6-month Readmission Research Articles

1076 3-Level ACDF Versus 3-Level Laminectomy and Fusion: Are There Differences in Outcomes? An Analysis of the QOD CSM Cohort

INTRODUCTION: Prior studies comparing anterior versus posterior approaches for multilevel cervical spondylotic myelopathy (CSM) are limited by the heterogeneity of levels operated. METHODS: The prospective QOD CSM cohort was queried for fusions across only three interspaces. Surgeries crossing the cervicothoracic junction were excluded. The cohort was divided into anterior cervical discectomy and fusion (ACDF) and posterior laminectomy-and-fusion. 24-month patient-reported outcomes were compared. RESULTS: Of 199 patients (123 ACDF, 76 posterior fusions), 24-month follow-up rates were similar (ACDF: 90.2% vs. 92.1%, p = 0.67). Preoperatively, ACDF were younger (60.8 ± 10.2 vs. 65.0 ± 10.3 yr, p < 0.01), used more private insurance (56.1% vs. 36.8%, p = 0.02), were more often employed (39.8% vs. 22.8%, p = 0.04), and independently ambulatory (14.6% vs. 31.6%, p < 0.01). Otherwise, the cohorts had equivalent baseline mJOA, NDI, NRS Arm-Pain, NRS Neck-Pain, and EQ-5D (p > 0.05). ACDF had shorter hospitalizations (1.6 vs. 3.9 days, p < 0.01) and less non-routine discharge (7.3% vs. 22.8%, p < 0.01) but higher postoperative dysphagia (13.5% vs. 3.5%, p = 0.049). Both groups demonstrated improvements in all outcomes at 24 months (p < 0.05). In multivariable analyses, ACDF was associated with the greatest 24-month NASS Satisfaction (NASS 1)(69.4% vs. 53.7%, OR = 2.44, p = 0.02). Otherwise, the cohorts shared similar 24-month patient-reported outcomes. There were no differences in 3-month readmission (4.1% ACDF vs. 3.9% posterior fusion, p = 0.97) and 24-month reoperation rate (13.5% ACDF vs. 18.6% posterior fusion, p = 0.36). CONCLUSIONS: In a cohort limited to 3-level surgeries, ACDF was associated with reduced blood loss, shorter lengths of hospitalization, and higher routine discharge rates; however, posterior cervical fusion resulted in less dysphagia. After controlling for confounders, the ACDF cohort had a significantly higher odds of maximum satisfaction. Patients should be counseled on the risks and benefits of each approach, given relatively comparable outcomes.

Evaluation of a hospital-initiated tobacco dependence treatment service: uptake, smoking cessation, readmission and mortality

BackgroundThe National Health Service in England aims to implement tobacco dependency treatment services in all hospitals by 2024. We aimed to assess the uptake of a new service, adapted from the Ottawa Model of Smoking Cessation, and its impact on 6-month quit rates and readmission or death at 1-year follow-up.MethodsWe conducted a pragmatic service evaluation of a tobacco dependency service implemented among 2067 patients who smoked who were admitted to 2 acute hospitals in London, England, over a 12-month period from July 2020. The intervention consisted of the systematic identification of smoking status, automatic referral to tobacco dependence specialists, provision of pharmacotherapy and behavioural support throughout the hospital stay, and telephone support for 6 months after discharge. The outcomes were (i) patient acceptance of the intervention during admission, (ii) quit success at 6 months after discharge, (iii) death, or (iv) readmission up to 1 year following discharge. Multivariable logistic regression was used to estimate the impact of a range of clinical and demographic variables on these outcomes.ResultsThe majority (79.4%) of patients accepted support at the first assessment. Six months after discharge, 35.1% of successfully contacted patients reported having quit smoking. After adjustment, odds of accepting support were 51–61% higher among patients of all non-White ethnicity groups, relative to White patients, but patients of Mixed, Asian, or Other ethnicities had decreased odds of quit success (adjusted odds ratio (AOR) = 0.32, 95%CI = 0.15–0.66). Decreased odds of accepting support were associated with a diagnosis of cardiovascular disease or diabetes; however, diabetes was associated with increased odds of quit success (AOR = 1.88, 95%CI = 1.17–3.04). Intention to make a quit attempt was associated with a threefold increase in odds of quit success, and 60% lower odds of death, compared to patients who did not intend to quit. A mental health diagnosis was associated with an 84% increase in the odds of dying within 12 months.ConclusionsThe overall quit rates were similar to results from Ottawa models implemented elsewhere, although outcomes varied by site. Outcomes also varied according to patient demographics and diagnoses, suggesting personalised and culturally tailored interventions may be needed to optimise quit success.

