Single-cell sequencing reveals Hippo signaling as a driver of fibrosis in hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic inflammatory disease characterized by abscesses, nodules, dissecting/draining tunnels, and extensive fibrosis. Here, we integrate single-cell RNA sequencing, spatial transcriptomics, and immunostaining to provide an unprecedented view of the pathogenesis of chronic HS, characterizing the main cellular players and defining their interactions. We found a striking layering of the chronic HS infiltrate and identified the contribution of 2 fibroblast subtypes (SFRP4+ and CXCL13+) in orchestrating this compartmentalized immune response. We further demonstrated the central role of the Hippo pathway in promoting extensive fibrosis in HS and provided preclinical evidence that the profibrotic fibroblast response in HS can be modulated through inhibition of this pathway. These data provide insights into key aspects of HS pathogenesis with broad therapeutic implications.

Outcomes of breast reconstruction in patients with stage IV breast cancer

BACKGROUND

Patients with Stage IV breast cancer are living longer but breast reconstruction in this setting remains controversial. There is limited research evaluating the benefits of breast reconstruction in this patient cohort.

STUDY DESIGN

Drawing from the Mastectomy Reconstruction Outcomes Consortium (MROC) dataset, a prospective cohort study that involved 11 leading medical centers in the US and Canada, we compared patient-reported outcomes (PROs) assessed utilizing the BREAST-Q, a condition-specific, validated patient-reported outcome measure (PROM) for mastectomy reconstruction, as well as complications between a cohort of patients with Stage IV disease undergoing reconstruction and a control group of women with Stage I-III disease also receiving reconstruction.

RESULTS

Among the MROC population, 26 patients with Stage IV and 2613 women with Stage I-III breast cancer underwent breast reconstruction. Preoperatively, the Stage IV cohort reported significantly lower baseline scores for satisfaction with breast (p = 0.004), psychosocial well-being (p = 0.043) and sexual well-being (p = 0.001), compared with Stage I-III women. Following breast reconstruction, Stage IV patients' mean PRO scores improved over baseline and were not significantly different from those of Stage I-III reconstruction patients. There were also no significant differences in overall/any (p = 0.782), major (p = 0.751) or minor complication (p = 0.787) rates between the two groups at two years following reconstruction.

CONCLUSIONS

The findings in this study suggest that breast reconstruction offers significant quality-of-life benefits for women with advanced breast cancer with no increase in postoperative complications and thus may be a reasonable option in this clinical setting.

Contribution of plasma cells and B cells to hidradenitis suppurativa pathogenesis

Hidradenitis suppurativa (HS) is a debilitating chronic inflammatory skin disease characterized by chronic abscess formation and development of multiple draining sinus tracts in the groin, axillae, and perineum. Using proteomic and transcriptomic approaches, we characterized the inflammatory responses in HS in depth, revealing immune responses centered on IFN-γ, IL-36, and TNF, with lesser contribution from IL-17A. We further identified B cells and plasma cells, with associated increases in immunoglobulin production and complement activation, as pivotal players in HS pathogenesis, with Bruton’s tyrosine kinase (BTK) and spleen tyrosine kinase (SYK) pathway activation as a central signal transduction network in HS. These data provide preclinical evidence to accelerate the path toward clinical trials targeting BTK and SYK signaling in moderate-to-severe HS.

B-cells and plasma cells are critical pathogenic cell populations in chronic Hidradenitis Suppurativa and are potential therapeutic targets.

Accuracy of Predicted Resection Weights in Breast Reduction Surgery

Background:

Many insurance carriers continue to deny coverage for reduction mammaplasty unless a minimum amount of resected breast tissue per breast is achieved during surgery. This study investigates the accuracy of preoperative prediction that a minimum weight of 500 g can be resected and evaluates potential risk factors for not meeting this insurance requirement.

