of care for high-risk patients. 相似文献58.
59.
Isibor J. Arhuidese Michol A. Cooper Muhammad Rizwan Besma Nejim Mahmoud B. Malas 《Journal of vascular surgery》2019,69(2):517-525.e1
Objective
The objective of this study was to compare the outcomes of arteriovenous fistulas (AVFs) with arteriovenous grafts (AVGs) in a large population-based cohort of elderly patients in the United States.Methods
A retrospective analysis was performed of all patients ≥75 years old in the prospectively maintained United States Renal Database System who had an AVF or AVG placed for hemodialysis (HD) access between January 2007 and December 2011. Outcomes were mortality, conduit patency, maturation, time to catheter-free dialysis, and infection. A χ2 test, Student t-test, Kaplan-Meier analysis, and multivariable Cox regression analysis were employed.Results
Of the 124,421 patients studied, there were 19,173 (15%) AVF initiates, 4480 (4%) AVG initiates, 29,872 (24%) AVF converts, 10,712 (9%) AVG converts, and 59,824 (48%) patients who persisted on HD catheters. Compared with AVF initiates, relative mortality was significantly higher for AVG initiates (adjusted hazard ratio [aHR], 1.24; P < .001), AVF converts (aHR, 1.36; P < .001), AVG converts (aHR, 1.62; P < .001), and catheter-persistent patients (aHR, 2.23; P < .001). Primary patency (aHR, 1.21; P < .001) and primary assisted patency (aHR, 1.31; P < .001) were higher for AVF. Secondary patency was higher for AVGs within the first 4 months (aHR, 1.12; P < .001) but higher for AVFs beyond that time point (aHR, 1.25; P < .001). Maturation rate and median time to maturation were 80% vs 84% (P < .001) and 46 vs 26 days (P < .001) for AVF vs AVG.Conclusions
Pre-emptive AVF remains the best mode of HD in elderly patients who can tolerate surgery. Patients who cannot tolerate pre-emptive surgery or have to initiate HD on an urgent basis with a catheter should convert to AVF when it is feasible if life expectancy is >4 months. If life expectancy is <4 months, surgical risk and quality of life should be considered in making the decision to persistently dialyze through HD catheter or to convert to AVG. 相似文献60.