The management of facial fractures in the polytrauma patient requires the coordination of multipl... more The management of facial fractures in the polytrauma patient requires the coordination of multiple surgical disciplines to optimize the functional and cosmetic outcome while minimizing overall morbidity and mortality. Although the plastic surgery literature historically advocates the early repair of facial fractures, the risk of general anesthesia in patients with associated injuries sometimes makes early repair unsafe. We compared early operative repair versus delayed operative repair of facial fractures in multitrauma patients. We specifically examined wound infection, overall complication rate, total length of hospital stay, days in the Intensive Care Unit (ICU), and days on the ventilator in the two groups. A 5-year (1991-1996) retrospective study of multitrauma patients with associated facial fractures was undertaken at an urban community hospital. We had a total of 82 patients, who were divided into three groups. Thirty-three patients did not have operative repair of the facial fractures during the initial admission and were followed by the plastic surgery service on an outpatient basis. These patients will not be discussed further. Seven patients underwent early operative repair, which was defined as repair within 48 hours of admission (group I). Forty-two patients had delayed operative repair, defined as repair more than 48 hours after admission (group II). The reasons for delayed repair included: excessive soft tissue swelling (16), intracranial injuries (12), unstable medical condition (8), and coordination of procedures with other services (6). Of the 49 patients who underwent operative repair, 43 were involved in motor vehicle accidents, 3 were injured by a fall from a height, 2 were involved in auto-pedestrian accidents, and 1 was a victim of assault. Forty-eight of the 49 patients were initially admitted to the ICU. Cumulative associated injuries were as follows: closed head injury (38), extremity fracture (21), blunt chest injuries (11), intra-abdominal injuries (5), vertebral column injuries (7), and ocular injuries (2). The average Injury Severity Score for Group I was 17.3 and for Group II, 18.1. In group I, there were no deaths, there were no wound infections, and the complication rate was 14.3 per cent. The average total number of days spent on the ventilator was 3.0, the average total number of days spent in the ICU was 5.0, and the average total hospital stay was 16.0 days. In group II, there were no deaths, the wound infection rate was 5 per cent, and the overall complication rate was 21 per cent. The average total number of days spent on the ventilator was 3.3, the average total number of days spent in the ICU was 5.8, and the average total days in the hospital was 14.8. Our results indicate that in a similar cohort of multitrauma patients, delayed repair did not increase length of ICU stay or hospital stay. The wound infection rate was negligible, and the complication rate was similar in the two groups. We conclude that a delay in repair of facial fractures in the critically ill patient has an acceptably low complication rate and may be advantageous in decreasing operative risk and minimizing cost by coordinating multiple procedures with various surgical subspecialties.
Background This study aimed to investigate the relationship between community-level economic depr... more Background This study aimed to investigate the relationship between community-level economic deprivation, as measured by the Distressed Communities Index (DCI) and ED visits on account of firearm injuries (assaults and unintentional). Methods A retrospective analysis was conducted using the Maryland State Emergency Department Databases (SEDD) from January 2019 to December 2020 to explore the association between the DCI and ED visits because of firearm injuries (assaults and unintentional). The DCI utilizes 7 variables, based on zip codes, generating 5 levels of socioeconomic distress (prosperous, comfortable, mid-tier, at-risk, and distressed). In a multivariate analysis, we adjusted for age, sex, mental conditions, alcohol addiction, substance abuse, smoking, race/ethnicity, insurance type, and median income. Results Of the 2725 ED visits for firearm injuries, 84.5% were Black and 88.5% male. The median age was 27 (21-35) years, and the mortality rate was 17.7%. A statistically significant association was found between economic deprivation and ED visits for firearm injuries. Compared to prosperous communities, the odds ratios (ORs) were comfortable (OR = 1.33, 95% CI 1.04-1.71, P = .03), mid-tier (OR = 1.69, 95% CI 1.33-2.15, P < .001), at-risk (OR = 1.53, 95% CI 1.17-1.99, P < .001), and distressed (OR = 2.65, 95% CI 2.11-3.33, P < .001). Discussion The study highlights the significant association between community-level economic deprivation, as measured by the Distressed Communities Index, and the incidence of firearm injuries in Maryland. The findings underscore the importance of addressing socioeconomic disparities and implementing targeted interventions to reduce firearm-related injuries in economically distressed communities.
Brief Reports should be submitted online to www.editorialmanager.com/ amsurg. (See details online... more Brief Reports should be submitted online to www.editorialmanager.com/ amsurg. (See details online under ''Instructions for Authors''.) They should be no more than 4 double-spaced pages with no Abstract or sub-headings, with a maximum of four (4) references. If figures are included, they should be limited to two (2). The cost of printing color figures is the responsibility of the author.
