1
|
Scott EJ, Rotar E, Dahl JJ, Beller JP, Money DT, Chancellor WZ, Mehaffey JH, Morisette M, Yarboro LT, Teman NR. Discordance among assays for monitoring? Anticoagulation during extracorporeal life support. Perfusion 2023; 38:1714-1721. [PMID: 36167522 DOI: 10.1177/02676591221129741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The optimal method for monitoring of anticoagulation in patients on extracorporeal life support (ECLS) is unknown. The objective of this study was to assess the relationship between anti-factor Xa level (anti-Xa; IU/mL) and activated partial thromboplastin time (aPTT; seconds) for monitoring intravenous unfractionated heparin anticoagulation in adult ECLS patients. METHODS Charts of all adult patients cannulated for ECLS from 2015 through 2017 were reviewed and laboratory and heparin infusion data were extracted for analysis. Time matched pairs of anti-Xa and aPTT were considered concordant if both laboratory values were within the same clinically utilized range. A hierarchical logistic regression model was used to determine factors associated with discordance while accounting for patient level effects. RESULTS A total of 1016 paired anti-Xa and aPTT values from 65 patients were evaluated. 500 (49.2%) paired samples were discordant with a degree of variability on linear regression (r2 = 0.315). The aPTT fell into a higher therapeutic range compared to the anti-Xa in 31.6% and lower in 17.3%. Logistic regression demonstrated that discordance was independently associated with time from initiation of ECLS (OR 1.17 per day, p < 0.001), average heparin infusion rate (OR 1.25 per U/kg/hr, p < 0.001), and INR (OR 3.22, p < 0.001). CONCLUSIONS Nearly half of all aPTT and anti-Xa values were in discordant ranges and discordance is more likely as the time on ECLS and the INR level increase. The use of either assay in isolation to guide heparin anticoagulation may lead to misestimation of the degree of anticoagulation in complex ECLS patients.
Collapse
Affiliation(s)
- Erik J Scott
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Evan Rotar
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Jolian J Dahl
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Jared P Beller
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | | | - W Z Chancellor
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - J H Mehaffey
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | | | - Leora T Yarboro
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| | - Nicholas R Teman
- Division of Cardiac Surgery, Health System University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
2
|
Abstract
OBJECTIVES The United States has the highest number of coronavirus disease 2019 (COVID-19) in the world, with high variability in cases and mortality between communities. We aimed to quantify the associations between socio-economic status and COVID-19-related cases and mortality in the U.S. STUDY DESIGN The study design includes nationwide COVID-19 data at the county level that were paired with the Distressed Communities Index (DCI) and its component metrics of socio-economic status. METHODS Severely distressed communities were classified by DCI>75 for univariate analyses. Adjusted rate ratios were calculated for cases and fatalities per 100,000 persons using hierarchical linear mixed models. RESULTS This cohort included 1,089,999 cases and 62,298 deaths in 3127 counties for a case fatality rate of 5.7%. Severely distressed counties had significantly fewer deaths from COVID-19 but higher number of deaths per 100,000 persons. In risk-adjusted analysis, the two socio-economic determinants of health with the strongest association with both higher cases per 100,000 persons and higher fatalities per 100,000 persons were the percentage of adults without a high school degree (cases: RR 1.10; fatalities: RR 1.08) and proportion of black residents (cases and fatalities: Relative risk(RR) 1.03). The percentage of the population aged older than 65 years was also highly predictive for fatalities per 100,000 persons (RR 1.07). CONCLUSION Lower education levels and greater percentages of black residents are strongly associated with higher rates of both COVID-19 cases and fatalities. Socio-economic factors should be considered when implementing public health interventions to ameliorate the disparities in the impact of COVID-19 on distressed communities.
