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Fisher AT, Mulaney-Topkar B, Sheehan BM, Garcia-Toca M, Sorial E, Sgroi MD. Association between heart failure and arteriovenous access patency in patients with end-stage renal disease on hemodialysis. J Vasc Surg 2024; 79:1187-1194. [PMID: 38157996 DOI: 10.1016/j.jvs.2023.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/17/2023] [Accepted: 12/19/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Heart disease and chronic kidney disease are often comorbid conditions owing to shared risk factors, including diabetes and hypertension. However, the effect of congestive heart failure (CHF) on arteriovenous fistula (AVF) and AV graft (AVG) patency rates is poorly understood. We hypothesize preexisting HF may diminish blood flow to the developing AVF and worsen patency. METHODS We conducted a single-institution retrospective review of 412 patients with end-stage renal disease who underwent hemodialysis access creation from 2015 to 2021. Patients were stratified based on presence of preexisting CHF, defined as clinical symptoms plus evidence of reduced left ventricular ejection fraction (EF) (<50%) or diastolic dysfunction on preoperative echocardiography. Baseline demographics, preoperative measures of cardiac function, and dialysis access-related surgical history were collected. Kaplan-Meier time-to-event analyses were performed for primary patency, primary-assisted patency, and secondary patency using standard definitions for patency from the literature. We assessed differences in patency for patients with CHF vs patients without CHF, patients with a reduced vs a normal EF, and AVG vs AVF in patients with CHF. RESULTS We included 204 patients (50%) with preexisting CHF with confirmatory echocardiography. Patients with CHF were more likely to be male and have comorbidities including, diabetes, chronic obstructive pulmonary disease, hypertension, and a history of cerebrovascular accident. The groups were not significantly different in terms of prior fistula history (P = .99), body mass index (P = .74), or type of hemodialysis access created (P = .54). There was no statistically significant difference in primary patency, primary-assisted patency, or secondary patency over time in the CHF vs non-CHF group (log-rank P > .05 for all three patency measures). When stratified by preoperative left ventricular EF, patients with an EF of <50% had lower primary (38% vs 51% at 1 year), primary-assisted (76% vs 82% at 1 year), and secondary patency (86% vs 93% at 1 year) rates than those with a normal EF. Difference reached significance for secondary patency only (log-rank P = .029). AVG patency was compared against AVF patency within the CHF subgroup, with significantly lower primary-assisted (39% vs 87% at 1 year) and secondary (62% vs 95%) patency rates for AVG (P < .0001 for both). CONCLUSIONS In this 7-year experience of hemodialysis access creation, reduced EF is associated with lower secondary patency. Preoperative CHF (including HF with reduced EF and HF with preserved EF together) is not associated with significant differences in overall hemodialysis access patency rates over time, but patients with CHF who receive AVG have markedly worse patency than those who receive AVF. For patients with end-stage renal disease and CHF, the risks and benefits must be carefully weighed, particularly for those with low EF or lack of a suitable vein for fistula creation.
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Affiliation(s)
- Andrea T Fisher
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA.