Background The objective of this study was to identify predictors of mortality among patients pre... more Background The objective of this study was to identify predictors of mortality among patients presenting to the emergency department (ED) with attempted suicides. Methods We analyzed data on emergency department (ED) visits for attempted suicides from the Nationwide Emergency Department Sample (NEDS) database from January 2010 to December 2017. The predictors of mortality were determined in multivariate analysis including age, sex, insurance, annual income, region of the country, mechanism of injury, mental health conditions (schizophrenia; depression; and anxiety, bipolar, and personality disorders), chronic illnesses (hypertension, diabetes, obesity, and dementia), and social risk factors such as alcohol addiction, smoking, and substance abuse. Results From 2010 to 2017, there were 979,383 ED visits for attempted suicides in the NEDS database. Among these patients, 10,301 (1.1%) died. Of these completed suicides, 73.9% were male with the median age of 43 years (IQR, 30) while the unsuccessful suicide attempt group had a median age of 30 years (IQR, 24) and were 42.7% male. The most common mechanisms of suicide attempt were poisoning (58.8%) and cut injury (25.6%). Gunshot was the most lethal mechanism accounting 40.3% of the completed suicides despite representing 1.3% of the attempts who came to ED. After controlling for common risk factors for attempted suicide, significant predictors of completed suicide include higher income status, uninsured status, male sex, and higher age. Discussion Among US patients presenting to the ED following attempted suicide, factors associated with suicide completion include increasing age, male sex, higher income, gunshot injuries, and uninsured status.
Blacks are several times more likely to undergo a leg amputation as compared to Whites. This is b... more Blacks are several times more likely to undergo a leg amputation as compared to Whites. This is because while peripheral artery disease (PAD), the most common cause of amputation, is more likely to be treated by revascularization (restoration of blood flow) in Whites, PAD is more likely to be treated by amputation in Blacks. Whereas an ongoing debate argues as to whether this disparity is primarily a sociologic versus a biologic phenomenon, I proposed that there are socioeconomic neighborhood stressors that create more severe PAD and renders individuals less likely to undergo successful revascularization and more likely to undergo amputation. Three specific aims are addressed in this dissertation resulting in three manuscripts. In Study 1, utilizing the Nationwide Inpatient Sample Database (NIS) in a retrospective study design, I determined that among patients admitted to the hospital for severe PAD, low socioeconomic status (SES) correlates positively with the likelihood of amputation, but paradoxically correlates negatively with the severity of PAD. In Study 2, I used the National Health and Nutrition Examination Survey, in a cross-sectional study design, to evaluate if there was a relationship between PAD severity, as determined by the ankle-brachial index (ABI) and the level of allostatic load. I did not identify an association. In Study 3, I employed the Nationwide Readmission Databases to show that low SES positively correlates with readmission for amputation following surgical revascularization. Findings from these three papers indicate that there is a positive correlation between low SES and the likelihood of amputation both upon initial admission as well as during subsequent follow up after surgical revascularization. I was unable to establish a clear relationship between PAD severity and allostatic load. The paradoxical finding that low SES individuals present with less severe manifestation of PAD signifies that there are yet-to-be-established factors involved in this complex disparity. This dissertatio [...]
African Annals of Thoracic and Cardiovascular Surgery, 2021
Department of Health Policy and Management, School of Public Health, University of Maryland, 4200... more Department of Health Policy and Management, School of Public Health, University of Maryland, 4200 Valley Dr, College Park, MD 20742, United States. Department of Surgery, Howard University College of Medicine, 2041 Georgia Ave NW, Washington, DC 20060, United States. Louis Stokes Health Sciences Library, College of Medicine, Howard University, 501 W Street NW, Washington, DC 20060, United States. Department of Behavioral and Community Health, School of Public Health, University of Maryland, 4200 Valley Dr, College Park, MD 20742, United States. University of Maryland Capital Region Health, 3001 Hospital Dr, Cheverly, MD 20785, United States.
BackgroundSedentary behavior is considered a separate construct from physical activity and engagi... more BackgroundSedentary behavior is considered a separate construct from physical activity and engaging in sedentary behaviors results in health effects independent of physical activity levels. A major source of sedentary behavior in children is time spent viewing TV or movies, playing video games, and using computers. To date no study has examined the impact of neighborhood socioeconomic status (SES) on pre-school children's screen time behavior.MethodsProxy reports of weekday and weekend screen time (TV/movies, video games, and computer use) were completed by 1633 parents on their 4-5 year-old children in Edmonton, Alberta between November, 2005 and August, 2007. Postal codes were used to classified neighborhoods into low, medium or high SES. Multiple linear and logistic regression models were conducted to examine relationships between screen time and neighborhood SES.ResultsGirls living in low SES neighborhoods engaged in significantly more weekly overall screen time and TV/movie...