Impact of reperfusion therapies on clot resolution and long-term outcomes in patients with pulmonary embolism

ObjectiveMajor progress in reperfusion strategies has substantially improved the short-term outcomes of patients with pulmonary embolism (PE), however, up to 50% of patients report persistent dyspnea after acute PE. MethodsA retrospective study of the PE response team registry and included patients with repeat imaging at 3 to 12 months. The primary outcome was to determine the incidence of residual pulmonary vascular obstruction following acute PE. Secondary outcomes included the development of PE recurrence, right ventricular (RV) dysfunction, chronic thromboembolic pulmonary hypertension, readmission, and mortality at 12 months. ResultsA total of 382 patients were included, and 107 patients received reperfusion therapies followed by anticoagulation. Patients who received reperfusion therapies including systemic thrombolysis, catheter-directed thrombolysis, and mechanical thrombectomy presented with a higher vascular obstructive index (47% vs 28%; P < .001) and signs of right heart strain on echocardiogram (81% vs 43%; P < .001) at the time of diagnosis. A higher absolute reduction in vascular obstructive index (45% vs 26%; 95% confidence interval, 14.0-25.6; P < .001), greater improvement in RV function (82% vs 65%; P = .021), and lower 12-month mortality rate (2% vs 7%; P = .038) and readmission rate (33% vs 46%; P = .031) were observed in the reperfusion group. No statistically significant differences were found between groups in the development of chronic thromboembolic pulmonary hypertension (8% vs 5%; P = .488) and PE recurrence (8% vs 6%; P = .646). ConclusionsWe observed a favorable survival and greater improvement in clot resolution and RV function in patients treated with reperfusion therapies.

COPD Assessment Test and risk of readmission in patients with bronchiectasis: a prospective cohort study.

Readmission following bronchiectasis exacerbation is a common and challenging clinical problem and few simple predictive tools exist. The COPD Assessment Test (CAT) is an easy-to-use questionnaire. This study aims to evaluate the predictive value of CAT scores in determining the risk of readmission in patients with bronchiectasis exacerbation. We conducted a prospective cohort study in 106 bronchiectasis patients admitted with exacerbation. All patients completed the CAT at admission and at discharge. Patients were followed-up for 12 months to collect data on readmission. The area under the curve was used to measure the predictive value of CAT at admission, CAT at discharge and change in CAT for readmission due to bronchiectasis exacerbation. 46 patients were readmitted for bronchiectasis exacerbation within 12 months. High CAT at admission was an independent risk factor for readmission within 12 months in patients with acute exacerbation of bronchiectasis (hazard ratio 3.201, 95% CI 1.065-9.624; p<0.038) after adjustment for confounding variables. The cut-off value of CAT at admission and CAT at discharge to predict 12-month readmission in patients with acute exacerbation of bronchiectasis was 23.5 (sensitivity 62.2%, specificity 83.6%) and 15.5 (sensitivity 52.2%, specificity 87.0%). CAT at admission is a strong predictor of readmission in patients with bronchiectasis exacerbation.

Association between red blood cell distribution width-to-platelet ratio and post-discharge readmission rate in patients with heart failure: A retrospective cohort study

BackgroundTo date, no studies have investigated the association between red blood cell distribution width (RDW)-to-platelet ratio (RPR) and readmission rates among patients with heart failure (HF). As such, the present study aimed to examine the relationship between RPR and readmission rates in patients with HF. MethodsData for this study were obtained from the Fourth People's Hospital (Zigong, Sichuan Province, China). Patients were diagnosed with HF in accordance with European Society of Cardiology criteria. The primary outcome was the 28-day readmission rate. Various logistic regression models were constructed to explore the association between RPR and the 28-day readmission rate. ResultsThe study comprised 1978 patients with HF, with a 28-day readmission rate of 6.98%. RPR emerged as an independent risk factor for 28-day readmission, evidenced by consistent results across the various regression-adjusted models. The covariate-adjusted propensity score model demonstrated that every 0.1 increase in RPR was associated with an 8.2% increase in 28-day readmission rate (odds ratio [OR] 1.082 [95% confidence interval (CI) 1.012–1.158]; P = 0.0212). Similarly, each 0.1 change in RPR was associated with a 9.8% (OR 1.098 [95% CI 1.014–1.188]) and 7.3% (OR 1.073 [95% CI 0.991–1.161]) increase in 3- and 6-month readmission rates, respectively. However, RPR was not statistically associated with the 6-month readmission rate. Curve fit plots illustrated a nonlinear positive correlation between RPR and 28-day, and 3- and 6-month readmissions. Moreover, the effects of RPR on 28-day, and 3- and 6-month readmission rates remained robust across subgroup variables in stratified analysis. Finally, the effect sizes of pooled multiply imputed data were consistent with the original data, suggesting robust results. ConclusionRPR was an independent risk factor for 28-day readmission among patients with HF and also demonstrated modest predictive value for readmissions at 3 and 6 months, despite being non-significant for the 6-month readmission rate. Early identification of patients with HF with elevated RPR would facilitate management and may confer favorable effects on prognosis.

