Comparing remission and recurrence of hypertension after bariatric surgery: vertical sleeve gastrectomy versus Roux-en-Y gastric bypass.

BACKGROUND: Bariatric surgery results in rapid weight loss and resolution of many co-morbidities including hypertension. OBJECTIVES: To investigate the association of the 2 most common bariatric surgical procedures, vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB), with sustained remission from hypertension, and evaluate other independent predictors of sustained remission. SETTING: Privately insured patients with hypertension in the United States undergoing bariatric surgery. METHODS: A cohort of hypertensive bariatric patients was created using detailed inclusion and exclusion criteria. Remission was defined as no refill of antihypertensive medication for 30 days after patients' medication was expected to run out, and recurrence as medication refill after at least 90 days of remission. RESULTS: Of 7006 patients in our cohort, 5874 experienced remission of their hypertension (83.8%). 745 of the 5874 (12.7%) patients later experienced recurrence. The adjusted hazard ratio of remission for VSG compared with RYGB was 1.06 (95% confidence interval [CI]; 1.0, 1.11). The adjusted hazard ratio of recurrence for VSG compared with RYGB was .84 (95% CI; .71, .97). A higher number of medications at the time of surgery was associated with a decreased likelihood of remission and an increased risk of recurrence of hypertension. CONCLUSION: There was no difference in the likelihood of remission of hypertension between VSG and RYGB. The number of medications at the time of surgery was the most important predictor of remission and recurrence of hypertension after surgery.

The effect of alcohol on facial Trauma outcomes: an analysis of the National Trauma Data Bank.

Maxillofacial trauma costs emergency departments approximately one billion dollars annually. Facial trauma has increased since 2000 and has been attributed to both increased use of computed tomography and interpersonal violence. Alcohol, male sex, and age 18-35 years are significant risk factors for interpersonal violence. This study is novel in using a large database to look at the effect of alcohol on clinical outcomes in facial trauma. A data analysis was performed in Stata/MP 14.2 using variables coded from the National Trauma Data Bank (NTDB); logistic regression was applied. A total 580,313 patient records were analyzed. Operations for facial fractures were performed in 20.19% of cases (n = 117,139). A positive alcohol test reduced the odds of requiring operative fixation in both the unadjusted (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.79-0.82, P < 0.001) and adjusted (OR 0.67, 95% CI 0.66-0.68, P < 0.001) models. Age and being struck (adjusted OR 1.99, 95% CI 1.91-2.07, P < 0.001) or shot (adjusted OR 1.95, 95% CI 1.84-2.06, P < 0.001) had a significant effect on operative fixation. Injury mechanisms related to interpersonal violence appeared to have higher operative fixation rates. This study did not find a correlation between acute intoxication and the need for an operative intervention. This further demonstrates the multifactorial nature of facial trauma and stresses the importance of injury and violence prevention on clinical outcomes.

Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND: Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were first addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST. METHODS: A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair. RESULTS: Sixty articles were identified. Of these, 51 articles were selected to construct the guidelines. CONCLUSION: There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically significant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.(AU)

Outcome of selective non-operative management of penetrating abdominal injuries from the North American National Trauma Database.

BACKGROUND: The aim of this study was to investigate trends in the practice of selective non-operative management (SNOM) for penetrating abdominal injury (PAI) and to determine factors associated with its failure. METHODS: The National Trauma Data Bank for 2002-2008 was reviewed. Patients with PAI were categorized as those who underwent successful SNOM (operative management not required) and those who failed SNOM (surgery required more than 4 h after admission). Yearly rates of SNOM versus non-therapeutic laparotomy (NTL) were plotted. Multivariable regression analysis was performed to identify factors associated with failed SNOM and mortality. RESULTS: A total of 12 707 patients with abdominal gunshot and 13 030 with stab wounds were identified. Rates of SNOM were 22.2 per cent for gunshot and 33.9 per cent for stab wounds, and increased with time (P < 0.001). There was a strong correlation between the rise in SNOM and the decline in NTL (r = - 0.70). SNOM failed in 20.8 and 15.2 per cent of patients with gunshot and stab wounds respectively. Factors predicting failure included the need for blood transfusion (odds ratio (OR) 1.96, 95 per cent confidence interval 1.11 to 3.46) and a higher injury score. Failed SNOM was independently associated with mortality in both the gunshot (OR 4.48, 2.07 to 9.70) and stab (OR 9.83, 3.44 to 28.00) wound groups. CONCLUSION: The practice of SNOM is increasing, with an associated decrease in the rate of NTL for PAI. In most instances SNOM is successful; however, its failure is associated with increased mortality. Careful patient selection and adherence to protocols designed to decrease the failure rate of SNOM are recommended.

Validating the Injury Severity Score (ISS) in different populations: ISS predicts mortality better among Hispanics and females.

INTRODUCTION: The Injury Severity Score (ISS) is the most commonly used measure of injury severity. The score has been shown to have excellent predictive capability for trauma mortality and has been validated in multiple data sets. However, the score has never been tested to see if its discriminatory ability is affected by differences in race and gender. OBJECTIVE: This study is aimed at validating the ISS in men and women and in three different race/ethnic groups using a nationwide database. METHODS: Retrospective analysis of patients age 18-64 y in the National Trauma Data Bank 7.0 with blunt trauma was performed. ISS was categorized as mild (<9,) moderate (9-15), severe (16-25), and profound (>25). Logistic regression was done to measure the relative odds of mortality associated with a change in ISS categories. The discriminatory ability was compared using the receiver operating characteristics curves (ROC). A P value testing the equality of the ROC curves was calculated. Age stratified analyses were also conducted. RESULTS: A total of 872,102 patients had complete data for the analysis on ethnicity, while 763,549 patients were included in the gender analysis. The overall mortality rate was 3.7%. ROC in Whites was 0.8617, in Blacks 0.8586, and in Hispanics 0.8869. Hispanics have a statistically significant higher ROC (P value < 0.001). Similar results were observed within each age category. ROC curves were also significantly higher in females than in males. CONCLUSION: The ISS possesses excellent discriminatory ability in all populations as indicated by the high ROCs.