Paula D. Strassle

Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Lower Surgical Risk Scores: A Systematic Review and Meta-Analysis of Early Outcomes

BACKGROUND The results from the PARTNER 2 trial showed the feasibility of transcatheter aortic valve replacement (TAVR) in intermediate surgical risk patients. Although low risk clinical trials will take time to conclude, some data has emerged comparing TAVR with surgical aortic valve replacement (SAVR) in lower risk patients. METHODS A Medline search was conducted using standard methodology to search for studies reporting results comparing TAVR and SAVR. Studies were included if the overall mean Society of Thoracic Surgeons Score was less than 4% (or equivalent Euroscore). A meta-analysis comparing the 30-day risk of clinical outcomes between TAVR and SAVR in the lower surgical risk population was conducted. RESULTS A total of four studies, including one clinical trial and three propensity-matched cohort studies met the inclusion criteria. Compared to SAVR, TAVR had a lower risk of 30-day mortality (RR 0.67, 95% CI 0.41, 1.10), stroke (RR 0.60, 95% CI 0.30, 1.22), bleeding complications (RR 0.51, 95% CI 0.40, 0.67) and acute kidney injury (RR 0.66, 95% CI 0.47, 0.94). However, a higher risk of vascular complications (RR 11.72, 95% CI 3.75, 36.64), moderate or severe paravalvular leak (RR 5.04, 95% CI 3.01, 8.43), and permanent pacemaker implantations (RR 4.62, 95% CI 2.63, 8.12) was noted for TAVR. CONCLUSION Among lower risk patients, TAVR and SAVR appear to be comparable in short term outcomes. Additional high quality studies among patients classified as low risk are needed to further explore the feasibility of TAVR in all surgical risk patients.

Comparative Analysis of Perioperative Outcomes and Costs Between Laparoscopic and Open Antireflux Surgery

BACKGROUND Laparoscopic antireflux surgery (LARS) has proven to be as effective as open antireflux surgery (OARS), but it is associated with a shorter hospital stay and a faster recover. The aims of this study were to assess the national use of LARS in the US and to compare the perioperative outcomes between laparoscopic and open antireflux procedures in a national cohort. STUDY DESIGN A retrospective population-based analysis was performed using the National Inpatient Sample for the period 2000 to 2013. The study included adult patients (18 years and older) diagnosed with gastroesophageal reflux disease (GERD), who underwent either laparoscopic or open fundoplication. Multivariable linear and logistic regression, adjusted for patient demographics, comorbidities, and hospital characteristics were used to assess the effect of the laparoscopic approach on patient outcomes. RESULTS A total of 75,544 patients were included, with 44,089 having LARS (58.4%) and 31,455 having OARS (41.6%). The rate of laparoscopic procedures increased from 24.8 LARS per 100 procedures in 2000, to 84.3 LARS per 100 procedures in 2013 (p < 0.0001). Patients undergoing laparoscopic surgery were less likely to experience postoperative venous thromboembolism, wound complications, infection, esophageal perforation, bleeding, cardiac failure, renal failure, respiratory failure, shock, and inpatient mortality. On average, the laparoscopic approach reduced length of stay by 2.1 days, and decreased hospital charges by

Timeline of health care–associated infections and pathogens after burn injuries

9,530. CONCLUSIONS The use of the laparoscopic approach for the surgical treatment of GERD has increased significantly in the last decade in the US. This approach is associated with lower morbidity and mortality, shorter hospital stay, and lower costs for the health care system.

Increasing Rates of Surgery for Patients With Nonmalignant Colorectal Polyps in the United States

BACKGROUND Infections are an important cause of morbidity and mortality after burn injuries. Here, we describe the time line of infections and pathogens after burns. METHODS A retrospective study was performed in a large tertiary care burn center from 2004-2013. Analyses were performed on health care-associated infections (HAIs) meeting Centers for Disease Control and Prevention criteria and on all positive cultures. Incidence rates per 1,000 days were calculated for specific HAI categories and pathogens and across hospitalization time (week 1, weeks 2-3, and week ≥4). RESULTS Among 5,524 patients, the median burn size was 4% of total body surface area (interquartile range, 2%-10%). Of the patients, 7% developed an HAI, of whom 33% had >1 HAI episode. Gram-positive bacteria were isolated earlier, and gram-negative bacteria were isolated later during hospitalization. Of 1,788 bacterial isolates, 44% met criteria for multidrug resistance, and 23% met criteria for extensive drug resistance. Bacteria tended to become increasingly resistant to antibiotics as time from admission increased. CONCLUSIONS We observed differences in infection type, pathogen, and antibiotic-resistant bacterium risk across time of hospitalization. These results may guide infection prevention in various stages of the postburn admission.

Improved Survival of Patients With Extensive Burns: Trends in Patient Characteristics and Mortality Among Burn Patients in a Tertiary Care Burn Facility, 2004–2013

BACKGROUND & AIMS Despite the availability of endoscopic therapy, many patients in the United States undergo surgical resection for nonmalignant colorectal polyps. We aimed to quantify and examine trends in the use of surgery for nonmalignant colorectal polyps in a nationally representative sample. METHODS We analyzed data from the Healthcare Cost and Utilization Project National Inpatient Sample for 2000 through 2014. We included all adult patients who underwent elective colectomy or proctectomy and had a diagnosis of either nonmalignant colorectal polyp or colorectal cancer. We compared trends in surgery for nonmalignant colorectal polyps with surgery for colorectal cancer and calculated age, sex, race, region, and teaching status/bed-size-specific incidence rates of surgery for nonmalignant colorectal polyps. RESULTS From 2000 through 2014, there were 1,230,458 surgeries for nonmalignant colorectal polyps and colorectal cancer in the United States. Among those surgeries, 25% were performed for nonmalignant colorectal polyps. The incidence of surgery for nonmalignant colorectal polyps has increased significantly, from 5.9 in 2000 to 9.4 in 2014 per 100,000 adults (incidence rate difference, 3.56; 95% confidence interval 3.40-3.72), while the incidence of surgery for colorectal cancer has significantly decreased, from 31.5 to 24.7 surgeries per 100,000 adults (incidence rate difference, -6.80; 95% confidence interval -7.11 to -6.49). The incidence of surgery for nonmalignant colorectal polyps has been increasing among individuals age 20 to 79, in men and women and including all races and ethnicities. CONCLUSIONS In an analysis of a large, nationally representative sample, we found that surgery for nonmalignant colorectal polyps is common and has significantly increased over the past 14 years.

