Clinical Outcomes of ULTRA EZY Bar vs Erich Arch Bar in Conservative Management of Maxillofacial Fractures: A Randomized Controlled Trial.

Objective: Various techniques have been employed from time to time to achieve maxillomandibular fixation, and arch bars provide an effective and versatile means of maxillomandibular fixation, and however, some of the issues occurring with it have been eliminated with the introduction of Ultralock EZY bar. The aim of the present study is to compare the advantages and disadvantages of Ultralock Ezy bar over the Erich arch bar in mid-face fracture or maxillary fracture or mandibular fracture or both requiring conservative treatment. Materials and Methods: A total of 20 patients reported to the Department of Oral and Maxillofacial Surgery in Sudha Rustagi Dental College and Hospital, Faridabad, with mid-face fracture/maxillary fracture, mandibular fracture or both. The treatment plan required intermaxillary fixation. As a part of treatment plan, group was selected randomly divided into 20 arches in each group that is test arch group and control arch group.Test arch group included arches in which Ultralock EZY bar was done. Control arch group included arches in which Erich arch bar was done. The parameters compared in both the groups were surgical time taken, injuries due to wires, arch bar stability, oral hygiene index, patient acceptance and comfort, pulp vitality, and complication (if any). Results: The average surgical time taken was less, and oral hygiene status and patient acceptance were better in test group. There was not much statistically significant difference in pulp vitality but number of cases with absence of pulp vitality were more in test group. Conclusion: This study emphasizes the use of Ultralock Ezy bar as a quick and easy method than Erich arch bar. Oral hygiene maintenance was comparatively better in patients with Ultralock Ezy bar than those with Erich arch bar. For the patients who require long-term IMF, Ultralock Ezy bars can be a viable option. Supplementary Information: The online version contains supplementary material available at 10.1007/s12663-022-01821-3.

Incidence and Clinical Presentation of Temporo-Mandibular Joint Disorders and their Association with Psychological Distress and Para-Functional Habits in a Non-Patient Population.

Purpose: The study aims at finding the incidence of temporo-mandibular joint disorders (TMDs) in a non-patient population and relates their association with psychological distress and parafunctional habits. Materials and Methods: A DC/TMD questionnaire and DASS-21 scale survey were completed by selected participants followed by clinical examination of TMDs symptoms in sample population. Results: A study sample of 855 participants revealed 36.65% population with various TMDs symptoms, while 63.5% population had no TMDs symptoms. 50.8% study participants were men, and 49.2% were women. Of all affected population, 16.2% had pain-related TMDs, 12.39% had intra-articular TMDs symptoms, and 8.07% had TMJ pain associated with pain or dysfunction. For all TMDs symptoms groups, the strongest correlations were for depression, while no significant associations were observed with parafunctional habits in all groups. Conclusions: Overall psychological distress and anxiety increased the prospects of TMDs symptoms. Clinical factors like muscle tenderness, crossbite and deep vertical overlap seem to be significant etiological factors, while angle molar relationship and parafunctional habits do not seem to be significant etiologic factors in TMDs.

Minimally traumatic extraction techniques in nonrestorable endodontically treated teeth: A comparative study.

Aim: The goal of this study was to assess the effectiveness of piezotome as compared to periotome extractions of nonrestorable endodontic treatment of teeth in terms of operational time, pain control, and postoperative bone loss considering the prosthetic rehabilitation in future. Materials and Methods: A double-blind, randomized controlled trial was conducted with 100 patients who wanted single-rooted teeth to be extracted (which failed endodontically). The participants have been randomized into two equal groups named as - (i) a periotome group (ii) and a piezotome group. Duration of the surgery, postoperative pain within 7 days, complications (if any) associated with the extraction process were performed as a part of clinical assessment. Bone loss has been analyzed 6 months after the surgery radiographically. The data have been recorded and analyzed using the version 22.0 of the SPSS software package. Results: All parameters in the periotome category (P < 0.05) were statistically significant except for bone loss and gingival laceration in comparison to piezotome group. In the piezotome group, a longer time was observed for surgery and delayed pain control was achieved. In our study, we found statistically significant more marginal bone loss in piezotome group in comparison with periotome group. Conclusion: The findings of this study indicate that for intraoperative and postoperative comfort periotome could be used as a safer and cheaper option for atraumatic extractions but piezosurgery may prove as a better choice soon for surgeries in the maxillofacial region to maintain soft-tissue integrity.