Collapse
Affiliation(s)
- R B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA, USA; Center for Health Policy, University of Virginia, Charlottesville, VA, USA.
| | - E J Charles
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA, USA; Center for Health Policy, University of Virginia, Charlottesville, VA, USA
| | - J H Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA, USA; Center for Health Policy, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
3
|
Chancellor WZ, Mehaffey JH, Hawkins RB, Charles EJ, Tribble C, Yarboro LT, Ailawadi G, Kirby JL. Electronic Glycemic Management System and Endocrinology Service Improve Value in Cardiac Surgery. Am Surg 2020; 87:568-575. [PMID: 33118411 DOI: 10.1177/0003134820950685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Postoperative glycemic control improves cardiac surgery outcomes but insulin protocols are limited by complexity and inflexibility. We sought to evaluate the effect of implementing an electronic glycemic management system (eGMS) in conjunction with a cardiac surgery endocrinology consult service on glycemic control and outcomes after cardiac surgery. METHODS All patients with a calculated preoperative risk of mortality who underwent cardiac surgery before and after implementation of an eGMS and an endocrinology consult service were identified. Glycemic control and surgical outcomes were compared using univariate analysis, and multivariate regression was used to model the risk-adjusted effects of the interventions on glycemic control, surgical outcomes, and resource utilization. The health care-related value added by the interventions was calculated by dividing risk-adjusted outcomes by total hospital costs. RESULTS A total of 2612 patients were identified, with 1263 patients in the preimplementation cohort and 1349 in the postimplementation cohort. Multivariate regression demonstrated fewer postoperative hyperglycemic events (odds ratio [OR] 0.8, 95% CI, 0.65-0.99) after protocol implementation without an increase in hypoglycemic events (OR 0.96, 95% CI, 0.71-1.3). Average day-weighted mean glucose decreased from 144 to 138 mg/dL (P < .001). The improved glycemic control correlated with a risk-adjusted decrease in composite morbidity or mortality (OR 0.61, 95% CI, 0.47-0.79). Although hospital costs increased after implementation, the protocol increased health care-related value by 38%. CONCLUSION Implementation of a protocol consisting of an eGMS paired with a cardiac surgery-specific endocrinology consult service was associated with improved glycemic control and reduced morbidity. Despite higher costs health care-related value increased as a result of eGMS implementation.
Collapse
Affiliation(s)
- William Z Chancellor
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - James H Mehaffey
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Robert B Hawkins
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Eric J Charles
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Curt Tribble
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Leora T Yarboro
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Gorav Ailawadi
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Jennifer L Kirby
- 2358 Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Virginia, USA
| |
Collapse
|
4
|
Rastogi R, Mehaffey JH, Turrentine BE, Maitland HS, Zaydfudim VM. Implementation of an Electronic Medical Record Risk Stratification Tool to Reduce Venous Thromboembolism Events. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
5
|
Lau CL, Beller JP, Boys JA, Zhao Y, Phillips J, Cosner M, Conaway MR, Petroni G, Charles EJ, Mehaffey JH, Mannem HC, Kron IL, Krupnick AS, Linden J. Adenosine A2A receptor agonist (regadenoson) in human lung transplantation. J Heart Lung Transplant 2020; 39:563-570. [PMID: 32503727 DOI: 10.1016/j.healun.2020.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 12/20/2019] [Accepted: 02/06/2020] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Currently, there are no clinically approved treatments for ischemia-reperfusion injury after lung transplantation. Pre-clinical animal models have demonstrated a promising efficacy of adenosine 2A receptor (A2AR) agonists as a treatment option for reducing ischemia-reperfusion injury. The purpose of this human study, is to conduct a Phase I clinical trial for evaluating the safety of continuous infusion of an A2AR agonist in lung transplant recipients. METHODS An adaptive, two-stage continual reassessment trial was designed to evaluate the safety of regadenoson (A2AR agonist) in the setting of lung transplantation. Continuous infusion of regadenoson was administered to lung transplant recipients that was started at the time of skin incision. Adverse events and dose-limiting toxicities, as pre-determined by a study team and assessed by a clinical team and an independent safety monitor, were the primary end-points for safety in this trial. RESULTS Between January 2018 and March 2019, 14 recipients were enrolled in the trial. Of these, 10 received the maximum infused dose of 1.44 µg/kg/min for 12 hours. No dose-limiting toxicities were observed. The steady-state plasma regadenoson levels sampled before the reperfusion of the first lung were 0.98 ± 0.46 ng/ml. There were no mortalities within 30 days. CONCLUSIONS Regadenoson, an A2AR agonist, can be safely infused in the setting of lung transplantation with no dose-limiting toxicities or drug-related mortality. Although not powered for the evaluation of secondary end-points, the results of this trial and the outcome of pre-clinical studies warrant further investigation with a Phase II randomized controlled trial.
