William Briggs

Concurrent prophylactic placement of inferior vena cava filter in gastric bypass and adjustable banding operations in the Bariatric Outcomes Longitudinal Database

INTRODUCTIONnPostoperative pulmonary embolism (PE) is a leading cause of morbidity and mortality after bariatric surgery. However, the concurrent prophylactic placement of an inferior vena cava filter (CPIVCF) in patients undergoing bariatric operations remains controversial. This study used the Bariatric Outcomes Longitudinal Database (BOLD) to establish associated characters and determine outcomes of CPIVCF for patients undergoing Roux-en-Y gastric bypass (GB) and adjustable gastric banding (AB) surgeries.nnnMETHODSnWe analyzed BOLD, a database of bariatric surgery patient information. GB and AB operations were categorized into open and laparoscopic approaches. Univariate logistic regressions were used to compare between non-CPIVCF and concurrent CPIVCF groups. Significant variables (P < .05) were subsequently input into multivariate regression models: CPIVCF was retained in each model.nnnRESULTSnA total of 322 CPIVCFs (0.33%) were identified from 97,218 GB and AB operations performed between 2007 and 2010 in this retrospective registry study. Significant differences were identified in male gender (21.1% vs 31.4%; P < .001), preoperative body mass index (BMI; 44.5 ± 6.6 vs 45.3 ± 7; P < .001), and African-American race (10.5% vs 18%; P < .001) between non-CPIVCF and CPIVCF groups. The CPIVCF group had more patients with previous nonbariatric surgery (50% vs 43.6%; P = .02), a history of venous thromboembolism (VTE; 21.4% vs 3.1%; P < .001), impairment of functional status (7.8% vs 3.1%; P < .001), lower extremity edema (47.2% vs 27.1%; P < .001), obesity hypoventilation syndrome (7.1% vs 2.1%; P < .001), obstructive sleep apnea syndrome (58.1% vs 43.3%; P < .001), and pulmonary hypertension (13% vs 4.1%; P < .001). Patients in the CPIVCF group were more likely to receive GB than gastric banding (77% vs 58.1%; P < .001) and an open surgical approach (21.4% vs 4.8%; P < .001). Operative duration was longer in the CPIVCF group (119 ± 67 vs 89 ± 52 minutes; P < .001). The CPIVCF group also had a longer length of hospital stay (3 ± 2 vs 2 ± 6 days; P = .048), was associated with higher incidence of deep venous thrombosis (DVT; 0.93% vs 0.12%; P < .001), and had a higher mortality (0.31% vs 0.03%; P = .003) from PE and indeterminate causes. In multivariate analysis, male gender, African-American race, previous nonbariatric surgery, a high BMI, obesity hypoventilation syndrome, history of VTE, lower extremity edema, and pulmonary hypertension were preoperative factors associated with CPIVCF.nnnCONCLUSIONSnCPIVCF was associated with specific clinical features, increased health care resource utilization, and a higher mortality in patients undergoing bariatric operations. Although selected patient characteristics influence surgeons to perform CPIVCF, this study was unable to establish an outcome benefit for CPIVCF.

Estimating the clinical impact of bringing a multimarker cardiac panel to the bedside in the ED

OBJECTIVESnWe examined the use of point-of-care (POC) testing of cardiac biomarkers against standard core laboratory testing to determine the time-savings and estimate a cost-benefit ratio at our institution.nnnMETHODSnWe prospectively enrolled 151 patients presenting to the emergency department undergoing evaluation for acute coronary syndrome and conducted both central laboratory troponin T (TnT) testing at baseline and 6 hours as well as POC assays of creatine kinase MB, troponin I (TnI), and myoglobin at baseline and 2 hours. Sensitivity/specificity was calculated to measure the ability of the POC-accelerated pathway to identify enzyme elevations at rates parallel to our core laboratory. The time-savings were calculated as the difference between the median of the current protocol and the accelerated POC pathway.nnnRESULTSnTroponin T tests were elevated in 12 patients, which were all detected by the accelerated pathway yielding a relative sensitivity of 100%. Time-saving between the accelerated pathway and core laboratory showed a saving of 390 minutes (6.5 hours). The accelerated POC pathway would have benefited 60% (95% confidence interval [CI], 52%-68%) of our patients with an estimated cost of

Comparison of conservative and operative treatment for blunt carotid injuries: Analysis of the National Trauma Data Bank

7.40 (95% CI,

Blood transfusion and its effect on the clinical outcomes of patients undergoing major lower extremity amputation.

