Munier Nazzal

Epidemiology of severe sepsis: 2008-2012

INTRODUCTIONnSevere sepsis continues to be a significant burden on society.nnnMETHODSnUsing the International Classification of Diseases, Ninth Revision, Clinical Modification codes, we analyzed the Healthcare Cost and Utilization Project National Inpatient Sample in order to estimate epidemiologic trends of severe sepsis from the years 2008 to 2012. The 2010 US Census, which included 308,745,538 individuals, was used to calculate incidence per 100,000 persons.nnnRESULTSnThere were a total of 6,067,789 discharges for severe sepsis. The annual incidence increased from 346/100,000 to 436/100,000 persons (P < .05). Individuals with 3 or greater organ system failures increased from 31.6% to 35.5% (P < .05), and they accounted for 57.2% to 66.7% of the total number of deaths. Overall mortality decreased from 22.2% to 17.3% (P < .05). Length of stay decreased from 9 to 7 days (P < .05). Those discharged to home with and without home-health increased (23%-27%; P < .05), but those discharged to skilled nursing facilities remained the same (35%).nnnCONCLUSIONSnThe incidence of severe sepsis continues to increase, whereas mortality decreases. However, one third of patients (those with ≥3 organ system failures) account for two thirds of the total number of deaths. More people are discharged home, whereas stable numbers go to facilities.

Outcome after thoracic aortic injury: experience in a level-1 trauma center.

Traumatic rupture of the thoracic aorta is a potentially fatal injury that leads to death in 75-90% of cases at the time of injury. In this report, we present our experience with traumatic thoracic aortic injury and compare the outcome in patients with respect to their hemodynamic stability at presentation and the timing of surgical repair. We performed a retrospective data analysis of the medical records of 30 patients who had sustained a traumatic rupture of the thoracic aorta during the period from January 1, 2000 to October 30, 2005. The demographic data, mechanism of injury, modality of diagnosis, location of injury, other associated injuries, hemodynamic stability at presentation, response to resuscitation, timing of aortic repair, as well as the resultant morbidities and mortalities were reviewed. Traumatic rupture of the thoracic aorta was diagnosed in 30 patients. The injury was located in the ascending aorta in two patients, in the aortic isthmus in 25 patients, and in the descending aorta (distal to the isthmus) in three patients. Associated injuries included head injury (50%), C spine (23.3%), lung injury (80%), and visceral (63%) and extremity (60%) injury. Seven patients (23%) were pronounced dead on arrival to the emergency room, 14 patients (47%) were hemodynamically unstable upon arrival, and nine patients (30%) were hemodynamically stable. In the unstable group, two patients (14%) expired before operative repair, 11 patients (79%) underwent emergent repair of the thoracic aorta resulting in 46% mortality, and one patient (7%) underwent delayed repair after initial stabilization with a splenectomy for a splenic laceration. In the stable group, three patients (33%) underwent early (within 24 hr) aortic surgery, while repair was delayed in six (67%). The mean duration of time spent prior to delayed repair was 20.85 days (range 2-53, median = 25). There was no mortality in this group. Acute traumatic thoracic aortic rupture remains a highly fatal condition. Hemodynamic instability remains the main mortality risk factor. Delayed repair is safe and is not associated with increased risk of aortic rupture in hemodynamically stable patients.

Fractured Internal Carotid Artery Stent

Carotid artery stenting is gaining wider acceptance as an alternative option in the treatment of carotid artery stenosis. Conventional complications such as stroke and recurrent in-stent restenosis are well documented in the literature. However, we believe that carotid stent complications are underreported. The carotid artery segment has features that are relatively smilar to the femoropopliteal segment with respect to forces affecting the stented segment, which can contribute to stent complications such as fracture. In this article, we present a case of internal carotid artery stent fracture and thrombus formation after the patient was exposed to direct trauma to the chest and neck.

Bilateral persistent sciatic artery with aneurysm formation and review of the literature.