Objectives-Black patients undergoing carotid endarterectomy (CEA) in the USA are more often sympt... more Objectives-Black patients undergoing carotid endarterectomy (CEA) in the USA are more often symptomatic at presentation and have more comorbidities, compared to White patients. However, the impact of race on outcomes after CEA is largely unknown. Methods-We identified CEA patients in the Vascular Quality Initiative (VQI) registry (2012-2017) and compared them by race (Black vs. White). All other non-White races (891, 1.4%) and Hispanics (2222, 3.4%) were excluded. We used multilevel logistic regression to account for differences in demographics and comorbidities. We assessed long-term survival using multivariable Cox regression. The primary outcome was perioperative stroke/death with long-term survival as a secondary outcome. Results-We included 57,622 CEA patients; 2909 (5.0%) were Black, of whom 983 (34%) were symptomatic. Of the 54,713 White patients, 16,132 (30%) were symptomatic. Black patients, compared to White patients, had a higher vascular disease burden and were less likely to be operated on in a high volume hospital, or by a high volume surgeon. In addition, Black symptomatic patients, compared to White symptomatic patients, were more often operated on <2 weeks after the index neurological symptom (47% vs. 40%, P<.001). Perioperative stroke/death was comparable between Black and White patients (
Objective: Our aim was to describe the racial and ethnic differences in presentation, baseline an... more Objective: Our aim was to describe the racial and ethnic differences in presentation, baseline and operative characteristics, and outcomes after aortoiliac aneurysm repair. Summary of Background Data: Previous studies have demonstrated racial and ethnic differences in prevalence of abdominal aortic aneurysms and showed more complex iliac anatomy in Asian patients. Methods: We identified all White, Black, Asian, and Hispanic patients undergoing aortoiliac aneurysm repair in the VQI from 2003 to 2019. We compared baseline comorbidities, operative characteristics, and perioperative outcomes by race and ethnicity. Results: In our 60,435 patient cohort, Black patients, followed by Asian patients, were most likely to undergo repair for aortoiliac (W:23%, B:38%, A:31%, H:22%, P &lt; 0.001) and isolated iliac aneurysms (W:1.0%, B:3.1%, A:1.5%, H:1.6%, P &lt; 0.001), and White and Hispanic patients were most likely to undergo isolated aortic aneurysm repair (W:76%, B:59%, A:68%, H:76%, P &lt; 0.001). Black patients were more likely to undergo symptomatic repair and underwent rupture repair at a smaller aortic diameter. The iliac aneurysm diameter was largest in Black and Asian patients. Asian patients were most likely to have aortic neck angulation above 60 degree, graft oversizing above 20%, and completion endoleaks. Also, Asian patients were more likely to have a hypogastric artery aneurysm and to undergo hypogastric coiling. Conclusion: Asian and Black patients were more likely to undergo repair for aortoiliac and isolated iliac aneurysms compared to White and Hispanic patients who were more likely to undergo repair for isolated aortic aneurysms. Moreover, there were significant racial differences in the demographics and anatomic characteristics that could be used to inform operative approach and device development.
Recipient pulmonary hypertension due to chronic congestive heart failure is a major cause of righ... more Recipient pulmonary hypertension due to chronic congestive heart failure is a major cause of right ventricular (RV) dysfunction after heart transplantation. We hypothesized that inhaled nitric oxide (NO), in the postoperative period, would a) selectively reduce pulmonary vascular resistance and improve RV hemodynamics and b) reduce the incidence of RV dysfunction compared with a matched historical group. Sixteen consecutive adult heart transplant recipients with lowest mean pulmonary artery (PA) pressures &gt;25 mmHg were prospectively enrolled. Inhaled NO at 20 parts per million (ppm) was initiated before termination of cardiopulmonary bypass (CPB). At 6 and 12 hours after CPB, NO was stopped for 15 minutes and systemic and pulmonary hemodynamics were measured. RV dysfunction was defined as central venous pressure &gt;15 mmHg and consistent echocardiographic findings. The incidence of RV dysfunction and 30-day survival in this group was compared with a historical cohort of 16 patients matched for pulmonary hypertension. Discontinuation of NO for 15 minutes at 6 hours after transplantation resulted in a significant rise in mean PA pressure, pulmonary vascular resistance (PVR), and RV stroke work index. Systemic hemodynamics were not affected by NO therapy. One patient in the NO-treated group, compared with 6 patients in the historical cohort group, developed RV dysfunction (P&lt; .05). The 30-day survival in the NO-treated group and the historical cohort group were 100% and 81%, respectively (P&gt; .05). In heart transplant recipients with pulmonary hypertension, inhaled NO in the postoperative period selectively reduces PVR and enhances RV stroke work. Furthermore, NO reduces the incidence of RV dysfunction in this group of patients when compared with a historical cohort matched for pulmonary hypertension. Inhaled NO is a useful adjunct to the postoperative treatment protocol of heart transplant patients with pulmonary hypertension.