Meta‐analysis of transfemoral TAVR versus surgical aortic valve replacement

Classic determinants of burn mortality are age, burn size, and the presence of inhalation injury. Our objective was to describe temporal trends in patient and burn characteristics, inpatient mortality, and the relationship between these characteristics and inpatient mortality over time. All patients aged 18 years or older and admitted with burn injury, including inhalation injury only, between 2004 and 2013 were included. Adjusted Cox proportional hazards regression models were used to estimate the relationship between admit year and inpatient mortality. A total of 5540 patients were admitted between 2004 and 2013. Significant differences in sex, race/ethnicity, burn mechanisms, TBSA, inhalation injury, and inpatient mortality were observed across calendar years. Patients admitted between 2011 and 2013 were more likely to be women, non-Hispanic Caucasian, with smaller burn size, and less likely to have an inhalation injury, in comparison with patients admitted from 2004 to 2010. After controlling for patient demographics, burn mechanisms, and differential lengths of stay, no calendar year trends in inpatient mortality were detected. However, a significant decrease in inpatient mortality was observed among patients with extensive burns (≥75% TBSA) in more recent calendar years. This large, tertiary care referral burn center has maintained low inpatient mortality rates among burn patients over the past 10 years. While observed decreases in mortality during this time are largely due to changes in patient and burn characteristics, survival among patients with extensive burns has improved.

Geographic distribution of live births with tetralogy of Fallot in North Carolina 2003 to 2012: Tetralogy of Fallot in NC

In the recently concluded PARTNER 2 trial, TF‐TAVR cohort was shown to have lower risks of death or disabling strokes as compared to SAVR, whereas the outcomes with transthoracic TAVR were comparable with SAVR.

Awareness of radiation risks from CT scans among patients and providers and obstacles for informed decision-making

BACKGROUND Geographic variation in congenital heart disease is not well-described. This study uses geographic information systems (GIS) to describe the spatial epidemiology of tetralogy of Fallot (TOF), in North Carolina (NC) and to compare travel time for cases to congenital heart centers in NC. METHODS Using the NC Birth Defects Monitoring Program database, live births with TOF born between 2003 and 2012 were identified. Birth certificates provided demographic variables. A denominator of live births/zip code was obtained from the NC live births database. ArcGIS® software was used to illustrate TOF prevalence by zip code, and SatScanTM was used to identify spatial clusters of TOF cases and to identify changes in cluster location over time. Driving time to each of five NC congenital heart centers was predicted based on road systems information. RESULTS A total of 496 infants were born with TOF between 2003 and 2012. The prevalence was 4.2/10,000 live births. A large cluster (330 zip codes, 306 cases) was identified in northeastern NC. Average driving time for each case to closest congenital heart center was: University of North Carolina 37 min, Vident Medical Center 64 min, Duke University 58 min, Carolinas Medical Center 89 min, and Wake Forest Baptist Health 57 min. Overall, average predicted driving time to the nearest congenital heart center was 61 min. CONCLUSION Approximately 50 infants/year were born with TOF in NC. One cluster was identified. Further study is necessary to explore potential explanations for the observed case cluster. As interest in regionalization of congenital heart surgery grows, GIS and spatial analysis can become increasingly useful tools for health care planning. Birth Defects Research (Part A) 106:881-887, 2016.

Association of Surgical Volume With Perioperative Outcomes for Esophagomyotomy for Esophageal Achalasia

IntroductionUsing the study design from a prominent 2004 study, we aimed to reassess patient, provider, and radiologist awareness of CT radiation more than a decade later.MethodsAdults presenting to the emergency department of a tertiary care center over a 2-week period with mild to moderate pain requiring an abdominopelvic CT scan were surveyed. Patients were asked if anyone had discussed the risks/benefits of the CT scan including radiation dose and were asked to estimate their dose compared to a chest X-ray. Emergency providers and radiologists were given similar surveys and were asked about potential obstacles to discussing CT radiation with patients.ResultsA total of 101 patients, 570 emergency providers, and 161 radiologists were surveyed. Twenty-three percent (14/61) of patients, 39% (219/568) of emergency providers, and 48% (77/161) of radiologists correctly selected the radiation dose range of an abdominopelvic CT. Seventy-eight percent (441/567) of emergency providers reported routinely discussing radiation dose with patients, while 20% (20/98) of patients reported that their emergency provider discussed radiation dose with them. Time limitation and concern of dissuading the patient from CT were the most commonly reported obstacles for discussing risks.ConclusionsPatients and providers in 2015 appear to be more aware of radiation dose from CT than they were in 2004. Discussion of CT scan radiation exposure and associated risks only occurs sometimes and may actually occur less frequently than perceived by emergency providers.

Role of Age, Tumor Grade, and Radiation Therapy on Immediate Postmastectomy Breast Reconstruction

This population-based analysis examines the association between surgical volume and postoperative results in patients with esophageal achalasia who underwent esophagomyotomy.