Important new recommendations are provided for the care of patients with an AAA, including suggestions to improve mutual decision-making between the treating physician and the patients and their families as well as a number of new strategies to enhance perioperative outcomes for patients undergoing elective and emergent repair. Areas of uncertainty are highlighted that would benefit from further investigation in addition to existing limitations in diagnostic tests, pharmacologic agents, intraoperative tools, and devices.

Objectives In population-based studies performed on multiple continents over the past two decades, diabetes mellitus has been negatively associated with the prevalence and progression of abdominal aortic aneurysm (AAA) disease. We investigated the possibility that metformin, the primary oral hypoglycemic agent in use worldwide, may influence the progression of AAA disease Methods Pre-operative AAA patients with diabetes were identified from an institutional database. After tabulating individual cardiovascular and demographic risk factors and prescription drug regimens, odds ratios for categorical influences on annual AAA enlargement were calculated via nominal logistical regression. Experimental AAA modeling experiments were subsequently performed in normoglycemic mice to validate the database-derived observations, as well as suggest potential mechanisms of metformin-mediated aneurysm suppression. Results Fifty eight patients met criteria for study inclusion. Of 11 distinct classes of medication considered, only metformin usage was negatively associated with AAA enlargement. This association remained significant after controlling for gender, age, cigarette smoking status and obesity. The median enlargement rate in AAA patients not taking oral diabetic medication was 1.5 mm/year; by nominal logistic regression, metformin, hyperlipidemia, and age ≥70 years were associated with below median enlargement, whereas sulfonylurea therapy, initial aortic diameter ≥40 mm and statin usage were associated with above median enlargement. In experimental modeling, metformin dramatically suppressed the formation and progression, with medial elastin and smooth muscle preservation and reduced aortic mural macrophage, CD8 T cell and neovessel density. Conclusions Epidemiologic evidence of AAA suppression in diabetes may be attributable to concurrent therapy with the oral hypoglycemic agent metformin.

SSI is a common complication after open revascularization and is associated with a more than twofold increased risk of early graft loss and reoperation. Several patient and operation-related risk factors that predict postoperative SSI were identified, suggesting that targeted improvements in perioperative care may decrease complications and improve outcomes in this patient population.

This large, contemporary, multi-institutional study demonstrated that asymptomatic RAAs rarely rupture (even when >2 cm), growth rate is 0.086 ± 0.08 cm/y, and calcification does not protect against enlargement. RAA open repair is associated with significant minor morbidity, but rarely a major morbidity or mortality. Aneurysm repair cured or improved hypertension in >50% of patients whose RAA was identified during the workup for difficult-to-control hypertension.

Strategies that reduce the volume of spinal fluid drainage but still control spinal fluid pressure are helpful in reducing serious complications. Patients with cerebral atrophy are at increased risk for complications of spinal fluid drainage.

BACKGROUND About one-quarter of rehospitalized Medicare patients are admitted to hospitals different from their original. The extent to which this practice is related to for-profit hospital status, and impacts payments and mortality, is unknown. OBJECTIVE To describe and examine predictors of and payments for rehospitalization to a different hospital within 30 days among Medicare beneficiaries in for-profit and in not-for-profit/public hospitals. DESIGN Retrospective cohort study. SETTING Medicare fee-for-service hospitals throughout the United States. PARTICIPANTS Random 5% national sample of Medicare beneficiaries with acute-care rehospitalizations within 30-days of discharge, 2005–2006 (N=74,564). MEASUREMENTS 30-day rehospitalizations to different hospitals; total payments/mortality over subsequent 30-days. Multivariate logistic and quantile regression models included index hospital for-profit status, discharge counts, geographic region, rural-urban commuting area, and teaching status; and patient sociodemographics, disabled status, comorbidities, and a measure of risk-adjustment. RESULTS 22% (16,622) of the sample was rehospitalized to a different hospital. Factors associated with increased risk for rehospitalization to a different hospital included being hospitalized within a for-profit, major medical school-affiliated, or low volume index hospital, and having a Medicare-defined disability. When compared to those rehospitalized to the same hospital, patients rehospitalized to different hospitals had significantly higher adjusted 30-day total payments (median additional $1,308/patient, p-value<0.001), but no significant differences in 30-day mortality, regardless of index hospital for-profit status. LIMITATIONS The analysis lacked detailed clinical data, and did not assess specific provider practice motivations or the role of patient choice. CONCLUSIONS Rehospitalizations to different hospitals are common among Medicare beneficiaries, more likely among those initially hospitalized at a for-profit hospital, and related to increased overall payments without improved mortality.

Genotype-guided personalization may improve the cost-effectiveness of prasugrel and ticagrelor after percutaneous coronary intervention for ACS, but ticagrelor for all patients may bean economically reasonable alternative in some settings.

In a nationwide analysis of diabetic Veterans Affairs patients, prescription for metformin was associated with decreased AAA enlargement. These findings provide further support for the conduct of prospective clinical trials to test the ability of metformin to limit progression of early AAA disease.