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Salafian K, Mazimba C, Volodin L, Varadarajan I, Pilehvari A, You W, Knio ZO, Ballen K. The impact of social vulnerability index on survival following autologous stem cell transplant for multiple myeloma. Bone Marrow Transplant 2024; 59:459-465. [PMID: 38238453 PMCID: PMC10994832 DOI: 10.1038/s41409-024-02200-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 10/09/2023] [Revised: 12/29/2023] [Accepted: 01/05/2024] [Indexed: 04/06/2024]
Abstract
Autologous hematopoietic stem cell transplantation (ASCT) is the standard of care for eligible patients with multiple myeloma (MM) to prolong progression-free survival (PFS). While several factors affect survival following ASCT, the impact of social determinants of health such as the CDC Social Vulnerability Index (SVI) is not well documented. This single-center retrospective analysis evaluated the impact of SVI on PFS following ASCT in MM patients. 225 patients with MM who underwent ASCT participated, with 51% transplanted in the last 5 years. At 5 years post-transplant, 55 (50%) achieved PFS and 66 (60%) remained alive. Higher SVI values were significantly associated with lower odds of PFS (OR = 0.521, p < 0.01, 95% CI [0.41, 0.66]) and OS (OR = 0.592, p < 0.01, 95% CI [0.46, 0.76]) post-transplant. Greater vulnerability scores in the socioeconomic status (OR = 0.890; 95% CI: [0.82, 0.96]), household characteristics (OR = 0.912; 95% CI: [0.87, 0.95]), and racial and ethnic minority status (OR = 0.854; 95% CI: [0.81, 0.90]) themes significantly worsened the odds of PFS. These results suggest high SVI areas may need more resources to achieve optimal PFS and OS. Future studies will focus on addressing factors within the socioeconomic status, household characteristics, and racial and ethnic minority subthemes, as these have a more pronounced effect on PFS.
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Affiliation(s)
- Kiarash Salafian
- Department of Medicine, University of Virginia Health, Charlottesville, VA, USA
| | - Christine Mazimba
- Division of Hematology/Oncology, University of Virginia Health, Charlottesville, VA, USA
| | - Leonid Volodin
- Division of Hematology/Oncology, University of Virginia Health, Charlottesville, VA, USA
| | - Indumathy Varadarajan
- Division of Hematology/Oncology, University of Virginia Health, Charlottesville, VA, USA
| | - Asal Pilehvari
- Department of Public Health Sciences, University of Virginia, and University of Virginia Comprehensive Cancer Center, Charlottesville, VA, USA
| | - Wen You
- Department of Public Health Sciences, University of Virginia, and University of Virginia Comprehensive Cancer Center, Charlottesville, VA, USA
| | - Ziyad O Knio
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, USA
| | - Karen Ballen
- Division of Hematology/Oncology, University of Virginia Health, Charlottesville, VA, USA.
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Holley ZL, Knio ZO, Pham LQ, Shakoor U, Zuo Z. Impact of functional status on 30-day resource utilization and organ system complications following index bariatric surgery: a cohort study. Int J Surg 2024; 110:253-260. [PMID: 37755382 PMCID: PMC10793737 DOI: 10.1097/js9.0000000000000785] [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: 06/28/2023] [Accepted: 09/10/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Bariatric surgical procedures carry an appreciable risk profile despite their elective nature. Identified risk factors for procedural complications are often limited to medical comorbidities. This study assesses the impact of functional status on resource utilization and organ system complications following bariatric surgery. MATERIALS AND METHODS This retrospective cohort study analyzed patients undergoing elective, index bariatric surgery from American College of Surgeons National Surgical Quality Improvement Program participating hospitals from 2015 to 2019 ( n =65 627). The primary independent variable was functional status. The primary outcome was unplanned resource utilization. Secondary outcomes included composite organ system complications and mortality. The impact of functional status was first investigated with univariate analyses. Survival and multivariate analyses were then performed on select complications with clinically and statistically significant incidence in the dependent cohort. RESULTS On univariate analysis, dependent functional status was associated with unplanned resource utilization [12.1% (27/223) vs. 4.1% (2661/65 404)]; relative risk, 2.98 (95% CI, 2.09-4.25); P < 0.001] and haematologic/infectious complications [6.7% (15/223) vs. 2.4% (1540/65 404); relative risk, 2.86 (95% CI, 1.75-4.67); P < 0.001]. Survival analysis demonstrated a significantly shorter time to both events in patients with dependent functional status ( P < 0.001). On multivariate analysis, dependent functional status was an independent predictor of unplanned resource utilization[adjusted odds ratio 2.17 (95% CI, 1.27-3.50); P = 0.003; model c-statistic, 0.572]) and haematologic/infectious complications [adjusted odds ratio, 2.20 ([95% CI, 1.14-3.86); P = 0.011; model c-statistic, 0.579]. CONCLUSION Patients with dependent functional status are at an elevated risk of unplanned resource utilization and haematologic/infectious complications following index bariatric surgery. The increased risk cannot be explained by medical comorbidities alone.
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Affiliation(s)
| | - Ziyad O. Knio
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, USA
| | | | | | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, USA
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3
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Knio ZO, Ising MS, Yount KW, Tanaka K, McNeil JS. Undiagnosed Factor VII Deficiency in Cardiac Surgery Complicated by Bleeding: A Case Report. A A Pract 2023; 17:e01713. [PMID: 37681735 DOI: 10.1213/xaa.0000000000001713] [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] [Indexed: 09/09/2023]
Abstract
Rare bleeding disorders in the perioperative period call for targeted resuscitation strategies. Factor VII deficiency, for instance, is often corrected with exogenous administration of recombinant factor VIIa. This activated clotting factor, initially designed for patients with hemophilia A or B with factor inhibitors, is gaining popularity as a salvage therapy for severe and persistent traumatic and surgical bleeding. This article describes the management of a cardiothoracic surgical patient with undiagnosed isolated factor VII deficiency who experienced significant postoperative bleeding which subsided after the administration of recombinant factor VIIa. In this case, EXTEM failed to detect a clotting factor deficiency.
