Adverse Discharge Disposition Research Articles

Radiographic sarcopenic obesity measurements in elderly trauma patients do not predict adverse discharge disposition over injury severity score

Introduction There is a need for a predictive tool for adverse discharge disposition in the injured elderly patient population. However, many measurements of frailty are not practical and radiographic measurements of muscle and adipose tissue have yet to be correlated with adverse discharge disposition in this population. Methods A retrospective review of a prospectively gathered trauma database at a level one trauma center was performed, studying all adult trauma patients aged 55 years or older with an inpatient stay of greater than 2 days. Patients with a non-survivable head trauma (head Abbreviated Injury Score of 6) or serious central nervous system injury, history of cirrhosis or solid organ transplantation, those actively being treated with immunosuppressive medications, and those without an abdominal computerized tomography (CT) scan within the first 48 h of admission were excluded. Sarcopenia, sarcopenic obesity (SO), and five-item frailty index (5-iFI) score were obtained and analyzed against adverse discharge disposition. Results The study evaluated 444 patients, of which 48.9% were male with a median age of 78 years (range 55–99 years). All patients sustained blunt trauma, shock index was positive in 13.7%, and median ISS was 10 (range 1–43). SO was not independently predictive of adverse discharge disposition. Additionally, neither sarcopenia nor 5-iFI scores were found to be independently predictive. Lower ISS and age were found to be protective against adverse discharge disposition. Conclusion CT-based measurements of muscle and adipose tissue may not add value over traditional injury scores in older trauma patients.

Cardiovascular Disease in Total Knee Arthroplasty: An Analysis of Hospital Outcomes, Complications, and Mortality.

Cardiovascular comorbidities have been identified as a significant risk factor for adverse outcomes following surgery. The purpose of this study was to investigate its prevalence and impact on postoperative outcomes, hospital metrics, and mortality in patients undergoing total knee arthroplasty (TKA). Our hypothesis was that patients with cardiovascular comorbidities would have worse outcomes, greater postoperative complication rates, and increased mortality compared to patients without cardiovascular disease. In this retrospective study, data from the National Inpatient Sample database from 2011 to 2020 were queried for patients who underwent TKA with preexisting cardiac comorbidities, including congestive heart failure (CHF), coronary artery disease (CAD), valvular dysfunction, and arrhythmia. Multivariate logistic regression analyses compared hospital metrics (length of stay, costs, and adverse discharge disposition), postoperative complications, and mortality rates while adjusting for demographic and clinical variables. All statistical analyses were performed using R studio 4.2.2 and Stata MP 17 and 18 with Python package. A total of 385,585 patients were identified. Those with preexisting CHF, CAD, valvular dysfunction, or arrhythmias were found to be older and at higher risk of adverse outcomes, including prolonged length of stay, increased hospital charges, and increased mortality (p < 0.001). Additionally, all preexisting cardiac diagnoses led to an increased risk of postoperative myocardial infarction, acute kidney injury (AKI), and need for transfusion (p < 0.001). The presence of valvular dysfunction, arrhythmia, or CHF was associated with an increased risk of thromboembolic events (p < 0.001). The presence of CAD and valvular dysfunction was associated with an increased risk of urologic infection (p < 0.001). This study demonstrated that CHF, CAD, valvular dysfunction, and arrhythmia are prevalent among TKA patients and associated with worse hospital metrics, higher risk of perioperative complications, and increased mortality. As our use of TKA rises, a lower threshold for preoperative cardiology referral in older individuals and early preoperative counseling/intervention in those with known cardiac disease may be necessary to reduce adverse outcomes.

