Conclusions: Outcomes for repair of ruptured abdominal aortic aneurysms (rAAA) might be improved by wider use of local anesthesia for EVAR and by recognizing that a minimum blood pressure of 70 mmHg may be too low a threshold for permissive hypotension.Summary: Most data on outcomes of patients with rAAAs are singlecenter studies and as such may be too small to identify clinical factors that could improve overall patient outcomes. The IMPROVE study is a pragmatic multicenter randomized clinical trial in which eligible patients with a clinical diagnosis of rAAA were allocated to a strategy of endovascular repair of RAAAA (EVAR) or to open repair. IMPROVE showed no difference in 30-day mortality with a strategy incorporating EVAR for repair of a rAAAA compared to a strategy of open repair for ruptured abdominal aortic aneurysm (IMPROVE trial investigators, Brit Med J 2014;348:f7661). In this paper the IMPROVE investigators sought to analyze influences of time and manner of hospital presentation, fluid volume status, type of anesthesia, type of endovascular repair and time to aneurysm repair on 30-day mortality for rAAA. This was a prespecified plan of analyses to include only the patients who underwent aneurysm repair for a proven diagnosis of rAAA . Adjustments were made for potential confounding factors. In IMPROVE, 568 of 613 randomized patients had a symptomatic or rAAA and diagnostic accuracy was 91%. Patients randomized outside routine working hours had higher operative mortality (adjusted odds ratio, 1.47, 95% CI, 1.00-2.17). There was no difference in mortality rates between those patients admitted directly to a trial center versus those transferred to a trail center from a referring institution. Lowest systolic blood pressure was strongly and independently associated with 30-day mortality (51% among those with systolic blood pressures below 70 mmHg). In addition, patients who received EVAR under local anesthesia alone had reduced 30-day mortality compared to those who had EVAR under general anesthesia (adjusted odds ratio, 0.27; 95% CI, 0.10-0.70). In patients with confirmed rupture the time from randomization to the operating suite was not associated with 30-day mortality (P ¼ .415).Comment: The data indicate that blood pressure of 70 mmHg may be too low for optimal results in a patient with rAAA and permissive hypotensive levels should be above this. In addition, when EVAR is used to treat a rAAAA it may be best to do it, if possible, under local anesthesia. Finally, given the fact that results for repair of rAAA are no worse for a patient who is transferred than for those with a primary presentation to a specialist center, along with the fact that patients undergoing off-hours repair do more poorly suggests that a skilled multidisciplinary vascular team including specialists anesthesia services is likely to provide the best results for repair of a rAAA in any individual region. Outcomes for patients with rAAA therefore may be best served by a policy of regionalization of care for such patients to speci...

Objective: To investigate the risk of deep neck infection (DNI) in patients with type 1 diabetes mellitus (T1DM). Methods: The database of the Registry for Catastrophic Illness Patients, affiliated to the Taiwan National Health Insurance Research Database, was used to conduct a retrospective cohort study. In total, 5741 patients with T1DM and 22,964 matched patients without diabetes mellitus (DM) were enrolled between 2000 and 2010. The patients were followed up until death or the end of the study period (31 December 2013). The primary outcome was the occurrence of DNI. Results: Patients with T1DM exhibited a significantly higher cumulative incidence of DNI than did those without DM (p < 0.001). The Cox proportional hazards model showed that T1DM was significantly associated with a higher incidence of DNI (adjusted hazard ratio, 10.71; 95% confidence interval, 6.02–19.05; p < 0.001). The sensitivity test and subgroup analysis revealed a stable effect of T1DM on DNI risk. The therapeutic methods (surgical or nonsurgical) did not differ significantly between the T1DM and non-DM cohorts. Patients with T1DM required significantly longer hospitalization for DNI than did those without DM (9.0 ± 6.2 vs. 4.1 ± 2.0 days, p < 0.001). Furthermore, the patients with T1DM were predisposed to DNI at a younger age than were those without DM. Conclusions: T1DM is an independent risk factor for DNI and is associated with a 10-fold increase in DNI risk. The patients with T1DM require longer hospitalizations for DNI and are younger than those without DM.

Objective To investigate the association between rheumatoid arthritis (RA) and deep neck infection (DNI). Study Design Retrospective cohort study. Methods Patients newly diagnosed with RA between 2000 and 2011 were identified from the National Health Insurance Research Database in Taiwan. Moreover, patients without RA were randomly selected and matched at a 1:4 ratio by age, sex, urbanization level, income, and diabetes mellitus. The patients were followed up until death or the end of the study period (December 31, 2013). The primary outcome was the occurrence of DNI. Results In total, 30,207 patients with RA and 120,828 matched patients without RA were enrolled. Patients with RA had a significantly higher cumulative incidence of DNI than those without RA (P < 0.001). The adjusted Cox proportional hazard model demonstrated that RA was significantly associated with a higher incidence of DNI (hazard ratio: 2.80, 95% confidence interval: 2.26–3.46, P < 0.001). Therapeutic methods (surgical or nonsurgical) did not differ significantly between the patients with RA‐DNI and with non–RA‐DNI. Patients with RA‐DNI had higher rates of tracheostomy, mediastinitis, mediastinitis‐related mortality, and mortality than patients with non–RA‐DNI, although these differences were without statistical significance. RA patients receiving no therapy experienced higher rates of DNI compared with those receiving methotrexate alone, disease‐modifying antirheumatic drugs, or biologic therapies. Conclusion This study is the first to investigate the association between RA and DNI. We conclude RA is an independent predisposing factor for DNI. Level of Evidence 4 Laryngoscope, 130:1402–1407, 2020

Highlights Deep neck infection is a life-threatening disease that invades deep neck space. Treatment for deep neck infection consists of antibiotics and surgical drainage with manually postoperative wound irrigation. The authors present a case in which an innovative continuous-irrigation approach was applied for wound care. This approach is an alternative approach for wound care in patients with deep neck infection.

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