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      Effect of regional versus general anesthesia on thirty-day outcomes following carotid endarterectomy: a cohort study

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          Background:

          The effect of regional versus general anesthesia on carotid endarterectomy outcomes is debated. This study assesses the effect of anesthetic technique on major morbidity and mortality and additional secondary endpoints following carotid endarterectomy.

          Materials and methods:

          This was a retrospective propensity-matched-cohort analysis investigating elective carotid endarterectomy patients in the 2015–2019 American College of Surgeons National Surgical Quality Improvement Program ( n=37 204). The primary endpoint was 30-day mortality and major morbidity, defined as stroke, myocardial infarction, or death. Secondary endpoints included minor morbidity, bleeding events, healthcare resource utilization, and length of hospital stay. Univariate, multivariable, and survival analyses were applied.

          Results:

          The 1 : 1 propensity-matched-cohort included 8304 patients (4152 in each group). Regional anesthesia was associated with similar incidences of major morbidity and mortality [odds ratio (OR), 0.81 (95% CI, 0.61–1.09); P = 0.162] and unplanned resource utilization [OR, 0.93 (95% CI, 0.78–1.11); P = 0.443], but lower incidences of minor morbidity [OR, 0.60 (95% CI, 0.44–0.81); P < 0.001] and bleeding events [OR, 0.49 (95% CI, 0.30–0.78); P = 0.002], and a shorter length of hospital stay [1.4 vs. 1.6 days; mean difference, -0.16 days (95% CI, -0.25 to -0.07); P < 0.001]. On multivariable analysis, regional anesthesia remained independently predictive of minor morbidity [adjusted odds ratio (AOR), 0.58 (95% CI, 0.42–0.79); P = 0.001] and bleeding events [AOR, 0.49 (95% CI, 0.30–0.77); P = 0.003]. Significance was maintained on survival analysis for these two endpoints. A mortality benefit was observed on univariate [OR, 0.50 (95% CI, 0.25–1.00); P = 0.045], multivariable [AOR, 0.49 (95% CI, 0.24–0.96); P = 0.043], and survival analysis ( P = 0.045).

          Conclusions:

          Carotid endarterectomy patients receiving regional anesthesia experience favorable outcomes compared to propensity-matched general anesthesia controls.

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          Most cited references36

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          MatchIt: Nonparametric Preprocessing for Parametric Causal Inference

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            Modeling Survival Data: Extending the Cox Model

            This is a book for statistical practitioners, particularly those who design and analyze studies for survival and event history data. Its goal is to extend the toolkit beyond the basic triad provided by most statistical packages: the Kaplan-Meier estimator, log-rank test, and Cox regression model. Building on recent developments motivated by counting process and martingale theory, it shows the reader how to extend the Cox model to analyse multiple/correlated event data using marginal and random effects (frailty) models. It covers the use of residuals and diagnostic plots to identify influential or outlying observations, assess proportional hazards and examine other aspects of goodness of fit. Other topics include time-dependent covariates and strata, discontinuous intervals of risk, multiple time scales, smoothing and regression splines, and the computation of expected survival curves. A knowledge of counting processes and martingales is not assumed as the early chapters provide an introduction to this area. The focus of the book is on actual data examples, the analysis and interpretation of the results, and computation. The methods are now readily available in SAS and S-Plus and this book gives a hands-on introduction, showing how to implement them in both packages, with worked examples for many data sets. The authors call on their extensive experience and give practical advice, including pitfalls to be avoided. Terry Therneau is Head of the Section of Biostatistics, Mayo Clinic, Rochester, Minnesota. He is actively involved in medical consulting, with emphasis in the areas of chronic liver disease, physical medicine, hematology, and laboratory medicine, and is an author on numerous papers in medical and statistical journals. He wrote two of the original SAS procedures for survival analysis (coxregr and survtest), as well as the majority of the S-Plus survival functions. Patricia Grambsch is Associate Professor in the Division of Biostatistics, School of Public Health, University of Minnesota. She has collaborated extensively with physicians and public health researchers in chronic liver disease, cancer prevention, hypertension clinical trials and psychiatric research. She is a fellow the American Statistical Association and the author of many papers in medical and statistical journals.
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              STROCSS 2019 Guideline: Strengthening the reporting of cohort studies in surgery

              The STROCSS guideline was developed in 2017 to improve the reporting quality of observational studies in surgery. Building on its impact and usefulness, we sought to update the guidelines two years after its publication.
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                Author and article information

                Contributors
                Journal
                Int J Surg
                Int J Surg
                JS9
                International Journal of Surgery (London, England)
                Lippincott Williams & Wilkins (Hagerstown, MD )
                1743-9191
                1743-9159
                May 2023
                14 April 2023
                : 109
                : 5
                : 1291-1298
                Affiliations
                [a ]Department of Anesthesiology, University of Virginia Health
                [b ]School of Medicine, University of Virginia, Charlottesville, Virginia, USA
                Author notes
                [* ]Corresponding author. Address: Department of Anesthesiology, University of Virginia Health, PO Box 800710, Charlottesville, VA 22908-0710, USA. Tel: +434 924 2283, fax: +434 982 0019. E-mail: zok3dg@ 123456virginia.edu (Z. O. Knio); E-mail: zz3c@ 123456virginia.edu (Z. Zuo).
                Author information
                http://orcid.org/0000-0001-5696-873X
                http://orcid.org/0000-0002-3542-5047
                Article
                00025
                10.1097/JS9.0000000000000356
                10389611
                37057905
                02f6b034-1616-45b8-bc5a-2488f4e7529e
                Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.

                This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0/

                History
                : 31 January 2023
                : 13 March 2023
                Categories
                Original Research
                Custom metadata
                T
                TRUE

                Surgery
                carotid endarterectomy,general anesthesia,major morbidity,mortality,perioperative outcomes,regional anesthesia

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