Publications by authors named "Kakra Hughes"

36 Publications

Racial Differences in Isolated Aortic, Concomitant Aortoiliac, and Isolated Iliac Aneurysms: This is a Retrospective Observational Study.

Ann Surg 2020 Dec 29. Epub 2020 Dec 29.

*The Divisions of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA †The Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands ‡The Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA §The Department of Surgery, Howard University and Hospital, Washington, D.C.

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 < 0.001) and isolated iliac aneurysms (W:1.0%, B:3.1%, A:1.5%, H:1.6%, P < 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 < 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.
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http://dx.doi.org/10.1097/SLA.0000000000004731DOI Listing
December 2020

Patterns and Trends of Gun Violence Against Women in the United States.

Ann Surg 2021 Feb 12. Epub 2021 Feb 12.

*Clive O. Callender, M.D., Howard-Harvard Health Sciences Outcomes Research Center, Howard University College of Medicine, Washington, DC †National Center for Excellence in Trauma and Violence Prevention, Howard University, Washington, DC ‡Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.

Objective: To examine patterns and trends of firearm injuries in a nationally representative sample of US women.

Summary Background Data: Gun violence in the United States exceeds rates seen in most other industrialized countries. Due to the paucity of data little is known regarding demographics and temporal variations in firearm injuries among women.

Methods: Data was extracted from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System (2001 - 2017) for women 18 years and older. Number of non-fatal firearm assaults and homicide per year were extracted and crude population-based injury rates were calculated. Sub-stratification by age-group and time period were performed.

Results: Between 2001 and 2017, there were 88,823 non-fatal firearm assaults involving women and 29,106 firearm homicides. There were 4,116 victims of non-fatal firearm assault in 2001 (3.8 per 10) and 12,959 by 2017 (10.0 per 10). Homicide rates were 1.5 per 10 in 2001 and 1.7 per 10 in 2017. Sub-stratification by age-group and time period showed that there were no significant changes in non-fatal firearm assault rates between 2001 and 2010 (P-trend = 0.132 in 18 - 44 yo; 0.298 in 45 - 64 yo). However between 2011 and 2017, non-fatal assault rates increased from 7.10 per 10 to 19.24 per 10 in 18 - 44 yo (P-trend = 0.013) and from 1.48 per 10 to 3.93 per 10 in 45 - 64 yo (P-trend = 0.003). Similar trends were seen with firearm homicide among 18 - 44 yo (1.91 per 10 to 2.47 per 10 in 2011-2017, P-trend = 0.022). However, the trends among 45 - 64 yo were not significant in both time periods.

Conclusions: Female victims of gun violence are increasing and more recent years have been marked with higher rates of firearm injuries, particularly among younger women. These data suggest that improved public health strategies and policies may be beneficial in reducing gun violence against US women.
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http://dx.doi.org/10.1097/SLA.0000000000004810DOI Listing
February 2021

Atherosclerotic Peripheral Artery Disease in the United States: Gender and Ethnic Variation in a Multiple Cause-of-Death Analysis.

Vasc Endovascular Surg 2020 Aug 29;54(6):482-486. Epub 2020 May 29.

Department of Surgery, Howard University College of Medicine, Washington, DC, USA.

Background: Atherosclerotic peripheral artery disease (PAD) is an important cause of morbidity in the United States. In this article, we conducted a multiple cause-of-death analysis of PAD to determine patterns and trends in its contribution to mortality.

Methods: The Centers for Disease Control and Prevention statistics data were used to determine the number of deaths with the following 10th revision of the codes selected as an underlying cause of death (UCOD) or a contributing cause considering multiple causes of death (MCOD): 170.2, 170.9, 173.9, 174.3, and 174.4. The age-adjusted death rates per 100 000 population by age, gender, race, ethnicity, and region were computed for the United States between the years 1999 and 2017. In these years, there were 47 728 569 deaths from all causes.

Results: In 1999 to 2017 combined, there were a total of 311 175 deaths associated with PAD as an UCOD. However, there were 1 361 253 deaths with PAD listed as an UCOD or a contributing cause in MCOD, which is 4.3 times higher than UCOD. Age-adjusted MCOD rates were higher in males (25.6) than in females (19.4). Among non-Hispanics, the rate in African American males and females was 1.2 times higher than in Caucasians. Age-adjusted MCOD rates have declined in African Americans and Caucasians irrespective of gender from 2000 to 2017.

Conclusion: Peripheral artery disease is mentioned 4 times as often on death certificates as a contributing cause of death as it is chosen as the UCOD. Overall, age-adjusted MCOD rates were higher in African Americans than Caucasians, males than females, and declined between 2000 and 2017.
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http://dx.doi.org/10.1177/1538574420928158DOI Listing
August 2020

Assessment of the "Weekend Effect" in Lower Extremity Vascular Trauma.

Ann Vasc Surg 2020 Jul 18;66:233-241.e4. Epub 2019 Dec 18.

Department of Surgery, Howard University College of Medicine, Washington, DC. Electronic address:

Background: Studies suggest that patients admitted on weekends may have worse outcomes as compared with those admitted on weekdays. Lower extremity vascular trauma (LEVT) often requires emergent surgical intervention and might be particularly sensitive to this "weekend effect." The objective of this study was to determine if a weekend effect exists for LEVT.

Methods: The National and Nationwide Inpatient Sample Database (2005-2014) was queried to identify all adult patients who were admitted with an LEVT diagnosis. Patient and hospital characteristics were recorded or calculated and outcomes including in-hospital mortality, amputation, length of stay (LOS), and discharge disposition were assessed. Independent predictors of outcomes were identified using multivariable regression models.

