Kakra Hughes

Racial/Ethnic Disparities in Amputation and Revascularization: A Nationwide Inpatient Sample Study

This study investigates whether ethnic minorities presenting with critical limb ischemia (CLI) are more likely to undergo major limb amputation compared to white patients. The Nationwide Inpatient Sample (NIS) database was used to identify all patients admitted with CLI; lower extremity revascularization; and major lower extremity amputation from 1998 to 2005. The NIS identified 240 139 patients presenting with CLI—68.2% white, 19.5% black, 9.0% Hispanic, and 1.24% Asian. In all, 83 328 patients underwent revascularization—73.7% white, 15.9% black, 7.4% Hispanic, and 1.1% Asian. The majority of the interventions were open. In all, 111 548 patients underwent a major lower extremity amputation—61% white, 25.4% black, 10.1% Hispanic, and 1.1% Asian. The mean Charlson comorbidity scores for amputation were 2.1 for whites, 2.0 for blacks, 2.3 for Hispanics, and 2.5 for Asians (for all data, P < .05). Blacks make up a disproportionately higher proportion of patients admitted for CLI and undergoing amputation, with a lower proportion undergoing revascularization.

Racial/ethnic disparities in revascularization for limb salvage: an analysis of the National Surgical Quality Improvement Program database.

Introduction: Previous reports have suggested that black patients have a higher rate of major lower extremity amputation and a lower rate of revascularization for limb salvage when compared to white patients. Objective: We undertook this study to determine the extent of this ethnic disparity in recent years and to evaluate whether the widespread adoption of endovascular techniques has had an impact on this disparity. Methods: The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) database was queried to identify all patients who had undergone an above- or below-knee amputation as well as all patients who had undergone an open or endovascular revascularization procedure for critical limb ischemia for the years 2005 to 2006. Patient demographics and 30-day outcomes were recorded, and comparisons were made among the different ethnic groups. Results: There were 1568 patients identified in the NSQIP database as having undergone a major lower extremity amputation in 2005 and 2006. Of these patients, 54% were white, 29% black, 8% Hispanic, and 0.7% Asian. Eight percent of patients did not have identifying ethnic data. The group undergoing amputation was primarily male (61%) with a mean age of 65. Median length of stay was 11 days, and 30-day mortality was 9% following amputation. During this same time period, 4191 patients underwent an open surgical procedure and 569 patients underwent an endovascular procedure for the purposes of limb salvage. Of those patients undergoing an open procedure, 74% were white, 12% black, 4% Hispanic, 0.4% Asian, and 10% did not have identifying ethnic data. Open surgical patients were primarily male (63%) with a mean age of 66. Median length of stay was 6 days, and 30-day mortality was 3.3%. Of those patients undergoing an endovascular procedure, 79% were white, 10% black, 2% Hispanic, 1% Asian, and 8% did not have identifying ethnic data. The endovascular group was also primarily male (61%) with a mean age of 68. Median length of stay was 5 days, and 30-day mortality was 4%. Conclusion: There remains a significant ethnic disparity in limb-salvage revascularization. Blacks comprise 29% of patients undergoing a major lower extremity amputation, but only 12% of those undergoing an open surgical procedure and 10% of those undergoing an endovascular procedure for limb salvage. The widespread adoption of endovascular revascularization techniques appears not to have had much impact on this disparity.

Open versus endovascular repair of thoracic aortic aneurysms: a Nationwide Inpatient Sample study.