| | - Bianca Mulaney-Topkar
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA; Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Brian M Sheehan
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA; Division of Vascular Surgery, Intermountain Health, Salt Lake City, UT
| | - Manuel Garcia-Toca
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA; Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | - Ehab Sorial
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA; Vascular and Interventional Specialists of Orange County, Orange, CA
| | - Michael D Sgroi
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA
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Paisley MJ, Adkar S, Sheehan BM, Stern JR. Aortoiliac Occlusive Disease. Semin Vasc Surg 2022; 35:162-171. [DOI: 10.1053/j.semvascsurg.2022.04.005] [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: 03/17/2022] [Revised: 04/11/2022] [Accepted: 04/11/2022] [Indexed: 12/24/2022]
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Christian AB, Maithel S, Grigorian A, Kabutey NK, Dolich M, Kong A, Gambhir S, Sheehan BM, Nahmias J. Comparison of Nonoperative and Operative Management of Traumatic Penetrating Internal Jugular Vein Injury. Ann Vasc Surg 2020; 72:440-444. [PMID: 32949747 DOI: 10.1016/j.avsg.2020.08.149] [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: 04/17/2020] [Revised: 05/22/2020] [Accepted: 08/26/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Small case series have suggested that selective nonoperative management (NOM) of penetrating internal jugular vein (IJV) injuries is safe and feasible in select patients lacking "hard signs" mandating exploration. Therefore, we sought to compare NOM to operative management (OM) of penetrating IJV injury, hypothesizing that both strategies have similar patient outcomes and mortality when patients are appropriately selected. METHODS The Trauma Quality Improvement Program (2013-2016) was queried for patients with penetrating IJV injury with an abbreviated injury scale score of the neck ≥3. Demographics and patient outcomes were compared between patients undergoing NOM and patients undergoing OM, followed by a multivariable logistic regression model to analyze the risk of mortality. RESULTS A penetrating IJV injury was identified in 188 (0.01%) patients meeting inclusion criteria, and OM was performed in 124 (66.0%) patients, whereas 64 (34.0%) patients underwent NOM. Although the OM group had a higher rate of pneumothorax (8.9% vs. 0.0%, P = 0.01), there was no difference in any other concomitant injuries or demographic data (all P > 0.05). The OM group had a higher rate of ventilator days (3 vs. 2 days, P = 0.01) but no other significant differences in morbidity or mortality (P > 0.05). After controlling for covariates, OM was associated with similar risk of mortality compared with NOM of patients with penetrating IJV injury (odds ratio 1.05, confidence interval 0.23-4.83, P = 0.95). CONCLUSIONS The NOM of penetrating IJV injuries is associated with similar risk of morbidity and mortality compared with OM, suggesting that NOM may be used in appropriately selected patients. Future research is needed to determine the ideal patients suited for NOM and to identify risk factors and outcomes associated with failure of NOM.
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Affiliation(s)
- Ashton B Christian
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Shelley Maithel
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Areg Grigorian
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Nii-Kabu Kabutey
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Matthew Dolich
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Allen Kong
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Sahil Gambhir
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Brian M Sheehan
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Jeffry Nahmias
- Department of General Surgery, University of California, Irvine Medical Center, Orange, CA.
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Gambhir S, Grigorian A, Swentek L, Maithel S, Sheehan BM, Daly S, Lekawa M, Nahmias J. Esophageal Trauma: Analysis of Incidence, Morbidity, and Mortality. Am Surg 2020. [DOI: 10.1177/000313481908501012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Traumatic esophageal injury is a highly lethal but rare injury with minimal data in the trauma population. We sought to provide a descriptive analysis of esophageal trauma (ET) to identify the incidence, associated injuries, interventions, and outcomes. We hypothesized that blunt trauma is associated with higher risk of death than penetrating trauma. The Trauma Quality Improvement Program (2010–2016) was queried for patients with ET. Patients with blunt and penetrating trauma were compared using chi-square and Mann-Whitney U tests. A multivariable logistic regression model was used to determine risk of mortality. Of 1,403,466 adult patients, 651 (<0.01%) presented with ET. The most common associated thoracic injuries were rib fractures (38.7%) and pneumothorax (26.7%). More patients with a penetrating mechanism underwent open repair of the esophagus than those with blunt mechanism (46.2% vs 11.7%, P < 0.001). After controlling for covariates, there was no difference in risk of mortality between blunt and penetrating trauma ( P = 0.65). The mortality rate for patients with esophageal injury surviving greater than 24 hours was 7.5 per cent. In this large national database analysis, ET was rare and most commonly associated with rib fractures and pneumothorax. Contrary to our hypothesis, the risk of mortality was equivalent between blunt and penetrating ET.
