Odunayo Olorunfemi

Incidence, predictors, and outcomes associated with pneumothorax during cardiac electronic device implantation: A 16-year review in over 3.7 million patients

BACKGROUND Pneumothorax (PTX) is a potential complication of vascular access during cardiac implantable electronic device (CIED) procedures and is being scrutinized as a health care-acquired condition. OBJECTIVE The purpose of this study was to determine the trends in PTX incidence in the United Stated over a 16-year period and to determine whether PTX is associated with increased mortality after adjustment for other factors. METHODS Using weighted sampling in the largest inpatient health database in the United States (National Inpatient Sample), we evaluated data from patients with a primary procedure of CIED implantation from 1998 to 2013 who had at least 1 new vascular access (new or upgrade of prior CIED). The unadjusted and adjusted associations of PTX with mortality and other parameters were examined. RESULTS Among 3,764,703 CIED procedures, PTX occurred in 47,839 cases (1.3%). The apparent incidence of PTX peaked at 1.6% in 2012 and 2013, although this result may have been affected by a concomitant decrease of inpatient (vs outpatient) CIED. PTX was significantly associated with pulmonary complications, chest tube insertion, length of stay, and costs. Mortality was statistically higher in patients with PTX (1.2% vs 0.7%; P <.001), a relationship that remained significant in a multivariate logistic regression analysis (odds ratio 1.50, 95% confidence interval 1.36-1.65; P <.001). Age >80 years, female gender, Caucasian race, chronic obstructive pulmonary disease, and dual-chamber (vs single-chamber) device were all associated with higher odds for PTX occurrence. Placement of a chest tube was a major determinant of worse outcomes and higher costs. CONCLUSION PTX remains an important complication of CIED procedures and is associated with increased morbidity, mortality, and costs.

Impact of Left Atrial Appendage Exclusion on Cardiovascular Outcomes in Patients With Atrial Fibrillation Undergoing Coronary Artery Bypass Grafting (From the National Inpatient Sample Database)

Left atrial appendage (LAA) exclusion is performed by some surgeons in patients with atrial fibrillation (AF) who undergo coronary artery bypass grafting (CABG). However, the available evidence regarding the efficacy and safety of this procedure remains mixed. We queried the Nationwide Inpatient Survey Database for the 10-year period from 2004 to 2013. Using International Classification of Diseases, Ninth Edition, Clinical Modification diagnosis codes, we identified patients who had a diagnosis of AF and underwent a primary procedure of CABG with or without LAA exclusion. We then performed a 1:5 matching based on the CHA2DS2VASc score between patients who got LAA exclusion and those who did not (control group). The primary outcome was the incidence of in-hospital cerebrovascular events, whereas the secondary outcomes included in-hospital bleeding events, pericardial effusion, cardiac tamponade, postoperative shock, and mortality. Our analysis included a total of 15,114 patients. Patients who underwent LAA exclusion had significantly less incidence of cerebrovascular events (2.0% vs 3.1%, p = 0.002). However, LAA exclusion group had higher incidences of bleeding events (36.4% vs 21.3%, p <0.001), pericardial effusion (2.7% vs 1.2%, p <0.001), cardiac tamponade (0.6% vs 0.2%, p <0.001), and postoperative shock (1.2% vs 0.4%, p <0.001). LAA exclusion was associated with higher in-hospital mortality (1.6% vs 0.3%, p <0.001). Multivariate regression analysis showed that LAA exclusion was significantly associated with lower cerebrovascular accident events and higher in-hospital mortality. In conclusion, LAA exclusion in patients with AF undergoing CABG might be associated with a lower incidence of in-hospital cerebrovascular events. This benefit is offset by a higher incidence of higher bleeding events, pericardial effusion, cardiac tamponade, postoperative shock, and in-hospital mortality.

Comparison of Outcomes in Patients Having Acute Myocardial Infarction With Versus Without Sickle-Cell Anemia

Sickle-cell disease (SCD) affects millions worldwide. Sickle-cell anemia (SCA), the most severe form of this disease, is the most common inherited blood disorder in the United States. There are limited data on the incidence, clinical characteristics, and outcomes of acute myocardial infarction (AMI) in these patients. Using data from the National Inpatient Sample database, we matched cases (AMI with SCA) with controls (AMI without SCA) in a 1:1 ratio for age, gender, race, and year of admission. We compared both groups in terms of clinical characteristics and inpatient outcomes and performed a logistic regression with mortality as the primary outcome. Using weighted samples, we also described trends of SCA in the general population of patients with AMI. Of the 2,386,657 admissions with AMI, SCA was reported in 501 (0.02%) patients, and 495 were successfully matched to controls. Patients with SCA were less likely to have risk factors for coronary artery disease than those without SCA. Patients with SCA were more likely to develop pneumonia, respiratory failure, and acute renal failure, and require mechanical ventilation, hemodialysis for acute renal failure and blood transfusion. In-hospital mortality was significantly higher in patients with SCA. In a multivariate analysis, SCA was an independent predictor of mortality (odds ratio 3.49; 95% confidence interval 1.99 to 6.12; p = < .001). In conclusion, myocardial infarction occurs in patients with SCA at a relatively early age. These patients do not typically have the traditional risk factors for the acute coronary syndrome. Mortality in these patients is significantly higher in age-, gender-, and race-matched controls.

