1
|
Bonaroti JW, Ozel M, Chen T, Darby JL, Sun X, Moheimani H, Reitz KM, Kar UK, Zuckerbraun BS, Das J, Okonkwo DO, Billiar TR. Transcriptomic and Proteomic Characterization of the Immune Response to Elective Spinal Reconstructive Surgery: Impact of Aging and Comparison with Traumatic Injury Response. J Am Coll Surg 2024; 238:924-941. [PMID: 38095316 PMCID: PMC11017837 DOI: 10.1097/xcs.0000000000000922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/15/2023] [Accepted: 11/28/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Major surgery triggers trauma-like stress responses linked to age, surgery duration, and blood loss, resembling polytrauma. This similarity suggests elective surgery as a surrogate model for studying polytrauma immune responses. We investigated stress responses across age groups and compared them with those of polytrauma patients. STUDY DESIGN Patients undergoing major spinal reconstruction surgery were divided into older (age >65 years, n = 5) and young (age 18 to 39 years, n = 6) groups. A comparison group consisted of matched trauma patients (n = 8). Blood samples were collected before, during, and after surgery. Bone marrow mononuclear cells and peripheral blood mononuclear cells were analyzed using cellular indexing of transcriptomes and epitopes sequencing or single-cell RNA sequencing. Plasma was subjected to dual-platform proteomic analysis (SomaLogic and O-link). RESULTS Response to polytrauma was highest within 4 hours. By comparison, the response to surgery was highest at 24 hours. Both insults triggered significant changes in cluster of differentiation 14 monocytes, with increased inflammation and lower major histocompatibility complex-class 2 expression. Older patient's cluster of differentiation 14 monocytes displayed higher inflammation and less major histocompatibility complex-class 2 suppression; a trend was also seen in bone marrow mononuclear cells. Although natural killer cells were markedly activated after polytrauma, they were suppressed after surgery, especially in older patients. In plasma, innate immunity proteins dominated at 24 hours, shifting to adaptive immunity proteins by 6 weeks with heightened inflammation in older patients. Senescence-associated secretory phenotype proteins were higher in older patients at baseline and further elevated during and after surgery. CONCLUSIONS Although both major surgery and polytrauma initiate immune and stress responses, substantial differences exist in timing and cellular profiles, suggesting major elective surgery is not a suitable surrogate for the polytrauma response. Nonetheless, distinct responses in young vs older patients highlight the utility of elective spinal in studying patient-specific factors affecting outcomes after major elective surgery.
Collapse
Affiliation(s)
- Jillian W Bonaroti
- From the Department of Surgery (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar), University of Pittsburgh, Pittsburgh, PA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar)
| | - Mehves Ozel
- From the Department of Surgery (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar), University of Pittsburgh, Pittsburgh, PA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar)
| | - Tianmeng Chen
- From the Department of Surgery (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar), University of Pittsburgh, Pittsburgh, PA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar)
| | - Jennifer L Darby
- From the Department of Surgery (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar), University of Pittsburgh, Pittsburgh, PA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar)
| | - Xuejing Sun
- From the Department of Surgery (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar), University of Pittsburgh, Pittsburgh, PA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar)
- Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, China (Sun)
| | - Hamed Moheimani
- From the Department of Surgery (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar), University of Pittsburgh, Pittsburgh, PA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar)
| | - Katherine M Reitz
- From the Department of Surgery (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar), University of Pittsburgh, Pittsburgh, PA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar)
| | - Upendra K Kar
- From the Department of Surgery (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar), University of Pittsburgh, Pittsburgh, PA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar)
| | - Brian S Zuckerbraun
- From the Department of Surgery (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar), University of Pittsburgh, Pittsburgh, PA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar)
| | - Jishnu Das
- Center for Systems Immunology, Departments of Immunology and Computational and Systems Biology (Das), University of Pittsburgh, Pittsburgh, PA
| | - David O Okonkwo
- Department of Neurosurgery (Okonkwo), University of Pittsburgh, Pittsburgh, PA
| | - Timothy R Billiar
- From the Department of Surgery (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar), University of Pittsburgh, Pittsburgh, PA
- Pittsburgh Trauma Research Center, Division of Trauma and Acute Care Surgery, Pittsburgh, PA (Bonaroti, Ozel, Chen, Darby, Sun, Moheimani, Reitz, Kar, Zuckerbraun, Billiar)
| |
Collapse
|
2
|
Jarosinski M, Kennedy JN, Khamzina Y, Alie-Cusson FS, Tzeng E, Eslami M, Sridharan ND, Reitz KM. Percutaneous thrombectomy for acute limb ischemia is associated with equivalent limb and mortality outcomes compared with open thrombectomy. J Vasc Surg 2024; 79:1151-1162.e3. [PMID: 38224861 PMCID: PMC11032234 DOI: 10.1016/j.jvs.2024.01.014] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/23/2023] [Accepted: 01/09/2024] [Indexed: 01/17/2024]
Abstract
BACKGROUND Acute limb ischemia (ALI) carries a 15% to 20% risk of combined death or amputation at 30 days and 50% to 60% at 1 year. Percutaneous mechanical thrombectomy (PT) is an emerging minimally invasive alternative to open thrombectomy (OT). However, ALI thrombectomy cases are omitted from most quality databases, limiting comparisons of limb and survival outcomes between PT and OT. Therefore, our aim was to compare in-hospital outcomes between PT and OT using the National Inpatient Sample. METHODS We analyzed survey-weighted National Inpatient Sample data (2015-2020) to include emergent admissions of aged adults (50+ years) with a primary diagnosis of lower extremity ALI undergoing index procedures within 2 days of hospitalization. We excluded hospitalizations with concurrent trauma or dissection diagnoses and index procedures using catheter-directed thrombolysis. Our primary outcome was composite in-hospital major amputation or death. Secondary outcomes included in-hospital major amputation, death, in-hospital reintervention (including angioplasty/stent, thrombolysis, PT, OT, or bypass), and extended length of stay (eLOS; defined as LOS >75th percentile). Adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) were generated by multivariable logistic regression, adjusting for demographics, frailty (Risk Analysis Index), secondary diagnoses including atrial fibrillation and peripheral artery disease, hospital characteristics, and index procedure data including the anatomic thrombectomy level and fasciotomy. A priori subgroup analyses were performed using interaction terms. RESULTS We included 23,795 survey-weighted ALI hospitalizations (mean age: 72.2 years, 50.4% female, 79.2% White, and 22.3% frail), with 7335 (30.8%) undergoing PT. Hospitalization characteristics for PT vs OT differed by atrial fibrillation (28.7% vs 36.5%, P < .0001), frequency of intervention at the femoropopliteal level (86.2% vs 88.8%, P = .009), and fasciotomy (4.8% vs 6.9%, P = .006). In total, 2530 (10.6%) underwent major amputation or died. Unadjusted (10.1% vs 10.9%, P = .43) and adjusted (aOR = 0.96 [95% CI, 0.77-1.20], P = .74) risk did not differ between the groups. PT was associated with increased odds of reintervention (aOR = 2.10 [95% CI, 1.72-2.56], P < .0001) when compared with OT, but this was not seen in the tibial subgroup (aOR = 1.31 [95% CI, 0.86-2.01], P = .21, Pinteraction < .0001). Further, 79.1% of PT hospitalizations undergoing reintervention were salvaged with endovascular therapy. Lastly, PT was associated with significantly decreased odds of eLOS (aOR = 0.80 [95% CI, 0.69-0.94], P = .005). CONCLUSIONS PT was associated with comparable in-hospital limb salvage and mortality rates compared with OT. Despite an increased risk of reintervention, most PT reinterventions avoided open surgery, and PT was associated with a decreased risk of eLOS. Thus, PT may be an appropriate alternative to OT in appropriately selected patients.
Collapse
Affiliation(s)
| | - Jason N Kennedy
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | | | - Edith Tzeng
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Mohammad Eslami
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
3
|
Yu J, Khamzina Y, Kennedy J, Liang NL, Hall DE, Arya S, Tzeng E, Reitz KM. The Association Between Frailty and Outcomes Following Ruptured Abdominal Aortic Aneurysm Repair. J Vasc Surg 2024:S0741-5214(24)00983-2. [PMID: 38614142 DOI: 10.1016/j.jvs.2024.04.021] [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] [Received: 02/06/2024] [Revised: 03/28/2024] [Accepted: 04/07/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysm (AAA). Early postoperative outcomes are associated with both patients' physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAA (rAAA). STUDY DESIGN Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI; robust≤20, normal 21-29, frail 30-39, very frail≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHR) with 95% confidence intervals (95%CI). Interaction terms evaluated the association's moderation. RESULTS We identified 5,806 patients (age 72±9 years; 77% male; EVAR 65%; robust 6%; normal 48%; frail 36%; very frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR [aHR = 1.43 (95%CI 1.19-1.73)] was associated with increased 1-year mortality when compared to EVAR. Increasing frailty status [frail aHR = 1.26 (95%CI 1.00-1.59); very frail aHR =1.64 (95%CI 1.26-2.13)] was associated with increased 1-year mortality, which was moderated by repair type (P-interaction<.05). OSR was associated with increased 1-year mortality in normal [aHR = 1.49 (95%CI 1.20-1.87)] and frail [aHR = 1.51 (95%CI 1.20-1.89)], but not among robust [aHR = 0.88 (95%CI 0.59-1.32)] and very frail [aHR = 1.29 (95%CI 0.97-1.72)] patients. CONCLUSION Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared to EVAR. However, there was no difference between OSR and EVAR among robust patients who can well-tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.
Collapse
Affiliation(s)
- Jia Yu
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Jason Kennedy
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Surgery Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA; Wolff Center, UPMC, Pittsburgh, PA
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
| | - Edith Tzeng
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA.
| |
Collapse
|
4
|
Donohue JK, Jarosinski M, Reitz KM, Khamzina Y, Ledyard J, Liang NL, Chaer RA, Sridharan ND. Socioeconomic factors predict successful supervised exercise therapy completion. J Vasc Surg 2024; 79:904-910. [PMID: 38092308 PMCID: PMC10960665 DOI: 10.1016/j.jvs.2023.12.008] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/29/2023] [Accepted: 12/07/2023] [Indexed: 01/04/2024]
Abstract
OBJECTIVE Supervised exercise therapy (SET) for patients with intermittent claudication (IC) can lower the risk of progression to chronic limb-threatening ischemia and amputation, while preserving and restoring functional status. Despite supporting evidence, it remains underutilized, and among those who initiate programs, attrition rates are extremely high. We hypothesize that socioeconomic factors may represent significant barriers to SET completion. METHODS Patients with IC referred to SET at a multi-hospital, single-institution health care system (2018-2022) from a prospectively maintained database were retrospectively analyzed. Our primary endpoint was SET program completion and graduation, defined as completion of 36 sessions. Our secondary endpoints were vascular intervention within 1 year of referral and change in ankle-brachial index (ABI). Baseline demographics were assessed using standard statistical methods. Predictors of SET graduation were analyzed using multivariable logistic regression generating adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Change in ABI was analyzed using t-test between subgroups. Reasons for attrition were tabulated. Patient Health Questionnaire-9 (PHQ-9), metabolic equivalent level, Vascular QOL, Duke Activity Status, and ABI were analyzed using paired t-tests across the entire cohort. RESULTS Fifty-two patients met inclusion criteria: mean age 67.85 ± 10.69 years, 19 females (36.54%), mean baseline ABI of 0.77 ± 0.16. The co-pays for 100% of patients were fully covered by primary and secondary insurance plans. Twenty-one patients (40.38%) completed SET. On multivariable analysis, residence in a ZIP code with median household income <$47,000 (aOR, 0.10; 95% CI, 0.01-0.76; P = .03) and higher body mass index (aOR, 0.81; 95% CI, 0.67-0.99; P = .04) were significant barriers to SET graduation. There were no differences in ABI change or vascular intervention within 1 year between graduates and non-graduates. Non-graduates reported transportation challenges (25.00%), lack of motivation (20.83%), and illness/functional limitation (20.83%) as primary reasons for SET attrition. Metabolic Equivalent Level (P ≤ .01) and Duke Activity Status scores (P = .04) were significantly greater after participating in a SET program. CONCLUSIONS Although SET participation improves lower extremity and functionality outcomes, only 40% of referred patients completed therapy in our cohort. Our findings suggest that both socioeconomic and functional factors influence the odds of completing SET programs, indicating a need for holistic pre-referral assessment to facilitate enhanced program accessibility for these populations.
