Browsing by Subject "outcomes"
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Item Open Access Are we improving in the optimization of surgery for high-risk adult cervical spine deformity patients over time?(Journal of neurosurgery. Spine, 2023-07) Passias, Peter G; Tretiakov, Peter S; Smith, Justin S; Lafage, Renaud; Diebo, Bassel; Scheer, Justin K; Eastlack, Robert K; Daniels, Alan H; Klineberg, Eric O; Khabeish, Khaled M; Mundis, Gregory M; Turner, Jay D; Gupta, Munish C; Kim, Han Jo; Schwab, Frank; Bess, Shay; Lafage, Virginie; Ames, Christopher P; Shaffrey, Christopher IObjective
The aim of this study was to investigate whether surgery for high-risk patients is being optimized over time and if poor outcomes are being minimized.Methods
Patients who underwent surgery for cervical deformity (CD) and were ≥ 18 years with baseline and 2-year data were stratified by year of surgery from 2013 to 2018. The cohort was divided into two groups based on when the surgery was performed. Patients in the early cohort underwent surgery between 2013 and 2015 and those in the recent cohort underwent surgery between 2016 and 2018. High-risk patients met at least 2 of the following criteria: 1) baseline C2-7 Cobb angle > 15°, mismatch between T1 slope and cervical lordosis ≥ 35°, C2-7 sagittal vertical axis > 4 cm, or chin-brow vertical angle > 25°; 2) age ≥ 70 years; 3) severe baseline frailty (Miller index); 4) Charlson Comorbidity Index (CCI) ≥ 1 SD above the mean; 5) three-column osteotomy as treatment; and 6) fusion > 10 levels or > 7 levels for elderly patients. The mean comparison analysis assessed differences between groups. Stepwise multivariable linear regression described associations between increasing year of surgery and complications.Results
Eighty-two CD patients met high-risk criteria (mean age 62.11 ± 10.87 years, 63.7% female, mean BMI 29.70 ± 8.16 kg/m2, and mean CCI 1.07 ± 1.45). The proportion of high-risk patients increased with time, with 41.8% of patients in the early cohort classified as high risk compared with 47.6% of patients in the recent cohort (p > 0.05). Recent high-risk patients were more likely to be female (p = 0.008), have a lower BMI (p = 0.038), and have a higher baseline CCI (p = 0.013). Surgically, high-risk patients in the recent cohort were more likely to undergo low-grade osteotomy (p = 0.003). By postoperative complications, recent high-risk patients were less likely to experience any postoperative adverse events overall (p = 0.020) or complications such as dysphagia (p = 0.045) at 2 years. Regression analysis revealed increasing year of surgery to be correlated with decreasing minor complication rates (p = 0.030), as well as lowered rates of distal junctional kyphosis by 2 years (p = 0.048).Conclusions
Over time, high-risk CD patients have an increase in frequency and comorbidity rates but have demonstrated improved postoperative outcomes. These findings suggest that spine surgeons have improved over time in optimizing selection and reducing potential adverse events in high-risk patients.Item Open Access Decongestion strategies and renin-angiotensin-aldosterone system activation in acute heart failure.(JACC Heart Fail, 2015-02) Mentz, Robert J; Stevens, Susanna R; DeVore, Adam D; Lala, Anuradha; Vader, Justin M; AbouEzzeddine, Omar F; Khazanie, Prateeti; Redfield, Margaret M; Stevenson, Lynne W; O'Connor, Christopher M; Goldsmith, Steven R; Bart, Bradley A; Anstrom, Kevin J; Hernandez, Adrian F; Braunwald, Eugene; Felker, G MichaelOBJECTIVES: The purpose of this study was to assess the relationship between biomarkers of renin-angiotensin-aldosterone system (RAAS) activation and decongestion strategies, worsening renal function, and clinical outcomes. BACKGROUND: High-dose diuretic therapy in patients with acute heart failure (AHF) is thought to activate the RAAS; and alternative decongestion strategies, such as ultrafiltration (UF), have been proposed to mitigate this RAAS activation. METHODS: This study analyzed 427 AHF patients enrolled in the DOSE-AHF (Diuretic Optimization Strategies in Acute Heart Failure) and CARRESS-HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure) trials. We assessed the relationship between 2 markers of RAAS activation (plasma renin activity [PRA] and aldosterone) from baseline to 72 h and 96 h and decongestion strategy: high- versus low-dose and continuous infusion versus bolus furosemide for DOSE-AHF and UF versus stepped pharmacologic care for CARRESS-HF. We determined the relationships between RAAS biomarkers and 60-day outcomes. RESULTS: Patients with greater RAAS activation at baseline had lower blood pressures, lower serum sodium levels, and higher blood urea