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Affiliation(s)
| | - Mickey S Ising
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Kenan W Yount
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma, Oklahoma City, Oklahoma
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Kline LA, Kothandaraman V, Knio ZO, Zuo Z. Effect of regional versus general anesthesia on thirty-day outcomes following carotid endarterectomy: a cohort study. Int J Surg 2023; 109:1291-1298. [PMID: 37057905 PMCID: PMC10389611 DOI: 10.1097/js9.0000000000000356] [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: 01/31/2023] [Accepted: 03/13/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND The effect of regional versus general anesthesia on carotid endarterectomy outcomes is debated. This study assesses the effect of anesthetic technique on major morbidity and mortality and additional secondary endpoints following carotid endarterectomy. MATERIALS AND METHODS This was a retrospective propensity-matched-cohort analysis investigating elective carotid endarterectomy patients in the 2015-2019 American College of Surgeons National Surgical Quality Improvement Program ( n =37 204). The primary endpoint was 30-day mortality and major morbidity, defined as stroke, myocardial infarction, or death. Secondary endpoints included minor morbidity, bleeding events, healthcare resource utilization, and length of hospital stay. Univariate, multivariable, and survival analyses were applied. RESULTS The 1 : 1 propensity-matched-cohort included 8304 patients (4152 in each group). Regional anesthesia was associated with similar incidences of major morbidity and mortality [odds ratio (OR), 0.81 (95% CI, 0.61-1.09); P = 0.162] and unplanned resource utilization [OR, 0.93 (95% CI, 0.78-1.11); P = 0.443], but lower incidences of minor morbidity [OR, 0.60 (95% CI, 0.44-0.81); P < 0.001] and bleeding events [OR, 0.49 (95% CI, 0.30-0.78); P = 0.002], and a shorter length of hospital stay [1.4 vs. 1.6 days; mean difference, -0.16 days (95% CI, -0.25 to -0.07); P < 0.001]. On multivariable analysis, regional anesthesia remained independently predictive of minor morbidity [adjusted odds ratio (AOR), 0.58 (95% CI, 0.42-0.79); P = 0.001] and bleeding events [AOR, 0.49 (95% CI, 0.30-0.77); P = 0.003]. Significance was maintained on survival analysis for these two endpoints. A mortality benefit was observed on univariate [OR, 0.50 (95% CI, 0.25-1.00); P = 0.045], multivariable [AOR, 0.49 (95% CI, 0.24-0.96); P = 0.043], and survival analysis ( P = 0.045). CONCLUSIONS Carotid endarterectomy patients receiving regional anesthesia experience favorable outcomes compared to propensity-matched general anesthesia controls.
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Affiliation(s)
- Leigh A. Kline
- Department of Anesthesiology, University of Virginia Health
| | | | - Ziyad O. Knio
- Department of Anesthesiology, University of Virginia Health
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia Health
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Knio ZO, Clancy PW, Zuo Z. Effect of spinal versus general anesthesia on thirty-day outcomes following total hip arthroplasty: A matched-pair cohort analysis. J Clin Anesth 2023; 87:111083. [PMID: 36848778 DOI: 10.1016/j.jclinane.2023.111083] [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: 01/30/2023] [Accepted: 02/17/2023] [Indexed: 02/27/2023]
Abstract
STUDY OBJECTIVE It has not yet been established whether total hip arthroplasty complications are associated with anesthetic technique (spinal versus general). This study assessed the effect of spinal versus general anesthesia on health care resource utilization and secondary endpoints following total hip arthroplasty. DESIGN Propensity-matched cohort analysis. SETTING American College of Surgeons National Surgical Quality Improvement Program participating hospitals from 2015 to 2021. PATIENTS Patients undergoing elective total hip arthroplasty (n = 223,060). INTERVENTIONS None. MEASUREMENTS The a priori study duration was 2015 to 2018 (n = 109,830). The primary endpoint was 30-day unplanned resource utilization, namely readmission and reoperation. Secondary endpoints included 30-day wound complications, systemic complications, bleeding events, and mortality. The impact of anesthetic technique was investigated with univariate analyses, multivariable analyses, and survival analyses. MAIN RESULTS The 1:1 propensity-matched cohort included 96,880 total patients (48,440 in each anesthesia group) from 2015 to 2018. On univariate analysis, spinal anesthesia was associated with a lower incidence of unplanned resource utilization (3.1% [1486/48440] vs 3.7% [1770/48440]; odds ratio [OR], 0.83 [95% CI, 0.78 to 0.90]; P < .001), systemic complications (1.1% [520/48440] vs 1.5% [723/48440]; OR, 0.72 [95% CI, 0.64 to 0.80]; P < .001), and bleeding events requiring transfusion (2.3% [1120/48440] vs 4.9% [2390/48440]; OR, 0.46 [95% CI, 0.42 to 0.49]; P < .001). On multivariable analysis, spinal anesthesia remained an independent predictor of unplanned resource utilization (adjusted odds ratio [AOR], 0.84 [95% CI, 0.78 to 0.90]; c = 0.646), systemic complications (AOR, 0.72 [95% CI, 0.64 to 0.81]; c = 0.676), and bleeding events (AOR, 0.46 [95% CI, 0.42 to 0.49]; c = 0.686). Hospital length of stay was also shorter in the spinal anesthesia cohort (2.15 vs 2.24 days; mean difference, -0.09 [95% CI, -0.12 to -0.07]; P < .001). Similar findings were observed in the cohort from 2019 to 2021. CONCLUSIONS Total hip arthroplasty patients receiving spinal anesthesia experience favorable outcomes compared to propensity-matched general anesthesia patients.
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Affiliation(s)
- Ziyad O Knio
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, United States of America
| | - Paul W Clancy
- School of Medicine, University of Virginia, Charlottesville, VA, United States of America
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, United States of America.