Purpose: Endovascular repair of descending thoracic aortic aneurysms has become an acceptable surgical option over the past decade. We sought to compare the results of open versus endovascular repair of thoracic aortic aneurysms (TEVAR) in the United States. Methods: The Nationwide Inpatient Sample (NIS) database was queried to identify all patients undergoing elective repair of a thoracic aortic aneurysm from 1998 to 2007 in the United States. Patient demographic data, preoperative comorbidities, and postoperative complications were recorded. Statistical analyses were performed comparing open versus endovascular repair. Multivariate analyses were conducted controlling for preoperative comorbidities including the presence of diabetes mellitus, cardiac, respiratory, and renal comorbidities as well as patient’s age, gender, and ethnicity. The primary end point was mortality. Secondary end points were postoperative neurologic, cardiac, and respiratory complications. Results: There were 8967 patients who met the inclusion criteria. Of these patients, 8255 (92%) had an open repair and 712 (8%) had an endovascular repair. The overall mortality was 4.5% (4.6% for open and 3.6% for endovascular). On multivariate analysis, the odds of death were reduced by 46% among patients undergoing endovascular repair when compared to open repair (odds ratio [OR]: 0.54; P = .016). There was also reduced odds of a postoperative neurologic complication (OR: 0.48; P = .015), cardiac complication (OR: 0.24; P < .001), and respiratory complication (OR: 0.38: P = .001) in the endovascular group. Conclusions: Nationwide data comparing open and TEVAR in the United States reveal decreased postoperative mortality and a decreased incidence of postoperative neurologic, cardiac, and respiratory complications for TEVAR.

Laparoscopic surgery for trauma: the realm of therapeutic management

BACKGROUND The use of laparoscopy in trauma is, in general, limited for diagnostic purposes. We aim to evaluate the therapeutic role of laparoscopic surgery in trauma patients. METHODS We analyzed the National Trauma Data Bank (2007 to 2010) for all patients undergoing diagnostic laparoscopy. Patients undergoing a therapeutic laparoscopic surgical procedure were identified and tabulated. Mortality and hospital length of stay for patients with isolated abdominal injuries were compared between the open and laparoscopic groups. RESULTS Of a total of 2,539,818 trauma visits in the National Trauma Data Bank, 4,755 patients underwent a diagnostic laparoscopy at 467 trauma centers. Of these, 916 (19.3%) patients underwent a therapeutic laparoscopic intervention. Common laparoscopic operations included diaphragm repair, bowel repair or resection, and splenectomy. Patients undergoing laparoscopic surgery had a significantly shorter length of stay than the open group (5 vs 6 days; P < .001). CONCLUSION Therapeutic laparoscopic surgery for trauma is feasible and may provide better outcomes.

Abdominal aortic aneurysm repair in nonagenarians.

BACKGROUND The feasibility of abdominal aortic aneurysm (AAA) repair in nonagenarians on a national level is largely unknown. We undertook this study to determine the outcomes of open and endovascular AAA repair in this population on a national level. METHODS A retrospective review of the Nationwide Inpatient Sample Database was conducted to determine all patients 90 years and older who underwent either an open or endovascular repair of a nonruptured AAA from 1997 to 2008. Preoperative comorbidities and postoperative complications in the inpatient setting were recorded. The primary end point was mortality. Secondary end points were postoperative neurologic, cardiac, and respiratory complications. This group was then compared with all adult patients less than 90 years old (age, 18-89) who had undergone repair of a nonruptured AAA during this same period. RESULTS Four hundred twenty-three patients 90 years and older underwent repair of a nonruptured AAA (compared with 52,370 < 90). Of these, 132 patients underwent open repair (31%) and 291 (69%) underwent endovascular repair. Inpatient mortality was 18.3% for the ≥90 open, 4.6% for the <90 open, 3.1% for the ≥90 endovascular, and 1.2% for <90 endovascular group. CONCLUSIONS Open repair of AAAs in nonagenarians is associated with significantly high perioperative mortality, whereas endovascular repair is feasible with acceptable perioperative mortality. This mortality, although significantly higher than that obtained for endovascular repair in patients <90, is nonetheless not significantly different for the mortality noted for patients <90 undergoing open AAA repair.

The sleepy surgeon: does night-time surgery for trauma affect mortality outcomes?