nitrogen (BUN) concentration. Continuous infusion furosemide and UF were associated with greater PRA increases (median: +1.66 vs. +0.66 ng/ml/h with continuous vs. bolus infusion, respectively, p = 0.021; +4.05 vs. +0.56 ng/ml/h with UF vs. stepped care, respectively, p = 0.014). There were no significant differences in RAAS biomarker changes with high- versus low-dose diuretic therapy (both: p > 0.5). Neither baseline log PRA nor log aldosterone was associated with increased death or HF hospitalization (hazard ratio [HR] for a doubling of 1.05; 95% confidence interval [CI]: 0.98 to 1.13; p = 0.18; and HR: 1.13; 95% CI: 0.99 to 1.28; p = 0.069, respectively). The change in RAAS biomarkers from baseline to 72 and 96 h was not associated with outcomes (both: p > 0.5). CONCLUSIONS: High-dose loop diuretic therapy did not result in RAAS activation greater than that with low-dose diuretic therapy. UF resulted in greater PRA increase than stepped pharmacologic care. Neither PRA nor aldosterone was significantly associated with short-term outcomes in this cohort. (Determining Optimal Dose and Duration of Diuretic Treatment in People With Acute Heart Failure [DOSE-AHF]; NCT00577135; Effectiveness of Ultrafiltration in Treating People With Acute Decompensated Heart Failure and Cardiorenal Syndrome [CARRESS]; NCT00608491).Item Open Access Development and validation of a unifying pre-treatment decision tool for intracranial and extracranial metastasis-directed radiotherapy.(Frontiers in oncology, 2023-01) Kowalchuk, Roman; Mullikin, Trey C; Breen, William; Gits, Hunter C; Florez, Marcus; De, Brian; Harmsen, William S; Rose, Peter Sean; Siontis, Brittany L; Costello, Brian A; Morris, Jonathan M; Lucido, John J; Olivier, Kenneth R; Stish, Brad; Laack, Nadia N; Park, Sean; Owen, Dawn; Ghia, Amol J; Brown, Paul D; Merrell, Kenneth WingBackground
Though metastasis-directed therapy (MDT) has the potential to improve overall survival (OS), appropriate patient selection remains challenging. We aimed to develop a model predictive of OS to refine patient selection for clinical trials and MDT.Patients and methods
We assembled a multi-institutional cohort of patients treated with MDT (stereotactic body radiation therapy, radiosurgery, and whole brain radiation therapy). Candidate variables for recursive partitioning analysis were selected per prior studies: ECOG performance status, time from primary diagnosis, number of additional non-target organ systems involved (NOS), and intracranial metastases.Results
A database of 1,362 patients was assembled with 424 intracranial, 352 lung, and 607 spinal treatments (n=1,383). Treatments were split into training (TC) (70%, n=968) and internal validation (IVC) (30%, n=415) cohorts. The TC had median ECOG of 0 (interquartile range [IQR]: 0-1), NOS of 1 (IQR: 0-1), and OS of 18 months (IQR: 7-35). The resulting model components and weights were: ECOG = 0, 1, and > 1 (0, 1, and 2); 0, 1, and > 1 NOS (0, 1, and 2); and intracranial target (2), with lower scores indicating more favorable OS. The model demonstrated high concordance in the TC (0.72) and IVC (0.72). The score also demonstrated high concordance for each target site (spine, brain, and lung).Conclusion
This pre-treatment decision tool represents a unifying model for both intracranial and extracranial disease and identifies patients with the longest survival after MDT who may benefit most from aggressive local therapy. Carefully selected patients may benefit from MDT even in the presence of intracranial disease, and this model may help guide patient selection for MDT.Item Open Access Effectiveness of catheter ablation of atrial fibrillation according to heart failure etiology.(Journal of arrhythmia, 2020-02) Black-Maier, Eric; Steinberg, Benjamin A; Trulock, Kevin M; Wang, Frances; Lokhnygina, Yuliya; O'Neal, Wanda; Al-Khatib, Sana; Atwater, Brett D; Daubert, James P; Frazier-Mills, Camille; Hegland, Donald D; Jackson, Kevin P; Jackson, Larry R; Koontz, Jason I; Lewis, Robert K; Sun, Albert Y; Thomas, Kevin L; Bahnson, Tristram D; Piccini, Jonathan PBackground
Catheter ablation is an important rhythm control therapy in patients with atrial fibrillation (AF) with concomitant heart failure (HF). The objective of this study was to assess the comparative efficacy of AF ablation patients with ischemic vs nonischemic heart failure.Methods
We conducted a retrospective, observational cohort study of patients with HF who underwent AF ablation. Outcomes were compared based on HF etiology and included in-hospital events, symptoms (Mayo AF Symptom Inventory [MAFSI]), and functional status (New York Heart Association class) and freedom from atrial arrhythmias at 12 months.Results