Methods:

A retrospective review was performed on 445 patients with bilateral symptomatic macromastia who sought consultation for breast reduction surgery from 2007 to 2012. Women were included for analysis if they had documented predicted resection weights and underwent small-to-moderate breast reduction (< 1,000 g per side; n = 323). Relevant demographic information, mean predicted resection weight, and the mean actual resection weight were collected for analysis.

Results:

Surgeon prediction of resection weight being over 500 g had a positive predictive value of 73%. In 61 patients (19%), the predicted weights were ≥ 500 g, but the actual weights were < 500 g. Thirty percentage of these 61 patients did not meet either Schnur or minimum weight requirements. Women with a body mass index < 30 were at significantly increased odds (odds ratio, 3.76; 95% confidence interval, 1.89–7.48; P = 0.002) of not meeting the minimum weight requirement at surgery compared with patients with a body mass index ≥ 30.

Conclusions:

The common insurance criterion of removing ≥ 500 g per breast during breast reduction surgery are not met in a distinct cohort of women who are clinically appropriate candidates. This risk is particularly increased in nonobese women possibly due to proportionately smaller breast mass compared with obese women.

What Should Be the Role of Plastic Surgeons in Nonanatomic Breast Reconstruction, including Tattooing?

The goal of plastic surgeons performing postmastectomy anatomic reconstruction is to create a breast structure that closely matches the shape and appearance of a patient's native breast. Tattoo artists have helped improve outcomes with nipple-areolar tattooing. Some patients now prefer to have more extensive, nonanatomic designs to help camouflage their scars. Two questions are considered here: What role should plastic surgeons have in supporting or performing nonanatomic reconstruction? And should insurance programs cover nonanatomic breast reconstruction options?

Simplifying Arterial Coupling in Microsurgery-A Preclinical Assessment of an Everter Device to Aid with Arterial Anastomosis

BACKGROUND

 A novel arterial everter device was engineered to simplify microvascular coupling of arteries by reliably securing the stiff, muscular wall of arteries over coupler pins. We compare microvascular coupling with the everter device to manual suturing for arterial anastomoses in a live large animal model.

MATERIALS AND METHODS

 In this preliminary study, bilateral external femoral arteries of five male swine were exposed and sharply divided. Arteries were anastomosed using either interrupted sutures (n = 5) or the everter device and Synovis Coupler (n = 5). The efficiency in engaging coupler pins, the time taken to perform the anastomosis, and vessel patency immediately post-op and at 1-week postanastomosis were evaluated. Vessel wall injury and luminal stenosis were compared between groups using histomorphometric analyses.

RESULTS

 On an average, 80% of coupler pins engaged the vessel walls after a single pass of the everter. The average time to perform the anastomosis was significantly less when using the everter/coupler compared with manual suturing (6:35 minutes versus 25:09 minutes, p < 0.001). Immediately post-op, 100% patency was observed in both groups. At 1 week post-op, four of five (80%) of coupled arteries and all five (100%) of hand-sewn arteries were patent. The degree of arterial wall injury, neointimal formation, and luminal stenosis for patent arteries were similar between groups.

CONCLUSIONS

 Successful arterial anastomoses using the everter device with the Synovis Coupler was easier and significantly more efficient when compared with a standard hand-sewn technique. Both techniques had acceptable patency rates and similar effects on the vessel wall and intima.

Guidelines of care for the management of cutaneous squamous cell carcinoma

Cutaneous squamous cell carcinoma (cSCC) is the second most common form of human cancer and has an increasing annual incidence. Although most cSCC is cured with office-based therapy, advanced cSCC poses a significant risk for morbidity, impact on quality of life, and death. This document provides evidence-based recommendations for the management of patients with cSCC. Topics addressed include biopsy techniques and histopathologic assessment, tumor staging, surgical and nonsurgical management, follow-up and prevention of recurrence, and management of advanced disease. The primary focus of these recommendations is on evaluation and management of primary cSCC and localized disease, but where relevant, applicability to recurrent cSCC is noted, as is general information on the management of patients with metastatic disease.