Long-Term Outcomes After Spinal Cord Stimulator Placement in Patients with Pre-procedural Active Opioid Use Versus Patients Who Were Opioid-Naïve

BACKGROUND: Outcome optimization after the placement of a spinal cord stimulator (SCS) is critical. The objective of this study was to determine if an association existed between pre-procedural opioid use (compared to patients who were opioid-naïve) and postoperative long-term outcomes following SCS placement. OBJECTIVE: To examine the impact of preprocedural opioid use on long-term outcomes after SCS therapy. STUDY DESIGN: Cohort study utilizing a nationwide database. SETTING: Retrospective. METHODS: With the use of data from HCA Healthcare’s national database, a retrospective cohort study was performed to analyze differences in outcomes between opioid-naïve patients and preoperative opioid users who underwent SCS placements. The primary outcome of interest was device explantation at 6 months and 12 months. Secondary outcome measurements included reoperations and readmissions at 6 months and 12 months, as well as operative complications. Multivariable logistic regression models were performed to analyze the association of preoperative opioid use with those outcomes. The odds ratio (OR), 95% confidence intervals (CI), and P values were reported for the independent variables. RESULTS: The final study population consisted of 13,893 patients who underwent SCS placements. In univariate analyses, patients who used opioids preoperatively had higher 6-month (3.6% vs. 2.6%) and one-year removal rates (3.6% vs. 2.8%) (all P &lt; 0.009). On multivariable logistic regression, those using opioids preoperatively had higher odds of removal at 6 months (OR = 1.290, 95% CI 1.05-1.58, P = 0.01) and at one year (OR = 1.23, 95% CI 1.01-1.50, P = 0.04). There was no difference between patients requiring preoperative opioids and patients who were opioid-naive as far as the odds of 6- or 12-month readmissions were concerned. Compared to the opioid-naive group, patients requiring preoperative opioids had increased odds of reoperation at 6 months (OR = 1.2, 95% CI 1.02-1.40, P = 0.03). There were no differences in the odds of complications between both cohorts. LIMITATIONS: Opioid use in this study was defined as using opioids preoperatively in the 30 days leading up to surgery. CONCLUSION: Patients requiring preoperative opioids before SCS placements had increased odds of SCS explantation at 6 months and 12 months, as well as increased odds of reoperation at 6 months. KEY WORDS: Spinal cord stimulation, opioid use, opioid use disorder, opioid tolerance, explant, readmission, outcomes

The Association Between Geriatric Nutritional Risk Index and Readmission Within Six Months in Elderly Heart Failure Patients: A Retrospective Cohort Study: Geriatric Nutritional Risk Index for Heart Failure Readmission Within 6 Months.

Background: The geriatric nutritional risk index (GNRI) is a valuable tool that may predict the prognosis of elderly patients with heart failure (HF). Malnutrition and low GNRI scores have been associated with a higher risk of hospitalization and mortality. This study aimed to investigate the association between GNRI and 6-month readmission for HF in elderly Chinese patients. Materials and Methods: The study utilized data from hospitalized HF patients by combining electronic medical records from the PhysioNet restricted health data database with external outcome data. In our study, we used the GNRI as the independent variable and assessed its association with the risk of readmission within 6 months. The main analytical methods were multivariable Cox regression, stratified analysis with interaction, threshold effect analysis, and Kaplan-Meier survival curves. Results: This study involved 767 elderly HF patients, 61.3% of whom had malnutrition. In the threshold analysis, HF patients' 6-month readmission risk was significantly reduced with increasing GNRI, with a hazard ratio (HR) and 95% confidence interval (CI) of 0.99 (0.97.1). Malnutrition group was associated with a higher risk of readmission within 6 months for HF patients in analyses that were controlled for confounding factors, with HRs and their 95% CI of 1.17 (0.99, 1.38), 1.18 (1, 1.4), and 1.44 (1.08,1.93), respectively. Subgroup analysis showed that GNRI levels had a consistent impact on outcome events, unaffected by covariates. Conclusions: GNRI was negatively correlated with the outcome event of readmission within 6 months in elderly HF patients. Malnutrition group showed a higher risk of readmission within 6 months.

Length of stay and economic sustainability of virtual ward care in a medium-sized hospital of the UK: a retrospective longitudinal study

ObjectiveTo evaluate the length of stay difference and its economic implications between hospital patients and virtual ward patients.DesignRetrospective longitudinal study.SettingWrightington, Wigan and Leigh (WWL) Teaching Hospitals, National Health Service (NHS)...