6.40-

Correlation between pericardial, mediastinal, and intrathoracic fat volumes with the presence and severity of coronary artery disease, metabolic syndrome, and cardiac risk factors

8.70) per direct patient care hour saved.nnnCONCLUSIONnOur data suggest that the use of an accelerated cardiac POC pathway could have dramatically impacted the care provided to a large percentage of our patients at a minimal cost per direct patient care hour saved.

Derivation of a pediatric growth curve for inferior vena caval diameter in healthy pediatric patients: brief report of initial curve development

OBJECTIVESnBlunt carotid injury (BCI) is uncommon but potentially devastating. The best treatment modality for this injury remains undetermined. We conducted this study to better understand the hospital course and treatment outcomes for patients with BCI who received different interventions.nnnMETHODSnBCI and related vascular procedures were identified by ICD-9-CM codes from the National Trauma Data Bank(1) using data gathered from 2002 to 2006. Conservative and operative treatment groups were compared by variables of patient demographics, initial assessment in the emergency department (ED), hospital course, and treatment outcomes. Open surgical and endovascular interventions were further compared.nnnRESULTSnA total of 842 BCI were identified from 1,633,126 discharged blunt trauma patients (0.05%). Of these, 762 (90.5%) were treated conservatively and 80 (9.5%) received operative intervention. No differences in demographics were observed between these treatment groups. On initial assessment, no differences between conservative and operative treatment groups were noted with regard to vital signs, Glasgow coma scale, presence of drugs or alcohol in blood, or Trauma Related Injury Severity Score survival probability. Significant differences were seen in terms of the presence of a base deficit (-3.1 +/- 6.8 vs -7.6 +/- 8.3; P = .01), likelihood of a positive head computed tomography (CT) scan (58.6% vs 26.1%; P = .003), and total Injury Severity Score (29.8 +/- 13.3 vs 26.1 +/- 14.1; P = .02). Hospital course and treatment outcomes were comparable, with no differences in hospital length of stay (13.4 +/- 15.3 days vs 13.7 +/- 13.6 days; P = .86), total Functional Independence Measure (8.8 +/- 3.3 vs 9.3 +/- 3.1; P = .38), progression of original neurologic insult (7.5% vs 4.6%; P = .61) or mortality (28.1% vs 19%; P = .08). When comparing open surgical to endovascular interventions (46 open, 34 endovascular, including 3 combined), the only significant differences were in the total Injury Severity Score (22.4 +/- 12.2 vs 31.4 +/- 15.4; P = .01) and length of intensive care unit (ICU) and hospital stay (5.0 +/- 6.0 days vs 10.7 +/- 10.4 days; P = .01, and 10.3 +/- 9.2 days vs 19.3 +/- 17.7 days; P = .01). Multivariate regression analysis confirmed that neither Functional Independence Measure (FIM) nor mortality was associated with conservative or operative treatment.nnnCONCLUSIONnBCI is rare and carries a poor prognosis. Operative intervention is not associated with functional improvement or a survival advantage. This study was unable to support that less invasive endovascular treatment improves treatment outcome when compared to open surgery.