Impact of ophthalmic webinars on the resident's learning experience during COVID-19 pandemic: An insight into its present and future prospects.

PURPOSE: To analyze the impact of ophthalmic webinars on the resident's learning experience during the COVID-19 pandemic (CP). METHODS: This cross-sectional nationwide study was carried out for 1 month during CP and included a total of 382 ophthalmic residents. A questionnaire was sent through various social media platforms. RESULTS: Residents expressed a decline in their clinical exposure (74%; 220), thesis work (58%; 218), and acquisition of the knowledge and skills (42.5%; 161) during CP. Benefits of webinars as perceived by the residents included gain in additional knowledge (77%; 286), feedback on queries (56%; 209), access to multiple speakers (50%; 191), and topics (30%; 110). Nearly 75% (291) of residents endorsed webinars as good to the very good academic tool, and 54% (202) preferred to continue attending webinars in the post-CP phase. However, connectivity/download/data issues (54%; 200) followed by loss of personal touch (53%; 188), lengthy or irrelevant topic (37%; 134), and poor transmission quality (33%; 121) were major deterrents against the webinar. CONCLUSION: The current study generated overall mixed responses from the ophthalmic postgraduate residents in favor of webinars. In the present format, webinars bear enormous potentials to supplement the traditional learning tools by providing uninterrupted learning experiences. However, they are still limited by their pedagogical and technical issues.

Evaluation of polycaprolactone scaffold for guided bone regeneration in maxillary and mandibular defects: A clinical study.

OBJECTIVE: This study was carried out to assess bone regeneration following the use of polycaprolactone (PCL) scaffold in maxillary and mandibular osseous defects. MATERIALS AND METHODS: This prospective study included ten patients with maxillary or mandibular osseous defects present due to enucleation of periapical cysts or alveolar clefts requiring bone grafting and for lateral ridge augmentation that were treated with PCL scaffold. The patients were assessed clinically for pain, swelling, infection, and graft exposure at 1 week, 3rd, and 5th month postoperatively and were also evaluated radiographically for bone fill using intraoral periapical and/or panoramic radiographs at 4th, 6th, and 9th month postoperatively. RESULTS: PCL scaffold was used in a total of six alveolar clefts and three cases of periapical cysts and one case of lateral ridge augmentation. Nine out of ten cases demonstrated wound dehiscence and scaffold exposure in the oral cavity. Radiographically, on comparison to the control regions, all these nine cases failed to demonstrate appreciable bone density gain. Only one case of radicular cyst in the mandible was recorded to have satisfactory healing. CONCLUSION: Although PCL scaffold has the potential for bone regeneration in osseous defects, the scaffold exhibited marked tendency for dehiscence in intraoral defects that significantly affected bone healing. A long-term study designed with a larger sample size and categorization of the defects is required to assess its efficacy in varied defects. Moreover, comparative evaluation of PCL and autogenous or alloplastic bone grafting material could provide assenting results.

Platelet derived growth factor-BB levels in gingival crevicular fluid of localized intrabony defect sites treated with platelet rich fibrin membrane or collagen membrane containing recombinant human platelet derived growth factor-BB: A randomized clinical and biochemical study.

