Association of Sex With Postoperative Mortality Among Patients With Heart Failure Who Underwent Elective Noncardiac Operations.
JAMA network open
2019; 2 (11): e1914420
Importance: Sex differences in postoperative outcomes in patients with heart failure (HF) have not been well characterized. Women generally experience a lower postoperative mortality risk after noncardiac operations. It is unclear if this pattern holds among patients with HF.Objectives: To determine if the risk of postoperative mortality is associated with sex among patients with HF who underwent noncardiac operations and to determine if sex is associated with the relationship between HF and postoperative mortality.Design, Setting, and Participants: This multisite cohort study used data from the US Department of Veterans Affairs Surgical Quality Improvement Project database for all patients who underwent elective noncardiac operations from October 1, 2009, to September 30, 2016, with a minimum of 1 year follow-up. The data analysis was conducted from May 1, 2018, to August 31, 2018.Exposures: Heart failure, left ventricular ejection fraction, and sex.Main Outcomes and Measures: Postoperative mortality at 90 days.Results: Among 609 735 patients who underwent elective noncardiac operations from 2009 to 2016, 47 997 patients had HF (7.9%; mean [SD] age, 68.6 [10.1] years; 1391 [2.9%] women) and 561 738 patients did not have HF (92.1%; mean [SD] age, 59.4 [13.4] years; 50 862 [9.1%] women). Among patients with HF, female sex was not independently associated with 90-day postoperative mortality (adjusted odds ratio [aOR], 0.97; 95% CI, 0.71-1.32). Although HF was associated with increased odds of postoperative mortality in both sexes compared with their peers without HF, the odds of postoperative mortality were higher among women with HF (aOR, 2.44; 95% CI, 1.73-3.45) than men with HF (aOR, 1.64; 95% CI, 1.54-1.74), suggesting that HF may negate the general protective association of female sex with postoperative mortality (P for interaction of HF*sex=.03). This pattern was consistent across all levels of left ventricular ejection fraction.Conclusions and Relevance: Although HF was associated with increased odds of postoperative mortality in both sexes compared with their peers without HF, the odds of postoperative mortality were higher among women with HF than men with HF, suggesting that HF may negate the general protective association of female sex with postoperative mortality risk in noncardiac operations.
View details for DOI 10.1001/jamanetworkopen.2019.14420
View details for PubMedID 31675085
Qualitative outcomes of Clean Cut: implementation lessons from reducing surgical infections in Ethiopia.
BMC health services research
2019; 19 (1): 579
BACKGROUND: Clean Cut is a six month, multi-modal, adaptive intervention aimed at reducing surgical infections through improving six critical perioperative processes: 1) handwashing/skin preparation, 2) surgical gown/drape integrity, 3) antibiotic administration, 4) instrument sterility, 5) gauze counts, and 6) WHO Surgical Safety Checklist use. The aim of this study was to elucidate themes across Clean Cut implementation sites in Ethiopia to improve implementation at future hospitals.METHODS: We conducted semi-structured interviews of 20 clinicians involved in Clean Cut at four hospitals. Participation was limited to Clean Cut team members and included surgeons, anesthetists, operating room (OR) nurses, ward nurses, OR managers, quality improvement personnel, and hospital administrators. Audio recordings were transcribed and coded using qualitative software. A codebook was inductively and iteratively derived between two researchers, tested for inter-rater reliability, and applied to all transcripts. We conducted thematic analysis to derive our final qualitative results.RESULTS: The interviews revealed barriers and facilitators to the implementation of Clean Cut, as well as strategies for future implementation sites. Key barriers included material resource limitations, feelings of job burden, existing gaps in infection prevention education, and communication errors during data collection. Common facilitators included strong hospital leadership support, commitment to improved patient outcomes, and organized Clean Cut training sessions. Future strategies include resource assessments, creating a sense of responsibility among staff, targeted training sessions, and incorporating new standards into daily routine.CONCLUSIONS: The findings of this study highlight the importance of engaging hospital leadership, providers and staff in quality improvement programs, and understanding their work contexts. The identified barriers and facilitators will inform future initiatives in the field of perioperative infection prevention.
View details for DOI 10.1186/s12913-019-4383-8
View details for PubMedID 31419972
Incontinence in Phelan-McDermid Syndrome.