Short-Term Outcomes of Total Arterial Revascularization Compared to Conventional Coronary Artery Bypass Graft in Patients with Multivessel Disease and Left Ventricular Dysfunction

Background. Multivessel coronary artery disease (CAD) and left ventricular dysfunction (LVD) present challenges in CABG. We aimed to compare early outcomes of total arterial revascularization (TAR) versus conventional CABG in this high-risk population. Methods. This was a retrospective cohort study based on a single-center registry of patients who underwent isolated CABG for multivessel CAD and LVD between January 2014 and December 2022. Primary outcome was in-hospital mortality. Secondary outcomes were early complications, graft patency rate at 3 months, readmission rate within 6 months, and freedom from angina rate within 6 months. Results. A total of 112 cases were included in this study; 52 patients for TAR and 60 patients for conventional CABG. Both groups had comparable baselines and operative profiles. In-hospital mortality was similar between TAR and conventional CABG (2 deaths, 3.85% vs 4 deaths, 6.67%, p = 0.810). TAR had shorter ICU (3.5 vs 5 days, p = 0.016) and hospital stay (10.5 vs 12 days, p = 0.007). Other postoperative complications were similar. At 3 months, TAR had superior graft patency (91.7% vs 83.7%, p = 0.034) and lower 6-month readmission (TAR: 2/50, 4.0% vs. CR: 10/56, 17.9%, p = 0.024). Freedom from angina rate within 6 months was similar between the two groups (TAR: 43/50, 86.0% vs. CR: 42/56, 75.0%, p = 0.240). Conclusion. Our findings suggest that TAR may offer benefits in terms of shorter hospital stays, higher early graft patency, and lower readmission rates for patients with multivessel CAD and LVD. However, further research, particularly large-scale, randomized trials with longer follow-up periods, are needed to fully understand the long-term clinical outcomes and confirm these promising early results.

Impact of traditional versus nontraditional initiation dosing schedule of paliperidone palmitate on 30-day readmission and safety.

Paliperidone palmitate (PP), a second-generation long-acting injectable antipsychotic, requires 2 injections upon initiation. Due to the fast-paced nature of the inpatient setting, the second dose may be administered earlier than recommended by labeled use despite the lack of evidence that evaluates this practice. This was a retrospective chart review that investigated the outcomes associated with the timing of the second PP initiation dose with the aim of comparing patients who received the second PP dose fewer than 3 days after the first injection with those who received it between 3 and 11 days after the first injection. The primary outcomes included 30-day psychiatric readmission, index hospitalization length of stay, and time until the next psychiatric hospitalization. Secondary outcomes included 6-month readmission and the percentage of patients who experienced an adverse event after the second injection. No statistically significant differences were observed between groups for 30-day readmission. There was a statistically significant shortened index length of hospitalization (median, 2 vs 4 days; P < 0.001) and a non-statistically significant trend for time until the next psychiatric hospitalization (median, 25 vs 47 days) when comparing those who received the nontraditional loading regimen to those who received the traditional labeled loading regimen. No differences were observed in the secondary outcomes or safety/tolerability. The results of the study indicate that there are no significant differences in readmission rates and adverse drug reactions in those who received the second PP dose earlier than recommended per labeled use. Larger, controlled studies are needed to further investigate clinical and safety outcomes.

The prognostic association of atrial fibrillation on heart failure hospitalizations after acute myocardial infarction

Abstract Aims The association of atrial fibrillation (AF) with heart failure (HF) specific hospitalizations after acute myocardial infarction (AMI) is unclear. We aim to study the association of AF and 6-month HF hospitalization after an AMI in a large American cohort. Methods and Results Adult survivors of a AMI hospitalization without cardiogenic shock were identified from the 2019 US Nationwide Readmissions Database. The unadjusted association of AF (pre-existing and denovo) with baseline characteristics and primary outcome of rate of 6-month HF admission, and secondary outcomes of fatal HF admission, composite of HF peri-AMI or a 6-month HF admission, and a composite of 6-month HF or death during a non−HF-related admission was evaluated using chi square tests or t-tests, and independent associations of AF on outcomes were evaluated using multivariable logistic regression. Cox proportional hazards models were used to identify the association of AF on cumulative incidence risk on HF readmission. Of 262,390 AMI survivors, AF was present in 18.0%. By 6-months, HF hospitalization occurred in 5.4% of all patients. AF was associated with a higher adjusted risk for 6-month HF admission (OR 1.42, 95% CI: 1.34-1.50). In the adjusted time-to-event analysis, AF was associated with a higher risk for 6-month HF readmission (HR 1.39, 95% CI 1.31-1.46, P&amp;lt;0.001). AF was associated with a higher risk for fatal HF and the composite outcomes. Conclusions AF was present in 1 in 6 AMI survivors without cardiogenic shock and AF was associated with a higher risk of HF hospitalization in the subsequent 6-month period.Cumulative Incidence CurvesOutcomes Table