Higher Risk of Bleeding in Asians Presenting With ST-Segment Elevation Myocardial Infarction: Analysis of the National Inpatient Sample Database

Bleeding is a major complication in patients presenting with ST-segment elevation myocardial infarction (STEMI). Several studies suggested that Asians are more susceptible to bleeding when treated with antiplatelets, anticoagulants, and thrombolytic agents. In our study, we aimed to investigate the association between Asian ethnicity and bleeding events in patients who presented with STEMI. We analyzed the Nationwide Inpatient Sample database from 2002 to 2013 and identified patients hospitalized with a primary diagnosis of STEMI. We compared clinical outcomes between patients of Asian and white ethnicity. Primary outcome was inhospital major bleeding defined as a composite of intracranial hemorrhage and blood transfusions for bleeding events. After exclusions, an estimated 1 695 680 white and 46 563 Asian patients with STEMI were included in the analysis. Asian patients had a higher incidence of inhospital major bleeding (3.6% vs 2.2%, P < .001) without a significant difference in inhospital mortality (9.3% vs 8.7%, P = .06). Asian ethnicity was an independent predictor for major bleeding (estimated odds ratio: 1.32; 95% confidence interval: 1.16-1.51; P < .001). This increased risk of bleeding would warrant further investigation of optimal treatment strategies tailored for patients with STEMI of Asian ethnicity.

Penetrating neck trauma in children: an uncommon entity described using the National Trauma Data Bank

BACKGROUND Penetrating neck trauma is uncommon in children; consequently, data describing epidemiology, injury pattern, and management are sparse. The aim of this study was to use the National Trauma Data Bank (NTDB) to describe pediatric penetrating neck trauma (PPNT). METHODS The NTDB was queried for children (defined as <15 years old) with PPNT between years 2008 and 2012. Descriptive analysis was used to describe age groups (0–5, 6–10, and 11–14 years) and injury type categorized as aerodigestive, vascular, cervical spine, and nerve. RESULTS A total of 1,238 patients with penetrating neck trauma were identified among 434,788 children in the NTDB (0.28%). Mean age was 7.9 years, and 70.6% of patients were male. The most common mechanisms of injury were stabbing (44%) and gunshot/firearm (24%). Most patients were treated at a pediatric trauma center (65.8%). Computed tomographic scan was the most frequent (42.2%) diagnostic study performed, followed by laryngoscopy (27.0%) and esophagoscopy (27.4%). Almost a quarter of patients (23.7%) went directly to the operating room from the emergency department (ED). Aerodigestive injuries were most common and occurred more frequently in the youngest age group (p < 0.001). Operative procedures for aerodigestive type injuries were most common (82.7%). There were 69 deaths, yielding a mortality rate of 5.6%. When adjusting for age, admission to a pediatric trauma center, and injury type, only vascular injury (odds ratio, 3.92; 95% confidence interval, 2.19–7.24; p < 0.0001) and ED hypotension (odds ratio, 27.12; 95% confidence interval, 15.11–48.67; p < 0.0001) were found to be independently associated with death. CONCLUSION PPNT is extremely rare—0.28% reported NTDB incidence. Age seems to influence injury type but does not affect mortality. Computed tomographic scan is the dominant diagnostic study used for selective management. Vascular injury type and hypotension on presentation to the ED were independently associated with mortality. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

In-Hospital Cerebrovascular Outcomes of Patients With Atrial Fibrillation and Cancer (from the National Inpatient Sample Database)

Limited data are available regarding the impact of cancer on cerebrovascular accidents in patients with atrial fibrillation (AF). We queried the Nationwide Inpatient Survey Database to identify patients who have diagnostic code for AF. We performed a 1:1 propensity matching based on the CHA2DS2VASc score and other risk factors between patients with AF who had lung, breast, colon, and esophageal cancer, and those who did not (control). The final cohort included a total of 31,604 patients. The primary outcome of in-hospital cerebrovascular accidents (CVA) was lower in the cancer group than in the control group (4% vs 7%, p < 0.001), but with only a weak association (ф = -0.067). In-hospital mortality was higher in the cancer group than in the control group (18% vs 11%, p < 0.001; ф = -0.099). A subgroup analysis according to cancer type showed similar results with a weak association with lower CVA in breast cancer (4% vs 7%; ф = -0.066, p < 0.001), lung cancer (4% vs 6%; ф = -0.062, p < 0.001), colon cancer (4% vs 6%; ф = -0.062, p < 0.001), and esophageal cancer (3% vs 7%; ф = -0.095, p < 0.001) compared with the control groups. A weak association with higher in-hospital mortality was demonstrated in lung cancer (20% vs 11%; ф = -0.127, p < 0.001), colon cancer (16% vs 11%; ф = -0.076, p < 0.001), and esophageal cancer (20% vs 12%; ф = -0.111, p < 0.001) compared with the control groups, but no significant difference between breast cancer and control groups in mortality (11% vs 11%; ф = -0.002, p = 0.888). In conclusion, in patients with AF, cancer diagnosis may not add a predictive role for in-hospital CVA beyond the CHADS2VASc score.