Results: There were 9,282 patients admitted with LEVT (2,866 weekend admissions vs. 6,416 weekday admissions). Patients admitted on weekends were likely to be younger than 45 years (68% weekend vs. 55% weekday, P < 0.001), male (81% weekend vs. 75% weekday, P < 0.001), and uninsured (22% weekend vs. 17% weekday, P < 0.001) as compared with patients admitted on weekdays. There were no statistically significant differences in mortality (3.8% weekend vs. 3.3% weekday, P = 0.209), amputation (7.2% weekend vs. 6.6% weekday, P = 0.258), or discharge home (57.4% weekend vs. 56.1% weekday, P = 0.271). There was no clinically significant difference in LOS (median 7 days weekend vs. 7 days weekday), P = 0.009. On multivariable regression analyses, there were no statistically significant outcome differences between the groups.

Conclusions: This study did not identify a weekend effect in LEVT patients in the United States. This suggests that factors other than the day of admission may be important in influencing outcomes after LEVT.
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http://dx.doi.org/10.1016/j.avsg.2019.11.046DOI Listing
July 2020

Exercise Training Induced Changes In Nuclear Magnetic Resonance-Measured Lipid Particles In Mild Cognitively Impaired Elderly African American Volunteers: A Pilot Study.

Clin Interv Aging 2019 5;14:2115-2123. Epub 2019 Dec 5.

Division of Geriatrics, Department of Medicine and Clinical, Howard University Hospital, Washington, DC, USA.

Purpose: Poor cardiorespiratory fitness (CRF) is linked to cognitive deterioration, but its effects on lipid heterogeneity and functional properties in older African American (AA) subjects with mild cognitive impairment (MCI) need elucidation. This study determined whether exercise training-induced changes in blood lipid particle sizes (LPS) were associated with CRF determined by VOMax in elderly AAs with MCI. Given the pivotal role of brain-derived neurotrophic factor (BDNF) on glucose metabolism, and therefore, "diabetic dyslipidemia", we also determined whether changes in LPS were associated with the levels of serum BDNF.

Methods: This analysis included 17 of the 29 randomized elderly AAs with MCI who had NMR data at baseline and after a 6-month training. We used Generalized Linear Regression (GLM) models to examine cardiorespiratory fitness (VOMax) effects on training-induced change in LPS in the stretch and aerobic groups. Additionally, we determined whether the level of BDNF influenced change in LPS.

Results: Collectively, mean VOMax (23.81±6.17) did not differ significantly between aerobic and stretch groups (difference=3.17±3.56, =0.495). Training-related changes in very low-density lipoprotein, chylomicrons, and total low-density lipoprotein (LDL) particle sizes correlated significantly with VOMax, but not after adjustment for age and gender. However, increased VOMax significantly associated with reduced total LDL particle size after similar adjustments ( = 0.046). While stretch exercise associated with increased protective large high-density lipoprotein particle size, the overall effect was not sustained following adjustments for gender and age. However, changes in serum BDNF were associated with changes in triglyceride and cholesterol transport particle sizes ( < 0.051).

Conclusion: Promotion of stretch and aerobic exercise to increase CRF in elderly AA volunteers with MCI may also promote beneficial changes in lipoprotein particle profile. Because high BDNF concentration may reduce CVD risk, training-related improvements in BDNF levels are likely advantageous. Large randomized studies are needed to confirm our observations and to further elucidate the role for exercise therapy in reducing CVD risk in elderly AAs with MCI.
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http://dx.doi.org/10.2147/CIA.S195878DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6900999PMC
March 2020

The effect of income and insurance on the likelihood of major leg amputation.

J Vasc Surg 2019 08 8;70(2):580-587. Epub 2019 Mar 8.

Clive O. Callender, MD, Howard-Harvard Health Sciences Outcomes Research Center, Howard University and Hospital, Washington, D.C.

Background: Although it has been suggested that individuals of low socioeconomic status and those with Medicaid or no insurance may be more likely to have their peripheral artery disease treated by leg amputation rather than by limb-saving revascularization, it is not clear if this disparity occurs consistently on a national basis, and if it does so in a linear fashion, such that poorer individuals are at progressively greater risk for amputation.

Objective: We undertook this study to determine if lower median household income and Medicaid/no insurance status are associated with a higher risk for amputation, and if this occurs in a progressively linear fashion.

Methods: The National (Nationwide) Inpatient Sample Database was queried to identify patients who were admitted with a diagnosis of critical limb ischemia from 2005 to 2014 and underwent either a major amputation or a revascularization procedure during that admission. Patients were stratified according to their insurance status and their median household income into four income quartiles. Multivariate logistic regression was performed to determine the effect of income and insurance status on the odds of undergoing amputation vs leg revascularization.

Results: Across the different insurance types, there was a significant decrease in the odds ratios for amputation as one progressed from one MHI quartile to a higher one: namely, Medicare (2.23, 1.87, 1.65, and 1.42 for the first, second, third, and fourth MHI quartiles); Medicaid (2.50, 2.28, 2.04, and 1.80 for the first, second, third, and fourth MHI quartiles); private insurance (1.52, 1.21, 1.16, and 1.00 for the first, second, third, and fourth MHI quartiles), and uninsured (1.91, 1.64, 1.10, and 1.22, for the first, second, third, and fourth MHI quartiles).

Conclusions: Lower MHI, Medicaid insurance, and uninsured status are associated with a greater likelihood of amputation and a lower likelihood of undergoing limb-saving revascularization. These disparities are exacerbated in stepwise fashion, such that lower income quartiles are at progressively greater risk for amputation.
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http://dx.doi.org/10.1016/j.jvs.2018.11.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6886256PMC
August 2019

Racial/ethnic Disparities in Lower Extremity Amputation Vs Revascularization: A Brief Review.

