Comparison of the Comprehensive Complication Index and Clavien-Dindo systems in predicting perioperative outcomes following radical nephroureterectomy.

BACKGROUND: Complications can occur following radical nephroureterectomy (RNU) in 20-40% of patients. The Comprehensive Complication Index (CCI) is an alternative grading system to the Clavien-Dindo (CD) grading system that aggregates all complications experienced by a patient on a continuous (as opposed to categorical) scale. We investigate whether the cumulative nature of CCI renders it superior to CD in predicting perioperative course after RNU. METHODS: The records of 596 patents who underwent RNU at 7 academic medical centers from 2005 to 2015 were reviewed. Complications occurring within 30 days of RNU were annotated using both the CD and CCI classification systems. Logistic regression was used to determine associations between CD and CCI with perioperative covariates as well as measures of convalescence [hospital length of stay (LOS) and readmission]. RESULTS: A total of 377 men and 219 women with a median age of 71, BMI of 27, and Charlson comorbidity score of 4 were included. Over half underwent a minimally invasive RNU. Median LOS following RNU was 6.0 days (range, 1-37 days) and readmission within 30-days occurred in 45 (8%) patients. Overall, 136 patients (23%) experienced a post-operative complication with 91 having a single complication and 45 with multiple (range, 2-6); 44 (7%) patients had Clavien III or greater complications, and the median CCI for those patients experiencing a complication was 20.9 (range, 8.7-100). Both the upper quartile of CCI (≥75th %) and major CD complications were associated with higher baseline Charlson score, ECOG ≥2, and CKD stage ≥ III (all P<0.05). However, only the upper quartile of CCI was associated with LOS (8.9 vs. 5.4 days, P<0.01) and hospital readmission (OR 3.2, 95% CI: 1.9-5.6, P=0.02) after RNU. CONCLUSIONS: The CD and CCI classification systems both are associated with similar baseline and perioperative characteristics for RNU patients. However, the cumulative nature of the CCI allows for superior prediction of postoperative course after RNU including LOS and readmission.

Management of Open Lower Extremity Wounds With Concomitant Fracture Using a Porcine Urinary Bladder Matrix.

BACKGROUND: Open wounds of the distal third of the leg and foot with exposed bone, fractures, and hardware are challenging wounds for which to achieve stable coverage. The orthopedic advances in lower extremity fracture management over the last 30 years have allowed a rethinking of the standard operative approach to close these complex wounds. MATERIALS AND METHODS: The ability of extracellular matrix (ECM) products to facilitate constructive remodeling of a wound seemed a reasonable approach for treatment, especially in patients who are often poor surgical candidates for more advanced reconstructive procedures. RESULTS: The authors reviewed 9 patients with 11 open fractures of the leg, ankle, or foot treated with a newer ECM wound healing device to total closure. The clinical course and patient management are reviewed. CONCLUSION: The authors conclude that newer ECM products can provide a reasonable method of management for patients who have wounds with exposed hardware, distal leg wounds, and open foot fractures compared to prolonged negative pressure wound therapy or complex reconstructive operative procedures.

Management of Open Distal Lower Extremity Wounds With Exposed Tendons Using Porcine Urinary Bladder Matrix.

Open wounds of the distal third of the leg and foot with an exposed tendon present a challenge in wound management and in attaining stable, durable coverage. The mobility of the tendon often leads to chronic inflammation that impedes wound closure, while the desiccation of the exposed tendon leads to progressive tendon necrosis. For the authors' cases, the ability of extracellular matrix (ECM) products to modulate wound bed inflammation and facilitate constructive remodeling of a wound seemed a reasonable approach in treating these wounds, especially in patients who are often poor surgical candidates for more advanced reconstructive procedures. METHODS: The authors reviewed 13 patients who had open wounds of the distal third of the leg and/or foot that had associated tendon involvement in the wound (Achilles, 6; tibialis anterior, 6; and peroneal, 1). Patients' wounds were treated to total closure. The clinical course and patient management is reviewed herein. RESULTS: The authors found newer ECM products can provide a more optimal method of management of patients with exposed tendons, as compared to prolonged negative pressure wound therapy. CONCLUSION: Furthermore, the authors conclude the use of newer ECM products yields a more stable, less scarred, reconstructed wound that more closely resembles normal foot and ankle appearance compared to other more complex reconstructive operative procedures.

Kidney Cancer in Rural Illinois: Lower Incidence Yet Higher Mortality Rates.

OBJECTIVE: To determine if rural status was associated with kidney and renal pelvis cancer (KCa) incidence and mortality in Illinois while controlling for known KCa risk factors and access to care variables. MATERIALS AND METHODS: Age-adjusted KCa incidence rates from 1991 to 2010 were calculated from Illinois State Cancer Registry data. Age-adjusted KCa mortality rates were obtained from health statistics embedded within SEER*Stat. Rural Urban Continuum Codes designated Illinois' 102 counties as urban, rural adjacent to, and rural non-adjacent to a metropolitan area. County-level demographics and physician density were obtained from the Area Health Resource File. Behavioral Risk Factor Surveillance System data were used for smoking, obesity, and hypertension prevalence. Analysis of variance, correlation, and regression analyses were used. RESULTS: The incidence of KCa was found to be higher among urban compared to rural counties after controlling for known risk factors (P < .01). A larger proportion of cases were diagnosed at a localized stage in urban counties (<0.01). Mortality rates were significantly higher in rural counties (P = .02). The final regression model found rural status, higher incidence rate, fewer with localized stage at diagnosis, and lower urologist density to be variables significantly associated with higher KCa mortality. CONCLUSION: KCa incidence was higher in urban counties whereas mortality was higher in rural counties. The higher number of KCa cases diagnosed at a localized stage in urban counties and lower urologist density in rural counties suggest that poorer access to care may contribute to higher KCa mortality in rural Illinois. Telemedicine may be an opportunity to improve this disparity.

War wounds: lessons learned from Operation Iraqi Freedom.

BACKGROUND: This study reports the experience of the plastic surgery department at Naval Medical Center San Diego in treating wounds resulting from combat during Operation Iraqi Freedom. Introduction of new technology and modification of medical treatments have emerged to provide greater success in preserving life and limb. METHODS: The authors conducted a retrospective review of all Navy and Marine Corps casualties treated by the authors' department between April of 2003 and December of 2005. All medical information surrounding the patients' treatment and medivac rosters were used to collect the data. RESULTS: The authors treated 68 patients, who underwent 240 operations. The age distribution was consistent with military enlistments (19 to 38 years). The majority of injuries were from blast (55 percent) and gunshot wounds (19 percent). The extremities were the site of injury in 91.2 percent of patients, with lower extremity wounds outnumbering upper extremity wounds approximately 2:1. The authors' wound management technique incorporated an aggressive surgical and antibiotic protocol, antibiotic-impregnated beads, and wound vacuum-assisted closure. The authors' limb salvage rate was high at 93.6 percent, with three amputations performed for flap failure. The acute osteomyelitis rate was 24.2 percent and the chronic osteomyelitis rate was 1.6 percent. CONCLUSIONS: The authors' results reflect a higher limb salvage rate than that achieved during previous wars. They feel their success was attributable to the use of wound vacuum-assisted closure, an aggressive surgical approach, and appropriate antibiotic therapy. Wound vacuum-assisted closure is the single intervention that is new among the authors' choices of techniques for treating combat wounds.