Epidemiology of distal radius fractures: Elucidating mechanisms, comorbidities, and fracture classification using the national trauma data bank

BackgroundAn update on the epidemiology of distal radius fractures in the United States is necessary, particularly as the elderly population grows. Additionally, age and frailty have been associated with complications following surgical fixation of DRFs. Herein, we utilize the National Trauma Data Bank, a robust nationwide resource, to investigate the relationship between demographics, comorbidities, injury and fracture characteristics, and admission details. MethodsPatients with isolated distal radius fractures were identified from the National Trauma Data Bank (2016–2019) according to ICD-10 codes. Univariate and multivariate regressions were conducted to determine independent risk factors for bilateral fractures, displaced fractures, open fractures, as well as length of hospital stay and adverse discharge disposition for patients undergoing inpatient surgical fixation. ResultsThe incidence of DRFs was 3.6/1,000 trauma-related emergency department visits and 10.8/1,000 upper extremity traumas. Trauma mechanism was significantly associated with displaced and open fractures. Age (OR 1.01, 95% CI 1.01–1.01), BMI (OR 1.02, 95% CI 1.01–1.02), smoking (OR 1.34, 95% CI 1.15–1.57), and alcohol level (trace: OR 2.18, 95% CI 1.41–3.29; intoxicated: OR 2.20, 95% CI 1.63–2.95) were significantly associated with open fractures. Machinery (β=2.04, 95% CI 1.00–3.08) and MVT (β=0.39, 95% CI 0.08–0.69) mechanisms were independent risk factors for longer length of stay. mFI-5 was an independent risk factor, in a stepwise fashion, for both length of stay and adverse discharge disposition. ConclusionsHigh-energy mechanisms and risk factors for poor skin quality were significantly associated with open fractures. mFI-5 was an independent risk factor for longer length of stay and non-routine discharges in patients of all ages, despite controlling for other comorbidities, unrelated complications, and mechanism of injury. Trauma mechanism was an independent risk factor for prolonged length of stay only, particularly in patients younger than 65 years of age.

Safety and healthcare resource utilisation in patients undergoing left-atrial appendage closure - A nationwide analysis

Abstract Background Percutaneous left-atrial appendage closure (LAAC) has emerged as a non-pharmacological alternative for stroke prevention in patients with atrial fibrillation (AF) not suitable for anticoagulation therapy. Real-world data on peri-procedural outcomes are limited. Purpose To analyse outcomes of peri-procedural in-hospital safety and healthcare resource utilisation after percutaneous LAAC. Methods The US National Inpatient Sample was utilised to identify AF patients undergoing LAAC from 2016 to 2019. Primary outcomes (safety) were in-hospital stroke or systemic embolism (SE), pericardial effusion (PE), major bleeding, device embolisation and mortality. Secondary outcomes (resource utilisation) were adverse discharge disposition, hospital length of stay (LOS) and treatment costs. Logistic and Poisson regression models were used to analye outcomes by adjusting for 10 confounders. Results 11,240 adult patients (with 41.9% being female) with AF undergoing LAAC were included. SE decreased by 97% between 2016 and 2019 [95% Confidence Interval (CI) 0-0.24] (P=0.003), while a trend to lower numbers of other peri-procedural complications was determined. In-hospital mortality remained stable (0.14%). Hospital LOS decreased by 18% (0.78-0.87, P&amp;lt;0.001) and adverse discharge rate by 41% (95% CI 0.41-0.86, P=0.005) between 2016 and 2019, while hospital costs did not significantly change (P=0.2). Of note, female patients had a higher risk of PE (OR 2.86 [95% CI 2.41-6.39]) and SE (OR 5.0 [95% CI 1.28-43.6]), while patients with multiple comorbidities had higher risks of major bleeding (P&amp;lt;0.001), mortality (P=0.031), longer hospital LOS (P&amp;lt;0.001) and increased treatment costs (P=0.073). Male patients had the most peculiar decrease in adverse discharge rate between 2016 and 2019: OR 0.45 [95% CI 0.27-0.77]. Significant differences in all outcomes were observed between male and female patients across US regions (Figure). Subgroup analyses confirmed that female patients had a prolonged LOS and higher risk of adverse discharge disposition than male patients. Conclusions LAAC has become a safer and more efficient procedure. Significant sex differences existed across US regions. Careful considerations should be taken when performing LAAC in female and comorbid patients.