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Knio ZO, Zhang L, Watts DA, Zuo Z. Late surgical start time is associated with increased blood transfusion following gastric bypass surgery. PLoS One 2023; 18:e0282139. [PMID: 36827326 PMCID: PMC9956042 DOI: 10.1371/journal.pone.0282139] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 02/08/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Surgical start time (SST) has demonstrated conflicting effects on perioperative outcomes due to confounding factors, such as increased acuity in later SST cases. This study investigated the effect of SST on blood transfusion after gastric bypass surgery, a complication-prone elective surgical procedure. METHODS This retrospective cohort study included all patients undergoing gastric bypass surgery at a single academic medical center from 2016 through 2021 (n = 299). The primary independent variable was SST (before vs. after 15:00). The primary outcome was blood transfusion. Secondary outcomes included postoperative respiratory failure, length of stay, acute kidney injury, and mortality. The associations between SST and outcomes were investigated with univariate analyses. Multivariate and receiver operating characteristic (ROC) analyses were applied to the primary outcome, adjusting for demographic and operative characteristics. RESULTS On univariate analysis, 15:00-18:43 SST was associated with an increased risk of blood transfusion (relative risk 4.32, 95% confidence interval 1.27 to 14.63, p = 0.032), but not postoperative respiratory failure, acute kidney injury, length of stay, or mortality. On multivariate analysis, the only independent predictor of postoperative blood transfusion was a 15:00-18:43 SST (adjusted odds ratio 4.32, 95% confidence interval 1.06 to 15.96, c-statistic = 0.638). ROC analysis demonstrated that compared to the 15:00 threshold, a 14:34 threshold predicted postoperative blood transfusion with better accuracy (sensitivity = 70.0%, specificity = 83.0%). CONCLUSIONS Despite having similar demographic and operative characteristics, gastric bypass patients in the late SST cohort had a greater incidence of postoperative blood transfusion in this single-center study.
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Affiliation(s)
- Ziyad O. Knio
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, United States of America
| | - Lena Zhang
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, United States of America
| | - David A. Watts
- School of Medicine, University of Virginia, Charlottesville, VA, United States of America
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia Health, Charlottesville, VA, United States of America
- * E-mail:
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Clancy PW, Knio ZO, Zuo Z. Positive SARS-CoV-2 detection on intraoperative nasopharyngeal viral testing is not associated with worse outcomes for asymptomatic elective surgical patients. Front Med (Lausanne) 2022; 9:1065625. [PMID: 36619625 PMCID: PMC9810621 DOI: 10.3389/fmed.2022.1065625] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
Background It has been demonstrated that surgical patients with COVID-19 are at increased risk for postoperative complications. However, this association has not been tested in asymptomatic elective surgical patients. Methods A retrospective cohort study among elective gynecological and spine surgery patients at a single tertiary medical center from July 2020 through April 2022 (n = 1,130) was performed. The primary endpoint was prolonged (>75th percentile for the corresponding surgical service) length of stay. Secondary endpoints included postoperative respiratory complications, duration of supplemental oxygen therapy, and other major adverse events. The association between SARS-CoV-2 detection and the above outcomes was investigated with univariate and multivariable analyses. Findings Of 1,130 patients who met inclusion criteria, 30 (2.7%) experienced intraoperative detection of SARS-CoV-2. Those with intraoperative viral detection did not experience an increased incidence of prolonged length of stay [16.7% vs. 23.2%; RR, 0.72 (95% CI, 0.32-1.61); P = 0.531] nor did they have a longer mean length of stay (4.1 vs. 3.9 days; P = 0.441). Rates of respiratory complications [3.3% vs. 2.9%; RR, 1.15 (95% CI, 0.16-8.11); P = 0.594] and mean duration of supplemental oxygen therapy (9.7 vs. 9.3 h; P = 0.552) were similar as well. All other outcomes were similar in those with and without intraoperative detection of SARS-CoV-2 (all P > 0.05). Interpretation Asymptomatic patients with incidental detection of SARS-CoV-2 on intraoperative testing do not experience disproportionately worse outcomes in the elective spine and gynecologic surgical population.
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Affiliation(s)
- Paul W. Clancy
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, United States,School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Ziyad O. Knio
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, United States
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, United States,*Correspondence: Zhiyi Zuo,
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Chiao SS, Razzaq KK, Sheeran JS, Forkin KT, Spangler SN, Knio ZO, Kellams AL, Tiouririne M. Effect of enhanced recovery after surgery for elective cesarean deliveries on neonatal outcomes. J Perinatol 2022; 42:1283-1287. [PMID: 35013588 DOI: 10.1038/s41372-021-01309-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/14/2021] [Accepted: 12/23/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the impact of initiation of an enhanced recovery after cesarean delivery (ERAC) protocol for elective cesarean delivery (CD) on neonatal outcomes. STUDY DESIGN We performed a retrospective analysis of elective CD at ≥39 weeks gestational age between September 2014 and August 2018 at a single institution before and after ERAC protocol implementation. Our primary outcome was composite neonatal complication rate and secondary outcome was rate of breastfeeding. We performed univariate analyses to detect differences in outcomes between the pre-ERAC and post-ERAC groups. RESULTS We included 362 neonates born via elective CD before (n = 135) and after (n = 227) ERAC implementation. The post-ERAC group experienced fewer composite neonatal complications (33.0% vs. 47.4%, p = 0.009) and greater breastfeeding rates (80.2% vs. 67.4%, p = 0.009) compared to the pre-ERAC group. CONCLUSION ERAC protocol implementation does not negatively impact neonates and may benefit both mother and baby.
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Affiliation(s)
- Sunny S Chiao
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA.
| | - Khadija K Razzaq
- University of Virginia School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Jessica S Sheeran
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Katherine T Forkin
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Sarah N Spangler
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Ziyad O Knio
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Ann L Kellams
- Department of Pediatrics, University of Virginia Health System, Charlottesville, VA, USA
| | - Mohamed Tiouririne
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA
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Knio ZO, Morales FL, Shah KP, Ondigi OK, Selinski CE, Baldeo CM, Zhuo DX, Bilchick KC, Mehta NK, Kwon Y, Breathett K, Thiele RH, Hulse MC, Mazimba S. A systemic congestive index (systemic pulse pressure to central venous pressure ratio) predicts adverse outcomes in patients undergoing valvular heart surgery. J Card Surg 2022; 37:3259-3266. [PMID: 35842813 PMCID: PMC9543661 DOI: 10.1111/jocs.16772] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/09/2022] [Accepted: 06/28/2022] [Indexed: 12/26/2022]
Abstract
Background and Aims Invasive hemodynamics may provide a more nuanced assessment of cardiac function and risk phenotyping in patients undergoing cardiac surgery. The systemic pulse pressure (SPP) to central venous pressure (CVP) ratio represents an integrated index of right and left ventricular function and thus may demonstrate an association with valvular heart surgery outcomes. This study hypothesized that a low SPP/CVP ratio would be associated with mortality in valvular surgery patients. Methods This retrospective cohort study examined adult valvular surgery patients with preoperative right heart catheterization from 2007 through 2016 at a single tertiary medical center (n = 215). Associations between the SPP/CVP ratio and mortality were investigated with univariate and multivariate analyses. Results Among 215 patients (age 69.7 ± 12.4 years; 55.8% male), 61 died (28.4%) over a median follow‐up of 5.9 years. A SPP/CVP ratio <7.6 was associated with increased mortality (relative risk 1.70, 95% confidence interval [CI] 1.08–2.67, p = .019) and increased length of stay (11.56 ± 13.73 days vs. 7.93 ± 4.92 days, p = .016). It remained an independent predictor of mortality (adjusted odds ratio 3.99, 95% CI 1.47–11.45, p = .008) after adjusting for CVP, mean pulmonary artery pressure, aortic stenosis, tricuspid regurgitation, smoking status, diabetes mellitus, dialysis, and cross‐clamp time. Conclusions A low SPP/CVP ratio was associated with worse outcomes in patients undergoing valvular heart surgery. This metric has potential utility in preoperative risk stratification to guide patient selection, prognosis, and surgical outcomes.