J Natl Med Assoc 2018 Dec 16;110(6):560-563. Epub 2018 Mar 16.

University of Maryland School of Public Health, College Park, MD, USA.

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http://dx.doi.org/10.1016/j.jnma.2018.02.003DOI Listing
December 2018

Burden of Peripheral Artery Disease in Sub-Saharan Africa and the Caribbean 1990 to 2015.

Vasc Endovascular Surg 2018 Oct 26;52(7):520-526. Epub 2018 Jun 26.

3 Department of Internal Medicine, Howard University College of Medicine, Washington, DC, USA.

Background: The estimated global prevalence of Peripheral artery disease (PAD) increased by 24% in span of 10 years (2000-2010) from 164 to 202 million. Despite scarcity of data on PAD in sub-Saharan Africa (SSA) and the Caribbean, estimates for PAD from these regions may be helpful for health-care providers.

Methods: The Global Burden of Disease Study 2015 quantified health loss from hundreds of diseases using systematic reviews and multilevel computer modeling. Estimated rates with 95% uncertainty intervals (UI) for PAD (ICD-10 I70.2) were examined for SSA and the Caribbean and compared to high-income North America (HINA). Disability-adjusted life years (DALYs) are years of healthy life lost representing total disease burden by combining years of life lost and years lived disabled.

Results: In 2015, estimated age-standardized DALYs per 100,000 due to PAD for males were as follows: Caribbean (34, UI: 29-39), HINA (36, UI: 30-42), and SSA (20, UI: 14-30). In contrast, DALYs in females were as follows: Caribbean (25, UI: 20-30), HINA (28, UI: 22-36), and SSA (17, UI: 11-26). For both sexes combined, the rate in Southern SSA was 55 (46-67). This reflects the extremely high rates in South Africa (males 90, UI: 77-107; females 63, UI: 53-75).

Conclusion: Estimated rate of DALYs per 100,000 was lowest in SSA. Within SSA, the rate in South Africa was highest, exceeding even HINA. Caribbean rates were intermediate.
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http://dx.doi.org/10.1177/1538574418784709DOI Listing
October 2018

The impact of race on outcomes after carotid endarterectomy in the United States.

J Vasc Surg 2018 08 23;68(2):426-435. Epub 2018 Feb 23.

Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. Electronic address:

Objective: Black patients undergoing carotid endarterectomy (CEA) in the United States are more often symptomatic at presentation and have more comorbidities compared with white patients. However, the impact of race on outcomes after CEA is largely unknown.

Methods: We identified CEA patients in the Vascular Quality Initiative registry (2012-2017) and compared them by race (black vs white). All other nonwhite 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 with 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 with white symptomatic patients, were more often operated on <2 weeks after the index neurologic symptom (47% vs 40%; P < .001). Perioperative stroke/death was comparable between black and white patients (symptomatic, 2.8% vs 2.2% [P = .2]; asymptomatic, 1.6% vs 1.3% [P = .2]), as was unadjusted survival at 3 years (93% vs 93%; P = .7). However, after adjustment, black patients did experience better long-term survival compared with white patients (hazard ratio, 0.8; 95% confidence interval, 0.7-0.9; P = .01). On multilevel logistic regression, race was not associated with perioperative stroke/death (odds ratio, 1.0; 95% confidence interval, 0.8-1.3; P = .98).

Conclusions: Despite the greater prevalence of vascular risk factors in black patients and racial inequalities in surgical treatment, rates of perioperative stroke/death and unadjusted survival were similar between white and black patients. Moreover, black patients experienced better adjusted long-term survival after CEA.
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http://dx.doi.org/10.1016/j.jvs.2017.11.087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6057797PMC
August 2018

Regional variation in racial disparities among patients with peripheral artery disease.

J Vasc Surg 2018 08 16;68(2):519-526. Epub 2018 Feb 16.

Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass. Electronic address:

Objective: Prior studies identified significant racial disparities as well as regional variation in outcomes of patients with peripheral artery disease (PAD). We aimed to determine whether regional variation contributes to these racial disparities.

Methods: We identified all white or black patients who underwent infrainguinal revascularization or amputation in 15 deidentified regions of the Vascular Quality Initiative between 2003 and 2017. We excluded three regions with <100 procedures. We used multivariable linear regression, allowing clustering at the hospital level to calculate the marginal effects of race and region on adjusted 30-day mortality, major adverse limb events (MALEs), and amputation. We compared long-term outcomes between black and white patients within each region and within patients of each race treated in different regions using multivariable Cox regression.

Results: We identified 90,418 patients, 15,527 (17%) of whom were black. Patients underwent 31,263 bypasses, 52,462 endovascular interventions, and 6693 amputations. Black patients were younger and less likely to smoke, to have coronary artery disease, or to have chronic obstructive pulmonary disease, but they were more likely to have diabetes, limb-threatening ischemia, dialysis dependence, and hypertension and to be self-insured or on Medicaid (all P < .05). Adjusted 30-day mortality ranged from 1.2% to 2.1% across regions for white patients and 0% to 3.0% for black patients; adjusted 30-day MALE varied from 4.0% to 8.3% for white patients and 2.4% to 8.1% for black patients; and adjusted 30-day amputation rates varied from 0.3% to 1.2% for white patients and 0% to 2.1% for black patients. Black patients experienced significantly different (both higher and lower) adjusted rates of 30-day mortality and amputation than white patients did in several regions (P < .05) but not MALEs. In addition, within each racial group, we found significant variation in the adjusted rates of all outcomes between regions (all P < .01). In adjusted analyses, compared with white patients, black patients experienced consistently lower long-term mortality (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.73-0.88; P < .001) and higher rates of MALEs (HR, 1.15; 95% CI, 1.06-1.25; P < .001) and amputation (HR, 1.33; 95% CI, 1.18-1.51; P < .001), with no statistically significant variation across the regions. However, rates of all long-term outcomes varied within both racial groups across regions.