Healthcare resource utilisation and safety outcomes in patients undergoing transcatheter mitral valve repair - A nationwide analysis

Abstract Background Since the publication of the EVEREST II, MITRA-FR and COAPT trials, the domain of transcatheter edge-to-edge repair (TEER) for mitral regurgitation has been rapidly progressing. However, real-world data on peri-procedural outcomes are still limited. Purpose To analyse outcomes of peri-procedural healthcare resource utilisation and in-hospital safety after TEER between 2016 and 2019 in the United States. Methods The US National Inpatient Sample was utilised to identify adult patients undergoing TEER. Primary outcomes (hospital resource utilisation) were hospital length of stay (LOS), hospital costs and adverse discharge disposition to a nursing or rehabilitation facility. Secondary outcomes (safety) were in-hospital mortality, post-procedural bleedings, vascular complications, ischemic strokes, cardiogenic shocks, cardiac arrests and pericardial tamponades. Multivariable regression models were used to analyse outcomes. Results 4,020 adult patients undergoing a TEER procedure were included. The included population was relatively frail: average age of 78.1 years (±9.7), average Charlson Comorbidity Index of 3 [IQR 1-4], average number of cardiovascular risk factors of 3 [2-4] per patient, average CHA2DS2-VASc score of 4 [3-5] and average simplified HAS-BLED score of 2 [2-3]. Distribution of the procedure was balanced between both sexes: 2,159 (53.7%) males vs. 1,861 (46.3%) females. Procedures were predominantly performed in large hospitals with 3,052 cases (75.9%), as well as in regional "hubs" at both US coastal regions with 543 cases (13.5%) in the Middle Atlantic region, 832 cases (20.7%) in the South Atlantic region, 535 cases (13.3%) in the East North Central region and 690 cases (17.2%) in the Pacific region. TEER procedure showed relatively save outcomes: 34 in-hospital deaths (0.8%), 119 (3.0%) post-procedural bleedings, 1 vascular complication requiring surgery, 24 (0.6%) ischemic strokes, 64 (1.6%) cardiogenic shocks, 20 (0.5%) cardiac arrests and 13 (0.3%) pericardial tamponades. Between 2016 and 2019, hospital LOS decreased by 22% [95% Confidence Interval (CI) 0.73-0.83], hospital costs by 6% [95% CI 0.90-0.98] and post-procedural discharge rates to a nursing or rehabilitation facility by 40% [95% CI 0.41-0.88]; each P&amp;lt;0.001 (Figure). Post-procedural bleedings and cardiac arrests were reduced by 55% [95% CI 0.27-0.76] and 87% [95% CI 0.02-0.61] during the study period, respectively. In-hospital mortality, ischemic stroke, cardiogenic shock and pericardial tamponade decreased numerically but were not statistically significant (due to low overall event rates). Of note, there was a linear increase in all adverse outcomes with increasing patient comorbidity level (P for trend &amp;lt;0.001), particularly in patients with atrial fibrillation or flutter. Conclusion TEER procedure has become a safer and more efficient procedure. Careful considerations should be taken when performing the procedure in patients with multiple comorbidities.

Is Preoperative Serum Albumin Predictive of Adverse Outcomes in Head and Neck Cancer Surgery?

Patients with head and neck cancer are at increased risk of malnutrition due to tumor burden and surgical morbidity. The purpose of this study was to evaluate the association between preoperative serum albumin and 30-day adverse outcomes in patients undergoing head and neck cancer surgery. This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database. Patients undergoing an ablative head and neck cancer procedure were included. Patients who had an unclear tumor location based on coding or missing outcome data were excluded. The primary predictor variable was preoperative albumin categorized as low (<3.4g/dL), intermediate (3.4 to 3.9g/dL), or high (>3.9g/dL). The primary outcome variable was intensive care unit (ICU)-level complications scored using the Clavien-Dindo classification system. This is a tool used to grade surgical complications, with grade IV and V complications defined as requiring ICU-level care. Covariates were demographic (age, sex, body mass index), medical (smoking, functional status, weight loss), and perioperative (concurrent procedures, tumor location, reconstructive modality). Descriptive, bivariate, and multiple logistic regression with bootstrap resampling statistics were used to evaluate the association between albumin and adverse outcomes. A significance level of P≤.05 was significant. A total of 4,491 subjects met inclusion criteria and had a documented albumin. There were 435 subjects with low albumin levels, 1,305 with intermediate levels, and 2,751 with high levels. In bivariate analysis, low albumin levels were associated with an increased risk of ICU-level complications, any complication, extended length of stay, and adverse discharge disposition (all P≤.001), while high levels were protective (all P≤.001). In bootstrapped multivariate analysis using intermediate albumin as the reference group and adjusting for demographics, tumor location, and reconstructive modality among others, low albumin levels were an independent predictor of ICU-level complications (P=.008, odds ratio, 1.64; 95% confidence interval, 1.14 to 2.40), while high levels were protective (P=.014, odds ratio, 0.689; 95% confidence interval, 0.521 to 0.923). Preoperative serum albumin was an independent predictor of adverse outcomes following ablative head and neck cancer procedures.