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Affiliation(s)
- Sahil Gambhir
- Department of Surgery, University of California Irvine Medical Center, Orange, California
| | - Areg Grigorian
- Department of Surgery, University of California Irvine Medical Center, Orange, California
| | - Lourdes Swentek
- Department of Surgery, University of California Irvine Medical Center, Orange, California
| | - Shelley Maithel
- Department of Surgery, University of California Irvine Medical Center, Orange, California
| | - Brian M. Sheehan
- Department of Surgery, University of California Irvine Medical Center, Orange, California
| | - Shaun Daly
- Department of Surgery, University of California Irvine Medical Center, Orange, California
| | - Michael Lekawa
- Department of Surgery, University of California Irvine Medical Center, Orange, California
| | - Jeffry Nahmias
- Department of Surgery, University of California Irvine Medical Center, Orange, California
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Maithel S, Fujitani RM, Grigorian A, Kabutey NK, Gambhir S, Sheehan BM, Nahmias J. Outcomes and Predictors of Popliteal Artery Injury in Pediatric Trauma. Ann Vasc Surg 2020; 66:242-249. [PMID: 31978483 DOI: 10.1016/j.avsg.2020.01.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 12/26/2019] [Accepted: 01/12/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Popliteal artery injury (PAI) is a rare occurrence in pediatric patients with significant consequences. Delays in diagnosis lead to severe complications such as lifelong disability and limb loss. We sought to identify outcomes and clinical predictors of PAI in the pediatric trauma population. METHODS The Pediatric Trauma Quality Improvement Program (2014-2016) was queried for patients ≤17 years old with PAI. Patient demographics and outcomes were characterized. A comparison of patients sustaining blunt versus penetrating PAI was performed. A multivariable logistic regression analysis was used to identify predictors of PAI. RESULTS From 119,132 patients, 58 (<0.1%) sustained a PAI with 74.1% from blunt trauma. Most of the patients were male (75.9%) with a median age of 15 and median Injury Severity Score of 9. A majority of the patients were treated with open repair (62.1%) in comparison to endovascular repair (10.3%) and nonoperative management (36.2%). The rates of open and endovascular repair and nonoperative management were similar between blunt and penetrating PAI patients (P = not significant). Concomitant injuries included popliteal vein injury (PVI) (12.1%), posterior tibial nerve injury (3.4%), peroneal nerve injury (3.4%), and closed fracture/dislocation of the femur (22.4%), patella (25.9%), and tibia/fibula (29.3%). Overall complications included compartment syndrome (8.6%), below-knee amputation (6.9%), and above-knee amputation (3.4%). The overall mortality was 3.4%. Patients with PAI secondary to penetrating trauma had a higher rate of concomitant PVI (26.7% vs. 7%, P = 0.04) and posterior tibial nerve injury (13.3% vs. 0%, P = 0.02) but a lower rate of closed fracture/dislocation of the patella (0% vs. 34.9%, P = 0.008) and tibia/fibula (0% vs. 39.5%, P = 0.004) compared to patients with PAI from blunt trauma. Predictors for PAI included PVI (odds ratio [OR] 296.57, confidence interval [CI] = 59.21-1,485.47, P < 0.001), closed patella fracture/dislocation (OR 50.0, CI = 24.22-103.23, P < 0.001), open femur fracture/dislocation (OR 9.05, CI = 3.56-22.99, P < 0.001), closed tibia/fibula fracture/dislocation (OR 7.44, CI = 3.81-14.55, P < 0.001), and open tibia/fibula fracture/dislocation (OR 4.57, CI = 1.80-11.59, P < 0.001). PVI had the highest association with PAI in penetrating trauma (OR 84.62, CI = 13.22-541.70, P < 0.001) while closed patella fracture/dislocation had the highest association in blunt trauma (OR 52.01, CI = 24.50-110.31, P < 0.001). CONCLUSIONS A higher index of suspicion should be present for PAI in pediatric trauma patients presenting with a closed patella fracture/dislocation after blunt trauma. PVI is most strongly associated with PAI in penetrating trauma. Prompt recognition of PAI is crucial as there is a greater than 10% amputation rate in the pediatric population.
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Affiliation(s)
- Shelley Maithel
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA.