Conclusions: Significant racial disparities exist in outcomes after lower extremity procedures in patients with PAD, with regional variation contributing to perioperative but not long-term outcome disparities. Underperforming regions should use these data to generate quality improvement projects, as understanding the etiology of these disparities is critical to improving the care of all patients with PAD.
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http://dx.doi.org/10.1016/j.jvs.2017.10.090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6057812PMC
August 2018

Racial disparities in outcomes after intact abdominal aortic aneurysm repair.

J Vasc Surg 2018 04 23;67(4):1059-1067. Epub 2017 Oct 23.

Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass. Electronic address:

Objective: We aimed to compare perioperative morbidity and mortality and late survival among black, white, and Asian patients undergoing intact abdominal aortic aneurysm (AAA) repair.

Methods: We identified all patients undergoing intact, infrarenal AAA repair in the Vascular Quality Initiative (VQI) from 2003 to 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, 1215 (5.2%) were black, and 318 (1.4%) were Asian. Black patients were more likely to be symptomatic (black, 16%; white, 9.1%; Asian, 11%; P < .001) and to undergo endovascular aneurysm repair (EVAR; black, 87%; white, 83%; Asian, 84%; P < .001). There were no differences in 30-day mortality after EVAR (black, 1.1%; white, 1.1%; Asian, 0.8%; P = .80) or open repair (black; 4.3%; white, 2.6%; Asian, 1.9%; P = .33). However, black patients were more likely to receive new postoperative dialysis (black, 1.6%; white, 0.8%; Asian; 0.7%; P = .01) and to return to the operating room (black, 4.3%; white, 2.9%; Asian, 0.9%; P < .01). Mean hospital length of stay was longer in black patients after EVAR (black, 3.3 days; white, 2.6 days; Asian, 2.6 days; P < .001) and in Asian and black patients after open repair (black, 10.5 days; white, 8.5 days; Asian, 13.0 days; P < .001). After multivariable adjustment, black patients were more likely than white patients to have postoperative dialysis (odds ratio, 2.2; 95% confidence interval [CI], 1.3-3.6; P < .01) and return to the operating room (odds ratio, 1.6; 95% CI, 1.2-2.2; P < .01). Five-year survival was highest for Asian patients (black, 84%; white, 85%; Asian, 92%), even in the adjusted Cox model (Asian: hazard ratio, 0.6; 95% CI, 0.4-0.97; P = .04).

Conclusions: Although perioperative mortality is comparable across races after AAA repair, black patients are more likely than white or Asian patients to develop new postoperative renal failure and return to the operating room, even after adjusting for differences in comorbidities, operative variables, and hospital volume. In addition, whereas Asian patients have the highest rate of postoperative myocardial infarction, they also have the highest late survival. Further studies are warranted to elucidate the mechanism of these disparities.
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http://dx.doi.org/10.1016/j.jvs.2017.07.138DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5869065PMC
April 2018

Black patients present with more severe vascular disease and a greater burden of risk factors than white patients at time of major vascular intervention.

J Vasc Surg 2018 02 23;67(2):549-556.e3. Epub 2017 Sep 23.

Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. Electronic address:

Background: Although 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 disease (PAD) interventions in the Vascular Quality Initiative (VQI) registry from 2009 to 2014. We excluded nonblack or nonwhite 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 likely to be on a statin before AAA (62% vs 69%; P < .001) or PAD intervention (61% vs 67%; P < .001) and also less likely to be discharged on an antiplatelet and statin regimen after these procedures (AAA, 60% vs 64% [P = .01]; PAD, 64% vs 67% [P < .001]). Black patients presented with more severe disease, including higher proportions of symptomatic carotid disease (36% vs 31%; P < .001), symptomatic or ruptured AAA (27% vs 16%; P < .001), and chronic limb-threatening ischemia (73% vs 62%; P < .001). Black patients more often presented with concurrent iliac artery aneurysms at the time of AAA repair (elective open AAA repair, 46% vs 26% [P < .001]; elective endovascular aneurysm repair, 38% vs 23% [P < .001]).

Conclusions: Black patients present with more advanced disease at the time of initial major vascular operation. Efforts to control risk factors, identify and treat arterial disease in a timely fashion, and optimize medical management among black patients may provide opportunity to improve current disparities.
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http://dx.doi.org/10.1016/j.jvs.2017.06.089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5794625PMC
February 2018

The Role of Hypoxia-Inducible Factor 1 in Mild Cognitive Impairment.

Cell Mol Neurobiol 2017 Aug 17;37(6):969-977. Epub 2016 Nov 17.

Geriatrics Division, Department of Medicine, Howard University Hospital, 2041 Georgia Ave NW, Washington, DC, 20060, USA.

