Nancy L. Reaven

Elevated body temperature independently contributes to increased length of stay in neurologic intensive care unit patients

Objective:Elevated temperature results in worse outcome in experimental models of cerebral ischemia and brain trauma. In critically ill neurologic and neurosurgical patients, elevated body temperature is common and is associated with neurologic deterioration and poor outcome. We sought to determine whether, after controlling for age, severity of illness, and complications, elevated body temperature remained an important predictor of intensive care unit (ICU) and hospital length of stay, mortality rate, and hospital disposition in a large cohort of patients emergently admitted to a neurologic ICU. Design:Prospectively collected data (demographics, diagnosis, Acute Physiology and Chronic Health Evaluation II score, Glasgow Coma Scale score, daily maximum temperature, complications, disposition) were retrospectively reviewed. Setting:A 20-bed neurology/neurosurgery ICU in a tertiary care academic, level I trauma, referral center. Subjects:From 6,759 admissions, those admitted after an elective procedure with length of stay ≤1 day, those <18 yrs old, and those with incomplete data were excluded, leaving 4,295 patients for this analysis. First, a hierarchical multiple regression analysis was performed to determine whether elevated body temperature was an independent predictor of length of stay. Second, a path analysis was performed to define the relationships among elevated body temperature, complications, and length of stay. Finally, a matched, weighted sample was developed to quantify the difference in length of stay. Interventions:None. Measurements and Main Results:We measured ICU and hospital length of stay, mortality rate, and discharge disposition. The presence of elevated body temperature was associated with a dose-dependent longer ICU and hospital length of stay, higher mortality rate, and worse hospital disposition. The most important predictor of ICU length of stay was the number of complications (β = .681) followed by elevated body temperature (β = .143). In the matched, weighted population, the presence of elevated body temperature was associated with 3.2 additional ICU days and 4.3 additional hospital days. Conclusion:In a large cohort of neurologic ICU patients, after we controlled for severity of illness, diagnosis, age, and complications, elevated body temperature was independently associated with a longer ICU and hospital length of stay, higher mortality rate, and worse outcome.

Impact of fever on outcome in patients with stroke and neurologic injury: a comprehensive meta-analysis.

Background and Purpose— Many studies associate fever with poor outcome in patients with neurological injury, but this relationship is blurred by divergence in populations and outcome measures. We sought to incorporate all recent scholarship addressing fever in brain-injured patients into a comprehensive meta-analysis to evaluate disparate clinical findings. Methods— We conducted a Medline search for articles since January 1, 1995 (in English with abstracts, in humans) and hand searches of references in bibliographies and review articles. Search terms covered stroke, neurological injury, thermoregulation, fever, and cooling. A total of 1139 citations were identified; we retained 39 studies with 67 tested hypotheses contrasting outcomes of fever/higher body temperature and normothermia/lower body temperature in patients with neurological injury covering 14 431 subjects. A separate meta-analysis was performed for each of 7 outcome measures. Significance was evaluated with Zc developed from probability values or t values. Correlational effect size, r(es), was calculated for each study and used to derive Cohen’s d unbiased combined effect size and relative risk. Results— Fever or higher body temperature was significantly associated with worse outcome in every measure studied. Relative risk of worse outcome with fever was: mortality, 1.5; Glasgow Outcome Scale, 1.3; Barthel Index, 1.9; modified Rankin Scale, 2.2; Canadian Stroke Scale, 1.4; intensive care length of stay, 2.8; and hospital length of stay, 3.2. Conclusions— In the pooled analyses covering 14 431 patients with stroke and other brain injuries, fever is consistently associated with worse outcomes across multiple outcome measures.

Mesh choice in ventral hernia repair: so many choices, so little time.

BACKGROUND Currently, >200 meshes are commercially available in the United States. To help guide appropriate mesh selection, the investigators examined the postsurgical experiences of all patients undergoing ventral hernia repair at their facility from 2008 to 2011 with ≥12 months of follow-up. METHODS A retrospective review of prospectively collected data was conducted. All returns (surgical readmission, office or emergency visit) for complications or recurrences were examined. The impact of demographics (age, gender, and body mass index [BMI]), risk factors (hernia grade, hernia size, concurrent and past bariatric surgery, concurrent and past organ transplantation, any concurrent surgery, and American Society of Anesthesiologists score), and prosthetic type (polypropylene, other synthetic, human acellular dermal matrix, non-cross-linked porcine-derived acellular dermal matrix, other biologic, or none) on the frequency of return was evaluated. RESULTS A total of 564 patients had 12 months of follow-up, and 417 patients had 18 months of follow-up. In a univariate regression analysis, study arm (biologic, synthetic, or primary repair), hernia grade, hernia size, past bariatric surgery, and American Society of Anesthesiologists score were significant predictors of recurrence (P < .05). Multivariate analysis, stepwise regression, and interaction tests identified three variables with significant predictive power: hernia grade, hernia size, and BMI. The adjusted odds ratios vs hernia grade 2 for surgical readmission were 2.6 (95% confidence interval [CI], 1.3 to 5.1) for grade 3 and 2.6 (95% CI, 1.1 to 6.4) for grade 4 at 12 months and 2.3 (95% CI, 1.1 to 4.6) for grade 3 and 4.2 (95% CI, 1.7 to 10.0) for grade 4 at 18 months. Large hernia size (adjusted odds ratio vs small size, 3.2; 95% CI, 1.6 to 6.2) and higher BMI (adjusted odds ratio for BMI ≥50 vs 30 to 34.99 kg/m(2), 5.7; 95% CI, 1.2 to 26.2) increased the likelihood of surgical readmission within 12 months. CONCLUSIONS The present data support the hypothesis that careful matching of patient characteristics to choice of prosthetic will minimize complications, readmissions, and the number of postoperative office visits.