BACKGROUND: Development of autologous and recombinant growth factor/matrix combination products represent a new emerging trend in regenerative therapeutics and have gained increasing attention as a strategy to optimize tissue regeneration. The aim of the present study was to evaluate the levels of platelet derived growth factor-BB (PDGF-BB) in gingival crevicular fluid (GCF) during early healing period after the regenerative treatment of intrabony defects using beta tricalcium phosphate (ß-TCP) as a bone regeneration material with either platelet rich fibrin (PRF) membrane or collagen membrane (CM) treated with recombinant human PDGF-BB (rhPDGF-BB). METHODS: Twenty patients (13 males and 7 females) with chronic periodontitis participated in this prospective, randomized clinical and biochemical study. Each patient was randomly assigned to PRF membrane (group A) or CM incorporated with rhPDGF-BB (group B). GCF samples were obtained on days 3, 7, 14, and 30 for evaluation of PDGF-BB levels and alkaline phosphatase (ALP) levels. RESULTS: On days 3 and 7 following surgery, mean levels of PDGF-BB at sites treated with PRF membrane or CM incorporated with rhPDGF-BB as a barrier membrane were not significantly different. PDGF-BB levels decreased significantly in samples collected on days 14 and 30 with significant differences between both the groups. ALP levels significantly increased from day 3 to day 30 but there was no difference between two groups. CONCLUSION: Within the limitations of the study, both PRF membrane and CM incorporated with rhPDGF-BB showed comparable GCF levels of PDGF-BB initially with PRF showing more sustained levels throughout the study period.

Quantification and Comparison of the Impact of the Smoking Status on Oral Polymorphonuclear Leukocyte and Malondialdehyde Levels in Individuals with Chronic Periodontitis: A Double-Blinded Longitudinal Interventional Study.

BACKGROUND: The formation of reactive oxygen species by oral polymorphonuclear leukocytes (oPMNs) is amplified in smokers with chronic periodontitis (CP) causing tissue damage which can be measured by quantifying levels of malondialdehyde (MDA). OBJECTIVE: To quantify and compare the impact of smoking status on oPMN and MDA in individuals with CP before and after scaling and root planing (SRP). MATERIALS AND METHODS: Sixty individuals were divided into four groups, namely, periodontally healthy (Group A), current smokers with CP (Group B), former smokers with CP (Group C), and nonsmokers with CP (Group D). Parameters assessed were bleeding on probing (BOP), gingival index (GI), probing pocket depth (PPD), clinical attachment level, gingival recession, periodontal inflamed surface area, salivary MDA, and oPMN at baseline and 6 and 12 weeks after SRP. RESULTS: Increased PPD (P = 0.01) and decreased GI (P = 0.021) was noted in Group B as compared to C and D at baseline. Periodontal intervention caused a greater resolution of inflammation in Groups C and D as compared to B as noted from the GI and BOP. A reduction in MDA (P = 0.074) was noted in Groups C and D as compared to B, and oPMN levels were higher (P = 0.009) in Group C and D as compared to B. CONCLUSION: Greater periodontal destruction is seen in current smokers than former and nonsmokers with CP. MDA can be considered as a reliable biomarker for oxidative stress as it directly correlates with the oPMN levels.

In silico analysis of nsSNPs in ABCB1 gene affecting breast cancer associated protein P-glycoprotein (P-gp).

Breast cancer is one of the most common cancers among women and increased expression of some polymorphic genes, which is rare within families, enhances the risk of breast cancer incidence. The correct identification of the functional SNPs of such genes is important for characterizing the functional aspect of these SNPs which can be assessed by evaluating their significant influence on the structure and function of proteins. Since the presence of SNPs in these genes affects the quality of life of a breast cancer patient, thus, the associated diagnostic markers have a reliable potential for assessing the prognosis of breast cancer. ATP-binding cassette (ABC) genes have been shown to obstruct the treatment of breast cancer by providing resistance to malignant cells from anti-cancer drugs. Some allelic variants of ABCG2 and ABCB1 are also associated with occurrence of skin toxicity during the treatment of breast cancer with anti-cancer drugs. The present study has incorporated comprehensive bioinformatics analysis to explore the possible disease-associated mutations of ABCB1 gene, a gene that resulted from gene-environment interaction study, and understand their consequential effect on the structural and functional behavior of P-glycoprotein. Two gene variants (R538S and M701R) of P-glycoprotein were selected as potentially detrimental point mutations, and these variants were modeled. Molecular dynamic simulation (MDS) studies unraveled the atomic interactions and motion trajectories of the native as well as the two mutant (R538S and M701R) structures and were predicted to have a deleterious effect on breast cancer associated P-gp. Thus, the present study may broaden the way to design novel potent drugs for overcoming the problems associated with multidrug resistance (MDR) resulting from a change in protein conformation due to a mutation in ABCB1 gene.