Neuroinflammation and reactive oxygen species are thought to mediate the pathogenesis of Alzheimer's disease (AD), suggesting that mild cognitive impairment (MCI), a prodromal stage of AD, may be driven by similar insults. Several studies document that hypoxia-inducible factor 1 (HIF-1) is neuroprotective in the setting of neuronal insults, since this transcription factor drives the expression of critical genes that diminish neuronal cell death. HIF-1 facilitates glycolysis and glucose metabolism, thus helping to generate reductive equivalents of NADH/NADPH that counter oxidative stress. HIF-1 also improves cerebral blood flow which opposes the toxicity of hypoxia. Increased HIF-1 activity and/or expression of HIF-1 target genes, such as those involved in glycolysis or vascular flow, may be an early adaptation to the oxidative stressors that characterize MCI pathology. The molecular events that constitute this early adaptation are likely neuroprotective, and might mitigate cognitive decline or the onset of full-blown AD. On the other hand, prolonged or overwhelming stressors can convert HIF-1 into an activator of cell death through agents such as Bnip3, an event that is more likely to occur in late MCI or advanced Alzheimer's dementia.
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http://dx.doi.org/10.1007/s10571-016-0440-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5435557PMC
August 2017

Lower Extremity Arterial Reconstruction in Octogenarians and Older.

Ann Vasc Surg 2016 Jul 10;34:171-7. Epub 2016 May 10.

Department of Surgery, Howard University College of Medicine and Hospital, Washington, DC. Electronic address:

Background: Despite previous single-institution studies showing that lower extremity arterial reconstruction (LEAR) in octogenarians and older patients may be undertaken with acceptable postoperative morbidity and mortality, there continues to be significant reluctance, in the vascular surgical community, to undertaking these complex revascularization procedures in this very elderly population. We undertook this study in an effort to determine the outcomes of LEAR in octogenarians and older patients on a national level.

Methods: The American College of Surgeons' National Surgical Quality Improvement Program database was queried to identify all patients who underwent LEAR between January 1, 2005 and December 31, 2009. Patient demographics and presenting comorbidities were recorded, and multivariate analyses were performed to compare outcomes in patients 80 and older to those in younger patients.

Results: There were 19,028 patients who underwent open infrainguinal LEAR during this time period. Patients ≥80 comprised 18% (3,486 patients), and patients <80 years comprised 82% (15,542 patients). Multivariate analysis demonstrated that patients aged ≥80 years had an increased likelihood of mortality (odds ratio [OR] 1.79; 95% confidence interval [CI] 1.42-2.26), cardiovascular (OR, 1.46; 95% CI, 1.12-1.89), respiratory (OR, 1.37; 95% CI, 1.12-1.67), and renal (OR, 1.57; 95% CI, 1.27-1.95) complications. There was, however, no significant difference in the likelihood of graft failure (OR, 1.04; 95% CI, 0.86-1.27), wound infection (OR, 0.92; 95% CI, 0.79-1.06), or major amputation (OR, 0.59; 95% CI, 0.13-2.74) between these 2 groups.

Conclusions: LEAR in octogenarians is associated with an increased risk of postoperative morbidity and mortality but no increased risk of wound infection, amputation, or graft failure.
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http://dx.doi.org/10.1016/j.avsg.2015.12.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4930703PMC
July 2016

Revision of Roux-En-Y Gastric Bypass for Weight Regain: a Systematic Review of Techniques and Outcomes.

Obes Surg 2016 07;26(7):1627-34

Department of Surgery, Howard University College of Medicine, Washington, DC, USA.

Background: Weight regain has led to an increase in revision of Roux-en-Y gastric bypass (RYGB) surgeries. There is no standardized approach to revisional surgery after failed RYGB. We performed an exhaustive literature search to elucidate surgical revision options. Our objective was to evaluate outcomes and complications of various methods of revision after RYGB to identify the option with the best outcomes for failed primary RYGB.

Method: A systematic literature search was conducted using the following search tools and databases: PubMed, Google Scholar, Cochrane Clinical Trials Database, Cochrane Review Database, EMBASE, and Allied and Complementary Medicine to identify all relevant studies describing revision after failed RYGB. Inclusion criteria comprised of revisional surgery for weight gain after RYGB.

Results: Of the 1200 articles found, only 799 were selected for our study. Of the 799, 24 studies, with a total of 866 patients, were included for a systematic review. Of the 24 studies, 5 were conversion to Distal Roux-en-y gastric bypass (DRYGB), 5 were revision of gastric pouch and anastomosis, 6 were revision with gastric band, 2 were revision to biliopancreatic diversion/duodenal switch (BPD/DS), and 6 were revision to endoluminal procedures (i.e., stomaphyx). Mean percent excess body mass index loss (%EBMIL) after revision up to 1 and 3-year follow-up for BPD/DS was 63.7 and 76 %, DRYGB was 54 and 52.2 %, gastric banding revision 47.6 and 47.3 %, gastric pouch/anastomosis revision 43.3 and 14 %, and endoluminal procedures at 32.1 %, respectively. Gastric pouch/anastomosis revision resulted in the lowest major complication rate at 3.5 % and DRYGB with the highest at 11.9 % when compared to the other revisional procedures. The mortality rate was 0.6 % which only occurred in the DRYGB group.

Conclusion: All 866 patients in the 24 studies reported significant early initial weight loss after revision for failed RYGB. However, of the five surgical revision options considered, BPD/DS, DRYGB, and gastric banding resulted in sustained weight loss, with acceptable complication rate.
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http://dx.doi.org/10.1007/s11695-016-2201-5DOI Listing
July 2016

Lower extremity arterial reconstruction in obese patients.

Am J Surg 2015 Apr 14;209(4):640-4. Epub 2015 Jan 14.

Department of Surgery, Howard University College of Medicine and Hospital, 2041 Georgia Avenue, #4B-04, Washington, DC 20060, USA. Electronic address:

Background: Previous reports have noted that obese patients undergoing lower extremity arterial reconstruction have higher complication rates compared with nonobese patients. We evaluated the effect of obesity on outcomes following open infrainguinal arterial reconstruction on a national level.

Methods: A query of the American College of Surgeons' National Surgical Quality Improvement Program Database was conducted to identify all adult patients who underwent open infrainguinal lower extremity arterial reconstruction from 2005 to 2009. Postoperative outcomes were analyzed in different body mass index groups.