Collapse
Affiliation(s)
- Christine L Lau
- Department of Surgery, University of Maryland, Baltimore, Maryland.
| | - Jared P Beller
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Joshua A Boys
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of California, San Diego, California
| | - Yunge Zhao
- Department of Surgery, University of Maryland, Baltimore, Maryland
| | - Jennifer Phillips
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Michael Cosner
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Mark R Conaway
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Gina Petroni
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Eric J Charles
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - J H Mehaffey
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Hannah C Mannem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Irving L Kron
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Department of Surgery, University of Arizona Health Sciences, Tucson, Arizona
| | | | - Joel Linden
- Division of Developmental Immunology, La Jolla Institute for Immunology and Department of Pharmacology, University of California, San Diego, California
| |
Collapse
|
6
|
Kwak M, Mehaffey JH, Hsu A, Hawkins RB, Schirmer B, Hallowell PT. Discussion on: Bariatric surgery is associated with reduction in non-alcoholic steatohepatitis and hepatocellular carcinoma: A propensity matched analysis. Am J Surg 2020; 219:508. [PMID: 32037049 DOI: 10.1016/j.amjsurg.2019.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
7
|
Mehaffey JH, Money D, Charles EJ, Schubert S, Piñeros AF, Wu D, Bontha SV, Hawkins R, Teman NR, Laubach VE, Mas VR, Tribble CG, Maluf DG, Sharma AK, Yang Z, Kron IL, Roeser ME. Adenosine 2A Receptor Activation Attenuates Ischemia Reperfusion Injury During Extracorporeal Cardiopulmonary Resuscitation. Ann Surg 2019; 269:1176-1183. [PMID: 31082918 PMCID: PMC6757347 DOI: 10.1097/sla.0000000000002685] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE We tested the hypothesis that systemic administration of an A2AR agonist will reduce multiorgan IRI in a porcine model of ECPR. SUMMARY BACKGROUND DATA Advances in ECPR have decreased mortality after cardiac arrest; however, subsequent IRI contributes to late multisystem organ failure. Attenuation of IRI has been reported with the use of an A2AR agonist. METHODS Adult swine underwent 20 minutes of circulatory arrest, induced by ventricular fibrillation, followed by 6 hours of reperfusion with ECPR. Animals were randomized to vehicle control, low-dose A2AR agonist, or high-dose A2AR agonist. A perfusion specialist using a goal-directed resuscitation protocol managed all the animals during the reperfusion period. Hourly blood, urine, and tissue samples were collected. Biochemical and microarray analyses were performed to identify differential inflammatory markers and gene expression between groups. RESULTS Both the treatment groups demonstrated significantly higher percent reduction from peak lactate after reperfusion compared with vehicle controls. Control animals required significantly more fluid, epinephrine, and higher final pump flow while having lower urine output than both the treatment groups. The treatment groups had lower urine NGAL, an early marker of kidney injury (P = 0.01), lower plasma aspartate aminotransferase, and reduced rate of troponin rise (P = 0.01). Pro-inflammatory cytokines were lower while anti-inflammatory cytokines were significantly higher in the treatment groups. CONCLUSIONS Using a novel and clinically relevant porcine model of circulatory arrest and ECPR, we demonstrated that a selective A2AR agonist significantly attenuated systemic IRI and warrants clinical investigation.