Among 242 patients (n = 70 [29%] ischemic, n = 172 [71%] nonischemic), patients with nonischemic cardiomyopathy were younger (mean age 64 ± 11.5 vs 69 ± 9.1, P = .002), more often female (36% vs 17%, P = .004), and had higher mean left-ventricular ejection fraction (47% vs 42%, P = .0007). There were no significant differences in periprocedural characteristics, including mean procedure time (243 ± 74.2 vs 259 ± 81.8 minutes, P = .1) and nonleft atrial ablation (17% vs 20%, P = .6). All-cause adverse events were similar in each group (15% vs 17%, P = .7). NYHA and MAFSI scores improved significantly at follow-up and did not differ according to HF etiology (P = .5; P = .10-1.00 after Bonferroni correction). There were no significant differences in freedom from recurrent atrial arrhythmia at 12-months between ischemic (74%) and nonischemic patients (78%): adjusted RR 0.63, 95% confidence interval 0.33-1.19.Conclusions
Catheter ablation in patients with AF and concomitant heart failure leads to significant improvements in functional and symptom status without significant differences between patients with ischemic vs nonischemic HF etiology.Item Open Access Emerging treatment options to improve cardiovascular outcomes in patients with acute coronary syndrome: focus on losmapimod.(Drug Des Devel Ther, 2015) Kragholm, Kristian; Newby, Laura Kristin; Melloni, ChiaraEach year, despite optimal use of recommended acute and secondary prevention therapies, 4%-5% of patients with acute coronary syndrome (ACS) experience relapse of ACS or other cardiovascular events including stroke, heart failure, or sudden cardiac death after the index ACS. The sudden atherosclerotic plaque rupture leading to an ACS event is often accompanied by inflammation, which is thought to be a key pathogenic pathway to these excess cardiovascular events. Losmapimod is a novel, oral p38 mitogen-activated protein kinase (MAPK) inhibitor that targets MAPKs activated in macrophages, myocardium, and endothelial cells that occur as a part of global coronary vascular inflammation following plaque rupture. This review aims to 1) discuss the pathophysiological pathways through which p38 MAPKs may play key roles in initiation and progression of inflammatory disease and how losmapimod is thought to counteract these p38 MAPKs, and 2) to describe the efficacy and safety data for losmapimod obtained from preclinical studies and randomized controlled trials that support the hypothesis that it has promise as a treatment for patients with ACS.Item Open Access Failure of nonoperative care in adult symptomatic lumbar scoliosis: incidence, timing, and risk factors for conversion from nonoperative to operative treatment.(Journal of neurosurgery. Spine, 2023-06) Clohisy, John CF; Smith, Justin S; Kelly, Michael P; Yanik, Elizabeth L; Baldus, Christine R; Bess, Shay; Shaffrey, Christopher I; Kim, Han Jo; LaBore, Adam; Pham, Vy; Bridwell, Keith HObjective
The Adult Symptomatic Lumbar Scoliosis (ASLS) study is a prospective multicenter trial with randomized and observational cohorts comparing operative and nonoperative treatment for ASLS. The objective of the present study was to perform a post hoc analysis of the ASLS trial to examine factors related to failure of nonoperative treatment in ASLS.Methods
Patients from the ASLS trial who initially received at least 6 months of nonoperative treatment were followed for up to 8 years after trial enrollment. Baseline patient-reported outcome measures (Scoliosis Research Society-22 [SRS-22] questionnaire and Oswestry Disability Index), radiographic data, and other clinical characteristics were compared between patients who did and did not convert to operative treatment during follow-up. The incidence of operative treatment was calculated and independent predictors of operative treatment were identified using multivariate regression.Results
Of 135 nonoperative patients, 42 (31%) crossed over to operative treatment after 6 months and 93 (69%) received only nonoperative treatment. In the observational cohort, 23 (22%) of 106 nonoperative patients crossed over to surgery. In the randomized cohort, 19 (66%) of 29 patients randomized to nonoperative treatment crossed over to surgery. The most impactful factors associated with crossover from nonoperative to operative treatment were enrollment in the randomized cohort and baseline SRS-22 subscore < 3.0 at the 2-year follow-up, closer to 3.4 at 8 years. In addition, baseline lumbar lordosis (LL) < 50° was associated with crossover to operative treatment. Each 1-point decrease in baseline SRS-22 subscore was associated with a 233% higher risk of conversion to surgery (hazard ratio [HR] 2.33, 95% confidence interval [CI] 1.14-4.76, p = 0.0212). Each 10° decrease in LL was associated with a 24% increased risk of conversion to operative treatment (HR 1.24, 95% CI 1.03-1.49, p = 0.0232). Enrollment in the randomized cohort was associated with a 337% higher probability of proceeding with operative treatment (HR 3.37, 95% CI 1.54-7.35, p = 0.0024).Conclusions