Limited predictive ability of surrogate indices of insulin sensitivity/resistance in Asian-Indian men

BACKGROUNDnPatients in need of lower extremity amputation are often debilitated and have coronary artery disease and underlying anemia. The transfusion of blood is a common practice in the perioperative management of these patients. However, blood transfusion has been reported to have a negative effect on the incidence of perioperative complications in other patient populations. We undertook this study to determine the effect of blood transfusion on the incidence of adverse postoperative events in patients undergoing major amputations.nnnMETHODSnWe conducted a retrospective review of 300 consecutive patients undergoing either above-knee or below-knee amputation over a 5-year period at our institution. The demographic variables, medical comorbidities, need for blood transfusion, and clinical outcomes were recorded. The impact of blood transfusion on clinical outcome was analyzed.nnnRESULTSnOf the 300 patients undergoing major amputation, 191 (64%) had one or more blood transfusions. The demographic variables and incidence of medical comorbidities were comparable between the two groups. Patients undergoing blood transfusion were 2.5 more likely to suffer from a postoperative cardiac arrhythmia, 12.8 times more likely to develop acute renal failure, 5.7 times more likely to have pneumonia, and 2.2 times more likely to have a urinary tract infection. Each of these adverse postoperative events was statistically more likely in the transfused group. The postoperative mortality was 13% for the transfused group and 6% for those not transfused, which was a nonsignificant difference. The intensive care unit stay and overall hospital stay were significantly longer in patients who had blood transfusions (difference of 2.1 and 5.4 days, respectively).nnnCONCLUSIONnBlood transfusion in patients undergoing major lower extremity amputation is associated with an increased incidence of adverse postoperative events and prolonged intensive care unit and hospital stays. We therefore suggest a restricted approach to blood transfusion in patients requiring major amputation.

Utility of Brain Natriuretic Peptide as a Predictor of Atrial Fibrillation After Cardiac Operations

AIMSnTo investigate the association of pericardial, mediastinal, and intrathoracic fat volumes with the presence and severity of coronary artery disease (CAD), metabolic syndrome (MS), and cardiac risk factors (CRFs).nnnMETHODS AND RESULTSnTwo hundred and sixteen consecutive patients who underwent cardiac magnetic resonance (CMR) imaging and had a coronary angiogram within 12 months of the CMR were studied. Fat volume was measured by drawing region of interest curves, from short-axis cine views from base to apex and from a four-chamber cine view. Pericardial fat, mediastinal fat, intrathoracic fat (addition of pericardial and mediastinal fat volumes), and fat ratio (pericardial fat/mediastinal fat) were analysed for their association with the presence and severity of CAD (determined based on the Duke CAD Jeopardy Score), MS, CRFs, and death or myocardial infarction on follow-up. Pericardial fat volume was significantly greater in patients with CAD when compared with those without CAD [38.3 ± 25.1 vs. 31.9 ± 21.4 cm(3) (P = 0.04)]. A correlation between the severity of CAD and fat volume was found for pericardial fat (β = 1, P < 0.01), mediastinal fat (β = 1, P = 0.03), intrathoracic fat (β = 2, P = 0.01), and fat ratio (β = 0.005, P = 0.01). These correlations persisted for all four thoracic fat measurements even after performing a stepwise linear regression analysis for relevant risk factors. Patients with MS had significantly greater mediastinal and intrathoracic fat volumes when compared with those without MS [126 ± 33.5 vs. 106 ± 30.1 cm(3) (P < 0.01) and 165 ± 54.9 vs. 140 ± 52 cm(3) (P < 0.01), respectively]. However, there was no significant difference in pericardial fat, mediastinal fat, intrathoracic fat, or fat ratio between patients with or without myocardial infarction during the follow-up [33.6 ± 22.1 vs. 35.7 ± 23.8 cm(3) (P = 0.67); 115 ± 26.2 vs. 114 ± 33.8 cm(3) (P = 0.84); 149 ± 44.7 vs. 150 ± 55.7 cm(3) (P = 0.95); and 0.27 ± 0.15 vs. 0.28 ± 0.14 (P = 0.70), respectively]. There was no significant difference in pericardial fat, mediastinal fat, intrathoracic fat, or fat ratio between patients who were alive compared with those who died during follow-up [36.6 ± 26.6 vs. 35.3 ± 23.2 cm(3) (P = 0.76); 114 ± 40.2 vs. 114 ± 31.4 cm(3) (P = 0.95); 150 ± 64.7 vs. 149 ± 52.5 cm(3) (P = 0.92); and 0.29 ± 0.15 vs. 0.28 ± 0.14 (P = 0.85), respectively].nnnCONCLUSIONnOur study confirms an association between pericardial fat volume with the presence and severity of CAD. Furthermore, an association between mediastinal and intrathoracic fat volumes with MS was found.