Effects of two desensitizing dentifrices on dentinal tubule occlusion with citric acid challenge: Confocal laser scanning microscopy study.

BACKGROUND: Dentin hypersensitivity results when patent tubules are exposed to pain-inducing external stimuli. AIM: This study aims to compare the effects of two desensitizing dentifrices containing NovaMin and arginine on dentinal tubule occlusion with and without citric acid challenge in vitro using confocal laser scanning microscopy (CLSM). MATERIALS AND METHODS: Forty dentin discs were randomly divided into Groups I and II containing twenty specimens each, treated with NovaMin and arginine-containing dentifrices, respectively. Groups I and II were divided into subgroups A and B where IA and IIA underwent CLSM analysis to determine the percentage of tubule occlusion while IB and IIB underwent 0.3% citric acid challenge and CLSM analysis. A novel grading system was devised to categorize tubule occlusion. RESULTS: In Group II, the percentage of occluded tubules was highest for IIA (72.25% ± 10.57%) and least for IIB (42.55% ± 8.65%) having statistical significance (P < 0.0005). In Group I, the difference between IA (49.9% ± 12.96%) and IB (43.15% ± 12.43%) was statistically insignificant (P = 0.249). On the comparison between IB and IIB statistically indifferent result was obtained (P = 0.901), whereas the difference between IA and IIA was statistically significant (P < 0.001). The results of grading system were for IA 50% of samples belonged to Grade 2, for IIA 60% - Grade 3, and for IB 70% and for IIB 90% - Grade 2. CONCLUSION: Dentinal tubule occlusion with arginine-containing dentifrice was significantly higher than NovaMin. However, it could not resist citric acid challenge as effectively as NovaMin. The effects of NovaMin were more sustainable as compared to arginine-containing dentifrice, thus proving to be a better desensitizing agent.

Effect of Pre-Procedural Chair-Side Finger Stretches on Pinch Strength amongst Dental Cohort- A Biomechanical Study.

INTRODUCTION: Ergonomics is the essential principle behind the health and successful practice for a dentist and dental hygienist. During the procedure of dental Scaling and Root Planing (SRP), a high level of pinch force is exerted by the finger muscles resulting in early muscle fatigue. AIM: This pilot study comparatively evaluated the Pinch Strength (PS) of the finger muscles, prior to and after SRP, amongst dental cohort performing chair-side hand and finger stretches to those not performing the same. MATERIALS AND METHODS: Forty dental professionals were recruited by purposive sampling for the study and allocated into a test and control group. PS was recorded for both groups following which the test group performed finger stretches comprising of rubber band stretch, tendon glide, finger flexion and extension, thumb flexion and finger webbing. The subjects of both the groups carried out SRP for 30 minutes after which PS was again recorded. Inter-group difference was analysed for variability at baseline and 30 minutes after SRP using independent samples/unpaired t-test. Within group comparison of PS measurement was done using paired t-test. RESULTS: The PS for the test group declined from 14.425±2.577 pounds (lbs) to 13.725±2.557 lbs, while for the control group, a decline in PS from 13.65±2.636 lbs to 10.675±2.478 lbs after SRP was noted. On comparing the difference of means of both groups, a statistically significant result was obtained. CONCLUSION: Work-related musculoskeletal disorders can be reduced by performing a few simple chair-side stretches. These stretches can help prevent the finger muscle fatigue during SRP and thus, increase its efficacy.

Outcomes After Use of Aortouniiliac Endoprosthesis Versus Modular or Unibody Bifurcated Endoprostheses for Endovascular Repair of Ruptured Abdominal Aortic Aneurysms.