Safety and Healthcare Resource Utilization in Patients Undergoing Left Atrial Appendage Closure-A Nationwide Analysis.

Percutaneous left atrial appendage closure (LAAC) has emerged as a non-pharmacological alternative for stroke prevention in patients with atrial fibrillation (AF) not suitable for anticoagulation therapy. Real-world data on peri-procedural outcomes are limited. The aim of this study was to analyze outcomes of peri-procedural safety and healthcare resource utilization in 11,240 adult patients undergoing LAAC in the United States between 2016 and 2019. Primary outcomes (safety) were in-hospital ischemic stroke or systemic embolism (SE), pericardial effusion (PE), major bleeding, device embolization and mortality. Secondary outcomes (resource utilization) were adverse discharge disposition, hospital length of stay (LOS) and costs. Logistic and Poisson regression models were used to analyze outcomes by adjusting for 10 confounders. SE decreased by 97% between 2016 and 2019 [95% Confidence Interval (CI) 0-0.24] (p = 0.003), while a trend to lower numbers of other peri-procedural complications was determined. In-hospital mortality (0.14%) remained stable. Hospital LOS decreased by 17% (0.78-0.87, p < 0.001) and adverse discharge rate by 41% (95% CI 0.41-0.86, p = 0.005) between 2016 and 2019, while hospital costs did not significantly change (p = 0.2). Female patients had a higher risk of PE (OR 2.86 [95% CI 2.41-6.39]) and SE (OR 5.0 [95% CI 1.28-43.6]) while multi-morbid patients had higher risks of major bleeding (p < 0.001) and mortality (p = 0.031), longer hospital LOS (p < 0.001) and increased treatment costs (p = 0.073). Significant differences in all outcomes were observed between male and female patients across US regions. In conclusion, LAAC has become a safer and more efficient procedure. Significant sex differences existed across US regions. Careful considerations should be taken when performing LAAC in female and comorbid patients.

Does frailty status predict outcome in major trauma in older people? A systematic review and meta-analysis.

The incidence of major trauma in older people is increasing. Frailty is likely to be a factor that influences the outcomes of trauma. We conducted a systematic review aiming to investigate whether frailty affects major trauma outcomes in older people and whether it is more predictive than age. Observational studies investigating frailty, major trauma severity and outcomes were eligible. We searched electronic databases (Ovid MEDLINE, PubMed, Ovid EMBASE and CINAHL) from 2010 to 01 January 2023. We used Joanna Briggs Institute software to assess the risk of bias and conduct meta-analyses of the relationships between frailty status and outcomes. We used a narrative synthesis to compare the predictive value of frailty and age. Twelve studies were eligible for meta-analyses. In-hospital mortality (odds ratio (OR) = 1.12, 95% confidence interval (CI) 1.05, 1.19), length of stay (OR = 2.04, 95% CI 1.51, 2.56), discharge to home (OR = 0.58, 95% CI 0.53, 0.63) and in-hospital complications (OR = 1.17, 95% CI 1.10, 1.24) were all associated with frailty. Frailty was found to be a more consistent predictor of adverse outcomes and mortality in older trauma patients than injury severity and age in six studies that reported multivariate regression analysis. Older trauma patients with frailty have higher in-hospital mortality rates, prolonged hospital stays, in-hospital complications and adverse discharge disposition. Frailty is a better predictor of adverse outcomes than age in these patients. Frailty status is likely to be a useful prognostic variable in guiding patient management and stratifying clinical benchmarks and research trials.