OBJECTIVE While several studies have evaluated the impact of obesity on outcomes following abdomi... more OBJECTIVE While several studies have evaluated the impact of obesity on outcomes following abdominal aortic aneurysm repair, literature examining this association in thoracic endovascular aortic repair (TEVAR) is sparse. Here, we use a multi-institutional, international database to assess the role of body mass index (BMI) on adverse outcomes in patients undergoing TEVAR for descending thoracic aortic aneurysms (DTAA) and type B dissections (TBD). METHODS A retrospective review of all patients undergoing TEVAR for DTAA or TBD from August 2014 to August 2020 was performed. Patients who were underweight (BMI<18.5Kg/m2) or obese (BMI≥30Kg/m2) were compared to those of normal weight (≥18.5-<30Kg/m2). Adjustment for confounding was done with multivariable logistic regression or Cox proportional hazards regression as appropriate for studying postoperative or long-term outcomes. Primary outcomes were 30-day and 1-year mortality. Other outcomes included any postoperative complication, stroke, and spinal cord ischemia. RESULTS A total of 3,423 participants were included in the study, of which 3.3% (n=113) were underweight, 65.9% (n=2,253) had normal weight and 30.8% (n=1,053) were obese. Compared to normal weight, there was no significant difference in 30-day mortality in underweight patients (OR, 1.81; 95%CI, 0.80-4.14; P=0.156). Obese patients undergoing TEVAR for TBD had a 2.7-fold increase in the odds of 30-day mortality compared to normal weight (OR, 2.67, 95%CI, 1.52-4.68; P=0.001). Obese and normal weight patients with DTAA had equivalent odds of 30-day mortality (OR, 1.32; 95%CI, 0.79-2.23, P=0.292). The adjusted hazard of 1-year mortality was 2-fold higher in underweight patients compared to normal weight (HR, 2.15, 95%CI, 1.41-3.29, P<0.001), driven by a higher risk of mortality among patients with thoracic aortic aneurysm (OR, 2.62; 95%CI, 1.63-4.21; P<0.001). There was no significant difference in 1-year mortality risk between normal weight and obesity in both DTAA (OR, 0.77; 95%, 0.54-1.09; P=0.146) and TBD (OR, 1.26; 95%CI, 0.85-1.86; P=0.248). CONCLUSIONS In this study, obese patients undergoing TEVAR for DTAA had comparable 30-day and 1-year mortality risk as normal weight individuals. Obese patients undergoing TEVAR for TBD demonstrated 2.7-fold increase in the odds of 30-day mortality, but equivalent mortality risk as normal weight patients at 1 year. TEVAR represents a safe minimally invasive option for treatment of DTAA in obese patients. Future work should be directed towards minimizing perioperative mortality among patients with TBD in order to optimize TEVAR outcomes.
Background-While many studies have demonstrated racial disparities after major vascular surgery, ... more Background-While many studies have demonstrated racial disparities after major vascular surgery, few have identified the reasons for these disparities and those that did often lacked clinical granularity. Therefore, our aim was to evaluate differences in initial vascular intervention between black and white patients. Methods-We identified black and white patients' initial carotid, abdominal aortic aneurysm (AAA), and infrainguinal peripheral artery (PAD) interventions in the Vascular Quality Initiative registry from 2009-2014. We excluded non-black or non-white patients as well as those with Hispanic ethnicity, asymptomatic PAD, or a history of prior ipsilateral interventions. We compared baseline characteristics and disease severity at time of intervention on a national and regional level. Results-We identified 76,372 patients (9% black), including 35,265 carotid (5% black), 17,346 AAA (5% black), and 23,761 PAD interventions (18% black). For all operations, black patients were younger, more likely female, and had more insulin-dependent diabetes, hypertension, congestive heart failure, renal dysfunction, and dialysis dependence. Black patients were less
Objective-We aimed to compare perioperative morbidity and mortality and late survival amongst bla... more Objective-We aimed to compare perioperative morbidity and mortality and late survival amongst black, white, and Asian patients undergoing intact AAA repair. Methods-We identified all patients undergoing intact, infrarenal AAA repair in the VQI from 2003-2017. We compared in-hospital outcomes by race using the Fisher Exact and Kruskal Wallis tests. Multivariable logistic and linear regression models of perioperative outcomes adjusted for differences in demographics, comorbidities, hospital volume, and procedure. We used Cox regression to evaluate late survival by race. Results-In the cohort, 21,961 (94%) patients were white, 1,215 (5.2%) were black, and 318 (1.4%) were Asian. Black patients were more likely to be symptomatic (Black:
