Impact of cardiovascular risk factors and disease on length of stay and mortality in patients with acute coronary syndromes.

BACKGROUND: Traditional risk factors for cardiovascular disease (CVD) have been thoroughly investigated. We aimed to investigate the impact of comorbid cardiovascular risk factors and diseases on length of stay (LOS) and mortality in patients presenting with acute coronary syndromes (ACS). METHODS: We examined prevalence of CVD, LOS and mortality from 25,287 consecutive admissions for ACS from seven hospitals across North West England between 2000 and 2013 using the ACALM (Algorithm for Comorbidities, Associations, Length of stay and Mortality) protocol using ICD-10 and OPCS-4 coding systems. RESULTS: Mean LOS was 7.0days and there were 9653 (38.2%) deaths in the ACS cohort over the 13-year period. Hypertension and hyperlipidaemia were associated with decreased LOS (6.95 and 4.8days respectively, P<0.001) and mortality (36.8% and 19.4% respectively, P<0.001), as was angina pectoris (5.4days and 33.5%, P<0.001). Type 2 diabetes was associated with increased LOS and mortality (7.8days, P<0.05; 44.4%, P<0.001), whereas type 1 diabetes was associated with increased mortality only (7.0days, P=0.42; 41.3%, P<0.001). Other concomitant CVD was associated with an increased LOS and mortality: peripheral vascular disease (8.6days, P<0.05; 53%, P<0.001), atrial fibrillation (10.9days, P<0.001; 63.5%, P<0.001), cerebrovascular disease (15.9days, P<0.001; 76%, P<0.001), heart failure (11days, P<0.001; 69.9%, P<0.001), and ischaemic heart disease (6.7days, P<0.001; 38.7%, P<0.05). CONCLUSION: CVD risk factors have a significant and varied impact on LOS and mortality in patients with ACS and it may be inappropriate to group them when assessing in-hospital risk. These factors should be used to identify patients at an increased risk of prolonged admissions and death post-ACS, and services should be directed accordingly.

Body weight, body image and primary postpartum haemorrhage: a review of the literature.

The prevalence of obesity during pregnancy is rising. Elevated BMI is a significant risk factor for adverse maternal and fetal outcomes, including primary postpartum haemorrhage (PPH). Addressing the issues surrounding obesity in pregnancy presents many biological, social and psychological challenges. BMI is an easily measured and modifiable anthropometrical risk factor and should be recorded in all pregnancies. BMI should be proactively managed prior to and during pregnancy. All women should be educated as to the risks of an elevated BMI during pregnancy and those at risk should have access to specialist medical and surgical support if required. Our aim was to investigate the associations between elevated BMI and adverse maternal and fetal outcomes including PPH, and to explore the psychological challenges of having an elevated BMI during pregnancy.

How does subintimal angioplasty compare to transluminal angioplasty for the treatment of femoral occlusive disease?

A best evidence topic in surgery was written according to a structured protocol. The question addressed how subintimal angioplasty (SIA) compares to transluminal angioplasty (TA) for the treatment of femoral occlusive disease. One hundred and thirty two papers were found using the reported search; the 5 which represented the best evidence to answer the question are discussed. The evidence on this subject is limited; there are no randomised controlled trials (RCTs) comparing SIA to TA for pathologically equivalent lesions. However SIA remains a safe and effective alternative to surgical bypass grafting when TA cannot be performed.

Should infected laparotomy wounds be treated with negative pressure wound therapy?

A best evidence topic in surgery was written according to a structured protocol. The question addressed whether there is any benefit in treating infected laparotomy wounds with negative pressure wound therapy (NPWT). Forty-five papers were found using the reported search; of which 4 represented the best evidence to answer the question. The evidence on this subject is limited; there is a single non-randomised controlled trial, 2 prospective cohort studies, and 1 retrospective cohort study discussed in this paper. From the available literature, the use of NPWT in infected laparotomy wounds does reduce the length of hospital stay, the number of dressing changes required and promote faster wound healing.

Is open surgery or endovascular therapy best to treat acute mesenteric occlusive disease?

A best evidence topic in vascular surgery was written according to a structured protocol. The question addressed whether endovascular treatment improved peri-operative outcomes when compared to an open approach to restore arterial perfusion in acute mesenteric occlusive disease. Four hundred and ninety seven papers were identified using the reported search; of which 4 represented the best evidence to answer the question and are discussed. The evidence on this subject is limited, comprising largely of non-randomised retrospective cohort studies. The evidence suggests that endovascular treatment is associated with reduced mortality and has better short-term peri-operative outcomes, as well as longer-term survival - however many endovascular cases require subsequent open surgery. There is also conflicting evidence to suggest endovascular therapy is associated with longer ICU stays. Aside from procedural complications, factors such as patient status, time delay to diagnosis and treatment may play a greater role in determining mortality rates. In summary, endovascular therapy appears to be a feasible treatment option with post-operative complications and inpatient mortality rates lower than those seen in open surgery.

National audit of the use of fibrinogen concentrate to correct hypofibrinogenaemia.

BACKGROUND: Massive haemorrhage occurs in a variety of clinical settings resulting in consumptive and dilutional coagulopathies leading to hypofibrinogenaemia. METHODS/MATERIALS: A prospective observational national cohort study was performed between November 2008 and June 2010 to collect safety data on the off-label use of a fibrinogen concentrate to treat acquired hypofibrinogenaemia. RESULTS: A prospective cohort of 63 patients with varying causes of hypofibrinogenaemia resulted from this data collection. A single infusion of fibrinogen concentrate was given in 49 (77%) of patients studied and 12 received more than one infusion. The median inter-quartile range (IQR) dose of fibrinogen infused was 49 (26-61) mg kg(-1). The median (IQR) fibrinogen level before and after infusion was 0.9 (0.6-1.3) and 1.8 (1.4-4.3) g L(-1), respectively (P < 0.001). In 31 patients (67%), bleeding stopped within 4 h and fibrinogen was reported to have contributed to this outcome by the treating clinicians. In 84% of cases the treating clinician reported that the use of fibrinogen concentrate reduced the rate of bleeding. Fibrinogen was associated with a statistically significant reduction in red blood cell transfusion (median 4 units before and 0 units after, P < 0.001) and fresh frozen plasma infusion (median 4 units before and 0 units after, P < 0.001). Three venous and one arterial non-fatal thrombotic events were recorded in the patients treated with fibrinogen. CONCLUSION: Fibrinogen concentrate can be used to correct hypofibrinogenaemia and may reduce blood product usage.