Collapse
Affiliation(s)
- Jack K Donohue
- University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | | | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Jonathan Ledyard
- Cardiopulmonary Rehabilitation, University of Pittsburgh, Pittsburgh, PA
| | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | |
Collapse
|
5
|
Li SR, Phillips AR, Reitz KM, Mikati N, Brown JB, Tzeng E, Makaroun MS, Guyette FX, Liang NL. Hypertension during transfer is associated with poor outcomes in unstable patients with ruptured abdominal aortic aneurysm. J Vasc Surg 2024; 79:755-762. [PMID: 38040202 DOI: 10.1016/j.jvs.2023.11.044] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 11/09/2023] [Accepted: 11/25/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE Limited data exist for optimal blood pressure (BP) management during transfer of patients with ruptured abdominal aortic aneurysm (rAAA). This study evaluates the effects of hypertension and severe hypotension during interhospital transfers in a cohort of patients with rAAA in hemorrhagic shock. METHODS We performed a retrospective, single-institution review of patients with rAAA transferred via air ambulance to a quaternary referral center for repair (2003-2019). Vitals were recorded every 5 minutes in transit. Hypertension was defined as a systolic BP of ≥140 mm Hg. The primary cohort included patients with rAAA with hemorrhagic shock (≥1 episode of a systolic BP of <90 mm Hg) during transfer. The primary analysis compared those who experienced any hypertensive episode to those who did not. A secondary analysis evaluated those with either hypertension or severe hypotension <70 mm Hg. The primary outcome was 30-day mortality. RESULTS Detailed BP data were available for 271 patients, of which 125 (46.1%) had evidence of hemorrhagic shock. The mean age was 74.2 ± 9.1 years, 93 (74.4%) were male, and the median total transport time from helicopter dispatch to arrival at the treatment facility was 65 minutes (interquartile range, 46-79 minutes). Among the cohort with shock, 26.4% (n = 33) had at least one episode of hypertension. There were no significant differences in age, sex, comorbidities, AAA repair type, AAA anatomic location, fluid resuscitation volume, blood transfusion volume, or vasopressor administration between the hypertensive and nonhypertensive groups. Patients with hypertension more frequently received prehospital antihypertensives (15% vs 2%; P = .01) and pain medication (64% vs 24%; P < .001), and had longer transit times (36.3 minutes vs 26.0 minutes; P = .006). Episodes of hypertension were associated with significantly increased 30-day mortality on multivariable logistic regression (adjusted odds ratio [aOR], 4.71; 95% confidence interval [CI], 1.54-14.39; P = .007; 59.4% [n = 19] vs 40.2% [n = 37]; P = .01). Severe hypotension (46%; n = 57) was also associated with higher 30-day mortality (aOR, 2.82; 95% CI, 1.27-6.28; P = .01; 60% [n = 34] vs 32% [n = 22]; P = .01). Those with either hypertension or severe hypotension (54%; n = 66) also had an increased odds of mortality (aOR, 2.95; 95% CI, 1.08-8.11; P = .04; 58% [n = 38] vs 31% [n = 18]; P < .01). Level of hypertension, BP fluctuation, and timing of hypertension were not significantly associated with mortality. CONCLUSIONS Hypertensive and severely hypotensive episodes during interhospital transfer were independently associated with increased 30-day mortality in patients with rAAA with shock. Hypertension should be avoided in these patients, but permissive hypotension approaches should also maintain systolic BPs above 70 mm Hg whenever possible.
Collapse
Affiliation(s)
- Shimena R Li
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Katherine M Reitz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Nancy Mikati
- Department of Emergency Medicine, University of Iowa Health Care, Iowa City, IA
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Michel S Makaroun
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nathan L Liang
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| |
Collapse
|
6
|
Hrebinko K, Anto VP, Reitz KM, Gamboa AC, Regenbogen SE, Hawkins AT, Hopkins MB, Ejaz A, Bauer PS, Wise PE, Balch GC, Holder-Murray J. Prophylactic defunctioning stomas improve clinical outcomes of anastomotic leak following rectal cancer resections: An analysis of the US Rectal Cancer Consortium. Int J Colorectal Dis 2024; 39:39. [PMID: 38498217 PMCID: PMC10948474 DOI: 10.1007/s00384-024-04600-3] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2024] [Indexed: 03/20/2024]
Abstract
PURPOSE Anastomotic leak (AL) is a complication of low anterior resection (LAR) that results in substantial morbidity. There is immense interest in evaluating immediate postoperative and long-term oncologic outcomes in patients who undergo diverting loop ileostomies (DLI). The purpose of this study is to understand the relationship between fecal diversion, AL, and oncologic outcomes. METHODS This is a retrospective multicenter cohort study using patient data obtained from the US Rectal Cancer Consortium database compiled from six academic institutions. The study population included patients with rectal adenocarcinoma undergoing LAR. The primary outcome was the incidence of AL among patients who did or did not receive DLI during LAR. Secondary outcomes included risk factors for AL, receipt of adjuvant therapy, 3-year overall survival, and 3-year recurrence. RESULTS Of 815 patients, 38 (4.7%) suffered AL after LAR. Patients with AL were more likely to be male, have unintentional preoperative weight loss, and are less likely to undergo DLI. On multivariable analysis, DLI remained protective against AL (p < 0.001). Diverted patients were less likely to undergo future surgical procedures including additional ostomy creation, completion proctectomy, or pelvic washout for AL. Subgroup analysis of 456 patients with locally advanced disease showed that DLI was correlated with increased receipt of adjuvant therapy for patients with and without AL on univariate analysis (SHR:1.59; [95% CI 1.19-2.14]; p = 0.002), but significance was not met in multivariate models. CONCLUSION Lack of DLI and preoperative weight loss was associated with anastomotic leak. Fecal diversion may improve the timely initiation of adjuvant oncologic therapy. The long-term outcomes following routine diverting stomas warrant further study.
Collapse
Affiliation(s)
- Katherine Hrebinko
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Vincent P Anto
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Katherine M Reitz
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Adriana C Gamboa
- Division of Surgical Oncology, MD Anderson Cancer Center, University of Texas, Austin, USA
| | - Scott E Regenbogen
- Division of Colorectal Surgery, Department of Surgery, University of Michigan, Ann Arbor, USA
| | - Alexander T Hawkins
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, USA
| | - M Benjamin Hopkins
- Section of Colon & Rectal Surgery, Division of General Surgery, Vanderbilt University Medical Center, Nashville, USA
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, USA
| | - Philip S Bauer
- Department of Surgery, Allegheny Health Network, Pittsburgh, USA
| | - Paul E Wise
- Section of Colon & Rectal Surgery, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, USA
| | - Glen C Balch
- Division of Colon & Rectal Surgery, Department of Surgery, Emory University, Atlanta, USA
| | - Jennifer Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Kaufmann Medical Office Building, Suite 603, 3471 Fifth Avenue, Pittsburgh, PA, 15213, USA.
| |
Collapse
|
7
|
George EL, Jacobs MA, Reitz KM, Massarweh NN, Youk AO, Arya S, Hall DE. Outcomes of Women Undergoing Noncardiac Surgery in Veterans Affairs Compared With Non-Veterans Affairs Care Settings. JAMA Surg 2024:2815492. [PMID: 38416481 PMCID: PMC10902781 DOI: 10.1001/jamasurg.2023.8081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/25/2023] [Indexed: 02/29/2024]
Abstract
Importance Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. Although veterans are predominantly male, the number of women receiving care within the VA has nearly doubled to 10% over the past decade and recent data comparing the surgical care of women in VA and non-VA care settings are lacking. Objective To compare postoperative outcomes among women treated in VA hospitals vs private-sector hospitals. Design, Setting, and Participants This coarsened exact-matched cohort study across 9 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) took place from January 1, 2016, to December 31, 2019. Multivariable Poisson models with robust standard errors were used to evaluate the association between VA vs private-sector care settings and 30-day mortality. Hospitals participating in American College of Surgeons NSQIP and VASQIP were included. Data analysis was performed in January 2023. Participants included female patients 18 years old or older. Exposures Surgical care in VA or private-sector hospitals. Main Outcomes and Measures Postoperative 30-day mortality and failure to rescue (FTR). Results Among 1 913 033 procedures analyzed, patients in VASQIP were younger (VASQIP: mean age, 49.8 [SD, 13.0] years; NSQIP: mean age, 55.9 [SD, 16.9] years; P < .001) and although most patients in both groups identified as White, there were significantly more Black women in VASQIP compared with NSQIP (29.6% vs 12.7%; P < .001). The mean risk analysis index score was lower in VASQIP (13.9 [SD, 6.4]) compared with NSQIP (16.3 [SD, 7.8]) (P < .001 for both). Patients in the VA were more likely to have a preoperative acute serious condition (2.4% vs 1.8%: P < .001), but cases in NSQIP were more frequently emergent (6.9% vs 2.6%; P < .001). The 30-day mortality, complications, and FTR were 0.2%, 3.2%, and 0.1% in VASQIP (n = 36 762 procedures) as compared with 0.8%, 5.0%, and 0.5% in NSQIP (n = 1 876 271 procedures), respectively (all P < .001). Among 1 763 540 matched women (n = 36 478 procedures in VASQIP; n = 1 727 062 procedures in NSQIP), these rates were 0.3%, 3.7%, and 0.2% in NSQIP and 0.1%, 3.4%, and 0.1% in VASQIP (all P < .01). Relative to private-sector care, VA surgical care was associated with a lower risk of death (adjusted risk ratio [aRR], 0.41; 95% CI, 0.23-0.76). This finding was robust among women undergoing gynecologic surgery, inpatient surgery, and low-physiologic stress procedures. VA surgical care was also associated with lower risk of FTR (aRR, 0.41; 95% CI, 0.18-0.92) for frail or Black women and inpatient and low-physiologic stress procedures. Conclusions and Relevance Although women comprise the minority of veterans receiving care within the VA, in this study, VA surgical care for women was associated with half the risk of postoperative death and FTR. The VA appears better equipped to meet the unique surgical needs and risk profiles of veterans, regardless of sex and health policy decisions, including funding, should reflect these important outcome differences.
Collapse
Affiliation(s)
- Elizabeth L. George
- Division of Vascular Surgery, Stanford University School of Medicine, California
- Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, California
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, California
| | - Michael A. Jacobs
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
| | | | - Nader N. Massarweh
- Perioperative and Surgical Care Service, Atlanta Veterans Affairs Healthcare System, Decatur, Georgia
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
| | - Ada O. Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pennsylvania
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, California
- Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, California
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, California
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pennsylvania
| |
Collapse
|
8
|
Hafeez MS, Phillips A, Reitz KM, Brown JB, Guyette FX, Liang NL. The Role of Integrated Air Transport System in Managing Abdominal Aortic Aneurysm Rupture Patients. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00191-6. [PMID: 38408516 DOI: 10.1016/j.ejvs.2024.02.033] [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] [Received: 04/29/2023] [Revised: 02/05/2024] [Accepted: 02/22/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE Ruptured abdominal aortic aneurysms (rAAAs) are highly morbid emergencies. Not all hospitals are equipped to repair them, and an air ambulance network may aid in regionalising speciality care to quaternary referral centres. The association of travel distance by air ambulance on rAAA mortality in patients transferred emergently for repair was examined. METHODS A retrospective review of institutional data. Adults with rAAA (2002 - 2019) transferred from an outside hospital (OSH) to a single quaternary referral centre for repair via air ambulance were identified. Patients who arrived via ground transport or post-repair at OSH for continued critical care were excluded. Patients were divided into "near" and "far" groups based on the 75th percentile of straight line travel distance (> 72 miles) between hospitals. The primary outcome was 30 day mortality. Multivariate logistic regression was used to assess the association of distance with mortality after adjusting for age, sex, race, cardiovascular comorbidities, and repair type. RESULTS A total of 290 patients with rAAA were transported a median distance of 40.4 miles (interquartile range 25.5, 72.7) with 215 (74.1%) near and 75 (25.9%) far patients. Both near and far groups had similar ages, sex, and race. There was no difference in pre-operative loss of consciousness, intubation, or cardiac arrest between groups. Endovascular aneurysm repair utilisation and intra-operative aortic occlusion balloon usage were also similar. Both observed (26.8% vs. 23.9%, p = .61) and adjusted odd ratio (0.70, 95% confidence interval 0.36 - 1.39, p = .32) 30 day mortality did not differ significantly between near and far groups. CONCLUSION Increasing distance travelled during transfer by air ambulance was not associated with worse outcomes in patients with rAAA. The findings support the regionalisation of rAAA repair to large quaternary centres via an integrated and robust air ambulance network.
Collapse
Affiliation(s)
- Muhammad Saad Hafeez
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Amanda Phillips
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joshua B Brown
- Division of Trauma and Acute Care Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| |
Collapse
|
9
|
Seymour CW, Urbanek KL, Nakayama A, Kennedy JN, Powell R, Robinson RAS, Kapp KL, Billiar TR, Vodovotz Y, Gelhaus SL, Cooper VS, Tang L, Mayr F, Reitz KM, Horvat C, Meyer NJ, Dickson RP, Angus D, Palmer OP. A Prospective Cohort Protocol for the Remnant Investigation in Sepsis Study. Crit Care Explor 2023; 5:e0974. [PMID: 38304708 PMCID: PMC10833627 DOI: 10.1097/cce.0000000000000974] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Sepsis is a common and deadly syndrome, accounting for more than 11 million deaths annually. To mature a deeper understanding of the host and pathogen mechanisms contributing to poor outcomes in sepsis, and thereby possibly inform new therapeutic targets, sophisticated, and expensive biorepositories are typically required. We propose that remnant biospecimens are an alternative for mechanistic sepsis research, although the viability and scientific value of such remnants are unknown. METHODS AND RESULTS The Remnant Biospecimen Investigation in Sepsis study is a prospective cohort study of 225 adults (age ≥ 18 yr) presenting to the emergency department with community sepsis, defined as sepsis-3 criteria within 6 hours of arrival. The primary objective was to determine the scientific value of a remnant biospecimen repository in sepsis linked to clinical phenotyping in the electronic health record. We will study candidate multiomic readouts of sepsis biology, governed by a conceptual model, and determine the precision, accuracy, integrity, and comparability of proteins, small molecules, lipids, and pathogen sequencing in remnant biospecimens compared with paired biospecimens obtained according to research protocols. Paired biospecimens will include plasma from sodium-heparin, EDTA, sodium fluoride, and citrate tubes. CONCLUSIONS The study has received approval from the University of Pittsburgh Human Research Protection Office (Study 21120013). Recruitment began on October 25, 2022, with planned release of primary results anticipated in 2024. Results will be made available to the public, the funders, critical care societies, laboratory medicine scientists, and other researchers.