Collapse
Affiliation(s)
- James H Mehaffey
- Department of Surgery, University of Virginia, Charlottesville, VA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Mehaffey JH, Charles EJ, Hawkins RB, Turrentine FE, Schirmer BD, Hallowell PT, Friel CM, Jones RS, Tracci MC. Socioeconomic “Distressed Communities Index” Improves NSQIP Risk Calculator. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
9
|
Elwood NR, Booth AT, Mehaffey JH, Carlson KJ, Hanks JB, Zeiger MA, Smith PW. Pathology and Surgical Characteristics Are Similar in Patients With and Without a Guidelines-Based Surgical Indication for Parathyroidectomy for Asymptomatic Primary Hyperparathyroidism. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
10
|
Krebs ED, Chancellor WZ, Beller JP, Mehaffey JH, Hawkins RB, Yarboro LT, Ailawadi G, Teman NR. Long-Term Implications of Tracheostomy in Cardiac Surgery Patients. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
11
|
Francois ME, Gilbertson NM, M Eichner NZ, Heiston EM, Mehaffey JH, Hassinger TE, Hallowell PT, Malin SK. Combining Short-Term Interval Training With Caloric-Restriction Improves ß-Cell Function In Obese Adults. Med Sci Sports Exerc 2018. [DOI: 10.1249/01.mss.0000537151.60457.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
12
|
Gilbertson NM, Eichner NZ, Heiston EM, Francois M, Gaítan JM, Mehaffey JH, Hassinger TE, Hallowell PT, Weltman A, Malin SK. Low-Calorie Diet Plus Interval Exercise Training Improves Metabolic Flexibility and Insulin Sensitivity in Obese Women. Med Sci Sports Exerc 2018. [DOI: 10.1249/01.mss.0000535819.70552.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
13
|
Heiston EM, Gilbertson NM, Eichner NZ, Gaitan JM, Francois ME, Mehaffey JH, Hassinger TE, Hallowell PT, Weltman A, Malin SK. Adding Short-Term Interval Exercise to a Low-Calorie Diet Favorably Influences Appetite in Obese Adults. Med Sci Sports Exerc 2018. [DOI: 10.1249/01.mss.0000535827.78176.5b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
14
|
Guerrier JB, Mehaffey JH, Schirmer BD, Hallowell PT. Reinforcement of the Staple Line during Gastric Sleeve: A Comparison of Buttressing or Oversewing, versus No Reinforcement- A Single-Institution Study. Am Surg 2018; 84:690-694. [PMID: 29966570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Laparoscopic sleeve gastrectomy (LSG) is a well-established treatment for morbid obesity. Staple line leak (SLL) remains one of the most serious and life-threatening complications after LSG; however, no consensus exists for prevention. The purpose of this study is to review and compare the different methods of staple line management used at our institution. Retrospective review of preoperative, intraoperative, and postoperative factors was performed for all patients undergoing LSG at a single institution between September 2010 and August 2015. Primary outcome measure was SLL by reinforcement method (none/Seamguard/Oversewing). A total of 256 patients undergoing LSG were included, 197 (76.95%) were women and 233 (87.11%) were whites. The patients had a mean age of 44.64 years and body mass index of 49.24 kg/m-2. Among those patients, 145 (56.64%) had staple line reinforced with suture (28, 10.94%) or Gore Seamguard (115, 44.92%) and 111 (43.36%) had no reinforcement, with no difference in baseline factors between the groups (all P > 0.05). Gastric leaks were identified in nine patients (3.52%) with no difference between reinforcement (2.7 vs 2.1%, P = 0.54) or leak test method (air vs methylene blue). However, oversewing the staple line was associated with higher incidence of stenosis (P < 0.01). SLL after LSG is a serious complication with significant morbidity and mortality. This study demonstrated that staple line reinforcement does not provide significant leak reduction but does reduce intraoperative staple line bleeding. In addition, oversewing the staple line was associated with postoperative sleeve stenosis without added benefits.