| | - Roy M Fujitani
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Areg Grigorian
- Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Nii-Kabu Kabutey
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Sahil Gambhir
- Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Brian M Sheehan
- Department of Vascular and Endovascular Surgery, University of California, Irvine Medical Center, Orange, CA
| | - Jeffry Nahmias
- Department of Trauma Surgery, University of California, Irvine Medical Center, Orange, CA
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Maithel S, Grigorian A, Fujitani RM, Kabutey NK, Sheehan BM, Gambhir S, Chen SL, Nahmias J. Incidence, morbidity, and mortality of traumatic superior mesenteric artery injuries compared to other visceral arteries. Vascular 2019; 28:142-151. [DOI: 10.1177/1708538119893827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
ObjectivesCeliac artery, superior mesenteric artery, and inferior mesenteric artery injuries are often grouped together as major visceral artery injuries with an incidence of <1%. The mortality rates range from 38–75% for celiac artery injuries and 25–68% for superior mesenteric artery injuries. No large series have investigated the mortality rate of inferior mesenteric artery injuries. We hypothesize that from all the major visceral artery injuries, superior mesenteric artery injury leads to the highest risk of mortality in adult trauma patients.MethodsThe Trauma Quality Improvement Program (2010–2016) was queried for patients with injury to the celiac artery, superior mesenteric artery, or inferior mesenteric artery. A multivariable logistic regression model was used for analysis. Separate subset analyses using blunt trauma patients and penetrating trauma patients were performed.ResultsFrom 1,403,466 patients, 1730 had single visceral artery injuries with 699 (40.4%) involving the celiac artery, 889 (51.4%) involving the superior mesenteric artery, and 142 (8.2%) involving the inferior mesenteric artery. The majority of patients were male (79.2%) with a median age of 39 years old, and median injury severity score of 22. Compared to celiac artery and inferior mesenteric artery injuries, superior mesenteric artery injuries had a higher rate of severe (grade >3) abbreviated injury scale for the abdomen (57.5% vs. 42.5%, p < 0.001). The overall mortality for patients with a single visceral artery injury was 20%. Patients with superior mesenteric artery injury had higher mortality compared to those with celiac artery and inferior mesenteric artery injuries (23.7% vs. 16.3%, p < 0.001). After controlling for covariates, traumatic superior mesenteric artery injury increased risk of mortality (OR = 1.72, CI = 1.24–2.37, p < 0.01) in adult trauma patients, while celiac artery ( p = 0.59) and inferior mesenteric artery ( p = 0.31) injury did not. After stratifying by mechanism, superior mesenteric artery injury increased risk of mortality (OR = 3.65, CI = 2.01–6.45, p < 0.001) in adult trauma patients with penetrating mechanism of injury but not in those with blunt force mechanism (OR = 1.22, CI = 0.81–1.85, p = 0.34).ConclusionsCompared to injuries of the celiac artery and inferior mesenteric artery, traumatic superior mesenteric artery injury is associated with a higher mortality. Moreover, while superior mesenteric artery injury does not act as an independent risk factor for mortality in adult patients with blunt force trauma, it nearly quadruples the risk of mortality in adult trauma patients with penetrating mechanism of injury. Future prospective research is needed to confirm these findings and evaluate factors to improve survival following major visceral artery injury.
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Affiliation(s)
- Shelley Maithel
- Irvine Department of General Surgery, University of California, Orange, CA, USA
| | - Areg Grigorian
- Irvine Department of General Surgery, University of California, Orange, CA, USA
| | - Roy M Fujitani
- Irvine Department of General Surgery, University of California, Orange, CA, USA
| | - Nii-Kabu Kabutey
- Irvine Department of General Surgery, University of California, Orange, CA, USA
| | - Brian M Sheehan
- Irvine Department of General Surgery, University of California, Orange, CA, USA
| | - Sahil Gambhir
- Irvine Department of General Surgery, University of California, Orange, CA, USA
| | - Samuel L Chen
- Irvine Department of General Surgery, University of California, Orange, CA, USA
| | - Jeffry Nahmias
- Irvine Department of General Surgery, University of California, Orange, CA, USA
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Gambhir S, Grigorian A, Swentek L, Maithel S, Sheehan BM, Daly S, Lekawa M, Nahmias J. Esophageal Trauma: Analysis of Incidence, Morbidity, and Mortality. Am Surg 2019; 85:1134-1138. [PMID: 31657309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Traumatic esophageal injury is a highly lethal but rare injury with minimal data in the trauma population. We sought to provide a descriptive analysis of esophageal trauma (ET) to identify the incidence, associated injuries, interventions, and outcomes. We hypothesized that blunt trauma is associated with higher risk of death than penetrating trauma. The Trauma Quality Improvement Program (2010-2016) was queried for patients with ET. Patients with blunt and penetrating trauma were compared using chi-square and Mann-Whitney U tests. A multivariable logistic regression model was used to determine risk of mortality. Of 1,403,466 adult patients, 651 (<0.01%) presented with ET. The most common associated thoracic injuries were rib fractures (38.7%) and pneumothorax (26.7%). More patients with a penetrating mechanism underwent open repair of the esophagus than those with blunt mechanism (46.2% vs 11.7%, P < 0.001). After controlling for covariates, there was no difference in risk of mortality between blunt and penetrating trauma (P = 0.65). The mortality rate for patients with esophageal injury surviving greater than 24 hours was 7.5 per cent. In this large national database analysis, ET was rare and most commonly associated with rib fractures and pneumothorax. Contrary to our hypothesis, the risk of mortality was equivalent between blunt and penetrating ET.