The management of facial fractures in the polytrauma patient requires the coordination of multipl... more The management of facial fractures in the polytrauma patient requires the coordination of multiple surgical disciplines to optimize the functional and cosmetic outcome while minimizing overall morbidity and mortality. Although the plastic surgery literature historically advocates the early repair of facial fractures, the risk of general anesthesia in patients with associated injuries sometimes makes early repair unsafe. We compared early operative repair versus delayed operative repair of facial fractures in multitrauma patients. We specifically examined wound infection, overall complication rate, total length of hospital stay, days in the Intensive Care Unit (ICU), and days on the ventilator in the two groups. A 5-year (1991-1996) retrospective study of multitrauma patients with associated facial fractures was undertaken at an urban community hospital. We had a total of 82 patients, who were divided into three groups. Thirty-three patients did not have operative repair of the facial fractures during the initial admission and were followed by the plastic surgery service on an outpatient basis. These patients will not be discussed further. Seven patients underwent early operative repair, which was defined as repair within 48 hours of admission (group I). Forty-two patients had delayed operative repair, defined as repair more than 48 hours after admission (group II). The reasons for delayed repair included: excessive soft tissue swelling (16), intracranial injuries (12), unstable medical condition (8), and coordination of procedures with other services (6). Of the 49 patients who underwent operative repair, 43 were involved in motor vehicle accidents, 3 were injured by a fall from a height, 2 were involved in auto-pedestrian accidents, and 1 was a victim of assault. Forty-eight of the 49 patients were initially admitted to the ICU. Cumulative associated injuries were as follows: closed head injury (38), extremity fracture (21), blunt chest injuries (11), intra-abdominal injuries (5), vertebral column injuries (7), and ocular injuries (2). The average Injury Severity Score for Group I was 17.3 and for Group II, 18.1. In group I, there were no deaths, there were no wound infections, and the complication rate was 14.3 per cent. The average total number of days spent on the ventilator was 3.0, the average total number of days spent in the ICU was 5.0, and the average total hospital stay was 16.0 days. In group II, there were no deaths, the wound infection rate was 5 per cent, and the overall complication rate was 21 per cent. The average total number of days spent on the ventilator was 3.3, the average total number of days spent in the ICU was 5.8, and the average total days in the hospital was 14.8. Our results indicate that in a similar cohort of multitrauma patients, delayed repair did not increase length of ICU stay or hospital stay. The wound infection rate was negligible, and the complication rate was similar in the two groups. We conclude that a delay in repair of facial fractures in the critically ill patient has an acceptably low complication rate and may be advantageous in decreasing operative risk and minimizing cost by coordinating multiple procedures with various surgical subspecialties.
Background This study aimed to investigate the relationship between community-level economic depr... more Background This study aimed to investigate the relationship between community-level economic deprivation, as measured by the Distressed Communities Index (DCI) and ED visits on account of firearm injuries (assaults and unintentional). Methods A retrospective analysis was conducted using the Maryland State Emergency Department Databases (SEDD) from January 2019 to December 2020 to explore the association between the DCI and ED visits because of firearm injuries (assaults and unintentional). The DCI utilizes 7 variables, based on zip codes, generating 5 levels of socioeconomic distress (prosperous, comfortable, mid-tier, at-risk, and distressed). In a multivariate analysis, we adjusted for age, sex, mental conditions, alcohol addiction, substance abuse, smoking, race/ethnicity, insurance type, and median income. Results Of the 2725 ED visits for firearm injuries, 84.5% were Black and 88.5% male. The median age was 27 (21-35) years, and the mortality rate was 17.7%. A statistically significant association was found between economic deprivation and ED visits for firearm injuries. Compared to prosperous communities, the odds ratios (ORs) were comfortable (OR = 1.33, 95% CI 1.04-1.71, P = .03), mid-tier (OR = 1.69, 95% CI 1.33-2.15, P &lt; .001), at-risk (OR = 1.53, 95% CI 1.17-1.99, P &lt; .001), and distressed (OR = 2.65, 95% CI 2.11-3.33, P &lt; .001). Discussion The study highlights the significant association between community-level economic deprivation, as measured by the Distressed Communities Index, and the incidence of firearm injuries in Maryland. The findings underscore the importance of addressing socioeconomic disparities and implementing targeted interventions to reduce firearm-related injuries in economically distressed communities.
Brief Reports should be submitted online to www.editorialmanager.com/ amsurg. (See details online... more Brief Reports should be submitted online to www.editorialmanager.com/ amsurg. (See details online under ''Instructions for Authors''.) They should be no more than 4 double-spaced pages with no Abstract or sub-headings, with a maximum of four (4) references. If figures are included, they should be limited to two (2). The cost of printing color figures is the responsibility of the author.