OBJECTIVES: Outcomes after endovascular repair (EVAR) of ruptured abdominal aortic aneurysms (rAAAs) have been widely published. There is, however, controversy on the role of the use of aortouniiliac endoprosthesis (AUI) versus modular or unibody bifurcated endoprosthesis (MUB) for repair of rAAAs. We study and compare 30-day outcomes after use of AUI and MUB for all rAAAs focusing specifically on patients with instability. MATERIALS AND METHODS: Patients who underwent EVAR for rAAA (n = 425) using AUI (n = 55; 12.9%) and MUB (n = 370; 87.1%) were identified from the American College of Surgeons' National Surgical Quality Improvement Program (2005-2010) database. Univariable and multivariable logistic regression analyses were performed. RESULTS: No significant difference ( P > .5) was seen in comorbidities between patients who underwent EVAR with AUI or MUB; there was also no change in endoprosthesis use from 2005 to 2010 ( P = .7). Patients who underwent EVAR with AUI more commonly had a history of peripheral arterial procedure (10.9% vs 4.6%; P = .053) and preoperative transfusion of >4 U packed red blood cells (18.2% vs 6.8%; P = .004). Use of AUI versus MUB was associated with more 30-day wound complications (16.4% vs 6.2%; P = .01), return to operating room (38.2% vs 20.0%; P = .003), and mortality (34.5% vs 21.4%; P = .03). On multivariable analysis, use of AUI was associated with an increased risk of 30-day mortality (odds ratio: 2.4; 95% confidence interval: 1.1-5.3). On subanalysis of the cohort for only the patients with unstable rAAA (n = 159; AUI = 29 and MUB = 130), 30-day mortality for AUI versus MUB was still higher but not statistically significant (44.8% vs 32.3%; P = .2). CONCLUSION: Endovascular repair for ruptured AAA using aortouniliac endoprosthesis is associated with higher 30-day mortality than using modular or unibody bifurcated endoprosthesis.

Efficacy of Two Pre-Procedural Rinses at Two Different Temperatures in Reducing Aerosol Contamination Produced During Ultrasonic Scaling in a Dental Set-up - A Microbiological Study.

Aerosol has been considered one of the main concerns in the dental community because of possible risk of infection transmission. Antiseptics used in the form of pre-procedural rinses can reduce aerosol contamination during dental procedures. The aim of this study is to evaluate and compare the efficacy of 0.05% cetylpyridinium chloride and 0.2% chlorhexidine pre-procedural rinses at 47ºC and 18ºC in reducing aerosol contamination during ultrasonic scaling procedures. Forty subjects were divided randomly and equally into four groups: A1 and A2 to receive cetylpyridinium chloride and B1 and B2 to receive chlorhexidine as pre-procedural rinses. Aerosol produced during the ultrasonic scaling procedure was collected on blood agar plates at three different locations, which were incubated at 37ºC for 48 hours and analysed for bacterial colony forming units (CFU). Cetylpyridinium chloride (0.05%) as a pre-procedural rinse was found to be equally effective in reducing aerosol contamination when compared with 0.2% chlorhexidine rinse (p > 0.05). Also, greater reduction of CFU was found with the use of tempered rinses at 47ºC with a highly statistically significant difference (p < 0.001). Cetylpyridinium chloride (0.05%) can be considered as a promising alternative to the gold standard 0.2% chlorhexidine, with tempering the rinse showing the definite edge.

Outcomes of Aortic Surgery for Abdominal Aortic Graft Infections.