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Affiliation(s)
- Ziyad O Knio
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Frances L Morales
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Kajal P Shah
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Olivia K Ondigi
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Christian E Selinski
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Cherisse M Baldeo
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - David X Zhuo
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA.,Division of Cardiology, Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Kenneth C Bilchick
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Nishaki K Mehta
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA.,Division of Cardiovascular Medicine, Beaumont Hospital, Royal Oak, Michigan, USA
| | - Younghoon Kwon
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Robert H Thiele
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Matthew C Hulse
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Sula Mazimba
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
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Beck EC, White JC, Gowd AK, Luo TD, Edge C, Knio ZO, O'Gara TJ. The Effect of State-Level Prescription Opioid Legislation on Patient Outcomes After Lumbar Tubular Microdecompression. Int J Spine Surg 2022; 16:8310. [PMID: 35710730 PMCID: PMC9421206 DOI: 10.14444/8310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In the United States, a statewide legislation titled the Strengthen Opioid Misuse Prevention (STOP) Act was enacted in 2017 to limit prescription opioid use and reduce dependence. The impact of state legislation curbing opioid prescription on outcomes after spine surgery is unknown. STUDY DESIGN Case series. METHODS Data from consecutive patients undergoing lumbar tubular microdecompression for symptomatic lumbar spine stenosis from June 2016 to June 2019 were retrospectively analyzed. Cases between June 2016 and December 2017 represent the group before the STOP act (pre-STOP), while cases between January 2018 and June 2019 represent the group after legislation enactment (post-STOP). Preoperative and postoperative patient functional scores including the EuroQol-Five Dimensions Index, Oswestry Disability Index (ODI), and the visual analog scale (VAS) for back and leg pain were compared between both groups. The meaningful clinically important difference (MCID) was calculated for each score and was compared between both groups as well. RESULTS A total of 147 patients met inclusion criteria, with 86 in the pre-STOP group and 61 in the post-STOP group. Analysis of postoperative scores demonstrated statistically lower VAS leg pain score averages in the post-STOP group (P < 0.05). Higher trends in achieving MCID among the post-STOP group were observed; however, the differences between both groups were not statistically significant (P > 0.05 for all). Additionally, there were no statistical differences in rates of unplanned pain-related clinic visits and emergency department (ED) visits, as well as no differences in the number of pain-related calls within 90 days after surgery between both groups. CONCLUSION The enactment of state legislation to curb the prescribing of opioids for postoperative pain did not negatively affect the rate of achieving clinically meaningful outcomes among patients undergoing lumbar tubular microdecompression for spinal stenosis. Additionally, decreasing the amount of opioids prescribed for postoperative pain does not increase the number of unplanned clinic or ED visits due to pain within 90 days after surgery. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Edward C Beck
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Jonathan C White
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Anirudh K Gowd
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Tianyi D Luo
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Carl Edge
- Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Ziyad O Knio
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Tadhg J O'Gara
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
- Department of Neurosurgery Surgery, Wake Forest Baptist Health, Winston-Salem, NC, USA
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Knio ZO, Thiele RH, Wright WZ, Mazimba S, Naik BI, Hulse MC. A Novel Hemodynamic Index of Post-operative Right Heart Dysfunction Predicts Mortality in Cardiac Surgical Patients. Semin Cardiothorac Vasc Anesth 2022; 26:200-208. [PMID: 35332827 DOI: 10.1177/10892532221080382] [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] [Indexed: 11/16/2022]
Abstract
INTRODUCTION This study aimed to investigate whether mortality following cardiac surgery was associated with the pulmonary artery pulsatility index (PAPi): pulmonary artery pulse pressure divided by central venous pressure (CVP), and a novel index: mean pulmonary artery pressure (mPAP) minus CVP. METHODS This retrospective analysis investigated all cardiac surgery patients in the Society of Thoracic Surgeons registry at a single academic medical center from January 2017 through March 2020 (n = 1510). The primary and secondary outcomes were mortality at 1 year and serum creatinine increase during index surgical admission, respectively. CVP, mPAP, PAPi, mPAP-CVP gradient, mean arterial pressure (MAP), and cardiac index (CI) were sampled continually from invasive hemodynamic monitors post-operatively. Associations with mortality were tested with univariate and multivariate analyses. The relationship with serum creatinine was investigated with Pearson's correlation at alpha = .05. RESULTS One-year mortality was observed in 44/1200 patients (3.7%). On univariate analysis, mortality was associated with minimums for mPAP, MAP, and CI and maximums for CVP, mPAP, PAPi, mPAP-CVP gradient, and CI (all P < .10). Model selection revealed that the only independently predictive parameters were minimum MAP (AOR = .880 [.819-.944]), maximum mPAP-CVP gradient (AOR = 1.082 [1.031-1.133]), and maximum CI (AOR = 1.421 [.928-2.068]), with model c-statistic = .770. A maximum mPAP-CVP gradient >20.5 predicted mortality with 54.5% sensitivity and 79.30% specificity, maintaining significance on survival analysis (P < .001). Peak increase in serum creatinine from baseline demonstrated a weak association with all parameters (max |r| = .33). CONCLUSIONS Mortality was not predicted by the post-operative PAPi; rather, it was independently predicted by the mPAP-CVP gradient, MAP, and CI.
