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Stutsrim AE, Brastauskas IM, Craven TE, Callahan KE, Pajewski NM, Davis RP, Corriere MA, Edwards MS, Goldman MP. Automated Electronic Frailty Index is Associated with Non-home Discharge in Patients Undergoing Open Revascularization for Peripheral Vascular Disease. Am Surg 2023; 89:4501-4507. [PMID: 35971786 DOI: 10.1177/00031348221121547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Frailty is associated with adverse surgical outcomes including post-operative complications, needs for post-acute care, and mortality. While multiple frailty screening tools exist, most are time and resource intensive. Here we examine the association of an automated electronic frailty index (eFI), derived from routine data in the Electronic Health Record (EHR), with outcomes in vascular surgery patients undergoing open, lower extremity revascularization. METHODS A retrospective analysis at a single academic medical center from 2015 to 2019 was completed. Information extracted from the EHR included demographics, eFI, comorbidity, and procedure type. Frailty status was defined as fit (eFI≤0.10), pre-frail (0.100.21). Outcomes included length of stay (LOS), 30-day readmission, and non-home discharge. RESULTS We included 295 patients (mean age 65.9 years; 31% female), with the majority classified as pre-frail (57%) or frail (32%). Frail patients exhibited a higher degree of comorbidity and were more likely to be classified as American Society of Anesthesiologist class IV (frail: 46%, pre-frail: 27%, and fit: 18%, P = 0.0012). There were no statistically significant differences in procedure type, LOS, or 30-day readmissions based on eFI. Frail patients were more likely to expire in the hospital or be discharged to an acute care facility (31%) compared to pre-frail (14%) and fit patients (15%, P = 0.002). Adjusting for comorbidity, risk of non-home discharge was higher comparing frail to pre-frail patients (OR 3.01, 95% CI 1.40-6.48). DISCUSSION Frail patients, based on eFI, undergoing elective, open, lower extremity revascularization were twice as likely to not be discharged home.
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Affiliation(s)
- Ashlee E Stutsrim
- Department of Vascular Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Ian M Brastauskas
- Department of Vascular Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Tim E Craven
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Kathryn E Callahan
- Department of Internal Medicine, Section of Gerontology and Geriatric Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Nicholas M Pajewski
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ross P Davis
- Department of Vascular Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Matthew A Corriere
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Matthew S Edwards
- Department of Vascular Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Matthew P Goldman
- Department of Vascular Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
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Velazquez-Ramirez G, Krebs J, Stafford JM, Ur R, Craven TE, Stutsrim AE, Goldman MP, Hurie JB, Edwards MS. Prevalence of chronic opioid use in patients with peripheral arterial disease undergoing revascularization. J Vasc Surg 2021; 75:186-194. [PMID: 34478808 DOI: 10.1016/j.jvs.2021.07.236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/29/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Opiate use, dependence, and the associated morbidity and mortality are major current public health problems in the United States. Little is known about patterns of opioid use in patients with peripheral arterial disease (PAD). The purpose of this study was to identify the prevalence of chronic preoperative and postoperative prescription opioid use in patients with PAD. A secondary aim was to determine the demographic, comorbid conditions, and operative characteristics associated with chronic opioid use. METHODS Using a single-institution database of patients with PAD undergoing open or endovascular lower extremity intervention from 2013 to 2014, data regarding opiate use and associated conditions were abstracted for analysis. Patients were excluded if they did not live in North Carolina or surgery was not for PAD. Preoperative (PreCOU) and postoperative chronic opioid use (PostCOU) were defined as consistent opioid prescription filling in the 3 months before and after the index procedure, respectively. Opioid prescription filling was assessed using the North Carolina Controlled Substance Reporting System. Demographics, comorbid conditions, other adjunct pain medication data, and operative characteristics were abstracted from our institutional electronic medical record. Associations with PreCOU were evaluated using