Background The objective of this study was to identify predictors of mortality among patients pre... more Background The objective of this study was to identify predictors of mortality among patients presenting to the emergency department (ED) with attempted suicides. Methods We analyzed data on emergency department (ED) visits for attempted suicides from the Nationwide Emergency Department Sample (NEDS) database from January 2010 to December 2017. The predictors of mortality were determined in multivariate analysis including age, sex, insurance, annual income, region of the country, mechanism of injury, mental health conditions (schizophrenia; depression; and anxiety, bipolar, and personality disorders), chronic illnesses (hypertension, diabetes, obesity, and dementia), and social risk factors such as alcohol addiction, smoking, and substance abuse. Results From 2010 to 2017, there were 979,383 ED visits for attempted suicides in the NEDS database. Among these patients, 10,301 (1.1%) died. Of these completed suicides, 73.9% were male with the median age of 43 years (IQR, 30) while the unsuccessful suicide attempt group had a median age of 30 years (IQR, 24) and were 42.7% male. The most common mechanisms of suicide attempt were poisoning (58.8%) and cut injury (25.6%). Gunshot was the most lethal mechanism accounting 40.3% of the completed suicides despite representing 1.3% of the attempts who came to ED. After controlling for common risk factors for attempted suicide, significant predictors of completed suicide include higher income status, uninsured status, male sex, and higher age. Discussion Among US patients presenting to the ED following attempted suicide, factors associated with suicide completion include increasing age, male sex, higher income, gunshot injuries, and uninsured status.
Blacks are several times more likely to undergo a leg amputation as compared to Whites. This is b... more Blacks are several times more likely to undergo a leg amputation as compared to Whites. This is because while peripheral artery disease (PAD), the most common cause of amputation, is more likely to be treated by revascularization (restoration of blood flow) in Whites, PAD is more likely to be treated by amputation in Blacks. Whereas an ongoing debate argues as to whether this disparity is primarily a sociologic versus a biologic phenomenon, I proposed that there are socioeconomic neighborhood stressors that create more severe PAD and renders individuals less likely to undergo successful revascularization and more likely to undergo amputation. Three specific aims are addressed in this dissertation resulting in three manuscripts. In Study 1, utilizing the Nationwide Inpatient Sample Database (NIS) in a retrospective study design, I determined that among patients admitted to the hospital for severe PAD, low socioeconomic status (SES) correlates positively with the likelihood of amputation, but paradoxically correlates negatively with the severity of PAD. In Study 2, I used the National Health and Nutrition Examination Survey, in a cross-sectional study design, to evaluate if there was a relationship between PAD severity, as determined by the ankle-brachial index (ABI) and the level of allostatic load. I did not identify an association. In Study 3, I employed the Nationwide Readmission Databases to show that low SES positively correlates with readmission for amputation following surgical revascularization. Findings from these three papers indicate that there is a positive correlation between low SES and the likelihood of amputation both upon initial admission as well as during subsequent follow up after surgical revascularization. I was unable to establish a clear relationship between PAD severity and allostatic load. The paradoxical finding that low SES individuals present with less severe manifestation of PAD signifies that there are yet-to-be-established factors involved in this complex disparity. This dissertatio [...]
African Annals of Thoracic and Cardiovascular Surgery, 2021
Department of Health Policy and Management, School of Public Health, University of Maryland, 4200... more Department of Health Policy and Management, School of Public Health, University of Maryland, 4200 Valley Dr, College Park, MD 20742, United States. Department of Surgery, Howard University College of Medicine, 2041 Georgia Ave NW, Washington, DC 20060, United States. Louis Stokes Health Sciences Library, College of Medicine, Howard University, 501 W Street NW, Washington, DC 20060, United States. Department of Behavioral and Community Health, School of Public Health, University of Maryland, 4200 Valley Dr, College Park, MD 20742, United States. University of Maryland Capital Region Health, 3001 Hospital Dr, Cheverly, MD 20785, United States.
BackgroundSedentary behavior is considered a separate construct from physical activity and engagi... more BackgroundSedentary behavior is considered a separate construct from physical activity and engaging in sedentary behaviors results in health effects independent of physical activity levels. A major source of sedentary behavior in children is time spent viewing TV or movies, playing video games, and using computers. To date no study has examined the impact of neighborhood socioeconomic status (SES) on pre-school children's screen time behavior.MethodsProxy reports of weekday and weekend screen time (TV/movies, video games, and computer use) were completed by 1633 parents on their 4-5 year-old children in Edmonton, Alberta between November, 2005 and August, 2007. Postal codes were used to classified neighborhoods into low, medium or high SES. Multiple linear and logistic regression models were conducted to examine relationships between screen time and neighborhood SES.ResultsGirls living in low SES neighborhoods engaged in significantly more weekly overall screen time and TV/movie...