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Affiliation(s)
- Ziyad O Knio
- Department of Anesthesiology, 12350University of Virginia Health System, Charlottesville, VA, USA
| | - Robert H Thiele
- Department of Anesthesiology, 12350University of Virginia Health System, Charlottesville, VA, USA
| | - W Zachary Wright
- Department of Anesthesiology, 12350University of Virginia Health System, Charlottesville, VA, USA
| | - Sula Mazimba
- Department of Medicine, Division of Cardiovascular Medicine, 12350University of Virginia Health System, Charlottesville, VA, USA
| | - Bhiken I Naik
- Department of Anesthesiology, 12350University of Virginia Health System, Charlottesville, VA, USA.,Department of Neurosurgery, 12350University of Virginia Health System, Charlottesville, VA, USA
| | - Matthew C Hulse
- Department of Anesthesiology, 12350University of Virginia Health System, Charlottesville, VA, USA
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Beck EC, Gowd AK, White JC, Knio ZO, O'Gara TJ. The effect of smoking on achieving meaningful clinical outcomes one year after lumbar tubular microdecompression: a matched-pair cohort analysis. Spine J 2021; 21:1303-1308. [PMID: 33774211 DOI: 10.1016/j.spinee.2021.03.020] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/05/2021] [Accepted: 03/22/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT There has been a shift in the spine literature in reporting meaningful outcomes, including meaningful clinically important difference (MCID), after surgery. The evidence on the effect of tobacco smoking at the time of lumbar tubular microdecompression (LTMD) on meaningful outcomes is limited. PURPOSE To compare differences in 1-year functional outcomes and rates of achieving MCID between current smokers and non-smokers who underwent LTMD for lumbar spinal stenosis (LSS). STUDY DESIGN A nested case control study to compare the difference in patient reported outcomes (PROs) between smokers and non-smokers 1-year after undergoing LTMD. PATIENT SAMPLE This study included patients that underwent single level LTMD by a single surgeon between January 2014 through August 2019. OUTCOME MEASURES Preoperative and postoperative PROs were recorded using the questionnaires EQ-5D, Oswestry Disability Index (ODI), and the visual analog scale (VAS) for back pain and leg pain. The MCID was also used. METHODS Current tobacco smokers at the time of surgery were matched 1:2 to non-smokers by age (+/- 1year). Preoperative and postoperative functional scores were compared between the two groups using independent t-tests. Additionally, thresholds for achieving MCID were calculated for each individual functional score, and were compared using Fisher's exact test. RESULTS Of the 183 patients with 1-year follow-up who met inclusion criteria, 35 patients were identified as smokers and were matched to 70 non-smokers. No statistical differences were identified between age, BMI, or gender. Comparison of preoperative PROs showed no statistically significant differences between smokers and non-smokers (p>0.05 for all), while smokers had statistically lower EQ-5D (p<0.001) and higher ODI (p=0.05), VAS back (p=0.033), and VAS leg (p=0.03) score averages at a minimum of one year follow-up. Evaluation of meaningful outcomes demonstrated non-smokers had higher rates of achieving MCID on at least 1 threshold score as compared to smokers (98.5% vs. 91.1%; p=0.043). CONCLUSIONS Current smokers at the time of surgery have inferior postoperative EQ-5D scores, increased pain and disability, and lower odds of achieving the MCID at 1-year after undergoing LTMD when compared to patients without any smoking history.
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Affiliation(s)
- Edward C Beck
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Medical Center Boulevard, 4th Floor Comprehensive Cancer Center, Winston-Salem, NC 27157, USA.
| | - Anirudh K Gowd
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Medical Center Boulevard, 4th Floor Comprehensive Cancer Center, Winston-Salem, NC 27157, USA
| | - Jonathan C White
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Medical Center Boulevard, 4th Floor Comprehensive Cancer Center, Winston-Salem, NC 27157, USA
| | - Ziyad O Knio
- Department of Anesthesiology, University of Virginia Health System, 200 Jeanette Lancaster Way Charlottesville, VA 22903, USA
| | - Tadhg J O'Gara
- Department of Orthopedic Surgery, Wake Forest Baptist Health, Medical Center Boulevard, 4th Floor Comprehensive Cancer Center, Winston-Salem, NC 27157, USA; Department of Neurosurgery , Wake Forest Baptist Health, Medical Center Boulevard, 4th Floor Comprehensive Cancer Center, Winston-Salem, NC 27157, USA
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Roller BL, Boutin RD, O'Gara TJ, Knio ZO, Jamaludin A, Tan J, Lenchik L. Accurate prediction of lumbar microdecompression level with an automated MRI grading system. Skeletal Radiol 2021; 50:69-78. [PMID: 32607805 DOI: 10.1007/s00256-020-03505-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Lumbar spine MRI interpretations have high variability reducing utility for surgical planning. This study evaluated a convolutional neural network (CNN) framework that generates automated MRI grading for its ability to predict the level that was surgically decompressed. MATERIALS AND METHODS Patients who had single-level decompression were retrospectively evaluated. Sagittal T2 images were processed by a CNN (SpineNet), which provided grading for the following: central canal stenosis, disc narrowing, disc degeneration, spondylolisthesis, upper/lower endplate morphologic changes, and upper/lower marrow changes. The grades were used to calculate an aggregate score. The variables and the aggregate score were analyzed for their ability to predict the surgical level. For each surgical level subgroup, the surgical level aggregate scores were compared with the non-surgical levels. RESULTS A total of 141 patients met the inclusion criteria (82 women, 59 men; mean age 64 years; age range 28-89 years). SpineNet did not identify central canal stenosis in 32 patients. Of the remaining 109, 96 (88%) patients had a decompression at the level of greatest stenosis. The higher stenotic grade was present only at the surgical level in 82/96 (85%) patients. The level with the highest aggregate score matched the surgical level in 103/141 (73%) patients and was unique to the surgical level in 91/103 (88%) patients. Overall, the highest aggregate score identified the surgical level in 91/141 (65%) patients. The aggregate MRI score mean was significantly higher for the L3-S1 surgical levels. CONCLUSION A previously developed CNN framework accurately predicts the level of microdecompression for degenerative spinal stenosis in most patients.