BACKGROUND: Literature on postoperative outcomes following aortic surgery for aortic graft infection (AGI) is limited by relatively small sample sizes, resulting in lack of national benchmarks for quality of care. We report in-hospital outcomes following abdominal aortic surgery for AGI and identify factors associated with postoperative complications using the Nationwide Inpatient Sample (NIS) database. METHODS: Patients who underwent aortic graft resection for AGI were identified from the 2002 to 2008 NIS database, a multicenter database capturing 20% of all US admissions. Multivariable logistic regression analyses were performed. RESULTS: Among 394 patients (men: 73.4%) who underwent abdominal aortic surgery for AGI, 53% of the admissions were emergent/urgent. A significant trend for decreasing number of abdominal aortic surgery for AGIs per year was observed (Pearson r correlation: -.96; P = .0006). Over the same time span, a significant correlation was also seen with decrease in open and increase in endovascular aortic aneurysm repairs in the NIS database. In-hospital rates of overall postoperative morbidity and mortality were 68.3% and 19.8%, respectively. In-hospital rates of postoperative respiratory failure, renal failure, and cardiac arrest were 35.5%, 14.2%, and 8.9%, respectively. Median length of stay was 26 days, with median hospital charges being US$184 162. On multivariable analysis, increase in age per year (odds ratio [OR] 1.07; 95% confidence interval [CI]: 1.03-1.12) was independently associated with postoperative morbidity, while higher hospital volume for this procedure was protective (OR: 0.71; 95% CI: 0.56-0.89). No preoperative factors were independently associated with postoperative mortality. CONCLUSION: Incidence of abdominal aortic surgery for AGI has progressively declined over the span of our study in association with decreased open and increased endovascular aortic aneurysm repairs. Aortic surgery for AGI is associated with very high morbidity and mortality rates along with prolonged lengths of stay and elevated hospital charges. The outcomes of operations for AGI are better in younger patients and higher volume hospitals.

Development and validation of a risk calculator for predicting postoperative pneumonia.

OBJECTIVE: To identify preoperative factors associated with an increased risk of postoperative pneumonia and subsequently develop and validate a risk calculator. PATIENTS AND METHODS: The American College of Surgeons' National Surgical Quality Improvement Program, a multicenter, prospective data set (2007-2008) was used. Univariate and multivariate logistic regression analyses were performed. The 2007 data set (N=211,410) served as the training set, and the 2008 data set (N=257,385) served as the validation set. RESULTS: In the training set, 3825 patients (1.8%) experienced postoperative pneumonia. Patients who experienced postoperative pneumonia had a significantly higher 30-day mortality (17.0% vs 1.5%; P<.001). On multivariate logistic regression analysis, 7 preoperative predictors of postoperative pneumonia were identified: age, American Society of Anesthesiologists class, chronic obstructive pulmonary disease, dependent functional status, preoperative sepsis, smoking before operation, and type of operation. The risk model based on the training data set was subsequently validated on the validation data set, with model performance being very similar (C statistic: 0.860 and 0.855, respectively). The high C statistic indicates excellent predictive performance. The risk model was used to develop an interactive risk calculator. CONCLUSION: Preoperative variables associated with an increased risk of postoperative pneumonia include age, American Society of Anesthesiologists class, chronic obstructive pulmonary disease, dependent functional status, preoperative sepsis, smoking before operation, and type of operation. The validated risk calculator provides a risk estimate for postoperative pneumonia and is anticipated to aid in surgical decision making and informed patient consent.

Development of a risk index for prediction of mortality after open aortic aneurysm repair.

OBJECTIVE: Open infrarenal abdominal aortic aneurysm (oAAA) repair is associated with significant morbidity and mortality. Although there has been a shift toward endovascular repair, many patients continue to undergo an open repair due to anatomic considerations. Tools currently existing for estimation of periprocedural risk in patients undergoing open aortic surgery have certain limitations. The objective of this study was to develop a risk index to estimate the risk of 30-day perioperative mortality after elective oAAA repair. METHODS: Patients who underwent elective oAAA repair (n = 2845) were identified from the American College of Surgeons' 2007 to 2009 National Surgical Quality Improvement Program (NSQIP), a prospective database maintained at >250 centers. Univariable and multivariable analyses were performed to evaluate risk factors associated with 30-day mortality after oAAA repair and a risk index was developed. RESULTS: The 30-day mortality after oAAA repair was 3.3%. Multivariable analysis identified six preoperative predictors of mortality, and a risk index was created by assigning weighted points to each predictor using the ß-coefficients from the regression analysis. The predictors included dyspnea (at rest: 8 points; on moderate exertion: 2 points; none: 0 points), history of peripheral arterial disease requiring revascularization or amputation (3 points), age >65 years (3 points), preoperative creatinine >1.5 mg/dL (2 points), female gender (2 points), and platelets <150,000/mm(3) or >350,000/mm(3) (2 points). Patients were classified as low (<7%), intermediate (7%-15%), and high (>15%) risk for 30-day mortality based on a total point score of <8, 8 to 11, and >11, respectively. There were 2508 patients (88.2%) patients in the low-risk category, 278 (9.8%) in the intermediate-risk category, and 59 (2.1%) in the high-risk category. CONCLUSIONS: This risk index has excellent predictive ability for mortality after oAAA repair and awaits validation in subsequent studies. It is anticipated to aid patients and surgeons in informed patient consent, preoperative risk assessment, and optimization.