Enrollment in the randomized cohort, a lower baseline SRS-22 subscore, and lower LL were associated with conversion from nonoperative treatment to surgery in patients (observational and randomized) who were initially managed nonoperatively in the ASLS trial.Item Open Access Increased Heart Rate Is Associated With Higher Mortality in Patients With Atrial Fibrillation (AF): Results From the Outcomes Registry for Better Informed Treatment of AF (ORBIT-AF).(J Am Heart Assoc, 2015-09-14) Steinberg, Benjamin A; Kim, Sunghee; Thomas, Laine; Fonarow, Gregg C; Gersh, Bernard J; Holmqvist, Fredrik; Hylek, Elaine; Kowey, Peter R; Mahaffey, Kenneth W; Naccarelli, Gerald; Reiffel, James A; Chang, Paul; Peterson, Eric D; Piccini, Jonathan P; Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT‐AF) Investigators and PatientsBACKGROUND: Most patients with atrial fibrillation (AF) require rate control; however, the optimal target heart rate remains under debate. We aimed to assess rate control and subsequent outcomes among patients with permanent AF. METHODS AND RESULTS: We studied 2812 US outpatients with permanent AF in the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation. Resting heart rate was measured longitudinally and used as a time-dependent covariate in multivariable Cox models of all-cause and cause-specific mortality during a median follow-up of 24 months. At baseline, 7.4% (n=207) had resting heart rate <60 beats per minute (bpm), 62% (n=1755) 60 to 79 bpm, 29% (n=817) 80 to 109 bpm, and 1.2% (n=33) ≥110 bpm. Groups did not differ by age, previous cerebrovascular disease, heart failure status, CHA2DS2-VASc scores, renal function, or left ventricular function. There were significant differences in race (P=0.001), sinus node dysfunction (P=0.004), and treatment with calcium-channel blockers (P=0.006) and anticoagulation (P=0.009). In analyses of continuous heart rates, lower heart rate ≤65 bpm was associated with higher all-cause mortality (adjusted hazard ratio [HR], 1.15 per 5-bpm decrease; 95% CI, 1.01 to 1.32; P=0.04). Similarly, increasing heart rate >65 bpm was associated with higher all-cause mortality (adjusted HR, 1.10 per 5-bpm increase; 95% CI, 1.05 to 1.15; P<0.0001). This relationship was consistent across endpoints and in a broader sensitivity analysis of permanent and nonpermanent AF patients. CONCLUSIONS: Among patients with permanent AF, there is a J-shaped relationship between heart rate and mortality. These data support current guideline recommendations, and clinical trials are warranted to determine optimal rate control. CLINICAL TRIAL REGISTRATION: URL: http://clinicaltrials.gov/. Unique identifier: NCT01165710.Item Open Access Inpatient Burden and Mortality of Goodpasture's Syndrome in the United States: Nationwide Inpatient Sample 2003-2014.(Journal of clinical medicine, 2020-02) Kaewput, Wisit; Thongprayoon, Charat; Boonpheng, Boonphiphop; Ungprasert, Patompong; Bathini, Tarun; Chewcharat, Api; Srivali, Narat; Vallabhajosyula, Saraschandra; Cheungpasitporn, WisitBackground: Goodpasture's syndrome is a rare, life-threatening, small vessel vasculitis. Given its rarity, data on its inpatient burden and resource utilization are lacking. We conducted this study aiming to assess inpatient prevalence, mortality, and resource utilization of Goodpasture's syndrome in the United States. Methods: The 2003-2014 National Inpatient Sample was used to identify patients with a principal diagnosis of Goodpasture's syndrome. The inpatient prevalence, clinical characteristics, in-hospital treatment, end-organ failure, mortality, length of hospital stay, and hospitalization cost were studied. Multivariable logistic regression was performed to identify independent factors associated with in-hospital mortality. Results: A total of 964 patients were admitted in hospital with Goodpasture's syndrome as the principal diagnosis, accounting for an overall inpatient prevalence of Goodpasture's syndrome among hospitalized patients in the United States of 10.3 cases per 1,000,000 admissions. The mean age of patients was 54 ± 21 years, and 47% were female; 52% required renal replacement therapy, whereas 39% received plasmapheresis during hospitalization. Furthermore, 78% had end-organ failure, with renal failure and respiratory failure being the two most common end-organ failures. The in-hospital mortality