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Affiliation(s)
- Brandon L Roller
- Department of Radiology, Wake Forest School of Medicine, Medical Center Blvd., Winston Salem, NC, 27157, USA.
| | - Robert D Boutin
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Tadhg J O'Gara
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Ziyad O Knio
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Amir Jamaludin
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - Josh Tan
- Department of Radiology, Wake Forest School of Medicine, Medical Center Blvd., Winston Salem, NC, 27157, USA
| | - Leon Lenchik
- Department of Radiology, Wake Forest School of Medicine, Medical Center Blvd., Winston Salem, NC, 27157, USA
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Vanhorn TA, Knio ZO, O'Gara TJ. Defining a Minimum Clinically Important Difference in Patient-Reported Outcome Measures in Lumbar Tubular Microdecompression Patients. Int J Spine Surg 2020; 14:538-543. [PMID: 32986575 DOI: 10.14444/7071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Patient-reported outcome measures (PROMs) are critical tools used in the assessment and reporting of surgical outcomes. However, significant differences in PROM scores have not been shown to consistently correlate with clinical improvement from the physician or patient perspective. Defining a minimum clinically important difference (MCID) for PROMs offers interpretation of surgical outcomes with an emphasis on patient-centered feedback. The goal of this study was to define a MCID for the following PROMs in lumbar tubular microdecompression (LTMD) patients: the EuroQol-Five Dimensions (EQ-5D) index, Oswestry Disability Index (ODI), leg pain visual analog scale (VAS), and low back pain VAS. METHODS This study examined 235 index LTMD patients with PROMs collected at preoperative evaluation and 1-year follow-up. Using an anchor-based approach with patient satisfaction index, a receiver operating characteristic analysis was performed to define a MCID in the EQ-5D index, ODI, leg pain VAS, and low back pain VAS. RESULTS The patients had a mean age of 65.18 ± 12.81 years, and 47.7% were male. The MCID values for the EQ-5D, ODI, leg pain VAS, and low back pain VAS are 0.219, 15.0-16.5, 0.5, and 2.5-3.5, respectively. CONCLUSIONS This study helps define a MCID for the EQ-5D index in LTMD patients. Given its ease of administration and economic relevance, further characterization of the EQ-5D index may warrant its use as a potential alternative or adjunct to the routinely collected PROMs following spine surgery. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Trent A Vanhorn
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ziyad O Knio
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Tadhg J O'Gara
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
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Abstract
Coronavirus disease 2019 (COVID-19) has gained international attention as it poses a significant threat to global health. Currently, medical researchers are working to exhaust all strategies that may prove beneficial in combating this disease. Heat has been shown to destabilize other coronavirus strains in testing environments, and it has been hypothesized that heated air may destabilize viral pathogens in vivo as well. The present report describes the engineering of a micro-sauna prototype for the delivery of heated air. Concept formulation, process highlights, and the final prototype are all discussed. The prototype can deliver air heated to 80-90 degrees Celsius in a safe and tolerable manner. The goal of this technical report is to further encourage the study of heated air as a potential COVID-19 treatment.
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Affiliation(s)
- Ziyad O Knio
- Department of Anesthesiology, University of Virginia, Charlottesville, USA
| | - J Alan Shelton
- Industrial Design, MIXXER Community Makerspace, Winston-Salem MIXXER Inc., Winston-Salem, USA
| | - Tadhg O'Gara
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, USA
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16
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Knio ZO, Schallmo MS, Hsu W, Corona BT, Lackey JT, Marquez-Lara A, Luo TD, Medda S, Wham BC, O'Gara TJ. Unilateral Laminotomy with Bilateral Decompression: A Case Series Studying One- and Two-Year Outcomes with Predictors of Minimal Clinical Improvement. World Neurosurg 2019; 131:e290-e297. [PMID: 31356984 DOI: 10.1016/j.wneu.2019.07.144] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/17/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess factors that may predict failure to improve at 12 and 24 months after unilateral laminotomy with bilateral decompression (ULBD) for the management of lumbar spinal stenosis. METHODS A database of 255 patients who underwent microdecompression surgery by a single orthopedic spine surgeon between 2014 and 2018 was queried. Patients who underwent primary single-level ULBD of the lumbar spine were included. Visual analog scale (VAS) for back pain and leg pain and Oswestry Disability Index (ODI) results were collected preoperatively and at 12 and 24 months postoperatively. Demographic, radiographic, and operative factors were assessed for associations with failure to improve. Clinically important improvement was defined as reaching or surpassing the previously established minimum clinically important difference for ODI (12.8) and not requiring revision. RESULTS A total of 68 patients were included. Compared with preoperative values for back pain, leg pain, and ODI (7.32, 7.53, and 51.22, respectively), there were significant improvements on follow-up at 12 months (2.89, 2.23, and 22.40, respectively; P < 0.001) and 24 months (2.80, 2.11, 20.32, respectively; P < 0.001). Based on the defined criteria, 50 patients showed clinically important improvement after ULBD. Of the 18 patients who failed to improve, 12 required revision. Independent predictors of failure to improve included female sex (adjusted odds ratio, 5.06; 95% confidence interval, 1.49-21.12; P = 0.014) and current smoker status (adjusted odds ratio, 5.39; 95% confidence interval, 1.39-23.97; P = 0.018). CONCLUSIONS ULBD for the management of lumbar spinal stenosis leads to clinically important improvement that is maintained over a 24-month follow-up period. Female sex and tobacco smoking are associated with poorer outcomes.
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Affiliation(s)
- Ziyad O Knio
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael S Schallmo
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Wesley Hsu
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Benjamin T Corona
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Justin T Lackey
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alejandro Marquez-Lara
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Tianyi D Luo
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Suman Medda
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Bradley C Wham
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Tadhg J O'Gara
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA; Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
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Knio ZO, Hsu W, Marquez-Lara A, Luo TD, St Angelo JM, Medda S, O'Gara TJ. Far Lateral Tubular Decompression: A Case Series Studying One and Two Year Outcomes with Predictors of Failure. Cureus 2019; 11:e5133. [PMID: 31523563 PMCID: PMC6741369 DOI: 10.7759/cureus.5133] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction The optimal surgical treatment of isolated lumbar foraminal stenosis has not been defined. Minimally invasive decompression of the foramen from a far lateral tubular decompression (FLTD) approach has been shown to not only have minimal morbidity but also highly variable success rates at short-term follow-up. It is important to quantify improvement and define the demographic and radiographic parameters that predict failure in this promising, minimally invasive surgical technique. This study investigates pain and disability score improvement following FLTD at 12 and 24 months and investigates associations with failure. Methods All patients who underwent lumbar FLTD by a single surgeon at a single institution from September 2015 to January 2018 were included in this prospective case series. Visual analog scale (VAS) for back pain and leg pain and Oswestry Disability Index (ODI) were collected preoperatively and at the 12- and 24- month follow-ups. Outcomes between visits were fitted to a linear mixed-effects model. The univariate analysis investigated demographic, radiographic, and operative associations with subsequent open revision. Results A total of 42 patients were included in this study. Back pain (VAS 5.84 to 3.32, p<0.001), leg pain (VAS 7.33 to 2.71, p<0.001), and ODI (48.97 to 28.50, p<0.001) demonstrated significant improvements at the 12-month follow-up. Back pain (VAS 3.71, p=0.004), leg pain (VAS 3.04, p<0.001), and ODI (30.63, p<0.001) improvements were maintained at 24-month follow-up. Four patients (9.5%) required subsequent open revision. Subsequent open revision was associated with prior spine surgery (RR=2.85 (2.07-3.63), p=0.045) and scoliosis ≥10° (RR=6.33 (4.87-7.80), p=0.013). Conclusion Back pain, leg pain, and ODI showed significant improvement postoperatively. Improvement is maintained at two years. Prior spine surgery and scoliosis ≥ 10° may be relative contraindications to FLTD.