Collapse
Affiliation(s)
- Christopher W Seymour
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kelly Lynn Urbanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Anna Nakayama
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jason N Kennedy
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Rachel Powell
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Kathryn L Kapp
- Department of Chemistry, Vanderbilt University, Nashville, TN
| | | | | | - Stacy L Gelhaus
- Department of Pharmacology and Chemical Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Vaughn S Cooper
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Lu Tang
- Department of Biostatistics, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Flo Mayr
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Katherine M Reitz
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Surgery, UPMC, Pittsburgh, PA
| | - Christopher Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Nuala J Meyer
- Pulmonary, Allergy, and Critical Care Medicine Division, Center for Translational Lung Biology University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Robert P Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI
- Division of Pulmonary & Critical Care Medicine, Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI
| | - Derek Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Octavia Peck Palmer
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| |
Collapse
|
10
|
Hafeez MS, Li SR, Reitz KM, Phillips AR, Habib SG, Jano A, Dai Y, Stone A, Tzeng E, Makaroun MS, Liang NL. Characterization of multiple organ failure after ruptured abdominal aortic aneurysm repair. J Vasc Surg 2023; 78:945-953.e3. [PMID: 37385354 PMCID: PMC10698734 DOI: 10.1016/j.jvs.2023.06.011] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Multiple organ failure (MOF) is associated with poor outcomes and increased mortality in sepsis and trauma. There are limited data regarding MOF in patients after ruptured abdominal aortic aneurysm (rAAA) repair. We aimed to identify the contemporary prevalence and characteristics of patients with rAAA with MOF. METHODS We retrospectively reviewed patients with rAAA who underwent repair (2010-2020) at our multihospital institution. Patients who died within the first 2 days after repair were excluded. MOF was quantified by modified (excluding hepatic system) Denver, Sequential Organ Failure Assessment (SOFA) score, and Multiple Organ Dysfunction Score (MODS) for postoperative days 3 to 5 to determine the prevalence of MOF. MOF was defined as a Denver score of >3, dysfunction in two or more organ systems by SOFA score, or a MODS score of >8. Kaplan-Meier curves and log-rank testing were used to evaluate differences in 30-day mortality between multiple organ failure and patients without MOF. Logistic regression was used to assess predictors of MOF. RESULTS Of 370 patients with rAAA, 288 survived past two days (mean age, 73±10.1 years; 76.7% male; 44.1% open repair), and 143 had data for MOF calculation recorded. From postoperative days 3 to 5, 41 (14.24%) had MOF by Denver, 26 (9.03%) by SOFA, and 39 (13.54%) by MODS criteria. Among these scoring systems, pulmonary and neurological systems were impacted most commonly. Among patients with MOF, pulmonary derangement occurred in 65.9% (Denver), 57.7% (SOFA), and 56.4% (MODS). Similarly, neurological derangement occurred in 92.3% (SOFA) and 89.7% (MODS), but renal derangement occurred in 26.8% (Denver), 23.1% (SOFA), and 10.3% (MODS). MOF by all three scoring systems was associated with increased 30-day mortality (Denver: 11.3% vs 41.5% [P < .01]; DOFA: 12.6% vs 46.2% [P < .01]; MODS: 12.5% vs 35.9% [P < .01]), as was MOF by any criteria (10.8% vs 35.7 %; P < .01). Patients with MOF were more likely to have a higher body mass index (55.9±26.6 vs 49.0±15.0; P = .011) and to have had a preoperative stroke (17.9% vs 6.0%; P = .016). Patients with MOF were less likely to have undergone endovascular repair (30.4% vs 62.1%; P < .001). Endovascular repair was protective against MOF (any criteria) on multivariate analysis (odds ratio, 0.23; 95% confidence interval, 0.08-0.64; P = .019) after adjusting for age, gender, and presenting systolic blood pressure. CONCLUSIONS MOF occurred in only 9% to 14% of patients after rAAA repair, but was associated with a three-fold increase in mortality. Endovascular repair was associated with a reduced MOF incidence.
Collapse
Affiliation(s)
- Muhammad Saad Hafeez
- Division of Vascular Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
| | - Shimena R Li
- Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
| | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
| | - Amanda R Phillips
- Division of Vascular Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
| | - Salim G Habib
- Division of Vascular Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
| | - Antalya Jano
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Yancheng Dai
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Andre Stone
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Edith Tzeng
- Division of Vascular Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
| | - Michel S Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
| | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA; Department of Surgery, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA.
| |
Collapse
|
11
|
Binko MA, Reitz KM, Chaer RA, Haga LM, Go C, Alie-Cusson FS, Tzeng E, Eslami MH, Sridharan ND. Selective Publication within Vascular Surgery: Characteristics of Discontinued and Unpublished Randomized Clinical Trials. Ann Vasc Surg 2023; 95:251-261. [PMID: 37311508 DOI: 10.1016/j.avsg.2023.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Discontinued and unpublished randomized clinical trials (RCTs) are common resulting in biased publication and loss of potential knowledge. The magnitude of selective publication within vascular surgery remains unknown. METHODS RCT relevant to vascular surgery registered (01/01/2010-10/31/2019) on ClinicalTrials.gov were included. Trials ending normally with conclusion of participant treatment and examination were considered completed whereas discontinued trials stopped early. Publications were identified through automatically indexed PubMed citations on ClinicalTrials.gov or manually identified on PubMed or Google Scholar >30 months after the completion date, the date the final participant was examined, allowing time for publication. RESULTS Of 108 RCT (n = 37, 837), 22.2% (24/108) were discontinued, including 16.7% (4/24) stopped prior to and 83.3% (20/24) after starting enrollment. Only 28.4% of estimated enrollment was achieved for all discontinued RCT. Nineteen (79.2%) investigators provided a reason for discontinuation, which most commonly included poor enrollment (45.8%), inadequate supplies or funding (12.5%), and trial design concerns (8.3%). Of the 20 trials terminated following enrollment, 20.0% (4/20) were published in peer-reviewed journals and 80.0% (16/20) failed to reach publication. Of the 77.8% trials completed, 75.0% (63/84) were published and 25.0% (21/84) remain unpublished. In a multivariate regression of completed trials, industry funding was significantly associated with decreased likelihood of peer-reviewed publication (OR = 0.18, (95% CI 0.05-0.71), P = 0.01). Of the discontinued and completed trials remaining unpublished, 62.5% and 61.9% failed to report results on ClinicalTrials.gov, respectively, encompassing a total of 4,788 enrollees without publicly available results. CONCLUSIONS Nearly 25% of registered vascular RCT were discontinued. Of completed RCT, 25% remain unpublished with industry funding associated with decreased likelihood of publication. This study identifies opportunities to report all findings for completed and discontinued vascular surgery RCT, whether industry sponsored, or investigator initiated.
Collapse
Affiliation(s)
- Mary A Binko
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Katherine M Reitz
- Division of Vascular Surgery, Department of Surgery, UPMC, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, Department of Surgery, UPMC, Pittsburgh, PA
| | - Lindsey M Haga
- Division of Vascular Surgery, Department of Surgery, UPMC, Pittsburgh, PA
| | - Catherine Go
- Division of Vascular Surgery, Department of Surgery, UPMC, Pittsburgh, PA
| | | | - Edith Tzeng
- Division of Vascular Surgery, Department of Surgery, UPMC, Pittsburgh, PA
| | - Mohammad H Eslami
- Division of Vascular Surgery, Department of Surgery, UPMC, Pittsburgh, PA
| | | |
Collapse
|
12
|
Yang A, Kennedy JN, Reitz KM, Phillips G, Terry KM, Levy MM, Angus DC, Seymour CW. Time to treatment and mortality for clinical sepsis subtypes. Crit Care 2023; 27:236. [PMID: 37322546 PMCID: PMC10268363 DOI: 10.1186/s13054-023-04507-5] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/23/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Sepsis is common, deadly, and heterogenous. Prior analyses of patients with sepsis and septic shock in New York State showed a risk-adjusted association between more rapid antibiotic administration and bundled care completion, but not an intravenous fluid bolus, with reduced in-hospital mortality. However, it is unknown if clinically identifiable sepsis subtypes modify these associations. METHODS Secondary analysis of patients with sepsis and septic shock enrolled in the New York State Department of Health cohort from January 1, 2015 to December 31, 2016. Patients were classified as clinical sepsis subtypes (α, β, γ, δ-types) using the Sepsis ENdotyping in Emergency CAre (SENECA) approach. Exposure variables included time to 3-h sepsis bundle completion, antibiotic administration, and intravenous fluid bolus completion. Then logistic regression models evaluated the interaction between exposures, clinical sepsis subtypes, and in-hospital mortality. RESULTS 55,169 hospitalizations from 155 hospitals were included (34% α, 30% β, 19% γ, 17% δ). The α-subtype had the lowest (N = 1,905, 10%) and δ-subtype had the highest (N = 3,776, 41%) in-hospital mortality. Each hour to completion of the 3-h bundle (aOR, 1.04 [95%CI, 1.02-1.05]) and antibiotic initiation (aOR, 1.03 [95%CI, 1.02-1.04]) was associated with increased risk-adjusted in-hospital mortality. The association differed across subtypes (p-interactions < 0.05). For example, the outcome association for the time to completion of the 3-h bundle was greater in the δ-subtype (aOR, 1.07 [95%CI, 1.05-1.10]) compared to α-subtype (aOR, 1.02 [95%CI, 0.99-1.04]). Time to intravenous fluid bolus completion was not associated with risk-adjusted in-hospital mortality (aOR, 0.99 [95%CI, 0.97-1.01]) and did not differ among subtypes (p-interaction = 0.41). CONCLUSION Timely completion of a 3-h sepsis bundle and antibiotic initiation was associated with reduced risk-adjusted in-hospital mortality, an association modified by clinically identifiable sepsis subtype.
Collapse
Affiliation(s)
- Anne Yang
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Pittsburgh Medical Center, PA, Pittsburgh, USA.
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA.
| | - Jason N Kennedy
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine M Reitz
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gary Phillips
- The Ohio State University, Center for Biostatistics, Columbus, OH, USA
| | | | - Mitchell M Levy
- Division of Pulmonary, Critical Care and Sleep Medicine, Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Christopher W Seymour
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
13
|
Jano A, Mak AK, Reitz KM, McPhee J, Ahuja V, Goodney P, Tzeng E. Assessing the Prevalence of Medical Optimization Therapy in Vascular Surgery Clinics. JAMA Surg 2023; 158:550-552. [PMID: 36723947 PMCID: PMC10173024 DOI: 10.1001/jamasurg.2022.7659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/11/2022] [Indexed: 02/02/2023]
Abstract
This cross-sectional study uses checklist data to assess optimal medical therapy prescribed for veterans with atherosclerotic cardiovascular disease.
Collapse
Affiliation(s)
- Antalya Jano
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Allison K. Mak
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Katherine M. Reitz
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - James McPhee
- VA Boston Healthcare System, Boston, Massachusetts
| | - Vanita Ahuja
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Philip Goodney
- VA White River Junction Health Care, White River Junction, Vermont
| | - Edith Tzeng
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| |
Collapse
|
14
|
Narayanan S, Althans AR, Reitz KM, Allen LH, Kurukulasuriya C, Larkin TM, Reinert NJ, Cunningham KE, Watson AR, Celebrezze JP, Medich DS, Holder-Murray J. Drainage of anorectal abscesses in the operating room is associated with a decreased risk of abscess recurrence and fistula formation. Am J Surg 2023; 225:347-351. [PMID: 36150906 PMCID: PMC9999175 DOI: 10.1016/j.amjsurg.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/23/2022] [Accepted: 09/04/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Timely incision and drainage (I&D) is first line management for anorectal abscesses. We aimed to define current practices in anorectal abscess management and identify factors associated with abscess recurrence and fistula formation. METHODS Index episodes of anorectal abscesses treated with I&D in 2014-2018 at a multi-hospital healthcare system were included. Association with one-year abscess recurrence or fistula formation was evaluated using Cox proportional hazard regression. Fistulae were captured only among patients without fistulae at the index operation. RESULTS A total of 458 patients met study criteria. One-year rate of abscess recurrence or fistula formation was 20.3%. When compared to bedside procedures, drainage in the operating room was associated with a reduced risk of either recurrence or fistula formation (aHR 0.20 [95%CI 0.114-0.367]). CONCLUSIONS Improved exposure and patient comfort in the operating room may allow more complete drainage contributing to decreased rates of abscess recurrence or fistula formation.
Collapse
Affiliation(s)
- Sowmya Narayanan
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alison R Althans
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Katherine M Reitz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Laura H Allen
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Timothy M Larkin
- Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Nathan J Reinert
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kellie E Cunningham
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Andrew R Watson
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James P Celebrezze
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David S Medich
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jennifer Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| |
Collapse
|
15
|
Reitz KM, Althouse AD, Forman DE, Zuckerbraun BS, Vodovotz Y, Zamora R, Raffai RL, Hall DE, Tzeng E. MetfOrmin BenefIts Lower Extremities with Intermittent Claudication (MOBILE IC): randomized clinical trial protocol. BMC Cardiovasc Disord 2023; 23:38. [PMID: 36681798 PMCID: PMC9862509 DOI: 10.1186/s12872-023-03047-8] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/05/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Peripheral artery disease (PAD) affects over 230 million people worldwide and is due to systemic atherosclerosis with etiology linked to chronic inflammation, hypertension, and smoking status. PAD is associated with walking impairment and mobility loss as well as a high prevalence of coronary and cerebrovascular disease. Intermittent claudication (IC) is the classic presenting symptom for PAD, although many patients are asymptomatic or have atypical presentations. Few effective medical therapies are available, while surgical and exercise therapies lack durability. Metformin, the most frequently prescribed oral medication for Type 2 diabetes, has salient anti-inflammatory and promitochondrial properties. We hypothesize that metformin will improve function, retard the progression of PAD, and improve systemic inflammation and mitochondrial function in non-diabetic patients with IC. METHODS 200 non-diabetic Veterans with IC will be randomized 1:1 to 180-day treatment with metformin extended release (1000 mg/day) or placebo to evaluate the effect of metformin on functional status, PAD progression, cardiovascular disease events, and systemic inflammation. The primary outcome is 180-day maximum walking distance on the 6-min walk test (6MWT). Secondary outcomes include additional assessments of functional status (cardiopulmonary exercise testing, grip strength, Walking Impairment Questionnaires), health related quality of life (SF-36, VascuQoL), macro- and micro-vascular assessment of lower extremity blood flow (ankle brachial indices, pulse volume recording, EndoPAT), cardiovascular events (amputations, interventions, major adverse cardiac events, all-cause mortality), and measures of systemic inflammation. All outcomes will be assessed at baseline, 90 and 180 days of study drug exposure, and 180 days following cessation of study drug. We will evaluate the primary outcome with linear mixed-effects model analysis with covariate adjustment for baseline 6MWT, age, baseline ankle brachial indices, and smoking status following an intention to treat protocol. DISCUSSION MOBILE IC is uniquely suited to evaluate the use of metformin to improve both systematic inflammatory responses, cellular energetics, and functional outcomes in patients with PAD and IC. TRIAL REGISTRATION The prospective MOBILE IC trial was publicly registered (NCT05132439) November 24, 2021.
