Amy Engel

Does an Obese Body Mass Index Affect Hospital Outcomes After Coronary Artery Bypass Graft Surgery

BACKGROUND More than one third of adults in the United States are obese. Coronary artery bypass graft surgery (CABG) has become necessary for many obese persons. We evaluated the effect of this procedure on in-hospital mortality and morbidity of patients based on their body mass index (BMI). METHODS Data in a cardiac surgery database were examined retrospectively. Data selected from the database included CABG surgery from January 2003 to December 2007. The resulting cohort included a total of 10,590 patients. The BMI was grouped into four categories: underweight (BMI < or = 19), normal weight (BMI 20 to 29), obese (BMI 30 to 39), and morbidly obese (BMI > or = 40). Regression analysis was conducted to determine whether BMI was an independent predictor of morbidity and mortality after CABG. RESULTS Our results indicate that patients with an obese BMI are not at greater risk for morbidity or mortality after CABG. Logistic regression analysis found that CABG patients in the underweight body mass index group had the greatest risk of mortality, prolonged ventilation, reoperation for bleeding, and renal failure. Linear regression indicated length of hospital stay and intensive care unit stay after surgery were the longest for patients with an underweight BMI. CONCLUSIONS Despite the comorbidities that are often present with obesity, an obese BMI was not found to be an independent predictor of morbidity or mortality after CABG. On the contrary, the underweight patients are at greater risk for mortality and complications after CABG surgery.

Changes in Ghrelin Levels Following Bariatric Surgery: Review of the Literature

Obesity is a severe health issue that is a global epidemic. Bariatric surgery is an accepted, popular, and effective therapy for weight loss. Ghrelin, a peptide secreted primarily by the fundus cells of the stomach, has been found to impact body weight by its influence on appetite. Although numerous studies have investigated serum ghrelin levels following bariatric surgery, there is no solid agreement yet as to the direction or magnitude of its change, or even its impact on weight loss. Some studies have found an increase in ghrelin, some have found a decrease, and others have found no change in ghrelin following bariatric surgery. The purpose of this review was to establish the impact of ghrelin changes following bariatric surgery.

Deciphering Mesenteric Venous Thrombosis: Imaging and Treatment

The principal cause of a high mortality rate in mesenteric vein thrombosis (MVT) is a delay in diagnosis. Recent data indicate that the mortality rate is decreasing owing to earlier diagnosis and anticoagulation. The authors examined the treatment profile of MVT to see how the increased use of imaging and early anticoagulation has impacted this process. They retrospectively analyzed the treatment paradigm with acute MVT at one institution over a 10-year period. Twenty-three patients were identified. Data were analyzed using chi-squares and Students t tests. Twenty-three patients (11 men and 12 women with an average age of 51.74 ±14.8 years) were identified with acute MVT between the years of 1993 and 2003. Five patients had splenic vein thrombosis, 17 had superior mesenteric vein thrombosis, 1 had inferior mesenteric vein thrombosis, and 12 had portal vein thrombosis. Nine patients had combination mesenteric vein segment thrombosis. Thrombolytics were utilized in a total of 6 patients. Four of the 6 patients in whom lytics were utilized had combined mesenteric vein thrombosis; however, these 4 patients did not require surgical intervention. There was no significant difference in length of hospital stay between patients taking lytics versus patients treated with traditional anticoagulation with heparin (p = 0.291). A hypercoagulable state was identified in 66.7% of the patients. Four patients required surgical intervention. The overall mortality rate was 8.7% (2 of 23). The use of thrombolytics was associated with a significant mortality (p = 0.04). The use of antibiotics made no difference in mortality (p = 0.235), nor did antibiotic use influence length of hospitalization (p = 0.192). MVT is relatively rare, and often the delay in diagnosis increases the mortality rate. In the majority of cases prompt anticoagulation will preserve bowel viability and decrease mortality and morbidity rates. The majority of patients do not need surgery. There is a marked increase in mortality rate when these patients progress to surgical intervention. An increased awareness and early diagnosis has led to decreased morbidity and mortality rates.

Predictors and outcomes of extended intensive care unit length of stay in patients undergoing coronary artery bypass graft surgery.