Results: Obese and morbidly obese patients had a higher risk of wound infection when compared with normal weight patients (odds ratios 2.1 and 2.7, P < .05). Obese patients had a lower mortality when compared with normal weight patients (odds ratio .83, P < .05).

Conclusions: Obesity was associated with an increase in wound infection after open lower extremity arterial reconstruction. Obesity, but not morbid obesity, was associated with decreased mortality.
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http://dx.doi.org/10.1016/j.amjsurg.2014.12.012DOI Listing
April 2015

The sleepy surgeon: does night-time surgery for trauma affect mortality outcomes?

Am J Surg 2015 Apr 19;209(4):633-9. Epub 2015 Jan 19.

Department of Surgery, Howard University, Washington, DC, USA. Electronic address:

Background: Sleepiness and fatigue affect surgical outcomes. We wished to determine the association between time of day and outcomes following surgery for trauma.

Methods: From the National Trauma Data Bank (2007 to 2010), we analyzed all adults who underwent an exploratory laparotomy between midnight and 6 am or between 7 am and 5 pm. We compared hospital mortality between these groups using multivariate logistic regression. Additionally, for each hour, a standardized mortality ratio was calculated.

Results: About 16,096 patients and 15,109 patients were operated on in the night time and day time, respectively. No difference was found in the risk-adjusted mortality rate between the 2 time periods (odds ratio .97, 95% confidence interval .893 to 1.058). However, hourly variations in mortality during the 24-hour period were noted.

Conclusion: Trauma surgery during the odd hours of the night did not have an increased risk-adjusted mortality when compared with surgery during the day.
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http://dx.doi.org/10.1016/j.amjsurg.2014.12.015DOI Listing
April 2015

Laparoscopic surgery for trauma: the realm of therapeutic management.

Am J Surg 2015 Apr 14;209(4):627-32. Epub 2015 Jan 14.

Department of Surgery, Howard University Hospital, Washington, DC, USA. Electronic address:

Background: The use of laparoscopy in trauma is, in general, limited for diagnostic purposes. We aim to evaluate the therapeutic role of laparoscopic surgery in trauma patients.

Methods: We analyzed the National Trauma Data Bank (2007 to 2010) for all patients undergoing diagnostic laparoscopy. Patients undergoing a therapeutic laparoscopic surgical procedure were identified and tabulated. Mortality and hospital length of stay for patients with isolated abdominal injuries were compared between the open and laparoscopic groups.

Results: Of a total of 2,539,818 trauma visits in the National Trauma Data Bank, 4,755 patients underwent a diagnostic laparoscopy at 467 trauma centers. Of these, 916 (19.3%) patients underwent a therapeutic laparoscopic intervention. Common laparoscopic operations included diaphragm repair, bowel repair or resection, and splenectomy. Patients undergoing laparoscopic surgery had a significantly shorter length of stay than the open group (5 vs 6 days; P < .001).

Conclusion: Therapeutic laparoscopic surgery for trauma is feasible and may provide better outcomes.
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http://dx.doi.org/10.1016/j.amjsurg.2014.12.011DOI Listing
April 2015

Racial disparities in the use of laparoscopic cholecystectomy still exist!

Am Surg 2015 Jan;81(1):E1-2

Department of Surgery, Howard University Hospital, Washington, DC, USA.

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January 2015

Abdominal aortic aneurysm repair in nonagenarians.

Ann Vasc Surg 2015 Feb 15;29(2):183-8. Epub 2014 Oct 15.

Department of Surgery, Upstate Medical University, Syracuse, NY.

Background: The feasibility of abdominal aortic aneurysm (AAA) repair in nonagenarians on a national level is largely unknown. We undertook this study to determine the outcomes of open and endovascular AAA repair in this population on a national level.

Methods: A retrospective review of the Nationwide Inpatient Sample Database was conducted to determine all patients 90 years and older who underwent either an open or endovascular repair of a nonruptured AAA from 1997 to 2008. Preoperative comorbidities and postoperative complications in the inpatient setting were recorded. The primary end point was mortality. Secondary end points were postoperative neurologic, cardiac, and respiratory complications. This group was then compared with all adult patients less than 90 years old (age, 18-89) who had undergone repair of a nonruptured AAA during this same period.

Results: Four hundred twenty-three patients 90 years and older underwent repair of a nonruptured AAA (compared with 52,370 < 90). Of these, 132 patients underwent open repair (31%) and 291 (69%) underwent endovascular repair. Inpatient mortality was 18.3% for the ≥90 open, 4.6% for the <90 open, 3.1% for the ≥90 endovascular, and 1.2% for <90 endovascular group.

Conclusions: Open repair of AAA's in nonagenarians is associated with significantly high perioperative mortality, whereas endovascular repair is feasible with acceptable perioperative mortality. This mortality, although significantly higher than that obtained for endovascular repair in patients <90, is nonetheless not significantly different for the mortality noted for patients <90 undergoing open AAA repair.
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http://dx.doi.org/10.1016/j.avsg.2014.07.037DOI Listing
February 2015

Racial/ethnic disparities in revascularization for limb salvage: an analysis of the National Surgical Quality Improvement Program database.

Vasc Endovascular Surg 2014 Jul-Aug;48(5-6):402-5. Epub 2014 Jul 30.

Department of Internal Medicine, Howard University, Washington, DC, USA.

Introduction: Previous reports have suggested that black patients have a higher rate of major lower extremity amputation and a lower rate of revascularization for limb salvage when compared to white patients.

Objective: We undertook this study to determine the extent of this ethnic disparity in recent years and to evaluate whether the widespread adoption of endovascular techniques has had an impact on this disparity.