Persistent sciatic artery (PSA) is an uncommon medical condition that can result in limb loss if it is not recognized or corrected. It is associated with 14% limb loss and 86% formation of aneurysm of the sciatic artery. In this study we describe a patient with bilateral persistent sciatic arteries associated with multiple aneurysms who presented with a large aneurysm formation and limb ischemia. The patient was treated with PSA embolization and exclusion of the aneurysm in the right leg with vein bypass. All reported cases in the English literature between 1965 and 2012 were reviewed and management options were compared.

Management of war-related vascular injuries: experience from the second gulf war

AimTo study the biomechanism, pattern of injury, management, and outcome of major vascular injuries treated at Mubarak Al-Kabeer Teaching Hospital, Kuwait during the Second Gulf War.MethodsThis is a descriptive retrospective study. War-related injured patients who had major vascular injuries and were treated at Mubarak Al-Kabeer Teaching Hospital from August 1990 to September 1991 were studied. Studied variables included age, gender, anatomical site of vascular injury, mechanism of injury, associated injuries, type of vascular repair, and clinical outcome.Results36 patients having a mean (SD) age of 29.8 (10.2) years were studied. 32 (89%) were males and 21 (58%) were civilians. Majority of injuries were caused by bullets (47.2%) and blast injuries (47.2%). Eight patients (22%) presented with shock.There were 31 arterial injuries, common and superficial femoral artery injuries were most common (10/31). Arterial repair included interposition saphenous vein graft in seven patients, thrombectomy with end-to-end / lateral repair in twelve patients, vein patch in two patients, and arterial ligation in four patients. Six patients had arterial ligation as part of primary amputation. 3/21 (14.3%) patients had secondary amputation after attempted arterial vascular repair of an extremity. There were a total of 17 venous injuries, 13 managed by lateral suture repair and 4 by ligation. The median (range) hospital stay was 8 (1–76) days. 5 patients died (14%).ConclusionsMajor vascular injuries occurred in 10% of hospitalized war-related injured patients. Our secondary amputation rate of extremities was 14%. The presence of a vascular surgeon within a military surgical team is highly recommended. Basic principles and techniques of vascular repair remain an essential part of training general surgeons because it may be needed in unexpected wars.

A single center experience with retrievable IVC filters

Objective To evaluate retrievable IVC filters in our institution and assess their retrieval following a well-structured follow up program. Design Retrospective cohort study. Materials The medical records of patients implanted with retrievable IVC filters were reviewed. Methods All retrievable filter insertions between July 2007 and August 2011 at our institution were reviewed. Data was analyzed for age, gender, indication, complications, retrieval rate, and brand of filter inserted. Statistical analysis was done using SPSS software v19. Chi-square was used to compare discrete data and t-test for continuous data. Pu2009<u20090.05 was significant. Results A total of 484 patients were reviewed of which 258 (53.1%) had a complete medical record. And 96 (37.2%) filters were placed as permanent at the time of insertion. An additional 40 (15.5%) filters were converted to permanent (total permanent filters 136; 52.7%). Death was reported in 26 (10%) patients and 96 (37.2%) out of the remaining 232 patients presented for potential retrieval. Also, 73 (28.2%) had an attempt to retrieve the filters, 69 (94.5%) were successful and 4 (5.4%) failed to retrieve. The remaining 23 (8.9%) patients declined retrieval. Filters studied include Celect (38%), Bard (31.4%), Option (26.2%), Tulip (4.1%), and Recovery (0.2%). Bard was more commonly used as a retrievable filter (80.9%). Retrieval on the first attempt was 90.4% (nu2009=u200966) successful. Of the remaining seven filters, three were successfully retrieved on a second attempt, and four failed to retrieve due to filter tilt. The success rates of retrieval for Celect and Tulip were significantly lower than for Bard (pu2009=u20090.04 and 0.023, respectively). Conclusion Our study showed that a variety of IVC filters can be retrieved successfully with minimal complication rates. In more than half of our patients, IVC filters were used as permanent. Failure of retrieval was most frequently due to filter tilting.