Collapse
Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | | | - Daniel E Forman
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Geriatrics Research, Education, and Clinical Care, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Center for Inflammation and Regeneration Modeling, McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
- Center for Systems Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ruben Zamora
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | | | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Geriatrics Research, Education, and Clinical Care, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Wolff Center, UPMC, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, South Tower, Rm 351.6, 200 Lothrop Street, Pittsburgh, PA, 15213, USA.
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| |
Collapse
|
16
|
Agrawal N, Eslami MH, Abou Ali AN, Reitz KM, Sridharan N. Adductor Canal Syndrome After Lesser Trochanter Avulsion Fracture in a 19 Year Old. J Vasc Surg Cases Innov Tech 2023; 9:101098. [PMID: 37101660 PMCID: PMC10123372 DOI: 10.1016/j.jvscit.2023.101098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/20/2022] [Indexed: 01/15/2023] Open
Abstract
A rare cause of limb ischemia in young patients, adductor canal syndrome, can be debilitating and result in functional impairment. Diagnosis and treatment may be delayed due to this vascular disease's rarity in young people and because the presenting symptoms can overlap with other more common causes of leg pain in young athletes. Here, authors discuss a young athletic patient with a history of year-long claudication. The patient's reported symptoms, exam findings, and imaging results were consistent with a diagnosis of adductor canal syndrome. This case proved uniquely challenging, given the extent of disease and illustrates potential approach considerations.
Collapse
Affiliation(s)
- Nishant Agrawal
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Mohammad H. Eslami
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Adham N. Abou Ali
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Katherine M. Reitz
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Natalie Sridharan
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Correspondence: Dr Natalie D. Sridharan, Assistant Professor, Heart and Vascular Institute, Department of Vascular Surgery, UPMC Presbyterian, 200 Lothrop St, Pittsburgh, PA, 15213
| |
Collapse
|
17
|
Reitz KM, Phillips AR, Tzeng E, Makaroun MS, Leeper CM, Liang NL. Characterization of immediate and early mortality after repair of ruptured abdominal aortic aneurysm. J Vasc Surg 2022; 76:1578-1587.e5. [PMID: 35803483 PMCID: PMC10088068 DOI: 10.1016/j.jvs.2022.06.090] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/21/2022] [Accepted: 06/28/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND We sought to compare immediate and early mortality among patients undergoing ruptured abdominal aortic aneurysm (RAAA) repair. Evaluation of RAAA has focused on 30-day postoperative mortality. Other emergency conditions such as trauma have demonstrated a multimodal mortality distribution within the 30-day window, expanding the pathophysiologic understanding and allowing for intervention investigations with practice changing and lifesaving results. However, the temporal distribution and risk factors of postoperative morbidity and mortality in RAAA have yet to be investigated. METHODS We evaluated factors associated with RAAA postoperative mortality in immediate (<1 day) and early (1-30 days) postoperative periods in a landmarked retrospective cohort study using data from the Vascular Quality Initiative (2010-2020). RESULTS We identified 5157 RAAA repairs (mean age, 72 ± 10 years; 77% male; 88% White; 61% endovascular). The mortality rate in the immediate period was 10.2% (528/5157) and the early mortality rate was 22.1% (918/4163). In multivariable regression analyses, signs of hemorrhagic shock (ie, hemoglobin <7 g/dL: adjusted odds ratio [aOR], 1.87 [95% confidence interval [CI], 1.14-3.06]; any preoperative systolic blood pressure <70 mm Hg: aOR, 1.40 [95% CI, 1.04-1.89]; and estimated blood loss >40%: aOR, 3.65 [95% CI, 2.29-5.83]) were associated with an increased risk of immediate mortality. Comorbid conditions (heart failure: aOR, 1.38 [95% CI, 1.00-1.92]; pulmonary disease: aOR, 1.29 [95% CI, 1.05-1.58]; elevated creatinine: aOR 1.26 [95% CI, 1.31-1.41]) were associated with increased risk of early mortality. CONCLUSIONS Immediate deaths were associated predominantly with shock from massive hemorrhage, whereas early deaths were associated with comorbid conditions predisposing patients to multisystem organ failure despite successful repair. These temporal distinctions should guide future mechanistic and intervention evaluations to improve RAAA mortality.
Collapse
Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Amanda R Phillips
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Michel S Makaroun
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Christine M Leeper
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nathan L Liang
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| |
Collapse
|
18
|
Reitz KM, Angus DC. Invited commentary on Sepsis. Surgery 2022:S0039-6060(22)00945-X. [PMID: 36443151 DOI: 10.1016/j.surg.2022.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 10/27/2022] [Indexed: 11/26/2022]
|
19
|
Li SR, Reitz KM, Kennedy J, Gabriel L, Phillips AR, Shireman PK, Eslami MH, Tzeng E. Epidemiology of age-, sex-, and race-specific hospitalizations for abdominal aortic aneurysms highlights gaps in current screening recommendations. J Vasc Surg 2022; 76:1216-1226.e4. [PMID: 35278654 PMCID: PMC9458770 DOI: 10.1016/j.jvs.2022.02.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 02/24/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND The detection and elective repair of abdominal aortic aneurysms (AAA) guided by known risk-factor specific screening decrease AAA-related mortality. However, minimal epidemiologic data exist for AAA in female persons and racial minority groups. We established the contemporary risk of US AAA hospitalization across age, sex, and race. METHODS National Inpatient Sample and US Census (2012-2018) data were used to quantify age-, sex-, and race-specific incidences and adjusted odds ratios (aOR) of AAA hospitalizations (≥18 years), associated risk factors, and in-hospital mortality. Interaction terms evaluated subgroups. RESULTS Among 1,728,374,183 US residents during the study period (51.3% female; 78.4% White, 12.7% Black, 5.7% Asian), 211,501,703 were hospitalized (aged 57.56 ± 0.04 years; 58.4% female; 64.9% White, 14.3% Black, 2.5% Asian) of which 291,850 were for AAA (aged 73.17 ± 0.04 years; 22.6% female; 81.8% White, 5.6% Black, 1.6% Asian). An estimated 15.2 (95% CI, 15.1-15.3) and 1.7 (95% CI, 1.7-1.7) hospitalizations per 100,000 residents were for intact AAA (iAAA) and ruptured AAA (rAAA) AAA, respectively. In addition, 16.2% of iAAA (83.8% male; 79.1% White) and 18.4% of rAAA (86.4% male; 75.0% White) hospitalizations occurred in patients less than 65 years of age. For iAAA, female sex (aOR, 0.27; 95% CI, 0.27-0.28) compared with male sex and both Black (0.47; 95% CI, 0.45-0.49) and Asian (0.86; 95% CI, 0.83-0.93) persons compared with White persons had a reduced aOR for hospitalization. For rAAA, the reduced aOR persisted for female sex (0.33; 95% CI, 0.32-0.36) and for Black persons (0.52; 95% CI, 0.46-0.58). Although female sex demonstrated an overall decreased odds of AAA hospitalization, female persons who were older, Black, or had peripheral vascular disease (Pinteractions < .001) had a relative increase in AAA hospitalization aOR. Female sex (aOR, 1.54; 95% CI, 1.38-1.70), but not Black or Asian race, was associated with increased mortality which was more pronounced for iAAA (1.93; 95% CI, 1.66-2.25) than rAAA (1.29; 95% CI, 1.13-1.48]; Pinteraction < .001). CONCLUSIONS We confirmed a substantially decreased adjusted risk of AAA hospitalization for females and racial minority groups; however, aging and comorbid peripheral vascular disease decreased these differences. The disparate risk of AAA hospitalization by sex and race highlights the importance of inclusivity in future AAA studies.
Collapse
Affiliation(s)
- Shimena R Li
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Katherine M Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA.
| | - Jason Kennedy
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA; Department of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Lucine Gabriel
- School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Amanda R Phillips
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX; South Texas Veterans Health Care System, San Antonio, TX; University Health, San Antonio, TX
| | - Mohammad H Eslami
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA; Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| |
Collapse
|
20
|
Reitz KM, Arya S, Hall DE. Quantifying Frailty Requires a Conceptual Model Before a Statistical Model. JAMA Surg 2022; 157:1065. [PMID: 35947376 PMCID: PMC10074604 DOI: 10.1001/jamasurg.2022.3110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Katherine M Reitz
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania
- Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Wolff Center at UPMC, Pittsburgh, Pennsylvania
| |
Collapse
|
21
|
Andraska EA, Phillips AR, Reitz KM, Asaadi S, Ho J, McDonald MM, Madigan M, Liang N, Eslami M, Sridharan N. Young patients without prior vascular disease are at increased risk of limb loss and reintervention after acute limb ischemia. J Vasc Surg 2022; 76:1354-1363.e1. [PMID: 35709858 PMCID: PMC9890507 DOI: 10.1016/j.jvs.2022.04.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/16/2022] [Accepted: 04/24/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The objective of the present study was to categorize the presentation and treatment of acute limb ischemia (ALI) in young patients and compare the adverse outcomes after revascularization compared with that of older patients. METHODS All the patients who had presented to a multi-institution healthcare system with ALI from 2016 to 2020 were identified. The presenting features, operative details, and outcomes were included in the present analysis. Patients with existing peripheral arterial disease (acute on chronic) were analyzed separately from those without (de novo thrombosis or embolus). Within these groups, younger patients (age, ≤50 years) were compared with older patients (age, >50 years). The 3-month major adverse limb event-free survival was the primary outcome. RESULTS A total of 232 patients (age, 60 ± 16 years; 44% female sex, 87% white race) were included in the analysis. Of the 232 patients, 119 were in the acute on chronic cohort and 113 were in the de novo thrombosis/embolism cohort. Age did not affect the overall outcomes (P = .45) or the outcomes for the acute on chronic group (P = .17). However, in the de novo thrombosis/embolism cohort, patients aged ≤50 years had worse major adverse limb event-free survival compared with patients aged >50 years (hazard ratio, 2.47; 95% confidence interval, 1.08-5.68; P = .03) after adjustment for Rutherford class, interval from presentation to the operating room, and smoking status. In the de novo thrombosis/embolism group, the operative approach was similar across the age groups (endovascular, 12% vs 14%; open, 48% vs 41%; hybrid, 41% vs 45%; P = .78). In the younger patients, embolism was more likely from a proximal arterial source (71%). In contrast, in the older patients, the source of embolism was more often a cardiac source (86%). The rates of hypercoagulable disease were equal across the age groups (10% vs 10%; P = .95). The In-hospital mortality was 3% overall (acute on chronic, 5%; de novo, 3%). CONCLUSIONS Despite advances in interventional options, for patients with ALI due to de novo thrombosis or embolus, younger age was associated with worse short-term limb-related outcomes.
Collapse
Affiliation(s)
- Elizabeth A Andraska
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Amanda R Phillips
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Katherine M Reitz
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Sina Asaadi
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jonathan Ho
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Michael Madigan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Nathan Liang
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mohammad Eslami
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Natalie Sridharan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| |
Collapse
|
22
|
Phillips AR, Andraska EA, Reitz KM, Habib S, Martinez-Meehan D, Dai Y, Johnson AE, Liang NL. Association between neighborhood deprivation and presenting with a ruptured abdominal aortic aneurysm before screening age. J Vasc Surg 2022; 76:932-941.e2. [PMID: 35314299 PMCID: PMC9482667 DOI: 10.1016/j.jvs.2022.03.009] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/04/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Recent data indicate social determinants of health (SDOH) have a great impact on prevention and treatment outcomes across a broad variety of disease states, especially cardiovascular diseases. The area deprivation index (ADI) is a validated measure of neighborhood level disadvantage capturing key social determinate factors. Abdominal aortic aneurysm rupture (rAAA) is highly morbid, but also preventable through evidence-based screening. However, the association between rAAA and SDOH is poorly characterized. Our objective is to study the association of SDOH with rAAA and screening age. METHODS This retrospective study included patients who underwent operative repair of a rAAA at a multihospital healthcare system (2003-2019). Deprivation was measured by the ADI (scale 1-100), grouped into quintiles for simplicity, with higher quintiles indicating greater deprivation. Patients with the highest quintile ADI (89-100) were categorized as the most deprived. We investigated the association between neighborhood deprivation with the odds of (i) undergoing repair for rAAA before screening age 65 and (ii) undergoing endovascular aortic repair (EVAR) using logistic regression, sequentially modeling nonmodifiable then both nonmodifiable and modifiable confounding variables. RESULTS There were 632 patients who met the inclusion criteria (aged 74.2 ± 9.4 years; 174 women [27.6%]; 564 White [89.2%]; ADI 66.8 ± 22.3). Those from the most deprived neighborhoods (n = 118) were younger (71.7 ± 10.0 years vs 74.8 ± 9.2 years; P = .002), more likely to be female (36% vs 26%; P = .031), more likely to be Black (5.9% vs 0.4%; P = .007), and fewer underwent EVAR (28% vs 39.5%; P = .020) compared with those from other neighborhoods. On sequential modeling, residing in the most deprived neighborhoods was associated with undergoing rAAA repair before age 65 after adjusting for nonmodifiable factors (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.39-2.95; P < .001), and nonmodifiable as well as modifiable factors (OR, 2.22; 95% CI, 1.56-3.16; P < .001). Those in the most deprived neighborhoods had a lower odds of undergoing EVAR compared with open repair after adjusting for nonmodifiable factors (OR, 0.64; 95% CI, 0.41-0.98; P = .042), and nonmodifiable as well as modifiable factors (OR, 0.61; 95% CI, 0.37-0.99; P = .047). CONCLUSIONS Among patients who underwent rAAA, residing in the most deprived neighborhoods was associated with greater adjusted odds of presenting under age 65 and undergoing an open repair. These neighborhoods represent tangible geographic targets that may benefit from a younger screening age, enhanced education, and access to care. These findings stress the importance of developing strategies for early prevention and diagnosis of cardiovascular diseases among patients with disadvantageous SDOH.