Association of Fat Grafting With Patient-Reported Outcomes in Postmastectomy Breast Reconstruction

Importance

Fat grafting has proven to be a useful adjunct to breast reconstruction for the treatment of contour irregularities and volume deficits, but the proposed US Food and Drug Administration regulations may severely limit the ability of plastic surgeons to continue its use in this clinical context.

Objective

To determine whether fat grafting is associated with patient-reported outcomes (PROs) in patients undergoing breast reconstruction.

Design, Setting, and Participants

A longitudinal, multicenter, prospective cohort study was conducted between February 1, 2012, and July 31, 2016, at the 11 sites associated with the Mastectomy Reconstruction Outcomes Consortium Study. Eligible patients included women 18 years or older presenting for breast reconstruction after mastectomy with 2 years or more of follow-up. All primary procedure types (implant based and flap based) were eligible. Patients were excluded if they had not completed breast mound reconstruction by 1 year after starting reconstruction.

Interventions

Fat grafting as an adjunct to breast mound reconstruction.

Main Outcomes and Measures

Primary end points were patient-reported outcome measures as assessed by the validated BREAST-Q survey, with higher scores on a 0- to 100-point scale indicating better health-related quality of life. Survey subscales included breast satisfaction, as well as psychosocial, physical, and sexual well-being. Patient-reported outcomes were compared between those who received and did not receive fat grafting.

Results

A total of 2048 women were included (mean [SD] age, 49.4 [10] years), with 165 (8.1%) undergoing fat grafting between years 1 and 2. One year postoperatively, patients who later underwent fat grafting reported significantly lower breast satisfaction (adjusted mean difference [AMD], -4.74; 95% CI, -8.21 to -1.28; P = .008), psychosocial well-being (AMD, -3.87; 95% CI, -7.33 to -0.40; P = .03), and sexual well-being (AMD, -5.59; 95% CI, -9.70 to -1.47; P = .008), compared with those who did not receive subsequent fat grafting. Following the procedure, the fat-grafted cohort reported similar breast satisfaction (AMD, -0.68; 95% CI, -4.42 to 3.06; P = .72), psychosocial well-being (AMD, -0.59; 95% CI, -3.92 to 2.74; P = .73), and sexual well-being (AMD, -2.94; 95% CI, -7.01 to 1.12; P = .15) 2 years postoperatively.

Conclusions and Relevance

Fat grafting may improve breast satisfaction, psychosocial well-being, and sexual well-being in patients undergoing breast reconstruction.

Acute Calcific Tendinitis of the Index Finger in a Child

BACKGROUND

Calcific tendinitis is characterized by calcium hydroxyapatite crystal deposition within tendons and is a common cause of musculoskeletal pain in adults. Its clinical manifestations may be acute, chronic, or asymptomatic. Acute calcific tendinitis is self-resolving condition that is rarely reported in the pediatric population and may be overlooked for more common processes, leading to unnecessary treatment.

METHODS

A chart reivew was performed of a single case of acute calcific tendonitis of the index finger in a child.

RESULTS

We describe a case of calcific tendinitis of the index finger in a 9-year-old boy who was referred to us for a second opinion after surgical exploration of an acutely inflamed digit was recommended based on his initial presentation. The calcifications and symptoms resolved over time without operative management.

CONCLUSIONS

Although rare in children, acute calcific tendinitis can present similar to an infection. However, appropriate managment is non-operative as the symptoms and radiographic findings resolve over time.

Optimizing the post-graduate institutional program evaluation process

BACKGROUND

Reviewing program educational efforts is an important component of postgraduate medical education program accreditation. The post-graduate review process has evolved over time to include centralized oversight based on accreditation standards. The institutional review process and the impact on participating faculty are topics not well described in the literature.