Journal of pediatric gastroenterology and nutrition
2019; 69 (2): e39–e42
The aim of the study was to evaluate gastrointestinal symptoms and continence in the context of Phelan-McDermid Syndrome (PMS).A prospective evaluation of children with PMS (n = 17) at the National Institutes of Health.Parent-reported history of symptoms were common: constipation (65%), reflux (59%), choking/gagging (41%), and more than half received gastrointestinal specialty care. No aspiration was noted in 11/11 participants who completed modified barium swallows. Four participants met criteria for functional constipation, 2 of whom had abnormal colonic transit studies. Stool incontinence was highly prevalent (13/17) with nonretentive features present in 12/17. Participants who were continent had significantly smaller genetic deletions (P = 0.01) and higher nonverbal mental age (P = 0.03) compared with incontinent participants.Incontinence is common in PMS and associated with intellectual functioning and gene deletion size. Management strategies may differ based on the presence of nonretentive fecal incontinence, functional constipation, and degree of intellectual disability for children with PMS.
View details for DOI 10.1097/MPG.0000000000002342
View details for PubMedID 30921255
View details for PubMedCentralID PMC6658348
Increased Prevalence of Hepatic Steatosis in Young Adults With Lifelong HIV.
The Journal of infectious diseases
2019; 220 (2): 266–69
Little is known about the effects of lifelong human immunodeficiency virus (HIV) or antiretroviral therapy on hepatic steatosis and fibrosis. Using transient elastography, we evaluated 46 young adults with lifelong HIV and 20 matched HIV-negative controls. Steatosis was present in 33% of persons with HIV and only 10% of controls (P = .04). Hepatic fibrosis scores were not elevated and did not differ between groups. Metabolic parameters, particularly increased waist circumference, and not HIV-specific factors, were significantly associated with steatosis. While this finding should be examined in larger cohorts, modifiable metabolic disturbances may be important targets to optimize liver health in this population.
View details for DOI 10.1093/infdis/jiz096
View details for PubMedID 30852587
View details for PubMedCentralID PMC6581896
Effect of Antiretroviral Therapy on Bone and Renal Health in Young Adults Infected With HIV in Early Life.
The Journal of clinical endocrinology and metabolism
2017; 102 (8): 2896–2904
HIV antiretroviral (ARV) therapy is associated with renal and bone toxicity, but little is known about the potential cumulative effects in adults exposed to ARVs from birth.To prospectively evaluate renal and bone health in young adults with lifelong HIV and extensive ARV exposure.Cross-sectional comparison of bone mineral density (BMD) by dual-energy X-ray absorptiometry, bone turnover, and renal function in young adults infected with HIV in early life (n = 65) to matched healthy controls (n = 23) and longitudinal evaluation (mean follow-up = 4.4 years) within a subset of the HIV cohort (n = 33).Government outpatient research clinic.Albumin/creatinine ratio, protein/creatinine ratio, anion gap, N-terminal telopeptides, and osteocalcin were significantly increased in persons with HIV compared with controls, whereas whole-body BMD and BMD z scores were lower. Within the HIV group, duration of tenofovir disoproxil fumarate (TDF) correlated with higher anion gap but did not correlate with bone parameters. Longer duration of didanosine and stavudine use correlated with lower BMD and BMD z scores. Longitudinal analyses revealed that BMD and bone metabolism significantly improved over time. No subject had an estimated glomerular filtration rate (eGFR) <60, but decline in eGFR correlated with increasing years of TDF exposure.Subclinical markers of renal dysfunction were increased in HIV-infected young adults and associated with TDF exposure, whereas lower bone density was associated with didanosine and stavudine exposure. The tendency for improvement in markers of bone health over time and the availability of less toxic ARV alternatives may herald improvements in renal and bone health for perinatally infected patients in adulthood.
View details for DOI 10.1210/jc.2017-00197
View details for PubMedID 28531309
View details for PubMedCentralID PMC5546869
T-cell Activation and E-selectin Are Associated With Coronary Plaque in HIV-infected Young Adults.
The Pediatric infectious disease journal
2017; 36 (1): 63–65
We evaluated immune activation and coronary artery plaque in young adults with human immunodeficiency virus acquired in early life (n = 31). Coronary plaque was positively associated with lipids, immune activation marker %CD8+CD38+DR+ and E-selectin, a marker of endothelial inflammation. Immune activation and endothelial inflammation may drive coronary plaque formation during the early stages of atherosclerosis in the context of chronic human immunodeficiency virus.
View details for DOI 10.1097/INF.0000000000001354
View details for PubMedID 27749650
View details for PubMedCentralID PMC5154863