Abstract 18568: Machine Learning Model for the Prediction of Early Discharge of Patient Underwent Transcatheter Aortic Valve Replacement Using Electronic Medical Record

Introduction: With the increasing experience in TAVR, early discharge (within 24 to 72 h) has become a goal to accelerate patient recovery. Several studies suggest the possibility of safe, early discharges. But there is little consensus and considerable variation in early discharge protocols. Optimizing patient selection for early discharge can avoid prolonged hospital stays and save substantial costs without sacrificing patient safety. Hypothesis: The decision for early discharge after TAVR can be modeled and predicted by a machine learning model based on EMR data. Methods: Detailed demography, laboratory, medications, and comorbidities data from the EMR of all 1075 TAVR patients at Brigham and Women's Hospital from 2017-22 were included in a Random Forest machine learning model to make a binary prediction of whether the patient will be discharged within 36 hours after the procedure. We performed a 10-fold cross-validation experiment using the proposed model on the 1075-patient data. Receiver-operating characteristics (ROC) evaluated the prediction accuracy and uncertainty of the model, and clinical outcomes of patients with early discharge were evaluated by 6-month readmissions. Results: The mean age was 81± 9 years; 57% were male. The median length of stay was 51.3 hours. A total of 481 (44.7%) were discharged within 36 hours. Only 12 patients in this cohort were admitted with 24 hours. The average area under the ROC curve (AUC) of the 10-fold cross-validation was 0.83 (SD 0.04). (Figure) A total of 76 (7.1%) patients were readmitted due to cardiovascular reasons within 6 months, including 16/481 (3.3%) early-discharge patients vs. 60/594 (10.1%) non-early discharge patients (p&lt;0.001). Conclusions: Our model accurately predicts early (36 hours) discharge after TAVR, indicating the feasibility of utilizing machine learning to develop an EMR-based patient risk stratification and early discharge protocol.

Abstract 17921: Diastolic Dysfunction Might Predict Outcomes in Acute Coronary Syndrome Patients Undergoing Primary Percutaneous Coronary Intervention

Introduction: Acute coronary syndrome (ACS) leads to diastolic dysfunction which might cause unfavorable long-term clinical outcomes. We aim to evaluate the association between diastolic parameters in patients with an ACS and event rates including 30-day mortality and 6-month readmission rates. Methodology: We studied 1579 patients with ACS who underwent primary percutaneous coronary intervention (PCI) from January 1, 2010 through December 31, 2020. Clinical, laboratory, transthoracic echocardiographic (TTE) and coronary angiographic parameters were retrospectively reviewed. Diastolic parameters (E/A ratio, TR velocity, LVEF and LAVI) in patients with left anterior descending artery (LAD) PCI (n=879) were compared with those who underwent PCI to non-LAD artery (n=700). Percentage of 6-month all-cause readmission, cardiogenic shock as well as mortality rates were calculated in both cohorts. Results: The mean age of 1579 ACS patients was 65 + 12 years, BMI 29 + 5 kg/m 2 , peak high sensitivity troponin 624 ng/L, E/A ratio 1.065, TR velocity 3.2 m/s, LAVI 34.26 mL/m 2 and LVEF 50.1%. The percentage of hospital readmission within 6 months was higher in patients with diastolic dysfunction and LAD PCI compared to those with non-LAD PCI (19% versus 16%, p - value=0.004). Although patients with diastolic dysfunction and LAD PCI had higher percentage of cardiogenic shock compared to non-LAD PCI group (6.0% versus 3.7%, p -value&lt;0.001), 1-year mortality did not differ between the 2 groups ( p -value=0.84). Conclusion: Diastolic dysfunction is associated with worse clinical outcomes in patients undergoing LAD PCI which warrants a larger prospective clinical study.