METHODS

We conducted multiple Plan-Do-Study-Act (PDSA) cycles to identify and implement areas for change to improve productivity in our institutional program review committee. We also conducted one focus group and six in-person interviews with 18 committee members to explore their perspectives on the committee's evolution. One author (MLL) reviewed the transcripts and performed the initial thematic coding with a PhD level research associate and identified and categorized themes. These themes were confirmed by all participating committee members upon review of a detailed summary. Emergent themes were triangulated with the University of Michigan Medical School's Admissions Executive Committee (AEC).

RESULTS

We present an overview of adopted new practices to the educational program evaluation process at the University of Michigan Health System that includes standardization of meetings, inclusion of resident members, development of area content experts, solicitation of committed committee members, transition from paper to electronic committee materials, and focus on continuous improvement. Faculty and resident committee members identified multiple improvement areas including the ability to provide high quality reviews of training programs, personal and professional development, and improved feedback from program trainees.

CONCLUSIONS

A standing committee that utilizes the expertise of a group of committed faculty members and which includes formal resident membership has significant advantages over ad hoc or other organizational structures for program evaluation committees.

Immediate Reconstruction of the Radiated Breast: Recent Trends Contrary to Traditional Standards

BACKGROUND

Immediate, implant-only breast reconstruction is traditionally discouraged in patients who receive radiation. It is not clear whether this widely recognized mantra of breast reconstruction is observed in practice. The purpose of this study was to evaluate immediate reconstruction trends and practices in patients who have undergone mastectomy and radiation therapy.

METHODS

Female patients with unilateral breast cancer who required radiation in addition to mastectomy were extracted from the Surveillance, Epidemiology, and End Results (SEER) database from 2000 through 2010. Patients who underwent immediate reconstruction were identified and analyzed. Univariate and logistic regression analyses were performed to study the relationship between reconstructive method and patient demographic and oncologic characteristics.

RESULTS

A total of 5,481 female patients who underwent radiation and breast reconstruction were included for analysis. Postmastectomy radiation therapy was performed in 98.3 % of the patients. The immediate breast reconstruction rate among patients requiring radiation increased from 13.6 to 25.1 %. The percentage of reconstructed patients who had implant-only reconstruction increased from 27 to 52 % (p < 0.001) with a decrease in tissue-only reconstruction from 56 to 32 % (p < 0.001). In regression analysis, the odds of implant reconstruction over autologous reconstruction increased each year by an odds ratio of 1.13 (95 % CI 1.10-1.15).

CONCLUSIONS

The frequency of immediate reconstruction continues to increase in the setting of postmastectomy radiation therapy, with immediate implant-based reconstruction representing the most commonly utilized method, contrary to traditional recommendations. These findings likely reflect changing attitudes towards implant reconstruction in the setting of planned postmastectomy radiation.

NCCN Guidelines implementation in the multidisciplinary Merkel Cell Carcinoma Program at the University of Michigan

Merkel cell carcinoma (MCC) is a rare malignancy of the skin, and prospective randomized clinical studies on management and treatment are very limited. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for MCC provide up-to-date, best evidence-based, and consensus-driven management pathways with the purpose of providing best care and outcomes. Multidisciplinary management with consensus treatment recommendations to individualize patient care within the framework of these guidelines is optimal. The University of Michigan multidisciplinary MCC program uses NCCN Guidelines in the management and treatment of its patients. This article discusses 4 patient presentations to highlight the implementation of the NCCN Guidelines for MCC at the University of Michigan.

Abdominal wall dynamics after component separation hernia repair

BACKGROUND

The component separation technique (CST) is an important technique now used frequently in complex ventral hernia repair (VHR). Although this technique has demonstrated superior success rates, there is a paucity of research describing how release of the external obliques coupled with rectus myofascial advancement alters the morphology of the abdominal architecture. In this study, we apply the new concept of analytic morphomics to describe the immediate changes in morphology of the abdomen that take place after VHR by CST.