Preoperative anemia is an independent predictor of postoperative mortality and adverse cardiac events in elderly patients undergoing elective vascular operations.

OBJECTIVE: The objective of this study was to assess the impact of preoperative anemia (hematocrit <39%) on postoperative 30-day mortality and adverse cardiac events in patients 65 years or older undergoing elective vascular procedures. BACKGROUND: Preoperative anemia is associated with adverse outcomes after cardiac surgery, but its association with postoperative outcomes after open and endovascular procedures is not well established. Elderly patients have a decreased tolerance to anemia and are at high risk for complications after vascular procedures. METHODS: Patients (N = 31,857) were identified from the American College of Surgeons' 2007-2009 National Surgical Quality Improvement Program-a prospective, multicenter (>250) database maintained across the United States. The primary and secondary outcomes of interest were 30-day mortality and a composite end point of death or cardiac event (cardiac arrest or myocardial infarction), respectively. RESULTS: Forty-seven percent of the study population was anemic. Anemic patients had a postoperative mortality and cardiac event rate of 2.4% and 2.3% in contrast to the 1.2% and 1.2%, respectively, in patients with hematocrit within the normal range (P < 0.0001). On multivariate analysis, we found a 4.2% (95% confidence interval, 1.9-6.5) increase in the adjusted risk of 30-day postoperative mortality for every percentage point of hematocrit decrease from the normal range. CONCLUSIONS: The presence and degree of preoperative anemia are independently associated with 30-day death and adverse cardiac events in patients 65 years or older undergoing elective open and endovascular procedures. Identification and treatment of anemia should be important components of preoperative care for patients undergoing vascular operations.

Impact of COPD on postoperative outcomes: results from a national database.

BACKGROUND: Although COPD affects large sections of the population, its effects on postoperative outcomes have not been rigorously studied. The objectives of this study were to describe the prevalence of COPD in patients undergoing surgery and to analyze the associations between COPD and postoperative morbidity, mortality, and hospital length of stay. METHODS: Patients with COPD who underwent surgery were identified from the National Surgical Quality Improvement Program database (2007-2008). Univariate and multivariate analyses were performed on this multicenter, prospective data set (N = 468,795). RESULTS: COPD was present in 22,576 patients (4.82%). These patients were more likely to be older, men, white, smokers, and taking corticosteroids and had a lower BMI (P < .0001 for each). Median length of stay was 4 days for patients with COPD vs 1 day in those without COPD (P < .0001). Thirty-day morbidity rates were 25.8% and 10.2% for patients with and without COPD, respectively (P < .0001). Thirty-day death rates were 6.7% and 1.4% for patients with and without COPD, respectively (P < .0001). After controlling for > 50 comorbidities through logistic regression modeling, COPD was independently associated with higher postoperative morbidity (OR, 1.35; 95% CI, 1.30-1.40; P < .0001) and mortality (OR, 1.29; 95% CI, 1.19-1.39; P < .0001). Multivariate analyses with each individual postoperative complication as the outcome of interest showed that COPD was associated with increased risk for postoperative pneumonia, respiratory failure, myocardial infarction, cardiac arrest, sepsis, return to the operating room, and renal insufficiency or failure (P < .05 for each). CONCLUSIONS: COPD is common among patients undergoing surgery and is associated with increased morbidity, mortality, and length of stay.