Collapse
Affiliation(s)
- Jean B Guerrier
- Department of Surgery, University of Virginia, Charlottesville, Virginia, USA
| | | | | | | |
Collapse
|
15
|
Turrentine FE, Mehaffey JH, Mehaffey RL, Mullen MG, Schirmer BD, Hallowell PT. Patient Reported Outcomes 10 years After Roux-en-Y Gastric Bypass. Obes Surg 2018; 27:2253-2257. [PMID: 28303505 DOI: 10.1007/s11695-017-2641-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Following weight-loss surgery, patients who failed to achieve or sustain weight loss have nevertheless reported high satisfaction with their long-term bariatric experience. Understanding this phenomenon better will likely improve patients' experiences. OBJECTIVE The purpose of this study was to explore patients' long-term experiences following bariatric surgery. SETTING A 604-bed academic health system in the USA. METHODS Participants rated satisfaction and shared spontaneous comments regarding their gastric bypass experience. A phenomenological mode of inquiry explored participants' experiences. Transcribed phrases were categorized and themes identified. RESULTS In a 2004 surgical cohort, with 55% (155/281) participation, 99% of participants rated bariatric experience satisfaction (mean score 8.4) and 74% (115/155) shared comments regarding experiences. Responses were categorized as positive (63% 72/115), neutral (25% 29/115), or negative (12% 14/115). Satisfaction, Appreciation, and Gratefulness emerged as themes from positive comments, with 8% (6/72) explicitly acknowledging amount of weight loss achieved. Twenty-five percent (18/72) spontaneously mentioned undergoing surgery again or recommending the procedure to others. Neutral comments contained the themes of Reflection, Acknowledgment, and Wistfulness. Themes of Dissatisfaction, Disappointment, and Regret emerged from negative comments. Forty-three percent (6/14) of negative comments remarked on regaining weight or not reaching goal weight. Twenty-one percent (3/14) of negative comments explicitly stated regret at having undergone surgery. CONCLUSIONS Participants readily shared comments regarding their gastric bypass experience. Exploring themes provided insight into patients' satisfaction with bariatric surgery even when weight-loss goals were not met and conversely substantial dissatisfaction even when weight loss occurred. This study underscores the importance of understanding the patients' long-term experience following bariatric surgery.
Collapse
Affiliation(s)
- Florence E Turrentine
- Department of Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908, USA.
| | - James H Mehaffey
- Department of Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908, USA
| | - Rachel L Mehaffey
- Department of Internal Medicine, University of Virginia, Charlottesville, VA, USA
| | - Matthew G Mullen
- Department of Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908, USA
| | - Bruce D Schirmer
- Department of Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908, USA
| | - Peter T Hallowell
- Department of Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908, USA
| |
Collapse
|
16
|
Abstract
Degenerative mitral valve disease causing mitral regurgitation is the most common organic valve pathology and is classified based on leaflet motion. The "French correction" mitral valve repair method restores normal valvular anatomy with extensive leaflet resection, chordal manipulation, and rigid annuloplasty. The American correction attempts to restore normal valve function through minimal leaflet resection, flexible annuloplasty, and use of artificial chordae. These differing methods of mitral valve repair reflect an evolution in principles, but both require understanding of the valve pathology and correction of leaflet prolapse and annular dilatation. Adhering to those unifying principles and ensuring that no patient leaves the operating room with significant persistent mitral regurgitation produces durable results and satisfactory patient outcomes.