rate was 7.7 per 100 admissions. The factors associated with increased in-hospital mortality were age older than 70 years, sepsis, the development of respiratory failure, circulatory failure, renal failure, and liver failure, whereas the factors associated with decreased in-hospital mortality were more recent year of hospitalization and the use of therapeutic plasmapheresis. The median length of hospital stay was 10 days. The median hospitalization cost was $75,831. Conclusion: The inpatient prevalence of Goodpasture's syndrome in the United States is 10.3 cases per 1,000,000 admissions. Hospitalization of patients with Goodpasture's syndrome was associated with high hospital inpatient utilization and costs.Item Open Access Long-term outcomes and management of the heart transplant recipient.(Best Pract Res Clin Anaesthesiol, 2017-06) McCartney, Sharon L; Patel, Chetan; Del Rio, J MauricioCardiac transplantation remains the gold standard in the treatment of advanced heart failure. With advances in immunosuppression, long-term outcomes continue to improve despite older and higher risk recipients. The median survival of the adult after heart transplantation is currently 10.7 years. While early graft failure and multiorgan system dysfunction are the most important causes of early mortality, malignancy, rejection, infection, and cardiac allograft vasculopathy contribute to late mortality. Chronic renal dysfunction is common after heart transplantation and occurs in up to 68% of patients by year 10, with 6.2% of patients requiring dialysis and 3.7% undergoing renal transplant. Functional outcomes after heart transplantation remain an area for improvement, with only 26% of patients working at 1-year post-transplantation, and are likely related to the high incidence of depression after cardiac transplantation. Areas of future research include understanding and managing primary graft dysfunction and reducing immunosuppression-related complications.Item Unknown Operative versus nonoperative treatment for adult symptomatic lumbar scoliosis at 5-year follow-up: durability of outcomes and impact of treatment-related serious adverse events.(Journal of neurosurgery. Spine, 2021-04) Smith, Justin S; Kelly, Michael P; Yanik, Elizabeth L; Baldus, Christine R; Buell, Thomas J; Lurie, Jon D; Edwards, Charles; Glassman, Steven D; Lenke, Lawrence G; Boachie-Adjei, Oheneba; Buchowski, Jacob M; Carreon, Leah Y; Crawford, Charles H; Errico, Thomas J; Lewis, Stephen J; Koski, Tyler; Parent, Stefan; Lafage, Virginie; Kim, Han Jo; Ames, Christopher P; Bess, Shay; Schwab, Frank J; Shaffrey, Christopher I; Bridwell, Keith HObjective
Although short-term adult symptomatic lumbar scoliosis (ASLS) studies favor operative over nonoperative treatment, longer outcomes are critical for assessment of treatment durability, especially for operative treatment, because the majority of implant failures and nonunions present between 2 and 5 years after surgery. The objectives of this study were to assess the durability of treatment outcomes for operative versus nonoperative treatment of ASLS, to report the rates and types of associated serious adverse events (SAEs), and to determine the potential impact of treatment-related SAEs on outcomes.Methods
The ASLS-1 (Adult Symptomatic Lumbar Scoliosis-1) trial is an NIH-sponsored multicenter prospective study to assess operative versus nonoperative ASLS treatment. Patients were 40-80 years of age and had ASLS (Cobb angle ≥ 30° and Oswestry Disability Index [ODI] ≥ 20 or Scoliosis Research Society [SRS]-22 subscore ≤ 4.0 in the Pain, Function, and/or Self-Image domains). Patients receiving operative and nonoperative treatment were compared using as-treated analysis, and the impact of related SAEs was assessed. Primary outcome measures were ODI and SRS-22.Results
The 286 patients with ASLS (107 with nonoperative treatment, 179 with operative treatment) had 2-year and 5-year follow-up rates of 90% (n = 256) and 74% (n = 211), respectively. At 5 years, compared with patients treated nonoperatively, those who underwent surgery had greater improvement in ODI (mean difference -15.2 [95% CI -18.7 to -11.7]) and SRS-22 subscore (mean difference 0.63 [95% CI 0.48-0.78]) (p < 0.001), with treatment effects (TEs) exceeding the minimum detectable measurement difference (MDMD) for ODI (7) and SRS-22 subscore (0.4). TEs at 5 years remained as favorable as 2-year TEs (ODI -13.9, SRS-22 0.52). For patients in the operative group, the incidence rates of treatment-related SAEs during the first 2 years and 2-5 years after surgery were 22.38 and 8.17 per 100 person-years, respectively. At 5 years, patients in the operative group who had 1 treatment-related SAE still had significantly greater improvement, with TEs (ODI -12.2, SRS-22 0.53; p < 0.001) exceeding the MDMD. Twelve patients who received surgery and who had 2 or more treatment-related SAEs had greater improvement than nonsurgically treated patients based on ODI (TE -8.34, p = 0.017) and SRS-22 (TE 0.32, p = 0.029), but the SRS-22 TE did not exceed the MDMD.Conclusions