Collapse
Affiliation(s)
- Amanda R Phillips
- Department of Surgery, Division of Vascular Surgery, UPMC, Pittsburgh, PA.
| | | | - Katherine M Reitz
- Department of Surgery, Division of Vascular Surgery, UPMC, Pittsburgh, PA
| | - Salim Habib
- Department of Surgery, Division of Vascular Surgery, UPMC, Pittsburgh, PA
| | | | - Yancheng Dai
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Amber E Johnson
- Department of Medicine, Division of Cardiology, UPMC, Pittsburgh, PA
| | - Nathan L Liang
- Department of Surgery, Division of Vascular Surgery, UPMC, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| |
Collapse
|
23
|
Lewis RE, Muluk SL, Reitz KM, Guyette FX, Brown JB, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Yazer MH, Heidel RE, Rowe AS, Sperry JL, Daley BJ. Prehospital plasma is associated with survival principally in patients transferred from the scene of injury: A secondary analysis of the PAMPer trial. Surgery 2022; 172:1278-1284. [PMID: 35864051 PMCID: PMC9999176 DOI: 10.1016/j.surg.2022.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/06/2022] [Accepted: 04/29/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND We sought to characterize if prehospital transfer origin from the scene of injury (SCENE) or from a referral emergency department (REF) alters the survival benefit attributable to prehospital plasma resuscitation in patients at risk of hemorrhagic shock. METHODS We performed a secondary analysis of data from a recently completed prehospital plasma clinical trial. All of the enrolled patients from either the SCENE or REF groups were included. The demographics, injury characteristics, shock severity and resuscitation needs were compared. The primary outcome was a 30-day mortality. Kaplan-Meier analysis and Cox-hazard regression were used to characterize the independent survival benefits of prehospital plasma for transport origin groups. RESULTS Of the 501 enrolled patients, the REF group patients (n = 111) accounted for 22% with the remaining (n = 390) originating from the scene. The SCENE group patients had higher injury severity and were more likely intubated prehospital. The REF group patients had longer prehospital times and received greater prehospital crystalloid and blood products. Kaplan-Meier analysis revealed a significant 30-day survival benefit associated with prehospital plasma in the SCENE group (P < .01) with no difference found in the REF group patients (P = .36). The Cox-regression verified after controlling for relevant confounders that prehospital plasma was independently associated with a 30-day survival in the SCENE group patients (hazard ratio 0.59; 95% confidence interval 0.39-0.89; P = .01) with no significant relationship found in the REF group patients (hazard ratio 1.03, 95% confidence interval 0.4-3.0). CONCLUSION Important differences across the SCENE and REF cohorts exist that are essential to understand when planning prehospital studies. Prehospital plasma is associated with a survival benefit primarily in SCENE group patients. The results are exploratory but suggest transfer origin may be an important determinant of prehospital plasma benefit.
Collapse
Affiliation(s)
- Rachel E Lewis
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN
| | - Sruthi L Muluk
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Francis X Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Richard S Miller
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
| | | | - Jeffrey A Claridge
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Herb A Phelan
- Department of Surgery, University of Texas Southwestern, Dallas, TX
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA
| | - R Eric Heidel
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN
| | - A Shawn Rowe
- Department of Surgery, University of Tennessee Medical Center at Knoxville, Knoxville, TN
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA.
| | - Brian J Daley
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, TN
| | | |
Collapse
|
24
|
Reitz KM, Kennedy J, Li SR, Handzel R, Tonetti DA, Neal MD, Zuckerbraun BS, Hall DE, Sperry JL, Angus DC, Tzeng E, Seymour CW. Association Between Time to Source Control in Sepsis and 90-Day Mortality. JAMA Surg 2022; 157:817-826. [PMID: 35830181 PMCID: PMC9280613 DOI: 10.1001/jamasurg.2022.2761] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Importance Rapid source control is recommended to improve patient outcomes in sepsis. Yet there are few data to guide how rapidly source control is required. Objective To determine the association between time to source control and patient outcomes in community-acquired sepsis. Design, Setting, and Particpants Multihospital integrated health care system cohort study of hospitalized adults (January 1, 2013, to December 31, 2017) with community-acquired sepsis as defined by Sepsis-3 who underwent source control procedures. Follow-up continued through January 1, 2019, and data analyses were completed March 17, 2022. Exposures Early (<6 hours) compared with late (6-36 hours) source control as well as each hour of source control delay (1-36 hours) from sepsis onset. Main Outcomes and Measures Multivariable models were clustered at the level of hospital with adjustment for patient factors, sepsis severity, resource availability, and the physiologic stress of procedures generating adjusted odds ratios (aOR) and 95% CI. Results Of 4962 patients with sepsis (mean [SD] age, 62 [16] years; 52% male; 85% White; mean [SD] Sequential Organ Failure Assessment score, 3.8 [2.5]), source control occurred at a median (IQR) of 15.4 hours (5.5-21.7) after sepsis onset, with 1315 patients (27%) undergoing source control within 6 hours. The crude 90-day mortality was similar for early and late source control (n = 177 [14%] vs n = 529 [15%]; P = .35). In multivariable models, early source control was associated with decreased risk-adjusted odds of 90-day mortality (aOR, 0.71; 95% CI, 0.63-0.80). This association was greater among gastrointestinal and abdominal (aOR, 0.56; 95% CI, 0.43-0.80) and soft tissue interventions (aOR, 0.72; 95% CI, 0.55-0.95) compared with orthopedic and cranial interventions (aOR, 1.33; 95% CI, 0.96-1.83; P < .001 for interaction). Conclusions and Relevance Source control within 6 hours of community-acquired sepsis onset was associated with a reduced risk-adjusted odds of 90-day mortality. Prioritizing the rapid identification of septic foci and initiation of source control interventions can reduce the number of avoidable deaths among patients with sepsis.
Collapse
Affiliation(s)
- Katherine M. Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania,Division of Vascular Surgery, UPMC, Pittsburgh, Pennsylvania
| | - Jason Kennedy
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shimena R. Li
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert Handzel
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel A. Tonetti
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew D. Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brian S. Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Daniel E. Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania,Center for Health Equity Research and Promotion, Veterans Affairs, Pittsburgh, Pennsylvania,Wolff Center, UPMC, Pittsburgh, Pennsylvania
| | - Jason L. Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Division of Vascular Surgery, UPMC, Pittsburgh, Pennsylvania,Veterans Affairs Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Christopher W. Seymour
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
25
|
Hafeez MS, Phillips AR, Reitz KM, Sridharan ND, Avgerinos E, Chaer RA. Socioeconomic Disadvantage Is Associated With Health Care Disparities in Mortality and Readmissions After Submassive (Intermediate-Risk) Pulmonary Embolism. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
26
|
Semaan DB, Phillips A, Reitz KM, Sridharan ND, Mulukutla S, Avgerinos E, Eslami MH, Chaer RA. Improved Short- and Long-term Survival with Catheter Directed Therapies over Medical Management in Patients with Submassive Pulmonary Embolism - A Retrospective Matched Cohort Study. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
27
|
Mak AK, Andraska EA, Reitz KM, Chaer R, Eslami MH, Avgerinos E. A single institutional experience with suction thrombectomy in acute mesenteric ischemia. Ann Vasc Surg Brief Rep Innov 2022; 2:100070. [PMID: 36733720 PMCID: PMC9890405 DOI: 10.1016/j.avsurg.2022.100070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute mesenteric ischemia (AMI) is typically treated by open surgery or hybrid techniques. Catheter-based aspiration thrombectomy represents another minimally invasive alternative with a potential additional safety benefit of minimizing the bleeding risk associated with thrombolytics. In this institutional case series, we present five clinical cases of aspiration thrombectomy for high-risk AMI using the Penumbra aspiration system. All patients underwent technically successful endovascular thrombectomy as demonstrated by intraoperative angiography results. However, bowel necrosis and sepsis adversely affected postoperative outcomes. Lack of intraoperative bowel assessment is a limitation of endovascular methods, highlighting the importance of patient selection.
Collapse
Affiliation(s)
- Allison K Mak
- University of Pittsburgh School of Medicine, United States
| | - Elizabeth A Andraska
- Department of Surgery, Division of Vascular Surgery, UPMC Heart and Vascular Institute, UPMC Presbyterian Hospital, Room E362.4, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213-2582, United States
| | - Katherine M Reitz
- Department of Surgery, Division of Vascular Surgery, UPMC Heart and Vascular Institute, UPMC Presbyterian Hospital, Room E362.4, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213-2582, United States
| | - Rabih Chaer
- Department of Surgery, Division of Vascular Surgery, UPMC Heart and Vascular Institute, UPMC Presbyterian Hospital, Room E362.4, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213-2582, United States
| | - Mohammed H Eslami
- Department of Surgery, Division of Vascular Surgery, UPMC Heart and Vascular Institute, UPMC Presbyterian Hospital, Room E362.4, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213-2582, United States
| | - Efthymios Avgerinos
- Department of Surgery, Division of Vascular Surgery, UPMC Heart and Vascular Institute, UPMC Presbyterian Hospital, Room E362.4, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213-2582, United States
| |
Collapse
|
28
|
Li SR, Handzel RM, Tonetti D, Kennedy J, Shapiro K, Rosengart MR, Hall DE, Seymour C, Tzeng E, Reitz KM. Consensus Current Procedural Terminology Code Definition of Source Control for Sepsis. J Surg Res 2022; 275:327-335. [PMID: 35325636 DOI: 10.1016/j.jss.2022.02.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/28/2021] [Revised: 01/13/2022] [Accepted: 02/13/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Unlike antibiotic and perfusion support, guidelines for sepsis source control lack high-quality evidence and are ungraded. Internally valid administrative data methods are needed to identify cases representing source control procedures to evaluate outcomes. METHODS Over five modified Delphi rounds, two independent reviewers identified Current Procedural Terminology (CPT) codes pertinent to source control. In each round, codes with perfect agreement were retained or excluded, whereas disagreements were reviewed by the panelists. Manual review of 400 patient records meeting Sepsis-3 criteria (2010-2017) clinically adjudicated which encounters included source control procedures (gold standard). The performance of consensus codes was compared with the gold standard to assess sensitivity, specificity, predictive values, and likelihood ratios. RESULTS Of 5752 CPT codes, 609 consensus codes represented source control procedures. Of 400 hospitalizations for sepsis, 39 (9.8%; 95% confidence interval [CI] 7.0%-13.1%) underwent gold standard source control procedures and 29 (7.3%; 95% CI 4.9-10.3%) consensus code-defined source control procedures. Thirty consensus codes were identified (20.0% gastrointestinal/intraabdominal, 10.0% genitourinary, 13.3% hepatopancreatobiliary, 23.3% orthopedic/cranial, 23.3% soft tissue, and 10.0% intrathoracic), which had 61.5% (95% CI 44.6%-76.6%) sensitivity, 98.6% (95% CI 96.8%-99.6%) specificity, 83.2% (95% CI 66.6%-92.4%) positive, and 95.9% (95% CI 93.9%-97.2%) negative predictive values. With pretest probability at sample prevalence, an identified consensus code had a posttest probability of 83.0% (95% CI 66.0%-92.0%), whereas consensus code absence had a probability of 4.0% (95% CI 3.0-6.0) for undergoing a source control procedure. CONCLUSIONS Using modified Delphi methodology, we created and validated CPT codes identifying source control procedures, providing a framework for evaluation of the surgical care of patients with sepsis.