Collapse
Affiliation(s)
- Sarah A Schubert
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, 1215 Lee Street, Box 800679, Charlottesville, VA 22908, USA.
| | - James H Mehaffey
- Department of Surgery, University of Virginia, Box 800709, Charlottesville, VA 22908, USA
| | - Eric J Charles
- Department of Surgery, University of Virginia, Box 800709, Charlottesville, VA 22908, USA
| | - Irving L Kron
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, 1215 Lee Street, Box 800679, Charlottesville, VA 22908, USA
| |
Collapse
|
17
|
Moses DA, Mehaffey JH, Strider DV, Tracci MC, Kern JA, Upchurch GR. Smoking Cessation Counseling Improves Quality of Care and Surgical Outcomes with Financial Gain for a Vascular Practice. Ann Vasc Surg 2017; 42:214-221. [PMID: 28389293 DOI: 10.1016/j.avsg.2016.12.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 11/22/2016] [Accepted: 12/05/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cigarette smoking is strongly associated with atherosclerotic disease. It is incumbent on vascular surgeons to provide smoking cessation counseling (SCC) to their patients. The objective of this study was to determine the association of SCC and improvement in quality of care. METHODS As a quality project using retrospective data, the study received institutional review board exemption status. A retrospective review of prospectively maintained database from April 2014 through March 2015 of outpatient encounters in a vascular surgery clinic was performed of current smokers. Through the quality support team, providers were encouraged to counsel smokers to quit, document the discussion, and bill specific Evaluate and Management codes (99406 and 99407). The number of outpatients by smoking status, documentation and billing of SCC, demographics of current smokers, and monetary collections were collected. Data were compared using a correlation coefficient calculated and tested for statistical significant using two-tailed t-test. RESULTS A sample of 1,077 visits by 612 currently smoking patients accounted for 24% of all outpatient vascular surgery visits. The average age was 61 years, and 64% were male. Comorbidities included 77% with hypertension, 32% with diabetes mellitus, and 14% with chronic kidney disease. Medically, 72% were on aspirin, 71% on statin, and 48% on beta blocker. A total of 208 (34%) never underwent a vascular intervention, and 183 (30%) had an intervention during the study period (44% for peripheral artery disease, 10% for carotid stenosis, 14% amputations, and 10% abdominal aortic aneurysm). Documentation improved from 65% of encounters during the first month to 89% in the peak month and 79% of total encounters. All-cause mortality rate was 2%, and this cohort demonstrated 75% SCC for 28 encounters. Fifty-five patients (9%) quit smoking for more than 30 days at the end of the study period, and this cohort had 69% of their 97 encounters with documented SCC. Increased SCC was correlated with decreased 30-day readmissions during the concurrent month (r = -0.711, P = 0.009) and the following month (r = -0.719, P = 0.008). There was a weak correlation with decreased amputations the following month (r = -0.5, P = 0.08). From a financial perspective, $1,373 was collected for 33 patients with a potential for collection of $7,460 predicted for minimum Medicare payment of 1 visit per patient. CONCLUSIONS Advising vascular patients in the arduous process of smoking cessation benefits both the patient and the health system. Proper documentation and billing decreases costs of early readmissions and increases departmental revenue.
Collapse
Affiliation(s)
- D A Moses
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA.