Retrospective evaluation of an intervention bundle on OPAT implementation in a large non-university hospital

ABSTRACT Objectives Optimization of outpatient parenteral antimicrobial therapy (OPAT) requires interdisciplinarity and an operational algorithm. This report retrospectively assesses the impact of a multimodal quality-enhancement intervention bundle on the implementation rate, efficacy, and safety of a home OPAT program in a Belgian large community-based hospital. Methods OPAT recipients between 1 March 2019 and 30 June 2022 were included. The OPAT trajectories were divided into pre-intervention (from 1 March 2019 to 31 October 2020) and post-intervention (from 1 November 2020 to 30 June 2022) groups. The quality-enhancement intervention bundle consisted of the involvement of an infectious disease specialist, revision and implementation of a state-of-the-art prosthetic joint infection diagnosis and treatment protocol, weekly multidisciplinary discussion of all prosthetic joint infections, revision of the OPAT algorithm, and the introduction of teicoplanin as an OPAT-convenient antimicrobial. Results Eighty-five patients were included in a total of 96 OPAT trajectories (n = 33 pre-intervention; n = 63 post-intervention). After the intervention, the number of OPAT trajectories nearly doubled. The number of patients with a recurrent infection within 6 months after OPAT completion decreased 15%. The overall 6-month mortality and readmission rates during OPAT treatment decreased 8% and 10%, respectively. Mortality during OPAT treatment did not change. These differences between pre- and post-intervention did not achieve statistical significance, despite the higher risk for complications in the post-intervention group because of increased infection complexity and required treatment duration. Conclusion Within a Belgian, single, large community-based hospital, a multimodal intervention bundle resulted in increases in OPAT implementation, infection complexity, and required treatment durations without statistically significant differences in outcomes.

Relation of serum uric acid levels to readmission and mortality in patients with heart failure

Data on the association between uric acid (UA) levels and clinical outcomes, such as readmission and mortality, in patients with heart failure are scarce. This study explores whether UA exhibits an independent association with the composite endpoint (clinical outcome during 6 months after discharge, including mortality and 6-month readmission) in patients with chronic heart failure while controlling for other covariates. This study was an observational retrospective study. A cohort of 1943 consecutive patients diagnosed with chronic heart failure, who were admitted between December 2016 and June 2019, was included in the study. Data were sourced from PhysioNet. The independent variable analyzed was the UA level, and the dependent variable was a composite endpoint comprising mortality and 6-month readmission. The study had 1943 participants, of which 91.04% were aged more than 60 years and 58.05% were female. The fully-adjusted model yielded a positive correlation between UA levels (per 10 µmol/L) and the composite endpoint as well as readmission, following adjustment for confounding variables (HR = 1.01, 95% CI 1.00–1.01). Notably, a non-linear relationship was observed between UA levels and the composite endpoint, particularly readmission, with a J-shaped correlation observed between UA levels and both the composite endpoint and readmission. Overall, we found that the serum UA levels at admission were independently and positively associated with the risk of the composite endpoint (clinical outcomes during 6 months after discharge), especially readmission after adjusting other covariates. A J-shaped relationship was observed between UA levels and the composite endpoint and readmission.

Newborn and Early Infant Outcomes Following Maternal COVID-19 Vaccination During Pregnancy

The study team previously showed that maternal mRNA COVID-19 vaccination during pregnancy confers protection against SARS-CoV-2 infection and COVID-19-related hospital admission in newborns and young infants. In this study, the study team evaluated newborn and early infant safety outcomes following maternal messenger RNA (mRNA) COVID-19 vaccination during pregnancy, for which there is limited comparative epidemiological evidence. To determine if maternal mRNA COVID-19 vaccination during pregnancy is associated with adverse newborn and early infant outcomes. This population-based retrospective cohort study took place in Ontario, Canada, using multiple linked health administrative databases. Singleton live births with an expected delivery date between May 1, 2021, and September 2, 2022, were included. Data were analyzed from January 2023 through March 2023. Maternal mRNA COVID-19 vaccination (1 or more doses) during pregnancy. Severe neonatal morbidity (SNM), neonatal death, neonatal intensive care unit (NICU) admission, neonatal readmission, and hospital admission up to 6 months of age. The study team calculated inverse probability of treatment weighted risk ratios (RRs) and fit weighted Cox proportional hazards regression models comparing outcomes in infants of mothers who received COVID-19 vaccination during pregnancy with those who received no COVID-19 vaccine doses before delivery. In total, 142 006 infants (72 595 male [51%]; mean [SD] gestational age at birth, 38.7 [1.7] weeks) were included; 85 670 were exposed to 1 or more COVID-19 vaccine doses in utero (60%). Infants of vaccinated mothers had lower risks of SNM (vaccine exposed 7.3% vs vaccine unexposed 8.3%; adjusted RR [aRR], 0.86; 95% CI, 0.83-0.90), neonatal death (0.09% vs 0.16%; aRR, 0.47; 95% CI, 0.33-0.65), and NICU admission (11.4% vs 13.1%; aRR, 0.86; 95% CI, 0.83-0.89). There was no association between maternal vaccination during pregnancy and neonatal readmission (5.5% vs 5.1%; adjusted hazard ratio, 1.03; 95% CI, 0.98-1.09) or 6-month hospital admission (8.4% vs 8.1%; adjusted hazard ratio, 1.01; 95% CI, 0.96-1.05). In this population-based cohort study in Ontario, Canada, maternal mRNA COVID-19 vaccination during pregnancy was associated with lower risks of SNM, neonatal death, and NICU admission. In addition, neonatal and 6-month readmissions were not increased in infants of mothers vaccinated during pregnancy.