Collapse
Affiliation(s)
- Shimena R Li
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Robert M Handzel
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Departments of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel Tonetti
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jason Kennedy
- Departments of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katherine Shapiro
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew R Rosengart
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Departments of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher Seymour
- Departments of Critical Care and Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katherine M Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
29
|
Phillips AR, Andraska EA, Reitz KM, Gabriel L, Salem KM, Sridharan ND, Tzeng E, Liang NL. Any Postoperative Surveillance Improves Survival after Endovascular Repair of Ruptured Abdominal Aortic Aneurysms. Ann Vasc Surg 2022; 80:50-59. [PMID: 34775012 PMCID: PMC8897248 DOI: 10.1016/j.avsg.2021.09.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 08/05/2021] [Revised: 09/20/2021] [Accepted: 09/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Endovascular aortic repair (EVAR) has advanced the care of patients with ruptured abdominal aortic aneurysms (rAAA) with improved early postoperative morbidity and mortality. However, this comes at the cost of a rigorous postoperative surveillance schedule to monitor for further aneurysmal degeneration. Adherence to surveillance recommendations is known to be poor in the elective setting, but has yet to be studied in the ruptured population. The aim of this study is to investigate predictors of incomplete surveillance after EVAR for rAAA (rEVAR) and examine how adherence impacts outcomes. METHODS This was a retrospective case control study of patients undergoing rEVAR at a multiple hospital single healthcare center (2003-2020). Patients were excluded if they underwent open conversion during their index hospitalization or died within 60 days of surgery. Follow-up was broadly categorized as complete surveillance (60-day postoperative visit and annually thereafter) or incomplete surveillance, comprising both patients with less than recommended surveillance (minimal surveillance) and completely lost to follow-up (LTF). Any follow-up was defined as patients with complete or minimal surveillance. We investigated predictors of complete versus incomplete surveillance by multivariate logistic regression. Secondary outcomes included overall survival and cumulative incidence of reintervention controlling for the competing risk of mortality, generating hazard ratios (HR) and subdistribution hazard ratios (SHR). RESULTS One-hundred and sixty patients (mean age 74 ± 10.1 years, 81.2% male) out of 673 total rAAA met study inclusion criteria. Complete surveillance was seen in 41.3% of our cohort, with the remainder with minimal surveillance (29.4%) or LTF (29.4%). Incomplete surveillance was associated with male sex (odds ratio [OR] 2.56; 95% CI 1.02-6.43), lack of a primary care provider (PCP; OR 0.20; 95% CI 0.04-0.99), and longer driving distance from home to treating hospital (OR 2.37; 95% CI 1.08-5.20). Survival was not different between complete and incomplete surveillance groups, however any follow-up conferred improved survival over LTF (HR 0.57; 95% CI 0.331-0.997; P = 0.049). Reintervention was associated with incomplete surveillance (SHR 0.29; 95% CI 0.11-0.75), and discharge to a facility (SHR 0.25; 95% CI 0.067-0.94). CONCLUSIONS Incomplete surveillance was observed in over 50% of patients who underwent rEVAR and was associated with male sex, lack of PCP, and longer driving distance. Any follow-up conferred a survival benefit, yet incomplete surveillance was associated with a lower risk of reintervention. Targeted strategies to prevent LTF, and less stringent, personalized follow-up plans that may confer similar survival benefit with better patient adherence should be investigated.
Collapse
Affiliation(s)
- Amanda R. Phillips
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213
| | - Elizabeth A. Andraska
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213
| | - Katherine M. Reitz
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213
| | - Lucine Gabriel
- University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Karim M. Salem
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Natalie D. Sridharan
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Edith Tzeng
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| | - Nathan L. Liang
- Department of Surgery, Division of Vascular Surgery, UPMC. 200 Lothrop Street, Pittsburgh, PA 15213,University of Pittsburgh School of Medicine. 3550 Terrace Street, Pitsburgh, PA 15213
| |
Collapse
|
30
|
George EL, Massarweh NN, Youk A, Reitz KM, Shinall MC, Chen R, Trickey AW, Varley PR, Johanning J, Shireman PK, Arya S, Hall DE. Comparing Veterans Affairs and Private Sector Perioperative Outcomes After Noncardiac Surgery. JAMA Surg 2022; 157:231-239. [PMID: 34964818 PMCID: PMC8717209 DOI: 10.1001/jamasurg.2021.6488] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Recent legislation facilitates veterans' ability to receive non-Veterans Affairs (VA) surgical care. However, contemporary data comparing the quality and safety of VA and non-VA surgical care are lacking. Objective To compare perioperative outcomes among veterans treated in VA hospitals with patients treated in private-sector hospitals. Design, Setting, and Participants This cohort study took place across 8 noncardiac specialties in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) and American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from January 1, 2015, through December 31, 2018. Multivariable log-binomial modeling was used to evaluate the association between VA vs private sector care settings and 30-day mortality. Unmeasured confounding was quantified using the E-value. Patients 18 years and older undergoing a noncardiac procedures were included. Exposures Surgical care in either a VA or private sector setting. Main Outcomes and Measures Primary outcome was 30-day postoperative mortality. Secondary outcome was failure to rescue, defined as a postoperative death after a complication. Results Of 3 910 752 operations (3 174 274 from NSQIP and 736 477 from VASQIP), 1 498 984 (92.1%) participants in NSQIP were male vs 678 382 (47.2%) in VASQIP (mean difference, -0.449 [95% CI, -0.450 to -0.448]; P < .001), and 441 894 (60.0%) participants in VASQIP were frail or very frail vs 676 525 (21.3%) in NSQIP (mean difference, -0.387 [95% CI, -0.388 to -0.386]; P < .001). Overall, rates of 30-day mortality, complications, and failure to rescue were 0.8%, 9.5%, and 4.7%, respectively, in NSQIP (n = 3 174 274 operations) and 1.1%, 17.1%, and 6.7%, respectively in VASQIP (736 477) (differences in proportions, -0.003 [95% CI, -0.003 to -0.002]; -0.076 [95% CI, -0.077 to -0.075]; 0.020 [95% CI, 0.018-0.021], respectively; P < .001). Compared with private sector care, VA surgical care was associated with a lower risk of perioperative death (adjusted relative risk, 0.59 [95% CI, 0.47-0.75]; P < .001). This finding was robust in multiple sensitivity analyses performed, including among patients who were frail and nonfrail, with or without complications, and undergoing low and high physiologic stress procedures. These findings were also consistent when year was included as a covariate and in nonparsimonious modeling for patient-level factors. Compared with private sector care, VA surgical care was also associated with a lower risk of failure to rescue (adjusted relative risk, 0.55 [95% CI, 0.44-0.68]). An unmeasured confounder (present disproportionately in NSQIP data) would require a relative risk of 2.78 [95% CI, 2.04-3.68] to obviate the main finding. Conclusions and Relevance VA surgical care is associated with lower perioperative mortality and decreased failure to rescue despite veterans having higher-risk characteristics. Given the unique needs and composition of the veteran population, health policy decisions and budgetary appropriations should reflect these important differences.
Collapse
Affiliation(s)
- Elizabeth L. George
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California,Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California,Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California
| | - Nader N. Massarweh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Ada Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katherine M. Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Myrick C. Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rui Chen
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California
| | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California
| | | | - Jason Johanning
- Department of Surgery, University of Nebraska Medical Center, Omaha,Nebraska Western Iowa Veterans Affairs Health System, Omaha
| | - Paula K. Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio,South Texas Veterans Health Care System, San Antonio
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California,Stanford-Surgery Policy Improvement Research & Education Center, Stanford University School of Medicine, Stanford, California,Surgical Service Line, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania,Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania,Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania,Geriatric Research Educational and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| |
Collapse
|
31
|
Reitz KM, Hall DE, Shinall MC, Shireman PK, Silverstein JC. Using the Unified Medical Language System to Expand the Operative Stress Score - First Use Case. J Surg Res 2021; 268:552-561. [PMID: 34464893 PMCID: PMC8678140 DOI: 10.1016/j.jss.2021.07.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/01/2021] [Accepted: 07/26/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The Unified Medical Language System (UMLS) maps relationships between and within >100 biomedical vocabularies, including Current Procedural Terminology (CPT) codes, creating a powerful knowledge resource which can accelerate clinical research. METHODS We used synonymy and concepts relating hierarchical structure of CPT codes within the UMLS, (1) guiding surgical experts in expanding the Operative Stress Score (OSS) from 565 originally rated CPT codes to additional, 1,853 related procedures; (2) establishing validity of the association between the added OSS ratings and 30-day outcomes in VASQIP (2015-2018). RESULTS The UMLS Metathesaurus and Semantic Network was converted into an interactive graph database (https://github.com/dbmi-pitt/UMLS-Graph) delineating ontology relatedness. From this UMLS-graph, the CPT hierarchy was queried obtaining all paths from each code to the hierarchical apex. Of 1,853 added ratings, 43% and 76% were siblings and cousins of original OSS CPT codes. Of 857,577 VASQIP cases (mean age, 64±11years; 91% male; 75% white), 786,122 (92%) and 71,455 (8%) were rated in the original and added OSS. Compared to original, added OSS cases included more females (14% versus 9%) and frail patients (25% versus 19%) undergoing high stress procedures (11% versus 8%; all P <.001). Postoperative mortality consistently increased with OSS. Very low stress procedures had <0.5% (original, 0.4% [95%CI, 0.4%-0.5%] versus added, 0.9% [95%CI, 0.6%-1.2%]) and very high 3.8% (original, 3.5% [95%CI, 3.0%-4.0%] versus added, 5.8% [95%CI, 4.6-7.3%]) mortality rates. CONCLUSIONS The synonymy and concepts relating biomedical data within the UMLS can be abstracted and efficiently used to expand the utility of existing clinical research tools.
Collapse
Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Geriatric Research Educational and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Wolff Center, UPMC, Pittsburgh, Pennsylvania
| | - Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Taxas; Department of Surgery, South Texas Veterans Health Care System, San Antonio, Taxas; University Health, San Antonio, Taxas
| | - Jonathan C Silverstein
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
32
|
Reitz KM, Terhorst L, Smith CN, Campwala IK, Owoc MS, Downs-Canner SM, Diego EJ, Switzer GE, Rosengart MR, Myers SP. Healthcare providers' perceived support from their organization is associated with lower burnout and anxiety amid the COVID-19 pandemic. PLoS One 2021; 16:e0259858. [PMID: 34797847 PMCID: PMC8604356 DOI: 10.1371/journal.pone.0259858] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/27/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Professional burnout represents a significant threat to the American healthcare system. Organizational and individual factors may increase healthcare providers' susceptibility or resistance to burnout. We hypothesized that during the COVID-19 pandemic, 1) higher levels of perceived organizational support (POS) are associated with lower risk for burnout and anxiety, and 2) anxiety mediates the association between POS and burnout. METHODS In this longitudinal prospective study, we surveyed healthcare providers employed full-time at a large, multihospital healthcare system monthly over 6 months (April to November 2020). Participants were randomized using a 1:1 allocation stratified by provider type, gender, and academic hospital status to receive one of two versions of the survey instrument formulated with different ordering of the measures to minimize response bias due to context effects. The exposure of interest was POS measured using the validated 8-item Survey of POS (SPOS) scale. Primary outcomes of interest were anxiety and risk for burnout as measured by the validated 10-item Burnout scale from the Professional Quality (Pro-QOL) instrument and 4-item Emotional Distress-Anxiety short form of the Patient Reported Outcome Measurement Information System (PROMIS) scale, respectively. Linear mixed models evaluated the associations between POS and both burnout and anxiety. A mediation analysis evaluated whether anxiety mediated the POS-burnout association. RESULTS Of the 538 participants recruited, 402 (75%) were included in the primary analysis. 55% of participants were physicians, 73% 25-44 years of age, 73% female, 83% White, and 44% had ≥1 dependent. Higher POS was significantly associated with a lower risk for burnout (-0.23; 95% CI -0.26, -0.21; p<0.001) and lower degree of anxiety (-0.07; 95% CI -0.09, -0.06; p = 0.010). Anxiety mediated the associated between POS and burnout (direct effect -0.17; 95% CI -0.21, -0.13; p<0.001; total effect -0.23; 95% CI -0.28, -0.19; p<0.001). CONCLUSION During a health crisis, increasing the organizational support perceived by healthcare employees may reduce the risk for burnout through a reduction in anxiety. Improving the relationship between healthcare organizations and the individuals they employ may reduce detrimental effects of psychological distress among healthcare providers and ultimately improve patient care.
Collapse
Affiliation(s)
- Katherine M. Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Lauren Terhorst
- School of Health and Rehabilitation Sciences, University of Pittsburgh, PA, United States of America
- Department of Clinical and Translational Science, University of Pittsburgh, PA, United States of America
| | - Clair N. Smith
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Insiyah K. Campwala
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Maryanna S. Owoc
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Stephanie M. Downs-Canner
- Department of Surgery, University of North Carolina-Chapel Hill School of Medicine, Chapel Hill, NC, United States of America
| | - Emilia J. Diego
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Galen E. Switzer
- Department of Clinical and Translational Science, University of Pittsburgh, PA, United States of America
- Department of General Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States of America
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
| | - Matthew R. Rosengart
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
- Department of Clinical and Translational Science, University of Pittsburgh, PA, United States of America
| | - Sara P. Myers
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
- * E-mail:
| |
Collapse
|
33
|
Reitz KM, Hall DE, Makaroun MS, Tzeng E, Liang NL. Early Postoperative Mortality Among US Veterans With a Robust Physiologic Reserve Undergoing Open or Endovascular Abdominal Aortic Aneurysm Repair. JAMA Netw Open 2021; 4:e2137245. [PMID: 34812851 PMCID: PMC8611481 DOI: 10.1001/jamanetworkopen.2021.37245] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
This cohort study uses data from the Veterans Affairs Surgical Quality Improvement Program database to examine the risk of early postoperative mortality among US veterans with a robust physiologic reserve undergoing open or endovascular abdominal aortic aneurysm repair.