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Affiliation(s)
- Ziyad O Knio
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, USA
| | - Wesley Hsu
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, USA
| | | | - Tianyi D Luo
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, USA
| | - John M St Angelo
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, USA
| | - Suman Medda
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, USA
| | - Tadhg J O'Gara
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, USA
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Goodwin AI, Haws BE, Knio ZO, Moerk PK, Miller AN. Isokinetic Strength Testing Following Intramedullary Nailing of Tibial Shaft Fractures Predicts Time to Recovery and Return of Muscle Strength in the Injured Extremity: A Prospective Case Series. HSS J 2018; 14:266-270. [PMID: 30258331 PMCID: PMC6148580 DOI: 10.1007/s11420-018-9611-y] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 03/02/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND The speed and degree of functional recovery over time after surgery for tibial shaft fracture has been previously described using subjective methods. QUESTIONS/PURPOSE This study aimed to quantitatively measure recovery of isokinetic strength in the injured leg after surgical repair of isolated closed tibial shaft fracture. METHODS In this prospective case series, patients were recruited after intramedullary nailing for isolated closed tibial shaft fracture at an academic medical center from January 2012 to December 2015. Recovery of isokinetic strength was quantified using an isokinetic dynamometer. Eight measures of isokinetic strength at 3, 6, and 12 months' follow-up were used to compare strength in the injured leg to the healthy leg. RESULTS In 36 patients recruited, there was a significant difference in strength between the healthy and injured legs at 3 months for seven of the eight metrics used, at 6 months for five of the eight metrics, and at 12 months for none of the eight metrics. Observing recovery of strength longitudinally, we saw significant improvement between 3 and 6 months for four of eight metrics and overall between 3 and 12 months for five of the eight metrics. All four metrics that showed a significant improvement between 3 and 6 months involved plantar flexion. No metrics showed significant improvement between 6 and 12 months. CONCLUSIONS Patients exhibited equal strength between their healthy and injured legs at 12 months after surgery. Improvement in strength occurred to a greater extent between 3 and 6 months after surgery than between 6 and 12 months. Plantar flexion appeared to improve more rapidly than dorsal extension.
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Affiliation(s)
| | - Brittany E. Haws
- Wake Forest University School of Medicine, Winston-Salem, NC 27157 USA
| | - Ziyad O. Knio
- Wake Forest University School of Medicine, Winston-Salem, NC 27157 USA
| | | | - Anna N. Miller
- Washington University School of Medicine, St. Louis, MO 63110 USA
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Mahmood E, Knio ZO, Mahmood F, Amir R, Shahul S, Mahmood B, Baribeau Y, Mueller A, Matyal R. Preoperative asymptomatic leukocytosis and postoperative outcome in cardiac surgery patients. PLoS One 2017; 12:e0182118. [PMID: 28873411 PMCID: PMC5584953 DOI: 10.1371/journal.pone.0182118] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 07/12/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Despite showing a prognostic value in general surgical patients, preoperative asymptomatic elevated white blood cell (WBC) count is not considered a risk factor for cardiac surgery. Whereas there is sporadic evidence of its value as a preoperative risk marker, it has not been looked at methodically as a specific index of outcome during cardiac surgery. Using a national database we sought to determine the relationship between preoperative WBC count and postoperative outcome in cardiac surgical patients. METHODS Cardiac surgeries were extracted from the 2007-2013 American College of Surgeons National Surgical Quality Improvement Program database. Leukocytosis was defined by a preoperative WBC count greater than 11,000 cells/μL. A univariate analysis compared the incidence of adverse outcomes for patients with and without leukocytosis. A multivariate logistic regression model was constructed in order to test whether leukocytosis was an independent predictor of morbidity and mortality. RESULTS Out of a total of 10,979 cardiac surgery patients 863 (7.8%) had preoperative leukocytosis. On univariate analysis, patients with leukocytosis experienced greater incidences of 30-day mortality, wound complications, and medical complications. Wound complications included surgical site infection as well as wound dehiscence. The medical complications included all other non-surgical causes of increased morbidity and infection leading to urinary tract infection, pneumonia, ventilator dependence, sepsis and septic shock. After stepwise model adjustment, leukocytosis was a strong predictor of medical complications (OR 1.22, 95% CI: 1.09-1.36, p = 0.002) with c-statistic of 0.667. However, after stepwise model adjustment leukocytosis was not a significant predictor of 30-day mortality and wound complications. CONCLUSION Preoperative leukocytosis is associated with adverse postoperative outcome after cardiac surgery and is an independent predictor of infection-related postoperative complications.