The Burden of Narcolepsy Disease (BOND) study: health-care utilization and cost findings.

OBJECTIVES The aim of this study was to characterize health-care utilization, costs, and productivity in a large population of patients diagnosed with narcolepsy in the United States. METHODS This retrospective, observational study using data from the Truven Health Analytics MarketScan Research Databases assessed 5 years of claims data (2006-2010) to compare health-care utilization patterns, productivity, and associated costs among narcolepsy patients (identified by International Classification of Diseases, Ninth Revision (ICD9) narcolepsy diagnosis codes) versus matched controls. A total of 9312 narcolepsy patients (>18 years of age, continuously insured between 2006 and 2010) and 46,559 matched controls were identified. RESULTS Compared with controls, narcolepsy subjects had approximately twofold higher annual rates of inpatient admissions (0.15 vs. 0.08), emergency department (ED) visits w/o admission (0.34 vs. 0.17), hospital outpatient (OP) visits (2.8 vs. 1.4), other OP services (7.0 vs. 3.2), and physician visits (11.1 vs. 5.6; all p<0.0001). The rate of total annual drug transactions was doubled in narcolepsy versus controls (26.4 vs. 13.3; p<0.0001), including a 337% and 72% higher usage rate of narcolepsy drugs and non-narcolepsy drugs, respectively (both p<0.0001). Mean yearly costs were significantly higher in narcolepsy compared with controls for medical services (

Association of Serum Potassium with All-Cause Mortality in Patients with and without Heart Failure, Chronic Kidney Disease, and/or Diabetes

8346 vs.

Comparative analysis of 18-month outcomes and costs of breast reconstruction flap procedures.

4147; p<0.0001) and drugs (

Immediate 1-stage vs. tissue expander postmastectomy implant breast reconstructions: a retrospective real-world comparison over 18 months.

3356 vs.

Cost analysis of intubation-related tracheal injury using a national database

1114; p<0.0001). CONCLUSIONS Narcolepsy was found to be associated with substantial personal and economic burdens, as indicated by significantly higher rates of health-care utilization and medical costs in this large US group of narcolepsy patients.

Essure hysteroscopic sterilization versus interval laparoscopic bilateral tubal ligation: a comparative effectiveness review.

Background: The relationship between serum potassium, mortality, and conditions commonly associated with dyskalemias, such as heart failure (HF), chronic kidney disease (CKD), and/or diabetes mellitus (DM) is largely unknown. Methods: We reviewed electronic medical record data from a geographically diverse population (n = 911,698) receiving medical care, determined the distribution of serum potassium, and the relationship between an index potassium value and mortality over an 18-month period in those with and without HF, CKD, and/or DM. We examined the association between all-cause mortality and potassium using a cubic spline regression analysis in the total population, a control group, and in HF, CKD, DM, and a combined cohort. Results: 27.6% had a potassium <4.0 mEq/L, and 5.7% had a value ≥5.0 mEq/L. A U-shaped association was noted between serum potassium and mortality in all groups, with lowest all-cause mortality in controls with potassium values between 4.0 and <5.0 mEq/L. All-cause mortality rates per index potassium between 2.5 and 8.0 mEq/L were consistently greater with HF 22%, CKD 16.6%, and DM 6.6% vs. controls 1.2%, and highest in the combined cohort 29.7%. Higher mortality rates were noted in those aged ≥65 vs. 50-64 years. In an adjusted model, all-cause mortality was significantly elevated for every 0.1 mEq/L change in potassium <4.0 mEq/L and ≥5.0 mEq/L. Diuretics and renin-angiotensin-aldosterone system inhibitors were related to hypokalemia and hyperkalemia respectively. Conclusion: Mortality risk progressively increased with dyskalemia and was differentially greater in those with HF, CKD, or DM.

Brain Injury and Fever: Hospital Length of Stay and Cost Outcomes

Background: Data from large-scale studies of breast reconstruction surgery outcomes and downstream costs are lacking. The authors assessed outcomes, patient return rates, and costs across a large, geographically diverse patient population undergoing autologous breast reconstruction. Methods: Insurance claims for patients undergoing free flap, latissimus dorsi flap, or transverse rectus abdominis myocutaneous (TRAM) flap autologous breast reconstruction were extracted from a U.S. health care database. Claims for an 18-month period after the initial (index) procedure were analyzed to assess episodes of care, complications, breast procedures, and costs. Results: Of 828 patients (274 free flaps, 302 latissimus dorsi flaps, and 252 TRAM flaps), 35 percent experienced postindex complications: incidences related to implant/graft/mesh and hematoma/seroma were highest in the latissimus dorsi arm (19 percent and 6 percent, respectively); the incidence related to breast necrosis was highest in the free flap arm (8 percent); and that related to wound complications was highest in the TRAM arm (6 percent). Returns for complications were 92.7, 84.4, and 115.5 of 100 patients in the free, latissimus dorsi, and TRAM flap arms (p < 0.05, TRAM flap versus other arms), respectively, and 105.5, 116.6, and 87.7 of 100 patients, respectively, for procedures unrelated to complications (p < 0.05, latissimus dorsi versus TRAM flaps). Nearly all patients returned at least once for treatments unrelated to complications. Mean total costs for index surgery plus postindex events were