Collapse
Affiliation(s)
- Katherine M. Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- UPMC, Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Daniel E. Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Wolff Center, UPMC, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs, Pittsburgh, Pennsylvania
| | - Michel S. Makaroun
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC, Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- UPMC, Presbyterian Hospital, Pittsburgh, Pennsylvania
| | - Nathan L. Liang
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC, Presbyterian Hospital, Pittsburgh, Pennsylvania
| |
Collapse
|
34
|
Hrebinko K, Reitz KM, Gamboa A, Regenbogen SE, Hawkins AT, Abdel-Misih SRZ, Wise PE, Balch GC, Holder-Murray JM. Neighborhood-Level Socioeconomic Status and Survival in Rectal Cancer: An Analysis of the US Rectal Cancer Consortium (USRCC). J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
35
|
Yan Q, Kim J, Reitz KM, Hall DE, Shinall MC, Stitzenberg KB, Kao LS, George E, Wang CP, Shireman PK. Sex Differences in Postoperative Complications and Mortality. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
36
|
Humar P, Phillips AR, Neal MD, Tzeng E, Reitz KM. Minimal Change in Abdominal Aortic Aneurysm Sac Regression for Diabetics after Endovascular Repair, Unchanged by Metformin Exposure. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
37
|
Hrebinko KA, Reitz KM, Mohammed MK, Nassour I, Watson AR, Cunningham KE, Medich DS, Celebrezze JP, Holder-Murray JM. Transanal excision with adjuvant therapy for pT1N0 rectal tumors with high-risk features offers equivalent survival to radical resection: A National Cancer Database analysis. J Surg Oncol 2021; 125:475-483. [PMID: 34705273 DOI: 10.1002/jso.26734] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/19/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Current guidelines favor transabdominal radical resection (RR) over transanal local excision (TAX) followed by adjuvant therapy (TAXa) for pT1N0 rectal tumors with high-risk features. Comparison of oncologic outcomes between these approaches is limited, although the former is associated with increased postoperative morbidity. We hypothesize that such treatment strategies result in equivalent long-term survival. METHODS A retrospective cohort study was conducted using the National Cancer Database (2010-2016) to identify patients with pT1N0 rectal adenocarcinoma with high-risk features who underwent TAX or RR for curative intent. The primary outcome was 5-year overall survival (OS), evaluated with log-rank and Cox-proportional hazards testing. RESULTS A total of 1159 patients (age 67.4 ± 12.9 years; 56.6% male; 83.3% White) met study criteria, of which 1009 (87.1%) underwent RR and 150 (12.9%) underwent TAXa. Patients undergoing TAXa had shorter lengths of stay (RR = 6.5 days, TAXa = 2.7 days, p < 0.001). The 5-year OS was equivalent between groups. TAX without adjuvant therapy was associated with an increased risk of mortality (hazard ratio 1.81, 95% confidence interval 1.17-2.78, p = 0.01). CONCLUSIONS This is the largest study to demonstrate equivalent 5-year OS between TAXa and RR for T1N0 rectal cancer with high-risk features. These findings may guide the development of prospective, randomized trials and influence changes in practice recommendations for early-stage rectal cancer.
Collapse
Affiliation(s)
- Katherine A Hrebinko
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Katherine M Reitz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Maryam K Mohammed
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Nassour
- Division of Surgical Oncology, Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Andrew R Watson
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kellie E Cunningham
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David S Medich
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - James P Celebrezze
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jennifer M Holder-Murray
- Division of Colon and Rectal Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
38
|
Reitz KM, Althouse AD, Meyer J, Arya S, Goodney PP, Shireman PK, Hall DE, Tzeng E. Association of Smoking With Postprocedural Complications Following Open and Endovascular Interventions for Intermittent Claudication. JAMA Cardiol 2021; 7:45-54. [PMID: 34613348 DOI: 10.1001/jamacardio.2021.3979] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Smoking is a key modifiable risk factor in the development and progression of peripheral artery disease, which often manifests as intermittent claudication (IC). Smoking cessation is a first-line therapy for IC, yet a minority of patients quit smoking prior to elective revascularization. Objective To assess if preprocedural smoking is associated with an increased risk of early postprocedural complications following elective open and endovascular revascularization. Design, Setting, and Participants This retrospective cohort study used nearest-neighbor (1:1) propensity score matching of 2011 to 2019 data from the Veterans Affairs Surgical Quality Improvement Program, including all cases with a primary diagnosis of IC and excluding emergent cases, primary procedures that were not lower extremity revascularization, and patients with chronic limb-threatening ischemia within 30 days of the intervention. All data were abstracted June 18, 2020, and analyzed from July 26, 2020, to June 30, 2021. Exposures Preprocedural cigarette smoking. Main Outcomes and Measures Any and organ system-specific (ie, wound, respiratory, thrombosis, kidney, cardiac, sepsis, and neurological) 30-day complications and mortality, overall and in prespecified subgroups. Results Of 14 350 included cases of revascularization, 14 090 patients (98.2%) were male, and the mean (SD) age was 65.7 (7.0) years. A total of 7820 patients (54.5%) were smoking within the preprocedural year. There were a total of 4417 endovascular revascularizations (30.8%), 4319 hybrid revascularizations (30.1%), and 5614 open revascularizations (39.1%). A total of 1594 patients (11.1%) had complications, and 57 (0.4%) died. Among 7710 propensity score-matched cases (including 3855 smokers and 3855 nonsmokers), 484 smokers (12.6%) and 34 nonsmokers (8.9%) experienced complications, an absolute risk difference (ARD) of 3.68% (95% CI, 2.31-5.06; P < .001). Compared with nonsmokers, any complication was higher for smokers following endovascular revascularization (26 [4.3%] vs 52 [2.1%]; ARD, 2.19%; 95% CI, 0.77-3.60; P = .003), hybrid revascularization (204 [17.3%] vs 163 [14.1%]; ARD, 3.18%; 95% CI, 0.23-6.13; P = .04), and open revascularization (228 [15.4%] vs 153 [10.3%]; ARD, 5.18%; 95% CI, 2.78-7.58; P < .001). Compared with nonsmokers, respiratory complications were higher for smokers following endovascular revascularization (20 [1.7%] vs 6 [0.5%]; ARD, 1.17%; 95% CI, 0.35-2.00; P = .009), hybrid revascularization (33 [2.8%] vs 10 [0.9%]; ARD, 1.93%; 95% CI, 0.85-3.02; P = .001), and open revascularization (32 [2.2%] vs 19 [1.3%]; ARD, 0.89%; 95% CI, 0-1.80; P = .06). Wound complications and graft failure were higher for smokers compared with nonsmokers following open interventions (wound complications: 146 [9.9%] vs 87 [5.8%]; ARD, 4.05%; 95% CI, 2.12-5.99; P < .001; graft failure: 33 [2.2%] vs 11 [0.7%]; ARD, 1.50%; 95% CI, 0.63-2.37; P = .001). In a sensitivity analysis, compared with active smokers (n = 5173; smoking within 2 weeks before the procedure), the risk of any complication was decreased by 65% for never smokers (n = 1197; adjusted odds ratio, 0.45; 95% CI, 0.34-0.59) and 29% for former smokers (n = 4755; cessation more than 1 year before the procedure; adjusted odds ratio, 0.71; 95% CI, 0.61-0.83; P = .001 for interaction). Conclusions and Relevance In this cohort study, more than half of patients with IC were smoking prior to elective revascularization, and complication risks were higher across all modalities of revascularization. These findings stress the importance of smoking cessation to optimize revascularization outcomes.
Collapse
Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Andrew D Althouse
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Joseph Meyer
- Department of Cardiology, Johns Hopkins, Baltimore, Maryland
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| | - Paula K Shireman
- Department of Surgery, UT Health San Antonio, University of Texas, San Antonio.,Department of Surgery, South Texas Veterans Health Care System, San Antonio
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Wolff Center at UPMC, Pittsburgh, Pennsylvania
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Vascular Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| |
Collapse
|
39
|
Reitz KM, Varley PR, Liang NL, Youk A, George EL, Shinall MC, Shireman PK, Arya S, Tzeng E, Hall DE. The Correlation Between Case Total Work Relative Value Unit, Operative Stress, and Patient Frailty: Retrospective Cohort Study. Ann Surg 2021; 274:637-645. [PMID: 34506319 PMCID: PMC8433485 DOI: 10.1097/sla.0000000000005068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Assess the relationships between case total work relative value units (wRVU), patient frailty, and the physiologic stress of surgical interventions. SUMMARY OF BACKGROUND DATA Surgeon reimbursement is frequently apportioned by wRVU. These subjective, procedure-specific valuations generated by physician survey estimate the intensity and time for typical patient care services. We hypothesized wRVU would not adequately account for patient-specific factors, such as frailty, that modify the required physician work, regardless of procedural complexity. METHODS Using National and Veterans Affairs Surgical Quality Improvement Programs (2015-2018), we evaluated the correlation between case total wRVU, patient frailty (risk analysis index) and physiologic surgical stress (operative stress score). RESULTS Of 4,111,371 (86%) cases, the correlation between total wRVU and operative stress was moderate [ρs = 0.587 (95% confidence interval, 0.586-0.587)], but negligible with frailty ρ = 0.177 (95% confidence interval, 0.176-0.178)]. Very high operative stress procedures [n = 34,047 (1%)] generated a mean total wRVU of 55.1 (standard deviation, 12.9), comprising 7%, 2%, and 1% of thoracic, vascular, and general surgical cases, respectively. Very frail patients [n = 152,535 (4%)] accounted for 9% of thoracic, 9% of vascular, 4% of general, 5% of urologic, and 4% of neurologic surgical cases, generating 21.0 (standard deviation, 12.4) mean total wRVU. Some nonfrail patients undergoing low operative stress procedures [n = 60,128 (2%)] nonetheless generated the highest quintile wRVU; these comprised >15% of plastic, gynecologic, and urologic surgical cases. CONCLUSIONS Surgeon reimbursement correlates with operative stress but not patient frailty. The total wRVU does not adequately reflect patient-specific factors that increase the physician workload required to render optimal care to complex patients.
Collapse
Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick R Varley
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nathan L Liang
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ada Youk
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Elizabeth L George
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Myrick C Shinall
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paula K Shireman
- Department of Surgery, University of Texas Health San Antonio, San Antonio, Texas
- Department of Surgery, South Texas Veterans Health Care System, San Antonio, Texas
- University Health System, San Antonio, Texas
| | - Shipra Arya
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Vascular Surgery, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Wolff Center, UPMC, Pittsburgh, Pennsylvania
| |
Collapse
|
40
|
Phillips AR, Reitz KM, Myers S, Thoma F, Andraska EA, Jano A, Sridharan N, Smith RE, Mulukutla SR, Chaer R. Association Between Black Race, Clinical Severity, and Management of Acute Pulmonary Embolism: A Retrospective Cohort Study. J Am Heart Assoc 2021; 10:e021818. [PMID: 34431356 PMCID: PMC8649302 DOI: 10.1161/jaha.121.021818] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Existing evidence indicates Black patients have higher incidence of pulmonary embolism (PE) and PE‐related mortality compared with other races/ethnicities, yet disparities in presenting severity and treatment remain incompletely understood. Methods and Results We retrospectively queried a multihospital healthcare system for all hospitalizations for acute PE (2012–2019). Of 10 329 hospitalizations, 8743 met inclusion criteria. Black patients (14.3%) were significantly younger (54.6±17.8 versus 63.1±16.6 years; P<0.001) and more female (56.1% versus 51.6%; P=0.003) compared with White patients. Using ordinal regression, Black race was significantly associated with higher PE severity after matching 1:3 on age and sex (1210:3264; odds ratio [OR], 1.08; 95% CI, 1.03–1.14), adjusting for clinical (OR, 1.13; 95% CI, 1.01–1.27), and socioeconomic (OR, 1.05; 95% CI, 1.05–1.35) characteristics. Among intermediate and high‐severity PE, Black race was associated with a decreased risk of intervention controlling for the competing risk of mortality and censoring on hospital discharge. This effect was modified by PE severity (P value <0.001), with a lower and higher risk of intervention for intermediate and high‐severity PE, respectively. Race was not associated with in‐hospital mortality (OR, 0.84; 95% CI, 0.69–1.02). Conclusions Black patients hospitalized with PE are younger with a higher severity of disease compared with White patients. Although Black patients are less likely to receive an intervention overall, this differed depending on PE severity with higher risk of intervention only for life‐threatening PE. This suggests nuanced racial disparities in management of PE and highlights the complexities of healthcare inequalities.