Objectives-Black patients undergoing carotid endarterectomy (CEA) in the USA are more often sympt... more Objectives-Black patients undergoing carotid endarterectomy (CEA) in the USA are more often symptomatic at presentation and have more comorbidities, compared to White patients. However, the impact of race on outcomes after CEA is largely unknown. Methods-We identified CEA patients in the Vascular Quality Initiative (VQI) registry (2012-2017) and compared them by race (Black vs. White). All other non-White races (891, 1.4%) and Hispanics (2222, 3.4%) were excluded. We used multilevel logistic regression to account for differences in demographics and comorbidities. We assessed long-term survival using multivariable Cox regression. The primary outcome was perioperative stroke/death with long-term survival as a secondary outcome. Results-We included 57,622 CEA patients; 2909 (5.0%) were Black, of whom 983 (34%) were symptomatic. Of the 54,713 White patients, 16,132 (30%) were symptomatic. Black patients, compared to White patients, had a higher vascular disease burden and were less likely to be operated on in a high volume hospital, or by a high volume surgeon. In addition, Black symptomatic patients, compared to White symptomatic patients, were more often operated on <2 weeks after the index neurological symptom (47% vs. 40%, P<.001). Perioperative stroke/death was comparable between Black and White patients (
Objective: Our aim was to describe the racial and ethnic differences in presentation, baseline an... more Objective: Our aim was to describe the racial and ethnic differences in presentation, baseline and operative characteristics, and outcomes after aortoiliac aneurysm repair. Summary of Background Data: Previous studies have demonstrated racial and ethnic differences in prevalence of abdominal aortic aneurysms and showed more complex iliac anatomy in Asian patients. Methods: We identified all White, Black, Asian, and Hispanic patients undergoing aortoiliac aneurysm repair in the VQI from 2003 to 2019. We compared baseline comorbidities, operative characteristics, and perioperative outcomes by race and ethnicity. Results: In our 60,435 patient cohort, Black patients, followed by Asian patients, were most likely to undergo repair for aortoiliac (W:23%, B:38%, A:31%, H:22%, P &lt; 0.001) and isolated iliac aneurysms (W:1.0%, B:3.1%, A:1.5%, H:1.6%, P &lt; 0.001), and White and Hispanic patients were most likely to undergo isolated aortic aneurysm repair (W:76%, B:59%, A:68%, H:76%, P &lt; 0.001). Black patients were more likely to undergo symptomatic repair and underwent rupture repair at a smaller aortic diameter. The iliac aneurysm diameter was largest in Black and Asian patients. Asian patients were most likely to have aortic neck angulation above 60 degree, graft oversizing above 20%, and completion endoleaks. Also, Asian patients were more likely to have a hypogastric artery aneurysm and to undergo hypogastric coiling. Conclusion: Asian and Black patients were more likely to undergo repair for aortoiliac and isolated iliac aneurysms compared to White and Hispanic patients who were more likely to undergo repair for isolated aortic aneurysms. Moreover, there were significant racial differences in the demographics and anatomic characteristics that could be used to inform operative approach and device development.
Recipient pulmonary hypertension due to chronic congestive heart failure is a major cause of righ... more Recipient pulmonary hypertension due to chronic congestive heart failure is a major cause of right ventricular (RV) dysfunction after heart transplantation. We hypothesized that inhaled nitric oxide (NO), in the postoperative period, would a) selectively reduce pulmonary vascular resistance and improve RV hemodynamics and b) reduce the incidence of RV dysfunction compared with a matched historical group. Sixteen consecutive adult heart transplant recipients with lowest mean pulmonary artery (PA) pressures &gt;25 mmHg were prospectively enrolled. Inhaled NO at 20 parts per million (ppm) was initiated before termination of cardiopulmonary bypass (CPB). At 6 and 12 hours after CPB, NO was stopped for 15 minutes and systemic and pulmonary hemodynamics were measured. RV dysfunction was defined as central venous pressure &gt;15 mmHg and consistent echocardiographic findings. The incidence of RV dysfunction and 30-day survival in this group was compared with a historical cohort of 16 patients matched for pulmonary hypertension. Discontinuation of NO for 15 minutes at 6 hours after transplantation resulted in a significant rise in mean PA pressure, pulmonary vascular resistance (PVR), and RV stroke work index. Systemic hemodynamics were not affected by NO therapy. One patient in the NO-treated group, compared with 6 patients in the historical cohort group, developed RV dysfunction (P&lt; .05). The 30-day survival in the NO-treated group and the historical cohort group were 100% and 81%, respectively (P&gt; .05). In heart transplant recipients with pulmonary hypertension, inhaled NO in the postoperative period selectively reduces PVR and enhances RV stroke work. Furthermore, NO reduces the incidence of RV dysfunction in this group of patients when compared with a historical cohort matched for pulmonary hypertension. Inhaled NO is a useful adjunct to the postoperative treatment protocol of heart transplant patients with pulmonary hypertension.