METHODS

We identified 21 patients who underwent VHR by CST and received both preoperative and postoperative computed tomography scans between 2004 and 2009 in our clinical database. The surgical technique involved incisional release of the external oblique muscle lateral to the linea semilunaris with rectus abdominis myofascial advancement in all patients. Using semiautomated morphomic analysis, we measured the pre- and post-operative dimensions of the abdominal wall including the anterior-posterior distance from the anterior vertebra-to-skin and fascia along with the circumferential area of the skin and fascial compartments. Paired Student t-tests were used to compare pre- and post-operative values.

RESULTS

After hernia repair, there was a decrease in the anterior vertebra-to-skin distance (16.6 cm-15.8 cm, P = 0.007). There were also decreases in total body area (968.0 cm(2)-928.6 cm(2), P = 0.017) and total body circumference (113.6 cm-111.4 cm, P = 0.016). The distance from fascia to skin decreased as well, almost to the point of statistical significance (3.3 cm-2.9 cm, P = 0.0505). Interestingly, fascia area and circumference did not decrease significantly after the operation (578.2 cm(2)-572.5 cm(2), P = 0.519, and 89.1 cm-88.6 cm, P = 0.394, respectively).

CONCLUSIONS

Morphomic analysis can be used to compare and pre- and post-operative changes in patients undergoing abdominal surgery. Our study demonstrates that component separation affects the dimensions of the entire abdomen, but leaves the fascia area and circumference relatively unchanged. These changes in the abdominal wall may help explain the muscular changes observed as a result of this operation and demonstrate that this is a functional operation that restores fascial area. By better defining the effects of this procedure, we can better understand the reason for its clinical success.

Cross-sectional area of the abdomen predicts complication incidence in patients undergoing sternal reconstruction

BACKGROUND

Sternal reconstruction with vascularized flaps is central to the management of sternal wound infections and mediastinitis but carries a high risk of complications. There is a need to identify reliable predictors of complication risk to help inform patients and clinicians in preparation for surgery. Unfortunately, body mass index and serum albumin may not be reliable predictors of complication rates. Analytic morphomics provides a robust quantitative method to measure patients' obesity as it pertains to their risk of complications in undergoing sternal reconstruction.

METHODS

We identified 34 patients with preoperative computed tomography scans of the abdomen from a cohort of sternal reconstructions performed between 1997 and 2010. Using semiautomated analytic morphomics, we identified the patients' skin and fascia layers between the ninth and 12th thoracic spine levels; from these landmarks, we calculated morphomic measurements of the patients' abdomens, including their total body cross sectional area and the cross sectional area of their subcutaneous fat. We obtained the incidence of complications from chart review and correlated the incidence of complications (including seroma, hematoma, recurrent wounds, mediastinitis, tracheostomy, and death) with patients' morphomic measurements.

RESULTS

Sixty-two percent of patients (n = 21) suffered complications after their operation. Those who suffered from complications, relative to those who did not have complications, had increased visceral fat area (12,547.2 mm(2)versus 6569.9 mm(2), P = 0.0080), subcutaneous fat area (16,520.2 mm(2)versus 8020.1 mm(2), P = 0.0036), total body area (91,028.6 mm(2)versus 67,506.5 mm(2), P = 0.0022), fascia area (69,238.4 mm(2)versus 56,730.9 mm(2), P = 0.0118), total body circumference (1101.8 mm versus 950.2 mm, P = 0.0017), and fascia circumference (967.5 mm versus 868.1 mm, P = 0.0077). We also demonstrated a significant positive correlation between the previously mentioned morphomic measurements and the incidence of complications in multivariate logistic regression models, with odds ratios ranging from 1.19-3.10 (P values ranging from 0.010-0.022).

CONCLUSIONS

Increases in abdominal morphomic measurements correlate strongly with the incidence of complications in patients undergoing sternal reconstruction. This finding may influence preoperative risk stratification and surgical decision making in this patient population.

A systematic review of morbidity associated with autologous breast reconstruction before and after exposure to radiotherapy: are current practices ideal?