The significantly greater improvement of operative versus nonoperative treatment for ASLS at 2 years was durably maintained at the 5-year follow-up. Patients in the operative cohort with a treatment-related SAE still had greater improvement than patients in the nonoperative cohort. These findings have important implications for patient counseling and future cost-effectiveness assessments.Item Open Access Outcomes After Revision Anterior Shoulder Stabilization: A Systematic Review.(Orthopaedic journal of sports medicine, 2020-05) Lau, Brian C; Johnston, Tyler R; Gregory, Bonnie P; Bejarano Pineda, Lorena; Wu, Mark; Fletcher, Amanda N; Hu, Jessica H; Ledbetter, Leila; Riboh, Jonathan CBackground
Primary shoulder stabilization is successful, but there continues to be a risk of recurrence after operative repair, particularly in the young athlete. It is important for surgeons to understand the outcomes after various revision stabilization techniques to best counsel patients and manage expectations.Purpose
To analyze recurrent instability and revision surgery rates in patients who underwent revision anterior glenohumeral stabilization procedures with either arthroscopic repair, open repair, coracoid transfer, free bone block, or capsular reconstruction.Study design
Systematic review; Level of evidence, 4.Methods
We performed a systematic review of level 2 to 4 evidence studies using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Clinical studies of revision anterior glenohumeral stabilization (arthroscopic repair, open repair, coracoid transfer, free bone block, or capsular reconstruction) with a minimum 2-year follow-up were analyzed. The rate of recurrent instability, rate of revision surgery, patient-reported outcomes, and range of motion were extracted and reported. Study methodological quality was evaluated using the Downs and Black quality assessment score.Results
A total of 37 studies met inclusion criteria and were available for analysis: 20 studies evaluated arthroscopic repair, 8 evaluated open repair, 5 evaluated Latarjet procedure, 3 evaluated bone block, and 2 evaluated capsular reconstruction. There was 1 study included in both arthroscopic and Latarjet procedures, for a total of 1110 revision cases. There was 1 level 2 study, and the remainder were level 3 or 4 with poor Downs and Black scores. Participants analyzed were most commonly young (weighted mean age, 26.1 years) and male (78.4%). The weighted mean clinical follow-up after revision surgery was 47.8 months. The weighted mean rate of recurrent instability was 3.8% (n = 245) after the Latarjet procedure, 13.4% (n = 260) after open repair, 16.0% (n = 531) after arthroscopic repair, 20.8% (n = 72) after bone block, and 31.0% (n = 35) after capsular reconstruction. The weighted mean rate of additional revision surgery was 0.0% after bone block, 0.02% after the Latarjet procedure, 9.0% after arthroscopic repair, 9.3% after open repair, and 22.8% after capsular reconstruction. Patient-reported outcomes and objective measures of range of motion and strength improved with all revision techniques.Conclusion
The current review identifies a deficiency in the literature pertaining to consistent meaningful outcomes and the effect of bone loss after revision shoulder stabilization. Published studies demonstrate, however, that revision shoulder stabilization using arthroscopic, open, coracoid transfer, or bone block techniques yielded satisfactory objective and patient-reported outcomes. The Latarjet procedure exhibited the lowest recurrent instability rate. This study confirms that recurrent instability remains a common problem, despite revision shoulder stabilization. The quality of research in revision shoulder stabilization remains poor, and higher quality studies are needed to establish best practices for treatment of this complex problem.Item Open Access Patterns of care quality and prognosis among hospitalized ischemic stroke patients with chronic kidney disease.