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Maithel S, Grigorian A, Kabutey NK, Sheehan BM, Gambhir S, Wolf RF, Jutric Z, Nahmias J. Hepatoportal Venous Trauma: Analysis of Incidence, Morbidity, and Mortality. Vasc Endovascular Surg 2019; 54:36-41. [DOI: 10.1177/1538574419878577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: Although traumatic injuries to the superior mesenteric vein (SMV), portal vein (PV), and hepatic vein (HV) are rare, their impact is significant. Small single center reports estimate mortality rates ranging from 29% to 100%. Our aim is to elucidate the incidence and outcomes associated with each injury due to unique anatomic positioning and varied tolerance of ligation. We hypothesize that SMV injury is associated with a lower risk of mortality compared to HV and PV injury in adult trauma patients. Methods: The Trauma Quality Improvement Program database (2010-2016) was queried for patients with injury to either the SMV, PV, or HV. A multivariable logistic regression model was used for analysis. Results: From 1,403,466 patients, 966 (0.07%) had a single major hepatoportal venous injury with 460 (47.6%) involving the SMV, 281 (29.1%) involving the PV, and 225 (23.3%) involving the HV. There was no difference in the percentage of patients undergoing repair or ligation between SMV, PV, and HV injuries ( P > .05). Compared to those with PV and HV injuries, patients with SMV injury had a higher rate of concurrent bowel resection (38.5% vs 12.1% vs 7.6%, P < .001) and lower mortality (33.3% vs 45.9% vs 49.3%, P < .01). After controlling for covariates, traumatic SMV injury increased the risk of mortality (odds ratio [OR] 1.59, confidence interval [CI] = 1.00-2.54, P = .05) in adult trauma patients; however, this was less than PV injury (OR = 2.77, CI = 1.56-4.93, P = .001) and HV injury (OR = 2.70, CI = 1.46-4.99, P = .002). Conclusion: Traumatic SMV injury had a lower rate of mortality compared to injuries of the HV and PV. SMV injury increased the risk of mortality by 60% in adult trauma patients, whereas PV and HV injuries nearly tripled the risk of mortality.
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Affiliation(s)
- Shelley Maithel
- University of California, Irvine Medical Center, Orange, CA, USA
| | - Areg Grigorian
- University of California, Irvine Medical Center, Orange, CA, USA
| | - Nii-Kabu Kabutey
- University of California, Irvine Medical Center, Orange, CA, USA
| | - Brian M. Sheehan
- University of California, Irvine Medical Center, Orange, CA, USA
| | - Sahil Gambhir
- University of California, Irvine Medical Center, Orange, CA, USA
| | - Ronald F. Wolf
- University of California, Irvine Medical Center, Orange, CA, USA
| | - Zeljka Jutric
- University of California, Irvine Medical Center, Orange, CA, USA
| | - Jeffry Nahmias
- University of California, Irvine Medical Center, Orange, CA, USA
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Delaplain PT, Phillips JL, Lundeberg M, Nahmias J, Kuza CM, Sheehan BM, Murphy LS, Pejcinovska M, Grigorian A, Gabriel V, Barie PS, Schubl SD. No Reduction in Surgical Site Infection Obtained with Post-Operative Antibiotics in Facial Fractures, Regardless of Duration or Anatomic Location: A Systematic Review and Meta-Analysis. Surg Infect (Larchmt) 2019; 21:112-121. [PMID: 31526317 DOI: 10.1089/sur.2019.149] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: We performed a systematic review of the literature on antibiotic prophylaxis practices in open reduction, and internal fixation of, facial fracture(s) (ORIFfx). We hypothesized that prolonged antibiotic prophylaxis (PAP) would not decrease the rate of surgical site infections (SSIs). Methods: We performed a systematic review of four databases: PubMed, CENTRAL, EMBase, and Web of Science, from inception through January 15, 2017. Three independent reviewers extracted fracture location (orbital, mid-face, mandible), antibiotic use, SSI incidence, and time from injury to surgery. Mantel-Haenszel and generalized estimating equations were carried out independently for each fracture zone. Results: Of the 587 articles identified, 54 underwent full-text review, yielding 27 studies that met our inclusion criteria. Of these, 16 studies (n = 2,316 patients) provided data for mandible fractures, four studies (n = 439) for mid-face fractures, and six studies (n = 377) for orbital fractures. Pooled analysis of each fracture type's SSI rate showed no statistically significant association with the odds ratio (OR) of developing an SSI. For mandible fractures treated with ORIFfx, the OR for an SSI after 24-72 hours of prophylaxis relative to <24 hours was 0.85 (95% confidence interval [CI] 0.62-1.17), whereas for >72 hours compared with <24 hours, the OR was 1.42 (95% CI) 0.96-2.11). For mid-face fractures, there was no improvement in SSI rate from PAP (OR 1.05; 95% CI 0.20-5.63). Conclusions: We did not demonstrate a lower rate of SSI associated with PAP for any ORIFfx repair. Post-operative antibiotics for >72 hours paradoxically may increase the SSI risk after mandible fracture repairs.