Improving Patient Flow in Acute Coronary Syndromes in the Face of Hospital Crowding

BackgroundA validated tool has long been sought to provide clinicians with a uniform and accurate method to assess hydration status in the pediatric emergency medicine population. Outpatient clinicians use CDC height- and weight-based curves for the assessment of physical development. In hospital, daily weights provide objective data; however, these are usually not available at presentation.One of the most promising techniques for the rapid assessment of volume is ultrasound (US) to obtain an indexed inferior vena cava diameter (IVCDi); as previously described. Prior studies have focused on IVCDi in dehydrated patients and have shown that it provides accurate estimates of right atrial pressure and volume status. The objective of this study is to derive an IVC growth curve in healthy pediatric patients.MethodsProspective cohort design enrolled healthy children between the ages of 4 weeks and 20 years. Patients presenting with fever, illnesses, or diagnoses known to affect the volume will be excluded. All eligible patients under 21, who have provided self or parental written consent, will undergo a brief ultrasound to obtain transverse and long images of both the IVC and the aorta; all scans will be digitally saved. Image quality will be subjectively rated as poor, fair, or good based on wall clarity. Poor quality images will be recorded but may be omitted from our analysis. Five clinicians completed a 1-h introduction to IVC-US and ten supervised scans prior to enrollment. Still images will be measured in order to determine IVCDi in both transverse and longitudinal planes. To assess inter-rater reliability, in 10% of cases, two clinicians will complete scans. All study scans will be over-read by a fellowship-trained sonologist.IVCDi will be plotted independently as functions of age, gender, BMI, and aortic diameter. Within each group, means with means or medians with 95% CIs will be calculated. Following uni- and bivariate analyses and assessment for colinearity, a variety of parametric and nonparametric regression procedures will be conducted. The smoothed curves will be approximated using a modified LMS estimation procedure.ResultsData for the initial curve derivation includes 25 patients ranging from 13 months to 20 years (mean 102 months or 8.5 years). Sixty-five percent of patients were enrolled from the ED, while 35% were enrolled from well-child clinic visits. When evaluating the size of IVC as a function of time linear growth, increasing size was found to proportionately increase with age of patient in months.ConclusionsData suggest a linear correlation between IVC size and age. Such data, when plotted as a new growth curve, may allow clinicians to plot a patients sonographic measurements in order to assess hydration health.

Authorship, collaboration, and predictors of extramural funding in the emergency medicine literature.

Insulin resistance is highly prevalent in Asian Indians and contributes to worldwide public health problems, including diabetes and related disorders. Surrogate measurements of insulin sensitivity/resistance are used frequently to study Asian Indians, but these are not formally validated in this population. In this study, we compared the ability of simple surrogate indices to accurately predict insulin sensitivity as determined by the reference glucose clamp method. In this cross-sectional study of Asian-Indian men (n = 70), we used a calibration model to assess the ability of simple surrogate indices for insulin sensitivity [quantitative insulin sensitivity check index (QUICKI), homeostasis model assessment (HOMA2-IR), fasting insulin-to-glucose ratio (FIGR), and fasting insulin (FI)] to predict an insulin sensitivity index derived from the reference glucose clamp method (SI(Clamp)). Predictive accuracy was assessed by both root mean squared error (RMSE) of prediction as well as leave-one-out cross-validation-type RMSE of prediction (CVPE). QUICKI, FIGR, and FI, but not HOMA2-IR, had modest linear correlations with SI(Clamp) (QUICKI: r = 0.36; FIGR: r = -0.36; FI: r = -0.27; P < 0.05). No significant differences were noted among CVPE or RMSE from any of the surrogate indices when compared with QUICKI. Surrogate measurements of insulin sensitivity/resistance such as QUICKI, FIGR, and FI are easily obtainable in large clinical studies, but these may only be useful as secondary outcome measurements in assessing insulin sensitivity/resistance in clinical studies of Asian Indians.