Pelvic exenteration for chronic fistulating pelvic sepsis after multimodal treatment of pelvic malignancy

BackgroundChronic fistulating pelvic sepsis is an uncommon complication of multimodal treatment of visceral pelvic tumours. Radical multi-visceral resection is reserved for patients with persistent, debilitating symptoms despite less invasive treatments and for which there is minimal published data. This study aimed to report the rates of morbidity and long-term sepsis control after pelvic exenteration for chronic fistulating pelvic sepsis. MethodsThis retrospective cohort study was conducted at a high-volume pelvic exenteration referral centre. Patients who underwent pelvic exenteration for chronic fistulating pelvic sepsis between September 1994 and January 2023 after previous treatment for pelvic malignancy were included. Data relating to postoperative morbidity, mortality and the rate of recurrent pelvic sepsis or fistulae were retrospectively collected. Results19 patients who underwent radical resection for chronic fistulating pelvic sepsis after previous pelvic cancer treatment were included. 11 patients were male (58 %) and median age was 62 years (range 42–79). Previously treated rectal (8 patients, 42 %), prostate (5, 26 %) and cervical cancer (5, 26 %) were most common. 18 patients (95 %) had previously received high-dose pelvic radiotherapy, and 14 (74 %) had required surgical resection. Total pelvic exenteration was performed in 47 % of patients, total cystectomy in 68 % and major pubic bone resection in 37 %. There was no intraoperative or postoperative mortality. Major complication rate was 32 %. 12-month readmission rate was 42 %. At last follow up, 74 % had no signs or symptoms of persisting pelvic sepsis. ConclusionsPelvic exenteration for refractory pelvic sepsis following treatment of malignancy is safe and effective in selected patients.

Geriatric Distal Femur Fractures Treated With Distal Femoral Replacement Are Associated With Higher Rates of Readmissions and Complications.

Compare mortality and complications of distal femur fracture repair among elderly patients who receive operative fixation versus distal femur replacement (DFR). Retrospective comparison. Medicare beneficiaries. Patients 65 years of age and older with distal femur fracture identified using Center for Medicare & Medicaid Services data from 2016 to 2019. Operative fixation (open reduction with plating or intramedullary nail) or DFR. Mortality, readmissions, perioperative complications, and 90-day cost were compared between groups using Mahalanobis nearest-neighbor matching to account for differences in age, sex, race, and the Charlson Comorbidity Index. Most patients (90%, 28,251/31,380) received operative fixation. Patients in the fixation group were significantly older (81.1 vs. 80.4 years, P < 0.001), and there were more an open fractures (1.6% vs. 0.5%, P < 0.001). There were no differences in 90-day (difference: 1.2% [-0.5% to 3%], P = 0.16), 6-month (difference: 0.6% [-1.5% to 2.7%], P = 0.59), and 1-year mortality (difference: -3.3% [-2.9 to 2.3], P = 0.80). DFR had greater 90-day (difference: 5.4% [2.8%-8.1%], P < 0.001), 6-month (difference: 6.5% [3.1%-9.9%], P < 0.001), and 1-year readmission (difference: 5.5% [2.2-8.7], P = 0.001). DFR had significantly greater rates of infection, pulmonary embolism, deep vein thrombosis, and device-related complication within 1 year from surgery. DFR ($57,894) was significantly more expensive than operative fixation ($46,016; P < 0.001) during the total 90-day episode. Elderly patients with distal femur fracture have a 22.5% 1-year mortality rate. DFR was associated with significantly greater infection, device-related complication, pulmonary embolism, deep vein thrombosis, cost, and readmission within 90 days, 6 months, and 1 year of surgery. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Impact of Hospital Volume on Long-Term Outcomes After Endovascular Therapy for Peripheral Artery Disease.