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Affiliation(s)
- Patrick T Delaplain
- Department of Surgery, University of California, Irvine Medical Center, Orange, California
| | - Jacquelyn L Phillips
- Department of Surgery, University of California, San Francisco East Bay, San Francisco, California
| | | | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine Medical Center, Orange, California
| | - Catherine M Kuza
- Department of Anesthesiology, University of Southern California, Los Angeles, California
| | - Brian M Sheehan
- Department of Surgery, University of California, Irvine Medical Center, Orange, California
| | - Linda S Murphy
- Reference Department, University of California-Irvine Libraries, NS, University of California, Irvine, Irvine, California
| | - Marija Pejcinovska
- Center for Statistical Consulting, University of California, Irvine, Irvine, California
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine Medical Center, Orange, California
| | - Viktor Gabriel
- Department of Surgery, University of California, Irvine Medical Center, Orange, California
| | - Philip S Barie
- Department of Surgery, Weill Cornell Medical College at New York/Presbyterian Hospital, New York, New York
| | - Sebastian D Schubl
- Department of Surgery, University of California, Irvine Medical Center, Orange, California
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Sheehan BM, Grigorian A, Gambhir S, Maithel S, Kuza CM, Dolich MO, Lekawa ME, Nahmias J. Early Tracheostomy for Severe Pediatric Traumatic Brain Injury is Associated with Reduced Intensive Care Unit Length of Stay and Total Ventilator Days. J Intensive Care Med 2019; 35:1346-1351. [PMID: 31455142 DOI: 10.1177/0885066619870153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To determine whether, similar to adults, early tracheostomy in pediatric patients with severe traumatic brain injury (TBI) improves inhospital outcomes including ventilator days, intensive care unit (ICU) length of stay (LOS), and total hospital LOS when compared to late tracheostomy. DESIGN Retrospective cohort analysis. SETTING The Pediatric Trauma Quality Improvement Program (TQIP) database. PATIENTS One hundred twenty-seven pediatric patients <16 years old with severe (>3) abbreviated injury scale TBI who underwent early (days 1-6) or late (day ≥7) tracheostomy between 2014 and 2016. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS The Pediatric TQIP database was queried for patients <16 years old with severe TBI, who underwent tracheostomy. Patient demographics and outcomes of early versus late tracheostomy were compared using Student t test, Mann-Whitney U test, and χ2 analysis. Sixteen patients underwent early tracheostomy while 111 underwent late tracheostomy. The groups had similar distributions of age, gender, mechanism of injury, and mean injury severity scores (P > .05). Early tracheostomy was associated with decreased ICU LOS (early: 17 vs late: 32 days, P < .05) and ventilator days (early: 9.7 vs late: 27.1 days, P < .05). There was no difference in total LOS (early: 26.7 vs late: 41.3 days, P = .06), the incidence of acute respiratory distress syndrome (early: 6.3% vs late: 2.7%, P = .45), pneumonia (early: 12.5% vs late: 29.7%, P = .15), or mortality (early: 0% vs late: 2%, P = .588) between the 2 groups. CONCLUSION Similar to adults, early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days. Future prospective trials are needed to confirm these findings. ARTICLE TWEET Early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days.