Collapse
Affiliation(s)
| | - Katherine M Reitz
- Division of Vascular Surgery University of Pittsburgh Pittsburgh PA.,Department of Surgery University of Pittsburgh Pittsburgh PA
| | - Sara Myers
- Department of Surgery University of Pittsburgh Pittsburgh PA
| | - Floyd Thoma
- Division of Cardiology University of Pittsburgh Pittsburgh PA
| | | | - Antalya Jano
- School of Medicine University of Pittsburgh Pittsburgh PA
| | - Natalie Sridharan
- Division of Vascular Surgery University of Pittsburgh Pittsburgh PA.,School of Medicine University of Pittsburgh Pittsburgh PA
| | - Roy E Smith
- School of Medicine University of Pittsburgh Pittsburgh PA.,Division of Hematology/Oncology University of Pittsburgh Pittsburgh PA
| | - Suresh R Mulukutla
- Division of Cardiology University of Pittsburgh Pittsburgh PA.,School of Medicine University of Pittsburgh Pittsburgh PA
| | - Rabih Chaer
- Division of Vascular Surgery University of Pittsburgh Pittsburgh PA.,School of Medicine University of Pittsburgh Pittsburgh PA
| |
Collapse
|
41
|
Phillips AR, Andraska EA, Martinez-Meehan D, Dai Y, Reitz KM, Johnson AE, Tzeng E, Liang NL. Rupture Before the Age of Abdominal Aortic Aneurysm Screening—Another Example of Disparities in Vascular Surgery? J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
42
|
Andraska EA, Phillips AR, Reitz KM, Asaadi S, Dai Y, Tzeng E, Makaroun M, Liang NL. Longer Follow-Up Intervals After EVAR Is Safe and Appropriate After Marked Aneurysm Sac Regression. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
43
|
Ramos AE, Reitz KM, Speranza G, Singh MJ, Chaer RA, Snyderman C, Hager ES. Safety of Nonoperative Management of Carotid Body Tumors. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
44
|
Li SR, Guyette F, Brown J, Zenati M, Reitz KM, Eastridge B, Nirula R, Vercruysse GA, O'Keeffe T, Joseph B, Neal MD, Zuckerbraun BS, Sperry JL. Early Prehospital Tranexamic Acid Following Injury Is Associated With a 30-day Survival Benefit: A Secondary Analysis of a Randomized Clinical Trial. Ann Surg 2021; 274:419-426. [PMID: 34132695 PMCID: PMC8480233 DOI: 10.1097/sla.0000000000005002] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We sought to characterize the timing of administration of prehospital tranexamic acid (TXA) and associated outcome benefits. BACKGROUND TXA has been shown to be safe in the prehospital setting post-injury. METHODS We performed a secondary analysis of a recent prehospital randomized TXA clinical trial in injured patients. Those who received prehospital TXA within 1 hour (EARLY) from time of injury were compared to those who received prehospital TXA beyond 1 hour (DELAYED). We included patients with a shock index of >0.9. Primary outcome was 30-day mortality. Kaplan-Meier and Cox Hazard regression were utilized to characterize mortality relationships. RESULTS EARLY and DELAYED patients had similar demographics, injury characteristics, and shock severity but DELAYED patients had greater prehospital resuscitation requirements and longer prehospital times. Stratified Kaplan-Meier analysis demonstrated significant separation for EARLY patients (N = 238, log-rank chi-square test, 4.99; P = 0.03) with no separation for DELAYED patients (N = 238, log-rank chi-square test, 0.04; P = 0.83). Stratified Cox Hazard regression verified, after controlling for confounders, that EARLY TXA was associated with a 65% lower independent hazard for 30-day mortality [hazard ratio (HR) 0.35, 95% confidence interval (CI) 0.19-0.65, P = 0.001] with no independent survival benefit found in DELAYED patients (HR 1.00, 95% CI 0.63-1.60, P = 0.999). EARLY TXA patients had lower incidence of multiple organ failure and 6-hour and 24-hour transfusion requirements compared to placebo. CONCLUSIONS Administration of prehospital TXA within 1 hour from injury in patients at risk of hemorrhage is associated with 30-day survival benefit, lower incidence of multiple organ failure, and lower transfusion requirements.
Collapse
Affiliation(s)
- Shimena R Li
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Francis Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Joshua Brown
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Mazen Zenati
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | | | - Brian Eastridge
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX
| | - Raminder Nirula
- Department of Surgery, University of Utah, Salt Lake City, UT
| | | | | | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, AZ
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
- Division of Trauma and General Surgery, Pittsburgh Trauma Research Center, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
45
|
Liang NL, Sridharan ND, Reitz KM, Eslami MH, Chaer RA, Tzeng E, Makaroun MS. New randomized controlled trials for abdominal aortic aneurysm treatment should focus on younger, good-risk patients. J Vasc Surg 2021; 73:2209. [PMID: 34024466 DOI: 10.1016/j.jvs.2020.11.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 11/17/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Nathan L Liang
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Natalie D Sridharan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Katherine M Reitz
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Mohammad H Eslami
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Rabih A Chaer
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Edith Tzeng
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Michel S Makaroun
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| |
Collapse
|
46
|
Reitz KM, Gruen DS, Guyette F, Brown JB, Yazer MH, Vodovotz Y, Johanssen PI, Stensballe J, Daley B, Miller RS, Harbrecht BG, Claridge J, Phelan HA, Neal MD, Zuckerbraun BS, Sperry JL. Age of thawed plasma does not affect clinical outcomes or biomarker expression in patients receiving prehospital thawed plasma: a PAMPer secondary analysis. Trauma Surg Acute Care Open 2021; 6:e000648. [PMID: 33634214 PMCID: PMC7880105 DOI: 10.1136/tsaco-2020-000648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/13/2021] [Accepted: 01/25/2021] [Indexed: 12/26/2022] Open
Abstract
Background Prehospital plasma administration during air medical transport reduces the endotheliopathy of trauma, circulating pro-inflammatory cytokines, and 30-day mortality among traumatically injured patients at risk of hemorrhagic shock. No clinical data currently exists evaluating the age of thawed plasma and its association with clinical outcomes and biomarker expression post-injury. Methods We performed a secondary analysis from the prehospital plasma administration randomized controlled trial, PAMPer. We dichotomized the age of thawed plasma creating three groups: standard-care, YOUNG (day 0-1) plasma, and OLD (day 2-5) plasma. We generated HRs and 95% CIs for mortality. Among all patients randomized to plasma, we compared predicted biomarker values at hospital admission (T0) and 24 hours later (T24) controlling for key difference between groups with a multivariable linear regression. Analyses were repeated in a severely injured subgroup. Results Two hundred and seventy-one patients were randomized to standard-care and 230 to plasma (40% YOUNG, 60% OLD). There were no clinically or statistically significant differences in demographics, injury, admission vital signs, or laboratory values including thromboelastography between YOUNG and OLD. Compared with standard-care, YOUNG (HR 0.66 (95% CI 0.41 to 1.07), p=0.09) and OLD (HR 0.64 (95% CI 0.42 to 0.96), p=0.03) plasma demonstrated reduced 30-day mortality. Among those randomized to plasma, plasma age did not affect mortality (HR 1.04 (95% CI 0.60 to 1.82), p=0.90) and/or adjusted serum markers by plasma age at T0 or T24 (p>0.05). However, among the severely injured subgroup, OLD plasma was significantly associated with increased adjusted inflammatory and decreased adjusted endothelial biomarkers at T0. Discussion Age of thawed plasma does not result in clinical outcome or biomarker expression differences in the overall PAMPer study cohort. There were biomarker expression differences in those patients with severe injury. Definitive investigation is needed to determine if the age of thawed plasma is associated with biomarker expression and outcome differences following traumatic injury. Level of evidence II.
Collapse
Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Danielle S Gruen
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Frances Guyette
- Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joshua B Brown
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Mark H Yazer
- Department of Pathology, University of Pittsburgh and the Institute for Transfusion Medicine, Pittsburgh, Pennsylvania, USA
| | - Yoram Vodovotz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pär I Johanssen
- Capital Region Blood Bank, Section for Transfusion Medicine, University of Copenhagen, Kobenhavn, Denmark
| | - Jakob Stensballe
- Capital Region Blood Bank, Section for Transfusion Medicine, University of Copenhagen, Kobenhavn, Denmark
| | - Brian Daley
- The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Richard S Miller
- Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Herb A Phelan
- Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jason L Sperry
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
47
|
Reitz KM, Seymour CW, Neal MD. Pharmacologic Prehabilitation-What About "the Polypill"? JAMA Surg 2021; 155:1083. [PMID: 32805047 DOI: 10.1001/jamasurg.2020.3013] [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: 11/14/2022]
Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Clinical Research, Investigation and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania
| | - Christopher W Seymour
- Clinical Research, Investigation and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Clinical Research, Investigation and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
48
|
Reitz KM, Salem K, Mohapatra A, Liang NL, Avgerinos ED, Singh MJ, Hager E. Complete Venous Ulceration Healing after Perforator Ablation Does Not Depend on Treatment Modality. Ann Vasc Surg 2020; 70:109-115. [PMID: 32603845 DOI: 10.1016/j.avsg.2020.06.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/06/2020] [Accepted: 06/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Venous leg ulceration (VLU) represents the most advanced form of chronic venous insufficiency (CVI). Persistent VLU that fails to respond to noninvasive treatment requires a minimally invasive endovascular treatment, which may include chemical (ultrasound-guided foam sclerotherapy [UGFS]) and thermal ablation (endovenous laser therapy [EVLT] or radiofrequency ablation [RFA]) targeting incompetent veins. Current guidelines suggest ablation of incompetent perforating veins (IPVs) juxtaposed to active or healed VLU; however, the ideal treatment modality is unknown. We hypothesize that similar to incompetent superficial vein treatment options therapies, VLU healing will be equivalent across minimally invasive IPV treatment options. METHODS Using the Vascular Low Frequency Disease Consortium, adults with VLU across 11 medical centers were retrospectively reviewed (2013-2017). We included those who underwent IPV therapies. The primary outcome was complete ulcer healing over time compared with cumulative hazard curves, log-rank testing, and multivariable Cox proportional hazard regression. Secondary outcomes included number of subsequent procedures, which were compared using negative binomial regression. RESULTS Of the 832 adults with VLU, 158 (19%) were exclusively treated conservatively, and 232 (28%) underwent index treatment for IPV and constitute the full and final cohort. The mean age was 60 ± 14 years, 57% were men, and the mean ulcer area was 3.0 cm2 (interquartile range, 1-6 cm2). Ninety-one (39%) were treated with EVLT, 127 (55%) RFA, and 14 (6%) UGFS. Patients treated with RFA were older (RFA 62 ± 14 years; EVLT 59 ± 14 years; UGFS 52 ± 9 years; P = 0.01), more likely to be men (RFA 68%, n = 86; EVLT 41%, n = 37; UGFS 64%, n = 9; P < 0.001), with a higher frequency of anticoagulation (RFA 36%, n = 46; EVLT 18%, n = 16; UGFS 14%, n = 2; P = 0.005). VLU did not significantly differ in size between groups (RFA 6.2 ± 8; EVLT 4.2 ± 5.4; UGFS 6.1 ± 8; P < 0.001). There were no differences in 1-year ulcer healing rates between groups (P = 0.18). The number of subsequent procedures did not differ by treatment modality (P = 0.47). CONCLUSIONS This multi-institutional retrospective study does not demonstrate any association of IPV treatment modality with differing rates of VLU healing or number of subsequent procedures.
Collapse
Affiliation(s)
| | - Karim Salem
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Michael J Singh
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Eric Hager
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
49
|
Reitz KM, Marroquin OC, Zenati MS, Kennedy J, Korytkowski M, Tzeng E, Koscum S, Newhouse D, Garcia RM, Vates J, Billiar TR, Zuckerbraun BS, Simmons RL, Shapiro S, Seymour CW, Angus DC, Rosengart MR, Neal MD. Association Between Preoperative Metformin Exposure and Postoperative Outcomes in Adults With Type 2 Diabetes. JAMA Surg 2020; 155:e200416. [PMID: 32267474 DOI: 10.1001/jamasurg.2020.0416] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Adults with comorbidity have less physiological reserve and an increased rate of postoperative mortality and readmission after the stress of a major surgical intervention. Objective To assess postoperative mortality and readmission among individuals with diabetes with or without preoperative prescriptions for metformin. Design, Setting, and Participants This cohort study obtained data from the electronic health record of a multicenter, single health care system in Pennsylvania. Included were adults with diabetes who underwent a major operation with hospital admission from January 1, 2010, to January 1, 2016, at 15 community and academic hospitals within the system. Individuals without a clinical indication for metformin therapy were excluded. Follow-up continued until December 18, 2018. Exposures Preoperative metformin exposure was defined as 1 or more prescriptions for metformin in the 180 days before the surgical procedure. Main Outcomes and Measures All-cause postoperative mortality, hospital readmission within 90 days of discharge, and preoperative inflammation measured by the neutrophil to leukocyte ratio were compared between those with and without preoperative prescriptions for metformin. The corresponding absolute risk reduction (ARR) and adjusted hazard ratio (HR) with 95% CI were calculated in a propensity score-matched cohort. Results Among the 10 088 individuals with diabetes who underwent a major surgical intervention, 5962 (59%) had preoperative metformin prescriptions. A total of 5460 patients were propensity score-matched, among whom the mean (SD) age was 67.7 (12.2) years, and 2866 (53%) were women. In the propensity score-matched cohort, preoperative metformin prescriptions were associated with a reduced hazard for 90-day mortality (adjusted HR, 0.72 [95% CI, 0.55-0.95]; ARR, 1.28% [95% CI, 0.26-2.31]) and hazard of readmission, with mortality as a competing risk at both 30 days (ARR, 2.09% [95% CI, 0.35-3.82]; sub-HR, 0.84 [95% CI, 0.72-0.98]) and 90 days (ARR, 2.78% [95% CI, 0.62-4.95]; sub-HR, 0.86 [95% CI, 0.77-0.97]). Preoperative inflammation was reduced in those with metformin prescriptions compared with those without (mean neutrophil to leukocyte ratio, 4.5 [95% CI, 4.3-4.6] vs 5.0 [95% CI, 4.8-5.3]; P < .001). E-value analysis suggested robustness to unmeasured confounding. Conclusions and Relevance This study found an association between metformin prescriptions provided to individuals with type 2 diabetes before a major surgical procedure and reduced risk-adjusted mortality and readmission after the operation. This association warrants further investigation.
Collapse
Affiliation(s)
- Katherine M Reitz
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania
| | - Oscar C Marroquin
- Clinical Analytics, UPMC Health Services Division, Pittsburgh, Pennsylvania
| | - Mazen S Zenati
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Jason Kennedy
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Mary Korytkowski
- Department of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edith Tzeng
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Stephen Koscum
- Clinical Analytics, UPMC Health Services Division, Pittsburgh, Pennsylvania
| | - David Newhouse
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ricardo Martinez Garcia
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jennifer Vates
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Timothy R Billiar
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Brian S Zuckerbraun
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Richard L Simmons
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephen Shapiro
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christopher W Seymour
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Derek C Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew R Rosengart
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
50
|
Reitz KM, Hager E. Venous Leg Ulceration Healing Following Perforated Vein Ablation Is Not Dependent On the Type Of Minimally Invasive Therapy. Ann Vasc Surg 2020. [DOI: 10.1016/j.avsg.2020.01.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|