To investigate the association between annual hospital volume of endovascular therapy (EVT) and long-term outcomes in patients with lower-extremity peripheral artery disease (PAD). We identified patients who underwent percutaneous endovascular transluminal angioplasty and thrombectomy of the extremities or percutaneous endovascular removal in the Japanese Diagnosis Procedure Combination inpatient database from April 2014 to March 2020 linked to the Survey of Medical Institutions data. A generalized linear model analysis was performed to assess 12-month amputation, all-cause death, composite outcome (amputation and death), and readmission. We also analyzed length of hospital stay and total health care costs during the first hospitalization. Among 127 486 eligible patients, 31 579, 31 913, 31 999, and 31 995 were in the first (1-27 cases/year), second (28-44 cases), third (45-67 cases), and fourth (68-289 cases) quartiles, respectively. There were no significant differences in 12-month amputation among the second (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.90-1.04), third (OR, 1.00; 95% CI, 0.93-1.07), and fourth (OR, 1.00; 95% CI, 0.93-1.07) quartile volumes compared with the first quartile. Significant differences were observed in 12-month death (OR for fourth quartile with reference to the first quartile, 0.71; 95% CI, 0.65-0.76), composite outcome (OR, 0.84; 95% CI, 0.80-0.89), and readmission (OR, 1.05; 95% CI, 1.02-1.09). We found that the annual hospital volume of EVT was not associated with decreased 12-month amputation in patients with lower-extremity PAD. In contrast, all-cause death and composite outcome were significantly decreased in hospitals with the highest volume. The association between hospital volume of endovascular therapy and long-term adverse clinical outcomes remains unclear. The present analyses showed no significant differences in 12-month amputation rates among the hospital volumes, whereas higher-volume quartiles were significantly associated with decreased 12-month all-cause death rates and composite outcome. There was also a positive association in the length of stay between the first quartile volume and the others, while no significant difference in total health care costs among the quartiles was observed. Further investigations are needed, including insights into operator volume and procedural characteristics, to clarify the relationship between hospital volume and long-term adverse outcomes.

Three-level ACDF versus 3-level laminectomy and fusion: are there differences in outcomes? An analysis of the Quality Outcomes Database cervical spondylotic myelopathy cohort.

The authors sought to compare 3-level anterior with posterior fusion surgical procedures for the treatment of multilevel cervical spondylotic myelopathy (CSM). The authors analyzed prospective data from the 14 highest enrolling sites of the Quality Outcomes Database CSM module. They compared 3-level anterior cervical discectomy and fusion (ACDF) and posterior cervical laminectomy and fusion (PCF) surgical procedures, excluding surgical procedures crossing the cervicothoracic junction. Rates of reaching the minimal clinically important difference (MCID) in patient-reported outcomes (PROs) were compared at 24 months postoperatively. Multivariable analyses adjusted for potential confounders elucidated in univariable analysis. Overall, 199 patients met the inclusion criteria: 123 ACDF (61.8%) and 76 PCF (38.2%) patients. The 24-month follow-up rates were similar (ACDF 90.2% vs PCF 92.1%, p = 0.67). Preoperatively, ACDF patients were younger (60.8 ± 10.2 vs 65.0 ± 10.3 years, p < 0.01), and greater proportions were privately insured (56.1% vs 36.8%, p = 0.02), actively employed (39.8% vs 22.8%, p = 0.04), and independently ambulatory (14.6% vs 31.6%, p < 0.01). Otherwise, the cohorts had equivalent baseline modified Japanese Orthopaedic Association (mJOA), Neck Disability Index (NDI), numeric rating scale (NRS)-arm pain, NRS-neck pain, and EQ-5D scores (p > 0.05). ACDF patients had reduced hospitalization length (1.6 vs 3.9 days, p < 0.01) and a greater proportion had nonroutine discharge (7.3% vs 22.8%, p < 0.01), but they had a higher rate of postoperative dysphagia (13.5% vs 3.5%, p = 0.049). Compared with baseline values, both groups demonstrated improvements in all outcomes at 24 months (p < 0.05). In multivariable analyses, after controlling for age, insurance payor, employment status, ambulation status, and other potential clinically relevant confounders, ACDF was associated with a greater proportion of patients with maximum satisfaction on the North American Spine Society Patient Satisfaction Index (NASS) (NASS score of 1) at 24 months (69.4% vs 53.7%, OR 2.44, 95% CI 1.17-5.09, adjusted p = 0.02). Otherwise, the cohorts shared similar 24-month outcomes in terms of reaching the MCID for mJOA, NDI, NRS-arm pain, NRS-neck pain, and EQ-5D score (adjusted p > 0.05). There were no differences in the 3-month readmission (ACDF 4.1% vs PCF 3.9%, p = 0.97) and 24-month reoperation (ACDF 13.5% vs PCF 18.6%, p = 0.36) rates. In a cohort limited to 3-level fusion surgical procedures, ACDF was associated with reduced blood loss, shorter hospitalization length, and higher routine home discharge rates; however, PCF resulted in lower rates of postoperative dysphagia. The procedures yielded comparably significant improvements in functional status (mJOA score), neck and arm pain, neck pain-related disability, and quality of life at 3, 12, and 24 months. ACDF patients had significantly higher odds of maximum satisfaction (NASS score 1). Given comparable outcomes, patients should be counseled on each approach's complication profile to aid in surgical decision-making.