The evaluation of national time trends, quality of care, and factors affecting the use of minimally invasive breast biopsy and open biopsy for diagnosis of breast lesions

BACKGROUNDnMinimally invasive breast biopsy is a recommended biopsy method for suspicious lesions. This study examines national trends and factors associated with the use of open breast biopsy (OBB).nnnMETHODSnThe national inpatient sample database was used to examine trends and factors associated with the use of OBB. Factors associated with OBB were evaluated using chi-square test for univariate analysis and logistic regression for multivariate analysis.nnnRESULTSnOBB rate was 34%. Patients below 50 years of age had OBB rates of 47%, while those above 50 had OBB rates of 29.1% (P < .001). Higher OBB rates were observed in Asian (39.8%) and Hispanic (40.6%) women compared with white women (34.1%, P < .001). Private insurance patients were more likely to have OBB compared with Medicaid/Medicare patients (40.9% vs 30.6%, P < .001). About 1.2% of women who underwent OBB required multiple biopsies for diagnosis compared with .5% for minimally invasive breast biopsy (P < .001).nnnCONCLUSIONSnOBB is still performed in one third of women despite higher morbidity and less accuracy. Factors associated with higher OBB rate included younger age; Asian ethnicity; private insurance; small, rural, and nonteaching hospitals.

Meniere's disease: importance of socioeconomic and environmental factors

STUDY OBJECTIVESn1. Describe the prevalence of Menieres disease in the United States. 2. Recognize important patient and environmental factors in Menieres disease.nnnMETHODSn• Discharge data from the Nationwide Inpatient Sample, the largest US all-payer inpatient care database was analyzed for Menieres disease between 2008 and 2010 in patients > 10 years old. Patient characteristics including prevalence, age, sex, race, household income, and geographic location were studied to determine any correlation with disease prevalence. • T-test, Chi-square and logistic regression testing was used to compare the differences between groups for continuous and categorical data.nnnRESULTSn• The lower limit of Menieres prevalence in the United States population was 73 per 100,000, females 84 per 100,000 compared to 56 per 100,000 among males (OR = 1.51, 95% CI 1.48-1.54, P < 0.01). • Prevalence was highest in Caucasians 91 per 100,000, and was significantly higher than other ethnic groups (P < 0.05). • Prevalence increased as age with the highest prevalence found in 81-90 year age group. • Midwest prevalence (94 per 100,000) was significantly higher than other regions (P < 0.001). • Menieres is more common in less populated locations and the prevalence decreased as population increased. • Menieres prevalence increased with household income. The highest prevalence was found among the 76th-100th quartile with rates of 86 per 100,000 for MD.nnnCONCLUSIONSnEnvironmental factors, race and ethnicity, gender and age appear to be important factors in the prevalence of Menieres disease.

Diagnostic imaging in carotid artery dissection: a case report and review of current modalities.

BACKGROUNDnThis case report presents the challenges associated with the existing screening modalities in the diagnosis of carotid artery dissection, and also reviews the diagnostic efficiency, limitations, and recent advances in imaging technology.nnnCASE PRESENTATIONnA 54-year-old man with blunt trauma and subsequent development of ischemic stroke and no clear initial evidence of carotid dissection with noninvasive screening, including magnetic resonance imaging, magnetic resonance angiography, and computed tomography angiography.nnnCONCLUSIONSnDespite emerging noninvasive imaging techniques, conventional angiography should still be considered to establish a diagnosis of carotid artery dissection, particularly when other imaging modalities are negative or inconclusive but a high degree of clinical suspicion exists based on symptoms or mechanism of injury.

Complications Secondary to the Bard Retrievable Filter : A Case Report

Recent trials have demonstrated the efficacy of short-term insertion of inferior vena cava filters in the treatment and prophylaxis of venous thromboembolism certain populations, especially those with a reversible contraindication to anticoagulation. This has widened the use of retrievable filters in the hope of avoiding the long-term complications of permanent filters. However, no trials have demonstrated complications for each individual retrievable filter; and therefore, the decision for insertion of caval filter should be thoroughly studied and the benefit clearly determined. We discuss our experience with complications that we have encountered during retrieval of the Bard recovery filter in two patients.