Temporal Trends in Inpatient Use of Intravascular Imaging Among Patients Undergoing Percutaneous Coronary Intervention in the United States

Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have emerged as helpful intravascular imaging tools to guide revascularization decisions during percutaneous coronary intervention (PCI). Studies have demonstrated that intravascular imaging is associated with improved clinical

Secondhand Smoke Exposure Among Community-Dwelling Adult Cancer Survivors in the United States: 1999–2012

Background: Little is known about the prevalence of secondhand smoke exposure (SHSe) among cancer survivors. We sought to determine the prevalence, trends, and correlates of SHSe among nonsmoking adult cancer survivors in the United States. Methods: Interview and serum cotinine data for nonsmoking adults, age 20 years and older, with a history of cancer (N = 686) were obtained from consecutive two-year cross-sectional cycles of the National Health and Nutrition Examination Survey from 1999 to 2012. SHSe was defined as serum cotinine 0.05–10 ng/mL among nonsmokers. We calculated and trended the prevalence of SHSe among nonsmoking cancer survivors. Multivariable logistic regression was used to examine the associations of SHSe with sociodemographic, smoking, and clinical characteristics. Survey weights were applied in estimating prevalence rates, adjusted ORs, and confidence intervals (CI). Results: The weighted aggregate SHSe and self-reported indoor SHSe prevalence rates over the study period were 28.26% (95% CI: 24.97%–31.55%) and 4.53% (95% CI: 3.48%–5.57%), respectively. SHS exposure declined from 39.61% (95% CI: 27.88%–51.34%) in 1999/2000 to 15.68% (95% CI: 9.38%–21.98%) in 2011/2012 (Ptrend < 0.001). Age ≥ 60 years was protective against SHSe, while being black, having less than high school education, poverty, and a smoking-related cancer history were associated with higher odds of SHSe. Conclusions: Fortunately, SHSe among nonsmoking cancer survivors in the United States is on the decline, although certain subgroups remain disproportionately burdened. Impact: These findings highlight clinical and public health imperatives to target socioeconomically disadvantaged nonsmoking cancer survivors to reduce their SHSe. Cancer Epidemiol Biomarkers Prev; 26(8); 1296–305. ©2017 AACR.

National Trends and Outcomes of Endomyocardial Biopsy for Patients With Myocarditis: From the National Inpatient Sample Database

BACKGROUND The utility of endomyocardial biopsy (EMB) in the management of myocarditis in the era of advanced cardiac imaging has been challenged. METHODS AND RESULTS The Nationwide Inpatient Sample Database (years 1998-2013) was queried to identify hospitalization records with a primary diagnosis of myocarditis, and underwent EMB procedure. We identified 22,299 hospitalization records with a diagnosis of myocarditis during the study period. Of those, 798 (3.6%) underwent EMB procedures. There was an average decrease in the incidence of EMB for myocarditis by 0.15% (P < .01) over the study period. Younger patients, women, and those with chronic kidney disease were more likely to undergo EMB. On multivariate analysis, patients with myocarditis who underwent EMB had higher in-hospital mortality (hazard ratio [HR] 1.97, 95% confidence interval [CI] 1.41-2.74) and longer median hospital stay (9 days vs 3 days; P < .001). EMB was associated with a higher incidence of cardiac tamponade (odds ratio [OR] 5.21, 95% CI 2.76-9.82), cardiogenic shock (OR 4.66, 95% CI 3.75-5.78), need for intra-aortic balloon pump (OR 3.52, 95% CI 2.49-4.97), and need for extracorporeal membrane oxygenation (OR 4.26, 95% CI 2.78-6.53). CONCLUSIONS The use of EMB in hospitalizations with myocarditis has decreased over time. The use of EMB was associated with a higher likelihood of in-hospital mortality and morbidity. Whether these findings represent a causative association from the procedure or a consequence of more severe disease in this group could not be confirmed in this study.

In-hospital outcomes of percutaneous ventricular assist devices versus intra-aortic balloon pumps in non-ischemia related cardiogenic shock

Introduction: This study compared inpatient outcomes related to the use of these two devices among patients who developed cardiogenic shock not due to acute myocardial infarction or coronary revascularization. Methods: We extracted admission‐level records of patients with a diagnosis of cardiogenic shock who underwent either PVAD or IABP implantation from the National Inpatient Sample (NIS) database from 2010 to 2014. Our outcomes of interest were mortality and length of stay. Results: Inpatient mortality was significantly higher in the PVAD cohort. In multivariate analysis, PVAD use in these patients was associated with higher mortality. There was no difference in the length of stay between both groups among patients that survived to discharge. Conclusion: In our analysis of the NIS database, the use of PVADs in patients with cardiogenic shock of non‐ischemic origin was associated with higher mortality when compared to IABP use.