| | - J H Mehaffey
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA
| | - D V Strider
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA
| | - M C Tracci
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA
| | - J A Kern
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA
| | - G R Upchurch
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA
| |
Collapse
|
18
|
Mehaffey JH, Hawkins R, Fashandi A, Tracci MC, Cherry K, Kron I, Upchurch G, Robinson WP. Lower Extremity Bypass Is Associated with Lower Short-Term Major Adverse Limb Events and Equivalent Major Adverse Cardiac Events Compared with Endovascular Intervention in A National Cohort with Critical Limb Ischemia. J Vasc Surg 2017. [DOI: 10.1016/j.jvs.2016.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
19
|
Mehaffey JH, LaPar DJ, Tracci MC, Cherry KJ, Kern JA, Kron I, Upchurch GR. Modifiable Factors Leading to Increased Length of Stay after Carotid Endarterectomy. Ann Vasc Surg 2016; 39:195-203. [PMID: 27554691 DOI: 10.1016/j.avsg.2016.05.126] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 04/11/2016] [Accepted: 05/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Carotid endarterectomy (CEA) is a commonly performed vascular operation. Yet, postoperative length of stay (LOS) varies greatly even within institutions. In this study, the morbidity and mortality, as well as financial impact of increased LOS were reviewed to establish modifiable factors associated with prolonged hospital stay. METHODS The Society for Vascular Surgery Vascular Quality Initiative database was used to identify all patients undergoing primary CEA at a single institution between June 1, 2011 and November 28, 2014. Preoperative patient characteristics, intraoperative details, postoperative factors, long-term outcomes, and cost data were reviewed using an Institutional Review Board-approved prospectively collected database. Multivariate analysis was used to determine statistical difference between patients with LOS ≤1 day and >1 day. RESULTS Complete 30-day variable and cost data were available for 219 patients with an average follow-up of 12 months. Seventy-nine (36%) patients had an LOS > 1 day. Variables determined to be statistically significant predictors of prolonged LOS included preoperative creatinine (P = 0.02) and severe congestive heart failure (P = 0.05) with self-pay status (P = 0.02) and preoperative beta-blocker therapy (P = 0.04) being protective. Shunt placement (P = 0.04), arterial re-exploration, and postoperative cardiac (P = 0.001) or neurological (P = 0.03) complications also resulted in prolonged hospitalization. Specific modifiable risk factors that contributed to increased LOS included operative start time after noon (P = 0.04), drain placement (P = 0.05), prolonged operative time (101 vs. 125 min, P = 0.01), return to the operating room (P = 0.01), and postoperative hypertension (P = 0.02) or hypotension (P = 0.04). Of note, there was no difference in LOS associated with technique (conventional versus eversion), patch use (P = 0.49), protamine administration (P = 0.60), electroencephalogram monitoring (P = 0.45), measurement of stump pressure (P = 0.63), Doppler (P = 0.36), or duplex (P = 0.92). Both hospital charges (P = 0.0001) and costs (P = 0.0001) were found to be significantly higher in patients with prolonged LOS, with no difference in physician charges (P = 0.10). Increased LOS after CEA was associated with an increase in 12-month mortality (P = 0.05). CONCLUSIONS Increased LOS was associated with increased hospital charges, costs, as well as significant morbidity and midterm mortality following CEA. Furthermore, this study highlights several modifiable risk factors leading to increased LOS. Identified factors associated with increase LOS can serve as targets for improving care in vascular surgery.
Collapse
Affiliation(s)
- James H Mehaffey
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA.
| | - Damien J LaPar
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Margret C Tracci
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Kenneth J Cherry
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - John A Kern
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Irving Kron
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| | - Gilbert R Upchurch
- Department of Vascular Surgery, University of Virginia, Charlottesville, VA
| |
Collapse
|
20
|
Mehaffey JH, Lapar D, Clement K, Seaman SJ, Turrentine FE, Miller M, Hallowell PT, Schirmer BD. 10-Year outcomes after Roux-en-Y gastric bypass. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
21
|
White MA, Agle SC, Fuhr HM, Mehaffey JH, Waibel BH, Zervos EE. Impact of pancreatic cancer and subsequent resection on glycemic control in diabetic and nondiabetic patients. Am Surg 2011; 77:1032-1037. [PMID: 21944519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The incidence of new onset or worsening diabetes is surprisingly low in patients after partial pancreatectomy for cancer, leading us to question what factors predict diminished glycemic control in those undergoing resection. All patients undergoing pancreatectomy for cancer at a large, rural university teaching hospital between 1996 and 2010 were identified. The incidence of new onset, or worsening, existing diabetes was determined based on pre and postoperative medication requirement. Univariate analysis was undertaken to identify factors that predict worsened glycemic control. One hundred and one (1 total, 79 Whipple, 21 distal) patients were identified, 41 per cent of which had preexisting diabetes. Nearly half of existing diabetics manifested an increased medication requirement prior to their cancer diagnosis. New onset diabetes occurred in 20 per cent of postoperative patients. Of established diabetics, 34 per cent had either improved glycemic control (9/41) or were cured (5/41) despite the reduction of islet cell mass that occurred with surgery. On univariate analysis, only prolonged hospitalization was associated with worsened glycemic control. Diminished glycemic control is a frequent presenting symptom of pancreatic cancer. Worsened or new onset diabetes is associated with length of stay, which can be influenced by a number of factors including complications and comorbidities.