the t test, Wilcoxon test, or two-sample median test (continuous), or the χ2 or Fisher exact tests (categorical). RESULTS A total of 202 patients undergoing open (108; 53.5%) or endovascular (94; 46.5%) revascularization for claudication or critical limb ischemia were identified for analysis. The mean age was 64.6 years, and 36% were female. Claudication was the indication for revascularization in 26.7% of patients, and critical limb ischemia was the indication in 73.3% of patients. The median preoperative ankle-brachial index (ABI) was 0.50. Sixty-eight patients (34%) met the definition for PreCOU. PreCOU was associated with female gender, history of chronic musculoskeletal pain, benzodiazepine use, and self-reported illicit drug use. Less than 50% of patients reported use of non-opiate adjunct pain medications. No association was observed between PreCOU and pre- or postoperative ABI, or number of prior lower extremity interventions. Following revascularization, the median ABI was 0.88. PreCOU was not associated with significant differences in postoperative complications, length of stay, or mortality. Overall, 71 patients (35%) met the definition for PostCOU, 14 of whom had no history of preoperative chronic opiate use. Ten patients with PreCOU did not demonstrate PostCOU. CONCLUSIONS Chronic opiate use was common in patients with PAD with a prevalence of approximately 35%, both prior to and following revascularization. Revascularization was associated with a termination of chronic opiate use in less than 15% of patients with PreCOU. Additionally, 10% of patients who did not use opiates chronically before their revascularization did so afterwards. Patients with PAD requiring intervention represent a high-risk group with regards to chronic opiate use. Increased diligence in identifying opioid use among patients with PAD and optimizing the use of non-narcotic adjunct pain medications may result in a lower prevalence of chronic opiate use and its attendant adverse effects.
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Affiliation(s)
- Gabriela Velazquez-Ramirez
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC.
| | - Jonathan Krebs
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Jeanette M Stafford
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Rebecca Ur
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Timothy E Craven
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Ashlee E Stutsrim
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Matthew P Goldman
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Justin B Hurie
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Matthew S Edwards
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
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Bosley ME, Stutsrim AE, Gross JL. Appendicitis in an Appendicostomy. Am Surg 2021:31348211023405. [PMID: 34056951 DOI: 10.1177/00031348211023405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 25-year-old man presented with right lower quadrant abdominal wall erythema, a punctum of purulence, and localized pain at the site of a previous appendicostomy. Cross-sectional imaging revealed appendicitis at his previous appendicostomy with a fecalith near the skin. He was managed with appendectomy. The surgical approach mimicked a loop ileostomy reversal by circumferentially dissecting the tissue around the appendicostomy to the level of the fascia and then dividing the appendix at the base of the cecum through a small two-centimeter incision. Appendicitis in a previous appendicostomy is uncommon and has only been described in three previous case reports (two adults and one child) and was surgically approached through a low-midline laparotomy. Our case is unique as it is an uncommon presentation of a common disease managed with a minimally invasive approach not previously described.
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Affiliation(s)
- Maggie E Bosley
- Department of Surgery, 12280Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Ashlee E Stutsrim
- Department of Surgery, 12280Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Jessica L Gross
- Department of Surgery, 12280Wake Forest Baptist Health, Winston-Salem, NC, USA
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Hassan M, Stutsrim AE, J Clark C. Large Canal of Nuck Hernia: The Female Equivalent of the Inguinoscrotal Hernia. Am Surg 2021:3134821998672. [PMID: 33626888 DOI: 10.1177/0003134821998672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Our patient was a 78-year-old woman with a large indirect inguinal hernia who underwent Lichtenstein repair. Literature review of the pathophysiology of indirect hernias revealed important discussion of the canal of Nuck in women and understanding embryologic development of ovaries and descent of testes.