OBJECTIVE While several studies have evaluated the impact of obesity on outcomes following abdomi... more OBJECTIVE While several studies have evaluated the impact of obesity on outcomes following abdominal aortic aneurysm repair, literature examining this association in thoracic endovascular aortic repair (TEVAR) is sparse. Here, we use a multi-institutional, international database to assess the role of body mass index (BMI) on adverse outcomes in patients undergoing TEVAR for descending thoracic aortic aneurysms (DTAA) and type B dissections (TBD). METHODS A retrospective review of all patients undergoing TEVAR for DTAA or TBD from August 2014 to August 2020 was performed. Patients who were underweight (BMI<18.5Kg/m2) or obese (BMI≥30Kg/m2) were compared to those of normal weight (≥18.5-<30Kg/m2). Adjustment for confounding was done with multivariable logistic regression or Cox proportional hazards regression as appropriate for studying postoperative or long-term outcomes. Primary outcomes were 30-day and 1-year mortality. Other outcomes included any postoperative complication, stroke, and spinal cord ischemia. RESULTS A total of 3,423 participants were included in the study, of which 3.3% (n=113) were underweight, 65.9% (n=2,253) had normal weight and 30.8% (n=1,053) were obese. Compared to normal weight, there was no significant difference in 30-day mortality in underweight patients (OR, 1.81; 95%CI, 0.80-4.14; P=0.156). Obese patients undergoing TEVAR for TBD had a 2.7-fold increase in the odds of 30-day mortality compared to normal weight (OR, 2.67, 95%CI, 1.52-4.68; P=0.001). Obese and normal weight patients with DTAA had equivalent odds of 30-day mortality (OR, 1.32; 95%CI, 0.79-2.23, P=0.292). The adjusted hazard of 1-year mortality was 2-fold higher in underweight patients compared to normal weight (HR, 2.15, 95%CI, 1.41-3.29, P<0.001), driven by a higher risk of mortality among patients with thoracic aortic aneurysm (OR, 2.62; 95%CI, 1.63-4.21; P<0.001). There was no significant difference in 1-year mortality risk between normal weight and obesity in both DTAA (OR, 0.77; 95%, 0.54-1.09; P=0.146) and TBD (OR, 1.26; 95%CI, 0.85-1.86; P=0.248). CONCLUSIONS In this study, obese patients undergoing TEVAR for DTAA had comparable 30-day and 1-year mortality risk as normal weight individuals. Obese patients undergoing TEVAR for TBD demonstrated 2.7-fold increase in the odds of 30-day mortality, but equivalent mortality risk as normal weight patients at 1 year. TEVAR represents a safe minimally invasive option for treatment of DTAA in obese patients. Future work should be directed towards minimizing perioperative mortality among patients with TBD in order to optimize TEVAR outcomes.
Background-While many studies have demonstrated racial disparities after major vascular surgery, ... more Background-While many studies have demonstrated racial disparities after major vascular surgery, few have identified the reasons for these disparities and those that did often lacked clinical granularity. Therefore, our aim was to evaluate differences in initial vascular intervention between black and white patients. Methods-We identified black and white patients' initial carotid, abdominal aortic aneurysm (AAA), and infrainguinal peripheral artery (PAD) interventions in the Vascular Quality Initiative registry from 2009-2014. We excluded non-black or non-white patients as well as those with Hispanic ethnicity, asymptomatic PAD, or a history of prior ipsilateral interventions. We compared baseline characteristics and disease severity at time of intervention on a national and regional level. Results-We identified 76,372 patients (9% black), including 35,265 carotid (5% black), 17,346 AAA (5% black), and 23,761 PAD interventions (18% black). For all operations, black patients were younger, more likely female, and had more insulin-dependent diabetes, hypertension, congestive heart failure, renal dysfunction, and dialysis dependence. Black patients were less
Objective-We aimed to compare perioperative morbidity and mortality and late survival amongst bla... more Objective-We aimed to compare perioperative morbidity and mortality and late survival amongst black, white, and Asian patients undergoing intact AAA repair. Methods-We identified all patients undergoing intact, infrarenal AAA repair in the VQI from 2003-2017. We compared in-hospital outcomes by race using the Fisher Exact and Kruskal Wallis tests. Multivariable logistic and linear regression models of perioperative outcomes adjusted for differences in demographics, comorbidities, hospital volume, and procedure. We used Cox regression to evaluate late survival by race. Results-In the cohort, 21,961 (94%) patients were white, 1,215 (5.2%) were black, and 318 (1.4%) were Asian. Black patients were more likely to be symptomatic (Black:
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