Collapse
Affiliation(s)
- Michael A White
- Division of Surgical Oncology, Department of Surgery, East Carolina University, Greenville, North Carolina, USA
| | | | | | | | | | | |
Collapse
|
22
|
White MA, Agle SC, Fuhr HM, Mehaffey JH, Waibel BH, Zervos EE. Impact of Pancreatic Cancer and Subsequent Resection on Glycemic Control in Diabetic and Nondiabetic Patients. Am Surg 2011. [DOI: 10.1177/000313481107700823] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The incidence of new onset or worsening diabetes is surprisingly low in patients after partial pancreatectomy for cancer, leading us to question what factors predict diminished glycemic control in those undergoing resection. All patients undergoing pancreatectomy for cancer at a large, rural university teaching hospital between 1996 and 2010 were identified. The incidence of new onset, or worsening, existing diabetes was determined based on pre and postoperative medication requirement. Univariate analysis was undertaken to identify factors that predict worsened glycemic control. One hundred and one (1 total, 79 Whipple, 21 distal) patients were identified, 41 per cent of which had preexisting diabetes. Nearly half of existing diabetics manifested an increased medication requirement prior to their cancer diagnosis. New onset diabetes occurred in 20 per cent of postoperative patients. Of established diabetics, 34 per cent had either improved glycemic control (9/41) or were cured (5/41) despite the reduction of islet cell mass that occurred with surgery. On univariate analysis, only prolonged hospitalization was associated with worsened glycemic control. Diminished glycemic control is a frequent presenting symptom of pancreatic cancer. Worsened or new onset diabetes is associated with length of stay, which can be influenced by a number of factors including complications and comorbidities.
Collapse
Affiliation(s)
- Michael A. White
- Division of Surgical Oncology, Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Steven C. Agle
- Division of Surgical Oncology, Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Hannah M. Fuhr
- Division of Surgical Oncology, Department of Surgery, East Carolina University, Greenville, North Carolina
| | - James H. Mehaffey
- Division of Surgical Oncology, Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Brett H. Waibel
- Division of Surgical Oncology, Department of Surgery, East Carolina University, Greenville, North Carolina
| | - Emmanuel E. Zervos
- Division of Surgical Oncology, Department of Surgery, East Carolina University, Greenville, North Carolina
| |
Collapse
|
23
|
Abstract
Since the discovery that gastric bypass surgery leads to the rapid reversal of type 2 diabetes mellitus in morbidly obese patients, researchers have been searching for possible mechanisms to explain the result. The significance of bariatric surgery is twofold. It offers hope and successful therapy to the severely obese; those with T2DM, sleep apnea, or polycystic ovary disease; and others plagued by the comorbidities of the metabolic syndrome. This article examines four surgical procedures and their outcomes.
Collapse
Affiliation(s)
- Walter J Pories
- Division of Bariatric Surgery, Department of Surgery, The Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Brody Medical Science 4W-48, Mail Stop 639, Greenville, NC 27834, USA.
| | | | | |
Collapse
|