BACKGROUND Sleepiness and fatigue affect surgical outcomes. We wished to determine the association between time of day and outcomes following surgery for trauma. METHODS From the National Trauma Data Bank (2007 to 2010), we analyzed all adults who underwent an exploratory laparotomy between midnight and 6 am or between 7 am and 5 pm. We compared hospital mortality between these groups using multivariate logistic regression. Additionally, for each hour, a standardized mortality ratio was calculated. RESULTS About 16,096 patients and 15,109 patients were operated on in the night time and day time, respectively. No difference was found in the risk-adjusted mortality rate between the 2 time periods (odds ratio .97, 95% confidence interval .893 to 1.058). However, hourly variations in mortality during the 24-hour period were noted. CONCLUSION Trauma surgery during the odd hours of the night did not have an increased risk-adjusted mortality when compared with surgery during the day.

Regional variation in racial disparities among patients with peripheral artery disease

Objective: Prior studies identified significant racial disparities as well as regional variation in outcomes of patients with peripheral artery disease (PAD). We aimed to determine whether regional variation contributes to these racial disparities. Methods: We identified all white or black patients who underwent infrainguinal revascularization or amputation in 15 deidentified regions of the Vascular Quality Initiative between 2003 and 2017. We excluded three regions with <100 procedures. We used multivariable linear regression, allowing clustering at the hospital level to calculate the marginal effects of race and region on adjusted 30‐day mortality, major adverse limb events (MALEs), and amputation. We compared long‐term outcomes between black and white patients within each region and within patients of each race treated in different regions using multivariable Cox regression. Results: We identified 90,418 patients, 15,527 (17%) of whom were black. Patients underwent 31,263 bypasses, 52,462 endovascular interventions, and 6693 amputations. Black patients were younger and less likely to smoke, to have coronary artery disease, or to have chronic obstructive pulmonary disease, but they were more likely to have diabetes, limb‐threatening ischemia, dialysis dependence, and hypertension and to be self‐insured or on Medicaid (all P < .05). Adjusted 30‐day mortality ranged from 1.2% to 2.1% across regions for white patients and 0% to 3.0% for black patients; adjusted 30‐day MALE varied from 4.0% to 8.3% for white patients and 2.4% to 8.1% for black patients; and adjusted 30‐day amputation rates varied from 0.3% to 1.2% for white patients and 0% to 2.1% for black patients. Black patients experienced significantly different (both higher and lower) adjusted rates of 30‐day mortality and amputation than white patients did in several regions (P < .05) but not MALEs. In addition, within each racial group, we found significant variation in the adjusted rates of all outcomes between regions (all P < .01). In adjusted analyses, compared with white patients, black patients experienced consistently lower long‐term mortality (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.73‐0.88; P < .001) and higher rates of MALEs (HR, 1.15; 95% CI, 1.06‐1.25; P < .001) and amputation (HR, 1.33; 95% CI, 1.18‐1.51; P < .001), with no statistically significant variation across the regions. However, rates of all long‐term outcomes varied within both racial groups across regions. Conclusions: Significant racial disparities exist in outcomes after lower extremity procedures in patients with PAD, with regional variation contributing to perioperative but not long‐term outcome disparities. Underperforming regions should use these data to generate quality improvement projects, as understanding the etiology of these disparities is critical to improving the care of all patients with PAD.