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Affiliation(s)
- Monalisa Hassan
- Department of General Surgery, 20814Howard University Hospital, Washington, DC, USA
| | - Ashlee E Stutsrim
- Department of General Surgery, 12280Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Clancy J Clark
- Department of General Surgery, 12280Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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Stutsrim AE, Griffin CM, Palavecino EL, Hildreth AN, Avery MD, Chang MC, Miller PR, Nunn AM. Screening for Bacteremia in Trauma Patients: Traditional Markers Fall Short. Am Surg 2020; 87:765-770. [PMID: 33170029 DOI: 10.1177/0003134820954786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Deranged physiology in trauma complicates the clinical identification of sepsis, resulting in overscreening for bacteremia. No clinical signs or biomarkers accurately diagnose sepsis in this population. Our objective was to evaluate the accuracy of the current criteria used to prompt screening for bacteremia in trauma patients and determine independent predictors of bacteremia. MATERIALS AND METHODS Adult trauma patients admitted to our level I academic trauma center who had blood cultures (BCs) drawn were identified. Those with positive BCs were compared to those with negative or false positive BCs. False positive was defined as a BC deemed contaminated and not treated at the discretion of the attending physician. RESULTS Over a 2-year period, 366 trauma patients had BCs drawn. After excluding surveillance cultures (those drawn to demonstrate bacteremia clearance), 492 unique BC sets were evaluated; 104 (21.1%) BC sets were positive; 30 (28.8%) of these were falsely positive, resulting in a true-positive rate of 15% in the screened population. Univariate analysis suggested temperature and heart rate were associated with positive BC, while multivariable analysis found only the presence of a central line and lactic acid to be predictive. Procalcitonin (PCT) was poorly predictive, with a positive predictive value of 18% and a negative predictive value of 91%. CONCLUSION Current tools for identifying bacteremia in trauma patients result in overscreening. PCT may have a limited role as a negative predictor for bacteremia. Given that false-positive BCs have negative patient and economic consequences, future study should focus on development of alternative screening modalities.
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Affiliation(s)
- Ashlee E Stutsrim
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Caitlin M Griffin
- Department of General Surgery, University of Louisville, Louisville, KY, USA
| | | | - Amy N Hildreth
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Martin D Avery
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Michael C Chang
- Department of General Surgery, University of South Alabama, Mobile, AL, USA
| | - Preston R Miller
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Andrew M Nunn
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Stutsrim AE, Eady JM, Collum M, Rebo GJ, Rebo KA, Miller PR, Nunn AM. Weight-Based Enoxaparin Achieves Adequate Anti-Xa Levels More Often in Trauma Patients: A Prospective Study. Am Surg 2020; 87:77-82. [PMID: 32915054 DOI: 10.1177/0003134820949519] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Previous research demonstrates that twice-daily enoxaparin is inadequate for venous thromboembolic (VTE) prophylaxis in critically ill trauma patients prompting dose adjustment based on anti-Xa levels. Most studies evaluate peak anti-Xa levels; however, data suggest that trough levels are associated with decreased VTE. We evaluated trough anti-Xa levels in noncritically ill trauma patients receiving fixed or weight-based enoxaparin. METHODS Peak and trough anti-Xa levels were prospectively collected from patients receiving at least 3 consecutive doses of enoxaparin (PRE). A performance improvement project prompted a change to weight-based dosing. Peak and trough levels were subsequently prospectively collected from the weight-based group (POST). Adequate peak was defined as ≥0.2 IU/mL and adequate trough as ≥0.1 IU/mL. PRE and POST groups were compared. RESULTS 200 patients were evaluated (100 PRE, 100 POST). In the PRE group, only 34% of trough and 61% of peak anti-Xa levels were adequate compared with 82% and 97%, respectively, in the POST group (P < .01). Median trough improved from 0.07 IU/mL to 0.2 IU/mL (P < .01). Median peak improved from 0.22 IU/mL to 0.47 IU/mL (P < .01). More patients achieved adequate peak and trough levels in the POST group (79% vs 31%, P < .01). 95% of patients with adequate troughs also had adequate peaks, whereas 75% with adequate peaks had adequate troughs. DISCUSSION Traditional enoxaparin dosing in noncritically ill trauma patients results in suboptimal anti-Xa levels. Weight-based enoxaparin improves both trough and peak anti-Xa levels obviating dose adjustment. Furthermore, troughs better predict adequate anti-Xa levels.
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Affiliation(s)
- Ashlee E Stutsrim
- 1228012279Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - J Matthew Eady
- 1228012279Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Magdalena Collum
- 1228012279Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Gerald J Rebo
- 8674Clinical Pharmacy, Novant Health Corporate Health, Winston-Salem, NC, USA
| | - Kristin A Rebo
- 1228012279Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Preston R Miller
- 1228012279Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Andrew M Nunn
- 1228012279Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Stutsrim AE, Zeller K. Bronchogenic Cyst of the Scapula Presenting as a Superficial Abscess in a 21-Month-Old Girl. Am Surg 2020; 88:1357-1358. [PMID: 32869665 DOI: 10.1177/0003134820945207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ashlee E Stutsrim
- 12280 Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Kristen Zeller
- 12280 Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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