Methods: The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database was queried to identify all patients who had undergone an above- or below-knee amputation as well as all patients who had undergone an open or endovascular revascularization procedure for critical limb ischemia for the years 2005 to 2006. Patient demographics and 30-day outcomes were recorded, and comparisons were made among the different ethnic groups.

Results: There were 1568 patients identified in the NSQIP database as having undergone a major lower extremity amputation in 2005 and 2006. Of these patients, 54% were white, 29% black, 8% Hispanic, and 0.7% Asian. Eight percent of patients did not have identifying ethnic data. The group undergoing amputation was primarily male (61%) with a mean age of 65. Median length of stay was 11 days, and 30-day mortality was 9% following amputation. During this same time period, 4191 patients underwent an open surgical procedure and 569 patients underwent an endovascular procedure for the purposes of limb salvage. Of those patients undergoing an open procedure, 74% were white, 12% black, 4% Hispanic, 0.4% Asian, and 10% did not have identifying ethnic data. Open surgical patients were primarily male (63%) with a mean age of 66. Median length of stay was 6 days, and 30-day mortality was 3.3%. Of those patients undergoing an endovascular procedure, 79% were white, 10% black, 2% Hispanic, 1% Asian, and 8% did not have identifying ethnic data. The endovascular group was also primarily male (61%) with a mean age of 68. Median length of stay was 5 days, and 30-day mortality was 4%.

Conclusion: There remains a significant ethnic disparity in limb-salvage revascularization. Blacks comprise 29% of patients undergoing a major lower extremity amputation, but only 12% of those undergoing an open surgical procedure and 10% of those undergoing an endovascular procedure for limb salvage. The widespread adoption of endovascular revascularization techniques appears not to have had much impact on this disparity.
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http://dx.doi.org/10.1177/1538574414543276DOI Listing
June 2015

Open versus endovascular repair of thoracic aortic aneurysms: a Nationwide Inpatient Sample study.

Vasc Endovascular Surg 2014 Jul-Aug;48(5-6):383-7. Epub 2014 Jun 19.

Division of Cardiothoracic Surgery, Baylor College of Medicine, Texas Heart Institute, Houston, TX, USA.

Purpose: Endovascular repair of descending thoracic aortic aneurysms has become an acceptable surgical option over the past decade. We sought to compare the results of open versus endovascular repair of thoracic aortic aneurysms (TEVAR) in the United States.

Methods: The Nationwide Inpatient Sample (NIS) database was queried to identify all patients undergoing elective repair of a thoracic aortic aneurysm from 1998 to 2007 in the United States. Patient demographic data, preoperative comorbidities, and postoperative complications were recorded. Statistical analyses were performed comparing open versus endovascular repair. Multivariate analyses were conducted controlling for preoperative comorbidities including the presence of diabetes mellitus, cardiac, respiratory, and renal comorbidities as well as patient's age, gender, and ethnicity. The primary end point was mortality. Secondary end points were postoperative neurologic, cardiac, and respiratory complications.

Results: There were 8967 patients who met the inclusion criteria. Of these patients, 8255 (92%) had an open repair and 712 (8%) had an endovascular repair. The overall mortality was 4.5% (4.6% for open and 3.6% for endovascular). On multivariate analysis, the odds of death were reduced by 46% among patients undergoing endovascular repair when compared to open repair (odds ratio [OR]: 0.54; P = .016). There was also reduced odds of a postoperative neurologic complication (OR: 0.48; P = .015), cardiac complication (OR: 0.24; P < .001), and respiratory complication (OR: 0.38: P = .001) in the endovascular group.

Conclusions: Nationwide data comparing open and TEVAR in the United States reveal decreased postoperative mortality and a decreased incidence of postoperative neurologic, cardiac, and respiratory complications for TEVAR.
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http://dx.doi.org/10.1177/1538574414540484DOI Listing
June 2015

Racial/ethnic disparities in amputation and revascularization: a nationwide inpatient sample study.

Vasc Endovascular Surg 2014 Jan 7;48(1):34-7. Epub 2013 Nov 7.

1Department of Surgery, Howard University, Washington, DC, USA.

This study investigates whether ethnic minorities presenting with critical limb ischemia (CLI) are more likely to undergo major limb amputation compared to white patients. The Nationwide Inpatient Sample (NIS) database was used to identify all patients admitted with CLI; lower extremity revascularization; and major lower extremity amputation from 1998 to 2005. The NIS identified 240 139 patients presenting with CLI--68.2% white, 19.5% black, 9.0% Hispanic, and 1.24% Asian. In all, 83 328 patients underwent revascularization--73.7% white, 15.9% black, 7.4% Hispanic, and 1.1% Asian. The majority of the interventions were open. In all, 111 548 patients underwent a major lower extremity amputation--61% white, 25.4% black, 10.1% Hispanic, and 1.1% Asian. The mean Charlson comorbidity scores for amputation were 2.1 for whites, 2.0 for blacks, 2.3 for Hispanics, and 2.5 for Asians (for all data, P < .05). Blacks make up a disproportionately higher proportion of patients admitted for CLI and undergoing amputation, with a lower proportion undergoing revascularization.
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http://dx.doi.org/10.1177/1538574413510618DOI Listing
January 2014

Diabetes is not associated with an increased peri-operative mortality or non-infectious morbidity following lower extremity arterial reconstruction.

Am J Surg 2014 Apr 12;207(4):573-7. Epub 2013 Oct 12.

Howard University College of Medicine and Hospital, Department of Surgery, 2041 Georgia Avenue, NW, #4B.34, Washington, DC 20060, USA.