Racial disparities in outcomes after intact abdominal aortic aneurysm repair

Objective: We aimed to compare perioperative morbidity and mortality and late survival among black, white, and Asian patients undergoing intact abdominal aortic aneurysm (AAA) repair. Methods: We identified all patients undergoing intact, infrarenal AAA repair in the Vascular Quality Initiative (VQI) from 2003 to 2017. We compared in‐hospital outcomes by race using the Fisher exact and Kruskal‐Wallis tests. Multivariable logistic and linear regression models of perioperative outcomes adjusted for differences in demographics, comorbidities, hospital volume, and procedure. We used Cox regression to evaluate late survival by race. Results: In the cohort, 21,961 (94%) patients were white, 1215 (5.2%) were black, and 318 (1.4%) were Asian. Black patients were more likely to be symptomatic (black, 16%; white, 9.1%; Asian, 11%; P < .001) and to undergo endovascular aneurysm repair (EVAR; black, 87%; white, 83%; Asian, 84%; P < .001). There were no differences in 30‐day mortality after EVAR (black, 1.1%; white, 1.1%; Asian, 0.8%; P = .80) or open repair (black; 4.3%; white, 2.6%; Asian, 1.9%; P = .33). However, black patients were more likely to receive new postoperative dialysis (black, 1.6%; white, 0.8%; Asian; 0.7%; P = .01) and to return to the operating room (black, 4.3%; white, 2.9%; Asian, 0.9%; P < .01). Mean hospital length of stay was longer in black patients after EVAR (black, 3.3 days; white, 2.6 days; Asian, 2.6 days; P < .001) and in Asian and black patients after open repair (black, 10.5 days; white, 8.5 days; Asian, 13.0 days; P < .001). After multivariable adjustment, black patients were more likely than white patients to have postoperative dialysis (odds ratio, 2.2; 95% confidence interval [CI], 1.3–3.6; P < .01) and return to the operating room (odds ratio, 1.6; 95% CI, 1.2–2.2; P < .01). Five‐year survival was highest for Asian patients (black, 84%; white, 85%; Asian, 92%), even in the adjusted Cox model (Asian: hazard ratio, 0.6; 95% CI, 0.4–0.97; P = .04). Conclusions: Although perioperative mortality is comparable across races after AAA repair, black patients are more likely than white or Asian patients to develop new postoperative renal failure and return to the operating room, even after adjusting for differences in comorbidities, operative variables, and hospital volume. In addition, whereas Asian patients have the highest rate of postoperative myocardial infarction, they also have the highest late survival. Further studies are warranted to elucidate the mechanism of these disparities.

The Role of Hypoxia-Inducible Factor 1 in Mild Cognitive Impairment

Neuroinflammation and reactive oxygen species are thought to mediate the pathogenesis of Alzheimer’s disease (AD), suggesting that mild cognitive impairment (MCI), a prodromal stage of AD, may be driven by similar insults. Several studies document that hypoxia-inducible factor 1 (HIF-1) is neuroprotective in the setting of neuronal insults, since this transcription factor drives the expression of critical genes that diminish neuronal cell death. HIF-1 facilitates glycolysis and glucose metabolism, thus helping to generate reductive equivalents of NADH/NADPH that counter oxidative stress. HIF-1 also improves cerebral blood flow which opposes the toxicity of hypoxia. Increased HIF-1 activity and/or expression of HIF-1 target genes, such as those involved in glycolysis or vascular flow, may be an early adaptation to the oxidative stressors that characterize MCI pathology. The molecular events that constitute this early adaptation are likely neuroprotective, and might mitigate cognitive decline or the onset of full-blown AD. On the other hand, prolonged or overwhelming stressors can convert HIF-1 into an activator of cell death through agents such as Bnip3, an event that is more likely to occur in late MCI or advanced Alzheimer’s dementia.

Diabetes is not associated with an increased peri-operative mortality or non-infectious morbidity following lower extremity arterial reconstruction

BACKGROUND The aim of this study was to determine if, at a national level, diabetes mellitus is associated with worse perioperative outcomes after open lower extremity arterial reconstruction. METHODS Using Current Procedural Terminology codes, the National Surgical Quality Improvement Program database was queried to identify diabetic and nondiabetic patients who underwent open lower extremity arterial reconstruction from January 1, 2005, to December 31, 2007. These 2 groups were then compared using bivariate and multivariate analyses. RESULTS There was no difference in mortality between the 2 groups (3.3% in diabetics and 3.5% in nondiabetics, P = .618). On multivariate analysis, there was no difference in the incidence of cardiac, pulmonary, or renal complications between the 2 groups. Diabetics, though, were more likely to develop infectious complications postoperatively. CONCLUSIONS After lower extremity arterial reconstruction, diabetes is not associated with an increased risk for mortality or an increased rate of major postoperative complications. Diabetics, however, have an increased rate of certain perioperative infections.