PURPOSE

The specific aim of this study was to conduct a systematic review of the literature to assess outcomes data on complications and aesthetic results associated with autologous tissue-based breast reconstruction performed before or after chest wall irradiation.

METHODS

Studies from a PubMed search that met predetermined inclusion criteria were identified. Complications of interest included partial or total flap loss, fat necrosis, thrombosis, infection, seroma, hematoma, delayed wound healing, and flap fibrosis/contracture. Pooled complication rates were calculated.

RESULTS

A total of 20 articles were included in the study for autologous reconstruction. These primary articles were selected after screening 897 publications, with six studies presenting data on pre-reconstruction radiation, nine studies presenting data on post-reconstruction radiation, and five studies presenting data on both patient groups. Comparison of pooled complication rates between flaps irradiated before or after reconstruction were statistically similar, including total flap loss (1 vs. 4 %), wound healing complications (10 vs. 14 %), infection (4 vs. 6 %), hematoma (2 vs. 1 %), seroma (4 vs. 4 %), and fat necrosis (10 vs. 13 %). The pooled rate of flap contracture and fibrosis was 27 % in flap reconstructions exposed to radiotherapy. Statistical evaluation of aesthetic outcomes was impossible as a result of variability in assessment and reporting methods.

CONCLUSIONS

Review of the current literature suggests similar rates of complications and success rates in autologous breast reconstruction patients exposed to pre- or post-reconstruction radiation. Immediate autologous reconstruction should be considered as a viable option even in patients who are likely to require postmastectomy radiotherapy.

Malignant melanoma arising in the setting of epidermolysis bullosa simplex: an important distinction from epidermolysis bullosa nevus

IMPORTANCE

Patients with epidermolysis bullosa (EB) do not carry a significantly increased risk of melanoma but are prone to developing large, markedly atypical melanocytic nevi (EB nevi), which may mimic melanoma clinically and histologically. Many authors now favor a conservative approach in managing atypical pigmented lesions in patients with EB.

OBSERVATIONS

We present the case of a 30-year-old woman with severe EB simplex who sought care for a large red and black ulcerated plaque. The clinical differential diagnosis included EB nevus and melanoma. An incisional punch biopsy specimen revealed an atypical melanocytic proliferation with focal florid pagetoid spread and involving elongated rete ridges, consistent with invasive acral lentiginous melanoma. The subsequent amputation was confirmatory. Micrometastasis was detected in 1 of 5 sentinel lymph nodes.

CONCLUSIONS AND RELEVANCE

To our knowledge, this is the first reported case of melanoma arising in EB simplex-affected skin. It highlights the difficulty in differentiating melanoma from an EB nevus. Despite the increasing awareness of EB nevi, a high index of suspicion for melanoma should be maintained, and early biopsy is recommended when evaluating large pigmented lesions in patients with EB.

A systematic review of complications of implant-based breast reconstruction with prereconstruction and postreconstruction radiotherapy

PURPOSE

To conduct a systematic review of the literature to assess outcomes data on complications associated with implant-based breast reconstruction performed before or after chest wall radiation to assist in guiding the decision-making process for reconstruction of the irradiated breast.

METHODS

Studies from a PubMed search that met predetermined inclusion criteria were identified and included. Complications of interest were low- and high-grade capsular contractures, minor and major complications, reconstruction failure rates, and reconstruction completion rates. Pooled complication rates were calculated.

RESULTS

A total of 26 articles were included in the study after screening 1,006 publications, with 14 studies presenting data on prereconstruction radiation and 23 studies presenting data on postreconstruction radiation. Complication rates evaluated in patients exposed to radiation before or after implant reconstruction were not significantly different. Reconstruction failure rates were similar at 19 and 20 % for pre- and postreconstruction radiation patients, respectively. Completion rates were similar at 83 and 80 % for pre- and postreconstruction radiation patients, respectively.