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Affiliation(s)
- Eitezaz Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Ziyad O. Knio
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Rabia Amir
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Sajid Shahul
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Bilal Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
- Albany Medical College, Albany, New York, United States of America
| | - Yanick Baribeau
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ariel Mueller
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Robina Matyal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Hai T, Amador Y, Mahmood F, Jeganathan J, Khamooshian A, Knio ZO, Matyal R, Nicoara A, Liu DC, Senthilnathan V, Khabbaz KR. Changes in Tricuspid Annular Geometry in Patients with Functional Tricuspid Regurgitation. J Cardiothorac Vasc Anesth 2017; 31:2106-2114. [PMID: 29100836 DOI: 10.1053/j.jvca.2017.06.032] [Citation(s) in RCA: 7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To determine whether the indices of tricuspid annular dynamics that signify irreversible tricuspid valvular remodeling can improve surgical decision making by helping to better identify patients with functional tricuspid regurgitation who could benefit from annuloplasty. DESIGN Retrospective analysis study. SETTING Tertiary hospital. PARTICIPANTS A total number of 55 patients were selected, 18 with functional tricuspid valve (TV) regurgitation and 37 normal nonregurgitant TVs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS When comparing the basal, mid, and longitudinal diameters of the right ventricle between the nonregurgitant valve (NTR) group and the functional tricuspid regurgitation (FTR) group, tricuspid annulus was more dilated (p < 0.001, p = 0.001, and p = 0.006, respectively) and less nonplanar (p < 0.001) in the FTR group. At end-systole (ES), the posterolateral-anteroseptal axis was significantly greater in the FTR group than in the NTR group (mean difference = 7.15 mm; p < 0.001). The right ventricle in the FTR group was also significantly dilated with greater leaflet restriction (p = 0.015). CONCLUSIONS As compared to NTR TVs, FTR is associated with identifiable indices of tricuspid annular structural changes that are indicative of irreversible remodeling.
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Affiliation(s)
- Ting Hai
- Department of Anesthesiology, Peking University People's Hospital, Beijing, China; Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Yannis Amador
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Anesthesia, Hospital México, University of Costa Rica, San José, Costa Rica
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Jelliffe Jeganathan
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Arash Khamooshian
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Cardio-Thoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ziyad O Knio
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Robina Matyal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Alina Nicoara
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - David C Liu
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Venkatachalam Senthilnathan
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kamal R Khabbaz
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Knio ZO, Montealegre-Gallegos M, Yeh L, Chaudary B, Jeganathan J, Matyal R, Khabbaz KR, Liu DC, Senthilnathan V, Mahmood F. Tricuspid annulus: A spatial and temporal analysis. Ann Card Anaesth 2017; 19:599-605. [PMID: 27716689 PMCID: PMC5070318 DOI: 10.4103/0971-9784.191569] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Traditional two-dimensional (2D) echocardiographic evaluation of tricuspid annulus (TA) dilation is based on single-frame measurements of the septolateral (S-L) dimension. This may not represent either the axis or the extent of dynamism through the entire cardiac cycle. In this study, we used real-time 3D transesophageal echocardiography (TEE) to analyze geometric changes in multiple axes of the TA throughout the cardiac cycle in patients without right ventricular abnormalities. Materials and Methods: R-wave-gated 3D TEE images of the TA were acquired in 39 patients undergoing cardiovascular surgery. The patients with abnormal right ventricular/tricuspid structure or function were excluded from the study. For each patient, eight points along the TA were traced in the 3D dataset and used to reconstruct the TA at four stages of the cardiac cycle (end- and mid-systole, end- and mid-diastole). Statistical analyses were applied to determine whether TA area, perimeter, axes, and planarity changed significantly over each stage of the cardiac cycle. Results: TA area (P = 0.012) and perimeter (P = 0.024) both changed significantly over the cardiac cycle. Of all the axes, only the posterolateral-anteroseptal demonstrated significant dynamism (P < 0.001). There was also a significant displacement in the vertical axis between the points and the regression plane in end-systole (P < 0.001), mid-diastole (P = 0.014), and mid-systole (P < 0.001). Conclusions: The TA demonstrates selective dynamism over the cardiac cycle, and its axis of maximal dynamism is different from the axis (S-L) that is routinely measured with 2D TEE.
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Affiliation(s)
- Ziyad O Knio
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mario Montealegre-Gallegos
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Lu Yeh
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesia and Pain Medicine, University Medical Center, University of Groningen, Groningen, Netherlands,
| | - Bilal Chaudary
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jelliffe Jeganathan
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Robina Matyal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kamal R Khabbaz
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - David C Liu
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Venkatachalam Senthilnathan
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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22
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Mahmood F, Knio ZO, Yeh L, Amir R, Matyal R, Mashari A, Gorman RC, Gorman JH, Khabbaz KR. Regional Heterogeneity in the Mitral Valve Apparatus in Patients With Ischemic Mitral Regurgitation. Ann Thorac Surg 2017; 103:1171-1177. [PMID: 28274519 DOI: 10.1016/j.athoracsur.2016.11.083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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] [Received: 08/01/2016] [Revised: 10/17/2016] [Accepted: 11/28/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Apical displacement of the coaptation point of the mitral valve (MV) in response to ischemic mitral regurgitation (IMR) represents remodeling of the MV apparatus. Whereas it implies chronicity, it lacks specificity in discriminating normal from a significantly remodeled MV apparatus. Regional aspects of MV remodeling have shown superior value over global remodeling in predicting recurrence after MV repair for IMR. Quite possibly, presence of specific regional changes in MV geometry that are unique to chronic IMR patients could also be used to diagnose the presence and track progression of remodeling. Knowledge of these changes in MV apparatus in patients with IMR can possibly be used to identify patients for surgical intervention before irreversible remodeling occurs. METHODS Three-dimensional transesophageal echocardiographic data were collected from patients who underwent MV surgery for IMR (IMR group, n = 66), and from patients with normal valvular and biventricular function (control group, n = 10). The acquired data of the MV were geometrically analyzed to make regional comparisons between the IMR and the control group to identify measurements that reliably differentiate normal from remodeled MVs. RESULTS Lengthening of the middle potion of the anterior annulus (A2 regional perimeter: 11.149 mm versus 9.798 mm, p = 0.0041), larger nonplanarity angle (147.985 versus 140.720 degrees, p = 0.0459), and increased tenting angle of the posteromedial scallop of the posterior leaflet (P3 tenting angle: 44.354 versus 40.461 degrees, p = 0.0435) were sufficient in differentiating between IMR and the control group. CONCLUSIONS Specific three-dimensional changes in MV geometry can be used to reliably identify a significantly remodeled valve apparatus.
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Affiliation(s)
- Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ziyad O Knio
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Lu Yeh
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Department of Anesthesia and Pain Medicine, University of Groningen, University Medical Center, Groningen, Netherlands
| | - Rabia Amir
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Robina Matyal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Azad Mashari
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robert C Gorman
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph H Gorman
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kamal R Khabbaz
- Department of Surgery, Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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