Risk index for predicting perioperative stroke, myocardial infarction, or death risk in asymptomatic patients undergoing carotid endarterectomy.

OBJECTIVE: The latest guidelines recommend performance of carotid endarterectomy (CEA) on asymptomatic patients with high-grade carotid stenosis, only if the combined perioperative stroke, myocardial infarction (MI), or death risk is ≤3%. Our objective was to develop and validate a risk index to estimate the combined risk of perioperative stroke, MI, or death in asymptomatic patients undergoing elective CEA. METHODS: Asymptomatic patients who underwent an elective CEA (n = 17,692) were identified from the 2005-2010 National Surgical Quality Improvement Program, a multicenter, prospective database. Multivariable logistic regression analysis was performed with primary outcome of interest being the composite of any stroke, MI, or death during the 30-day periprocedural period. Bootstrapping was used for internal validation. A risk index was created by assigning weighted points to each predictor using the ß-coefficients from the regression analysis. RESULTS: Fifty-eight percent of the patients were men with a median age of 72 years. Thirty-day incidences of stroke, MI, and death were 0.9% (n = 167), 0.6% (n = 108), and 0.4% (n = 72), respectively. The combined 30-day stroke, MI, or death incidence was 1.8% (n = 324). On multivariable analysis, six independent predictors were identified and a risk index created by assigning weighted points to each predictor using the ß-coefficients from the regression analysis. The predictors included age in years (<60: 0 point; 60-69: -1 point; 70-79: -1 point; ≥80: 2 points), dyspnea (2 points), chronic obstructive pulmonary disease (3 points), previous peripheral revascularization or amputation (3 points), recent angina within 1 month (4 points), and dependent functional status (5 points). Patients were classified as low (<3%), intermediate (3%-6%), or high (>6%) risk for combined 30-day stroke, MI, or death, based on a total point score of <4, 4-7, and >7, respectively. There were 15,249 patients (86.2%) in the low-risk category, 2233 (12.6%) in the intermediate-risk category, and 210 (1.2%) in the high-risk category. CONCLUSIONS: The validated risk index can help identify asymptomatic patients who are at greatest risk for 30-day stroke, MI, and death after CEA, thereby aiding patient selection.

Development and validation of a risk calculator for prediction of mortality after infrainguinal bypass surgery.

OBJECTIVE: For peripheral arterial disease, infrainguinal bypass grafting (BPG) carries a higher perioperative risk compared with peripheral endovascular procedures. The choice between the open and endovascular therapies is to an extent dependent on the expected periprocedural risk associated with each. Tools for estimating the periprocedural risk in patients undergoing BPG have not been reported in the literature. The objective of this study was to develop and validate a calculator to estimate the risk of perioperative mortality ≤30 days of elective BPG. METHODS: We identified 9556 patients (63.9% men) who underwent elective BPG from the 2007 to 2009 National Surgical Quality Improvement Program data sets. Multivariable logistic regression analysis was performed to identify risk factors associated with 30-day perioperative mortality. Bootstrapping was used for internal validation. The risk factors were subsequently used to develop a risk calculator. RESULTS: Patients had a median age of 68 years. The 30-day mortality rate was 1.8% (n = 170). Multivariable logistic regression analysis identified seven preoperative predictors of 30-day mortality: increasing age, systemic inflammatory response syndrome, chronic corticosteroid use, chronic obstructive pulmonary disease, dependent functional status, dialysis dependence, and lower extremity rest pain. Bootstrapping was used for internal validation. The model demonstrated excellent discrimination (C statistic, 0.81; bias-corrected C statistic, 0.81) and calibration. The validated risk model was used to develop an interactive risk calculator using the logistic regression equation. CONCLUSIONS: The validated risk calculator has excellent predictive ability for 30-day mortality in a patient after an elective BPG. It is anticipated to aid in surgical decision making, informed patient consent, preoperative optimization, and consequently, risk reduction.