Background: The aim of this study was to determine if, at a national level, diabetes mellitus is associated with worse perioperative outcomes after open lower extremity arterial reconstruction.

Methods: Using Current Procedural Terminology codes, the National Surgical Quality Improvement Program database was queried to identify diabetic and nondiabetic patients who underwent open lower extremity arterial reconstruction from January 1, 2005, to December 31, 2007. These 2 groups were then compared using bivariate and multivariate analyses.

Results: There was no difference in mortality between the 2 groups (3.3% in diabetics and 3.5% in nondiabetics, P = .618). On multivariate analysis, there was no difference in the incidence of cardiac, pulmonary, or renal complications between the 2 groups. Diabetics, though, were more likely to develop infectious complications postoperatively.

Conclusions: After lower extremity arterial reconstruction, diabetes is not associated with an increased risk for mortality or an increased rate of major postoperative complications. Diabetics, however, have an increased rate of certain perioperative infections.
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http://dx.doi.org/10.1016/j.amjsurg.2013.03.013DOI Listing
April 2014

Small bowel perforation subsequent to mushroom bezoar as a presentation of Crohn's disease.

Am Surg 2013 Aug;79(8):E278-80

Department of Surgery, Howard University Hospital, Washington, DC 20060, USA.

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August 2013

Hemodialysis access.

Surg Clin North Am 2013 Aug 21;93(4):997-1012, x. Epub 2013 Jun 21.

Department of Surgery, Howard University Hospital, Howard University College of Medicine, Washington, DC 20060, USA.

The number of patients requiring dialysis is increasing, in particular those patients over the age of 75. The arteriovenous fistula is the preferred access for hemodialysis due to fewer complications and decreased mortality. Access complications are common and require early recognition and treatment. Postoperative access surveillance is important to ensure timely diagnosis and treatment of access-related complications. There is a continued need for high-quality data to assist in determining the best access for each patient.
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http://dx.doi.org/10.1016/j.suc.2013.05.002DOI Listing
August 2013

Endovascular repair of the descending thoracic aorta: a tale of two nations.

J Endovasc Ther 2013 Jun;20(3):273-5

Department of Cardiovascular Surgery, Texas Heart Institute at St. Luke's Episcopal Hospital, and the Michael E. DeBakey Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA.

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http://dx.doi.org/10.1583/12-4203C.1DOI Listing
June 2013

Diabetes mellitus is not associated with major morbidity following open abdominal aortic aneurysm repair.

J Surg Res 2013 Oct 14;184(2):751-4. Epub 2013 May 14.

Department of Surgery, Howard University College of Medicine, Washington, District of Columbia. Electronic address:

Background: It has been suggested that there is an increased morbidity and mortality risk for diabetics undergoing elective aortic surgery. This, however, is not universally accepted. In this study, we utilize a national database to determine if diabetes is associated with adverse outcomes following open, elective, infrarenal abdominal aortic aneurysm (AAA) repair.

Methods: The American College of Surgeons' National Surgical Quality Improvement Program database was queried to identify all patients who underwent an open, elective, nonruptured AAA repair from January 1, 2005 to December 31, 2007. Patient demographics, comorbidities, and outcomes were compared by diabetes status. Multivariate analysis was performed adjusting for demographics and comorbidities.

Results: There were 2110 American College of Surgeons' National Surgical Quality Improvement Program patients who underwent an open, elective, nonruptured AAA repair during this time period. Of these patients, 245 (11.6%) had diabetes mellitus. The overall mortality rate was 3.7% (5.3% for diabetics and 3.5% for nondiabetics, P = 0.171). On bivariate analysis, diabetics were more likely to present preoperatively with cardiovascular and renal comorbidities. Postoperatively, there was no significant difference in mortality or in cardiac, pulmonary, or renal complications. Diabetics were more likely to develop superficial surgical site infections (SSIs) (4.5% versus 1.6%, P = 0.002). On multivariate regression, there was no difference in mortality or major complications between diabetics and nondiabetics (OR 1.4, 95% CI 0.68-2.71). Diabetics, however, were almost three times more likely to develop superficial SSIs (OR 2.8, 95% CI 1.29-6.00).

Conclusions: Diabetes mellitus is not associated with significantly worse major outcomes following open, elective, infrarenal AAA repair. Diabetics, however, are more likely to develop superficial SSIs.
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http://dx.doi.org/10.1016/j.jss.2013.04.025DOI Listing
October 2013

Upper extremity bypass for chronic ischemia--a national surgical quality improvement program study database study.

Vasc Endovascular Surg 2013 Apr 20;47(3):192-4. Epub 2013 Feb 20.

Howard University College of Medicine and Hospital, Department of Surgery,Washington, DC 20060, USA.

Objective: We undertook this study to determine the outcomes of upper extremity arterial reconstruction for chronic ischemia.

Methods: The National Surgical Quality Improvement Program Database was queried to identify all patients who had undergone an upper extremity bypass for chronic ischemia between 2005 and 2007.

Results: A total of 55 patients were identified in a primarily female population (71% women). Mean age was 57. The most common preoperative diagnoses included ischemia resulting from prior arterial thromboembolism in 16 (29%) patients and atherosclerotic upper extremity arterial disease in 11 (20%) patients. The most common procedures performed included axillo-brachial bypass in 17 (31%) patients, brachial-brachial bypass in 11 (20%) patients, and carotid-brachial bypass in 11 (20%) patients. There were no perioperative deaths and no acute graft failures.

Conclusion: Although upper extremity bypass remains rare, the procedures appear to be safe with excellent 30-day results. Indications differ from those for lower extremity bypass.
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http://dx.doi.org/10.1177/1538574413478472DOI Listing
April 2013