Abstract  Objective: To assess risk predictors of increased intensive care unit (ICU) length of stay in patients undergoing isolated coronary artery bypass surgery (CABG) and assess outcomes associated with increased ICU length of stay. Methods: We conducted a nested case‐control study from a 9‐year hospitalization cohort with prospective data collection (N = 9869). Cases were CABG patients with ICU greater than or equal to 168 hours (N = 236) and controls were CABG patients with an ICU stay of less than 168 hours (N = 708). We examined 15 risk factors and 11 outcomes. Results: Nine risk factors proved significant in predicting an increased ICU length of stay. Cases were more likely to be older, with an increased pump time, and a lower body surface area. Cases tended to be female, with COPD, hypertension, and undergoing an urgent surgical procedure. Controls tended to have hypercholesterolemia and abnormal left ventricular hypertrophy. There was no significant difference between the cases and controls for the remaining six risk factors. Five of the nine significant predictors correlated with four predictors: age, urgent surgical procedure, pump time, and chronic obstructive pulmonary disorder (COPD). Using logistic regression analysis, we found that patients undergoing CABG had an increased ICU length of stay if they were older than 70 years (OR 2.59, 95% CI 1.86 to 3.62), with longer pump time (OR 2.45, 95% CI 1.75 to 3.44), had COPD (OR 2.04, 95% CI 1.36 to 3.05), and had an urgent surgical procedure (OR 1.59, 95% CI 1.12 to 2.26). Patients with an extended ICU length of stay were also found to experience 11 additional negative outcomes. Conclusion: In patients undergoing CABG surgery an increased age, increased pump time, COPD, and urgent surgical procedure significantly increased the risk of an increased ICU length of stay. Patients with an increased ICU length of stay also experienced more negative outcomes.

Robotic excision of atrial myxoma.

Abstract  Background: Advances in optics and instrumentation with the da Vinci S Surgical System have facilitated minimally invasive and robotic cardiac procedures including mitral valve repair and atrial myxoma excision. We report our retrospective data comparing robotically assisted myxoma excision with standard median sternotomy excision. Methods: Data were collected for cardiac myxoma resection performed between January 2000 and December 2009. The resulting cohort included a total of 57 patients. These patients were grouped into two categories: robotic‐assisted (n = 17) surgical procedures and traditional (nonrobotic; n = 40) surgical procedures. Presurgical and surgical risk factors were examined. Results: Univariate analysis comparing the surgical procedure groups and surgical risk factors found a significant difference in 3 of the 14 variables. Cannulation in all patients undergoing robotic‐assisted cardiac myxoma excision was performed through cannulating the common femoral artery and vein while cannulation for the traditional procedures was performed using the aorta and atrium except for two patients. For aortic occlusion, 14 of the robotic‐assisted cardiac myxoma patients had balloon occlusion and 34 of the traditional cardiac myxoma patients had aortic cross‐clamp occlusion. Operating time was significantly shorter for robotic cases (2.7 hours) compared with traditional cases (3.5 hours). Conclusion: Robotic excision of atrial myxomas is safe and may be an alternative to traditional open surgery in selected patients. (J Card Surg 2012;27:423‐426)

Gender differences in outcomes following aortic valve replacement surgery

OBJECTIVE The objective of this study was to assess outcome differences in aortic valve replacement based on gender. METHODS A study from a ten-year hospitalization cohort with prospective data collection was conducted. Included in the study were patients undergoing aortic valve replacement surgery between March 1997 and July 2003 (N=406). There were 223 males and 183 females included in the study. The study examined 41 potential confounding risk factors and 16 outcome variables. RESULTS Univariate analysis on potential confounding risk factors revealed a significant difference between males and females on 12 factors. Co-morbid disease, hypertension, current vascular disease, aortic insufficiency, body surface area, blood added on pump, and annulus size significantly correlated with age. The correlation resulted in five confounding risk factors: age, tobacco history, obesity, left ventricular hypertrophy, and creatinine level. Logistic regression analysis found that after controlling for age, tobacco history, obesity, left ventricular hypertrophy, and creatinine level, there is no difference between males and females on outcomes following aortic valve replacement. Additionally, choice of vascular prosthesis had no impact on post-operative outcomes. CONCLUSION After controlling for confounding variables, similar outcomes were observed for males and females undergoing aortic valve replacement.

Clinically unsuspected papillary microcarcinomas of the thyroid: a common finding with favorable biology?

BACKGROUND The purpose of this study was to describe the incidence and clinical/pathologic characteristics of papillary thyroid microcarcinoma (PMC) in a community hospital setting and to evaluate the frequency and characteristics of these lesions when unsuspected preoperatively. METHODS A total of 723 patients underwent a partial or total thyroidectomy. A retrospective review was performed. RESULTS A total of 194 of the 723 patients had a final diagnosis of papillary carcinoma. Ninety-six (49%) of these tumors were PMCs defined as being 1.0 cm or less in diameter. One third (32 of 96) of these lesions were multifocal and 16.7% (16 of 96) were found to have regional lymph node metastases. The majority (58%) of PMCs were found on final pathology and were clinically unsuspected (occult). Multifocality was found in 32.1% (18 of 56) of patients with clinically unsuspected PMC, with nodal metastases in 3.6% (2 of 56). The other 40 patients with PMC had surgeries performed for a clinical reason related to that pathologic lesion. This clinically suspected group was comparably multifocal (35%), but more likely to have cervical lymph node metastasis (35%). Sixty-six percent (37 of 56) diagnosed with a clinically unsuspected PMC underwent a partial thyroidectomy at the initial surgery. CONCLUSIONS The prevalence of clinically unsuspected PMC in our population undergoing thyroidectomy was 7.7% (56 of 723). In our institution, this is more than half of all PMCs. The incidence of cervical lymph node metastasis in clinically unsuspected PMC was only 3.6% compared with 35% in clinically suspected disease, suggesting that the biological behavior (and possibly treatment) may be different. Long-term follow-up evaluation is needed to better evaluate the significance of these differences.