CONCLUSIONS

Review of the current literature suggests similar overall success and failure rates with radiotherapy provided both before and after reconstruction. Failure rates in both groups of patients are clinically significant when considering implant reconstruction in the setting of radiation.

Female urethral reconstruction using a tubed rectus abdominis myocutaneous flap

We describe the novel use of a rectus abdominis myocutaneous flap for reconstruction of the female urethra following an oncological pelvic resection. Reconstruction of the female urethra from the bladder neck to external urethral orifice was successfully performed, avoiding the need for a urostomy. To our knowledge, the myocutaneous flap has never been described for complete urethral reconstruction.

Current concepts in the surgical management of rheumatoid and osteoarthritic hands and wrists

Rheumatoid arthritis (RA) is a progressively destructive disease. Gradual loss of hand function in RA patients affects their ability for self-care and interferes with their productivity in society. The continuing improvement in the medical management of RA has markedly decreased the incidence of RA hand surgery. In contrast to RA, osteoarthritis (OA) has less inflammatory reaction in the joints and is characterized by degradation of cartilage, resulting in joint destruction and osteophyte formation. The initial treatment of OA is medication and therapy. Steroid injection into affected joints can provide short-term relief, though repeat injections carry a cumulative risk of weakening the soft tissue. In this article the authors share their extensive experience in RA and OA hand surgery to provide a clear discussion of the indications and outcomes of its practice.

Surgical management of primary disease

Despite advancements in the treatment of melanoma, surgical management remains the cornerstone for treatment and long-term survival. The authors present their surgical approach to the patient with melanoma including evaluation, treatment, and reconstruction. In addition, management of melanoma occurring in difficult anatomic areas and in special patient populations is reviewed.

Epidemiology and impact of aspiration pneumonia in patients undergoing surgery in Maryland, 1999-2000

OBJECTIVE

The epidemiology of aspiration pneumonia and its impact on clinical and economic outcomes in surgical patients are poorly defined. We sought to identify preoperative patient characteristics and surgical procedures that are associated with an increased risk for aspiration pneumonia and to determine the clinical and economic impact in hospitalized surgical patients.

DESIGN

Observational study using a state discharge database.

SETTING

All hospitals in Maryland.

PATIENTS

We obtained discharge data for 318,880 adult surgical patients in 52 Maryland hospitals from January 1, 1999, through December 31, 2000.

MEASUREMENTS AND MAIN RESULTS

The primary outcome variable was a discharge diagnosis of aspiration pneumonia. Unadjusted and adjusted analyses were performed to identify patient characteristics and surgical procedures associated with an increased risk for aspiration pneumonia and to determine the impact on intensive care unit admission, in-hospital mortality, hospital length of stay, and total hospital charges. The overall prevalence of aspiration pneumonia was 0.8%. The prevalence varied among hospitals (range, 0% to 1.9%) and by surgical procedure (range, <0.1% to 19.1%). Patient characteristics independently associated with an increased risk included: male sex, nonwhite race, age of >60 yrs vs. 18-29 yrs, dementia, chronic obstructive pulmonary disease, renal disease, malignancy, moderate to severe liver disease, and emergency room admission. In patients undergoing procedures other than tracheostomy, aspiration pneumonia was independently associated with an increased risk for admission to the intensive care unit (odds ratio, 4.0; 95% confidence interval, 3.0-5.1), in-hospital mortality (odds ratio, 7.6; 95% confidence interval, 6.5-8.9), longer hospital length of stay (estimated mean increase of 9 days; 95% confidence interval, 8-10), and increased total hospital charges (estimated mean increase of 22,000 US dollars; 95% confidence interval, 19,000 US dollars-25,000 US dollars).

CONCLUSIONS

Aspiration pneumonia occurs in approximately 1% of surgical patients and is associated with significant morbidity, mortality, and costs of care. Given that the rate of aspiration pneumonia varies among hospitals, we can improve the quality and reduce the costs of care by implementing strategies to reduce the rate of aspiration pneumonia.