(J Am Heart Assoc, 2014-06-05) Ovbiagele, Bruce; Schwamm, Lee H; Smith, Eric E; Grau-Sepulveda, Maria V; Saver, Jeffrey L; Bhatt, Deepak L; Hernandez, Adrian F; Peterson, Eric D; Fonarow, Gregg CBACKGROUND: Relatively little is known about the quality of care and outcomes for hospitalized ischemic stroke patients with chronic kidney disease (CKD). We examined quality of care and in-hospital prognoses among patients with CKD in the Get With The Guidelines-Stroke (GWTG-Stroke) program METHODS AND RESULTS: We analyzed 679 827 patients hospitalized with ischemic stroke from 1564 US centers participating in the GWTG-Stroke program between January 2009 and December 2012. Use of 7 predefined ischemic stroke performance measures, composite "defect-free" care compliance, and in-hospital mortality were examined based on glomerular filtration rate (GFR) categorized as a dichotomous (+CKD as <60) or rank-ordered variable: normal (≥ 90), mild (≥ 60 to <90), moderate (≥ 30 to <60), severe (≥ 15 to <30), and kidney failure (<15 or dialysis). There were 236 662 (35%) ischemic stroke patients with CKD. Patients with severe renal dysfunction or failure were significantly less likely to receive guideline-based therapies. Compared with patients with normal kidney function (≥ 90), those with CKD (adjusted OR 0.91 [95% CI: 0.89 to 0.92]), moderate dysfunction (adjusted OR 0.94 [95% CI: 0.92 to 0.97]), severe dysfunction (adjusted OR 0.80 [95% CI: 0.77 to 0.84]), or failure (adjusted OR 0.72 [95% CI: 0.68 to 0.0.76]), were less likely to receive 100% defect-free care measure compliance. Inpatient mortality was higher for patients with CKD (adjusted odds ratio 1.44 [95% CI: 1.40 to 1.47]), and progressively rose with more severe renal dysfunction. CONCLUSIONS: Despite higher in-hospital mortality rates, ischemic stroke patients with CKD, especially those with greater severity of renal dysfunction, were less likely to receive important guideline-recommended therapies.Item Open Access Racial and Ethnic Differences in Treatment and Outcomes of Severe Aortic Stenosis: A Review.(JACC. Cardiovascular interventions, 2020-01) Wilson, Jimica B; Jackson, Larry R; Ugowe, Francis E; Jones, Terrell; Yankey, George SA; Marts, Colin; Thomas, Kevin LAortic stenosis (AS) is among the most common valvular heart diseases encountered in the United States. In this review the authors examine differences between racial and ethnic groups in the epidemiology and management of severe AS, explore potential explanations for these findings, and discuss the implications for improving the delivery of care to racially and ethnically diverse populations. Underrepresented racial and ethnic groups experience a paradoxically lower prevalence or incidence of AS relative to white subjects, despite having a higher prevalence of traditional risk factors. Historically, UREGs with severe AS have had lower rates of both surgical and transcatheter aortic valve replacement and experienced more post-surgical complications, including, bleeding, worsening heart failure, and rehospitalization. Last, UREGs with severe AS have an increased risk for morbidity and mortality relative to white patients. To date much of the research on AS has examined black-white differences, so there is a need to understand how other racial and ethnic groups with severe AS are diagnosed and treated, with examination of their resulting outcomes. Overall, racial and ethnic disparities in health care access and care delivery are a public health concern given the changing demographics of the U.S. population. These differences in AS management and outcomes highlight the need for additional research into contributing factors and appropriate interventions to address the lower rates of aortic valve replacement and higher morbidity and mortality among UREGs.Item Open Access Regional anesthesia for the trauma patient: improving patient outcomes.(Local Reg Anesth, 2015) Gadsden, Jeff; Warlick, AliciaTrauma is a significant health problem and a leading cause of death in all age groups. Pain related to trauma is frequently severe, but is often undertreated in the trauma population. Opioids are widely used to treat pain in injured patients but have a broad range of undesirable effects in a multitrauma patient such as neurologic and respiratory impairment and delirium. In contrast, regional analgesia confers excellent site-specific pain relief that is free from major side effects, reduces opioid requirement in trauma patients, and is safe and easy to perform. Specific populations that have shown benefits (including morbidity and mortality advantages) with regional analgesic techniques include those with fractured ribs, femur and hip fractures, and patients undergoing digital replantation. Acute compartment syndrome is a potentially devastating sequela of soft-tissue injury that complicates high-energy injuries such as proximal tibia fractures. The use of regional anesthesia in patients at risk for compartment syndrome is controversial; although the data is sparse, there is no evidence that peripheral nerve blocks delay the diagnosis, and these techniques may in fact facilitate the recognition of pathologic breakthrough pain. The benefits of regional analgesia are likely most influential when it is initiated as early as possible, and the performance of nerve blocks both in the emergency room and in the field has been shown to provide quality pain relief with an excellent safety profile.Item Open Access Systematic Postoperative Nausea Prophylaxis Feedback Improves Clinical Performance in Anesthesiology Residents.