The Influence of Ethnicity on Patient Satisfaction

Objective To investigate the influence of ethnicity on patient satisfaction with hospitalization care. Methods We conducted a random selection, cross-sectional study. Data were collected by telephone interviews over a three-year period utilizing a 16-question survey. Patients were excluded from the study if they were admitted for an obstetric visit, physical rehabilitation, or psychiatric illness or if we were unable to reach them by telephone. We used logistic regression to compare ethnicity with the responses for each of the 16 questions while controlling for three confounders (age, gender, and insurance status). For each question, patient responses of excellent and very good were considered satisfied. Patient responses of good, fair, and poor were considered not satisfied. Results We surveyed 7,795 patients. Compared to African-Americans, non-Hispanic white Americans were significantly older, included more males, and were insured by Medicaid less often (p < 0.05). Using multivariate analysis, we found that seven of the 16 questions exhibited significant satisfaction differences. African-Americans expressed significantly less satisfaction for two of six questions related to nursing care, two of three questions related to entire staff care, one of two question related to physician care, and one of three questions related to overall satisfaction (p < 0.05). However, African-Americans expressed significantly more satisfaction for one question related to nursing care. There was no difference between the two groups for nine of the 16 questions, including both questions regarding communication and coordination. Conclusion African-Americans reported significantly lower rates of satisfaction compared to non-Hispanic white Americans for six of 16 questions regarding satisfaction during hospitalization care.

Coronary artery bypass grafting in patients with dialysis-dependent end stage renal disease: a prospective, nested case-control study.

Abstract  Objective: To assess if coronary artery bypass grafting (CABG) patients with dialysis‐dependent end stage renal disease (ESRD) experience greater intraoperative and postoperative morbidity and mortality compared to CABG patients without ESRD. Methods: We conducted a nested case–control study from an 8‐year hospitalization cohort in which data were collected prospectively. Inclusion criteria included CABG surgery and age greater than 18 years. Cases were patients with dialysis dependent ESRD (N = 28) and controls were patients without ESRD (N = 84). Cases were matched to controls 1:3 on age, gender, tobacco history, and New York Heart Association Functional Class. The outcomes of interest were mortality, intensive care unit length of stay, total length of hospitalization, time on the ventilator, wound complications, pulmonary complications, neurological complications, gastrointestinal complications, arrhythmia, and intraoperative complications. Using logistic regression we controlled for 13 potential confounding variables. Results: There were no significant differences between the groups with the exception of total length of hospitalization. Patients with dialysis‐dependent ESRD had a significantly longer total hospitalization stay (21%) than patients without ESRD. There were no significant differences for the remaining nine outcomes of interest, including perioperative morbidity or mortality. Conclusion: Intraoperative and postoperative morbidity and mortality for CABG were not increased for patients with dialysis‐dependent ESRD compared to patients without ESRD. However, patients on dialysis undergoing CABG experienced a greater length of hospitalization than patients undergoing CABG who were not on dialysis.

Serum Chromium and Gestational Diabetes

Objective: To prospectively assess if chromium levels are different in gestational diabetics than in nondiabetic pregnant women. Therapeutic options could exist if levels are different. Methods: We conducted a 2-year prospective, gestational cohort study. The cohort included newly diagnosed pregnant patients. Two blood samples were taken, the first at consent, the second at the time of diabetes screening. Results: Five hundred eighty patients entered the cohort. One hundred fifty-five were lost to follow up and 425 patients completed the study (396 nondiabetics and 29 diabetics). The patients with gestational diabetes were significantly older, with a family history of gestational diabetes, and were significantly more likely to have been a gestational diabetic in a previous pregnancy (P < 05). There was no significant difference between the 2 groups for chromium levels both at enrollment (0.15 ± 0.06 ng/mL vs 0.14 ± 0.03 ng/mL; P = .28) and during the second trimester (0.14 ± 0.06 ng/mL vs 0.14 ± 0.04 ng/mL; P = .82). Conclusion: Serum chromium levels do not exhibit any significant variation between gestational diabetic women and nondiabetic women when assessed prospectively.