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Affiliation(s)
- Brian M Sheehan
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 8788University of California, Irvine, Orange, CA, USA
| | - Areg Grigorian
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 8788University of California, Irvine, Orange, CA, USA
| | - Sahil Gambhir
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 8788University of California, Irvine, Orange, CA, USA
| | - Shelley Maithel
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 8788University of California, Irvine, Orange, CA, USA
| | - Catherine M Kuza
- Department of Anesthesia, 5116University of Southern California, Los Angeles, CA, USA
| | - Matthew O Dolich
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 8788University of California, Irvine, Orange, CA, USA
| | - Michael E Lekawa
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 8788University of California, Irvine, Orange, CA, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 8788University of California, Irvine, Orange, CA, USA
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Sheehan BM, Kabutey NK, Chen SL, Maithel S, Gambhir S, Kuo IJ, Donayre CE, Fujitani RM. IP105. Shunting in Patients With Contralateral Carotid Artery Occlusion During Carotid Endarterectomy Does Not Improve Perioperative Risk of Stroke or Death. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.04.176] [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]
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Maithel S, Fujitani RM, Schnure A, Sheehan BM, Gambhir S, Kabutey NK, Yuki I, Suzuki S. IP109. An Analysis of Unusual Causes of Extracranial Cerebrovascular Artery Dissection. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.04.178] [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: 10/26/2022]
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Sheehan BM, Grigorian A, Maithel S, Borazjani B, Kabutey NK, Fujitani R, Lekawa M, Nahmias J. Penetrating Abdominal Aortic Injury: Comparison of Level I and II Trauma Centers. Ann Vasc Surg 2019. [DOI: 10.1016/j.avsg.2018.12.018] [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: 11/15/2022]
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Merrill JA, Sheehan BM, Carley KM, Stetson PD. Transition Networks in a Cohort of Patients with Congestive Heart Failure: A Novel Application of Informatics Methods to Inform Care Coordination. Appl Clin Inform 2015; 6:548-64. [PMID: 26504499 DOI: 10.4338/aci-2015-02-ra-0021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [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: 02/27/2015] [Accepted: 07/10/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Unnecessary hospital readmissions are one source of escalating costs that may be reduced through improved care coordination, but how best to design and evaluate coordination programs is poorly understood. Measuring patient flow between service visits could support decisions for coordinating care, particularly for conditions such as congestive heart failure (CHF) which have high morbidity, costs, and hospital readmission rates. OBJECTIVES To determine the feasibility of using network analysis to explore patterns of service delivery for patients with CHF in the context of readmissions. METHODS A retrospective cohort study used de-identified records for patients ≥18 years with an ICD-9 diagnosis code 428.0-428.9, and service visits between July 2011 and June 2012. Patients were stratified by admission outcome. Traditional and novel network analysis techniques were applied to characterize care patterns. RESULTS Patients transitioned between services in different order and frequency depending on admission status. Patient-to-service CoUsage networks were diffuse suggesting unstructured flow of patients with no obvious coordination hubs. In service-to-service Transition networks a specialty heart failure service was on the care path to the most other services for never admitted patients, evidence of how specialist care may prevent hospital admissions for some patients. For patients admitted once, transitions expanded for a clinic-based internal medicine service which clinical experts identified as a Patient Centered Medical Home implemented in the first month for which we obtained data. CONCLUSIONS We detected valid patterns consistent with a targeted care initiative, which experts could understand and explain, suggesting the method has utility for understanding coordination. The analysis revealed strong but complex patterns that could not be demonstrated using traditional linear methods alone. Network analysis supports measurement of real world health care service delivery, shows how transitions vary between services based on outcome, and with further development has potential to inform coordination strategies.
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Affiliation(s)
- J A Merrill
- Columbia University Medical Center , New York, NY, United States
| | - B M Sheehan
- Division of Health and Life Sciences, Intel Corporation, Santa Clara , CA, United States
| | - K M Carley
- Institute of Software Research, Carnegie Mellon University , Pittsburgh, PN, United States
| | - P D Stetson
- Memorial Sloan Kettering Cancer Center , New York, NY, United States
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