(J Educ Perioper Med, 2015-07) Greene, Nathaniel H; Norstedt, Peter A; Nair, Bala G; Souter, Karen JBACKGROUND: Electronic medical records can generate a wealth of information regarding compliance with perioperative clinical guidelines as well as patient outcomes. Utilizing this information to provide resident physicians with measures of their own clinical performance may positively impact residents' clinical performance. We hypothesize that providing residents with objective measures of their individual adherence to evidence based postoperative nausea and vomiting (PONV) management protocols will improve their compliance with standardized treatment methods. METHODS: We conducted a retrospective baseline analysis of junior anesthesiology residents' compliance with PONV prophylaxis guidelines for high-risk patients. This was followed by a prospective cohort study, before and after an educational intervention, a 15 minute lecture on PONV prophylaxis. The number of pharmacologic prophylactic interventions were tabulated for each operative case and reported back to individual residents in blind and anonymous fashion. The primary outcome was the use of two or more prophylactic interventions for a high-risk patient, while the secondary outcome was the use of three or more prophylactic interventions. A follow up survey was administered to participating residents regarding the use of their individualized clinical performance. RESULTS: After implementation of feedback, patients received a significantly higher amount of PONV prophylactic treatments (p=0.001, means of 1.35 vs. 1.99). Comparison of percentage compliance was 38% vs 73%, respectively (p<0.001). In a follow up survey, residents received the feedback intervention well and had no significant concern in the dissemination of deidentified performance outcomes publically. CONCLUSIONS: Resident compliance with PONV treatment guidelines was improved merely by auditing performance and providing individualized feedback. High-risk patients appear to receive more prophylactic agents after performance feedback and may be more effective than a more commonly used educational intervention to address the same topic. Providing direct performance feedback may be a useful tool for integration into graduate medical education programs.Item Open Access The nephroureterectomy: a review of technique and current controversies.(Translational andrology and urology, 2020-12) Barton, Gregory J; Tan, Wei Phin; Inman, Brant AThe nephroureterectomy (NU) is the standard of care for invasive upper tract urothelial carcinoma (UTUC) and has been around for well over one hundred years. Since then new operative techniques have emerged, new technologies have developed, and the surgery continues to evolve and grow. In this article, we review the various surgical techniques, as well as present the literature surrounding current areas of debate surrounding the NU, including the lymphatic drainage of the upper urinary tract, management of UTUC involvement with the adrenals and caval thrombi, surgical management of the distal ureter, the use of intravesical chemotherapy as well as perioperative systemic chemotherapy, as well as various outcome measures. Although much has been studied about the NU, there still is a dearth of level 1 evidence and the field would benefit from further studies.Item Open Access Thinking Outside the Box: Treating Acute Heart Failure Outside the Hospital to Improve Care and Reduce Admissions.(J Card Fail, 2015-08) DeVore, Adam D; Allen, Larry A; Eapen, Zubin JThe management of acute heart failure is shifting toward treatment approaches outside of a traditional hospital setting. Many heart failure providers are now treating patients in less familiar health care settings, such as acute care clinics, emergency departments, and skilled nursing facilities. In this review we describe the current pressures driving change in the delivery of acute heart failure and summarize the evidence regarding treatments for acute heart failure outside of the inpatient setting. We also provide considerations for the design of future treatment strategies to be implemented in alternative care settings.