Frailty independently predicts unfavorable discharge in non-operative traumatic brain injury: A retrospective single-institution cohort study.

Frailty is associated with adverse outcomes in traumatically injured geriatric patients but has not been well-studied in geriatric Traumatic Brain Injury (TBI). To assess relationships between frailty and outcomes after TBI. The records of all patients aged 70 or older admitted from home to the neurosurgical service of a single institution for non-operative TBI between January 2020 and July 2021 were retrospectively reviewed. The primary outcome was adverse discharge disposition (either in-hospital expiration or discharge to skilled nursing facility (SNF), hospice, or home with hospice). Secondary outcomes included major inpatient complication, 30-day readmission, and length of stay. 100 patients were included, 90% of whom presented with Glasgow Coma Score (GCS) 14-15. The mean length of stay was 3.78 days. 7% had an in-hospital complication, and 44% had an unfavorable discharge destination. 49% of patients attended follow-up within 3 months. The rate of readmission within 30 days was 13%. Patients were characterized as low frailty (FRAIL score 0-1, n = 35, 35%) or high frailty (FRAIL score 2-5, n = 65, 65%). In multivariate analysis controlling for age and other factors, frailty category (aOR 2.63, 95CI [1.02, 7.14], p = 0.005) was significantly associated with unfavorable discharge. Frailty was not associated with increased readmission rate, LOS, or rate of complications on uncontrolled univariate analyses. Frailty is associated with increased odds of unfavorable discharge disposition for geriatric patients admitted with TBI.

99. Racial disparities in spine surgery: a systematic review

<h3>BACKGROUND CONTEXT</h3> Racial disparities in access, outcomes, and quality of health care have been increasingly substantiated by research over the last few decades. Inequities based on race and ethnicity can be found across multiple surgical subspecialties. Despite increased efforts to mitigate racial bias, disparities persist, including in the field of spine surgery. <h3>PURPOSE</h3> To synthesize previous studies evaluating racial disparities in spine surgery. <h3>STUDY DESIGN/SETTING</h3> Systematic review. <h3>PATIENT SAMPLE</h3> Patients found in the literature on racial disparities in spine surgery. <h3>OUTCOME MEASURES</h3> The main outcome measures were the occurrence of racial disparities in postoperative outcomes, mortality, surgical management, readmissions and length of stay. <h3>METHODS</h3> We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on racial disparities in spine surgery. Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses (PRISMA) guidelines and protocol. <h3>RESULTS</h3> A total of 1,753 publications were assessed. Twenty-two articles met inclusion criteria. Seventeen studies compared Caucasians (CAs) and African Americans (AAs) groups; fourteen studies reported adverse outcomes for AAs. When compared to CAs, AA patients had higher odds of postoperative complications including mortality, cerebrospinal fluid leak, nervous system complications, bleeding, infection, in-hospital complications, adverse discharge disposition and delay in diagnosis. Further, AAs were found to have increased odds of readmission and longer length of stay. Finally, AAs were found to have higher odds of nonoperative treatment for spinal cord injury, were more likely to undergo posterior approach in the treatment of cervical spondylotic myelopathy and were less likely to receive cervical disc arthroplasty compared to CAs for similar indications. <h3>CONCLUSIONS</h3> This systematic review of spine literature found that when compared to CA patients, AA patients had worse health outcomes. Further investigation of root causes of these racial disparities in spine surgery is warranted. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Postoperative outcomes for Nunavut Inuit at a Canadian quaternary care centre: a retrospective cohort study.

Background:Structural aspects of health care systems, such as limited access to specialized surgical and perioperative care, can negatively affect the outcomes and resource use of patients undergoing elective and emergency surgical procedures. The aim of this study was to compare postoperative outcomes of Nunavut Inuit and non-Inuit patients at a Canadian quaternary care centre.Methods:We conducted a retrospective cohort study involving adult (age ≥ 18 yr) patients undergoing inpatient surgery from 2011 to 2018 at The Ottawa Hospital, the quaternary referral hospital for the Qikiqtaaluk Region of Nunavut. The study was designed and conducted in collaboration with Nunavut Tunngavik Incorporated. The primary outcome was a composite of in-hospital death or complications.Secondary outcomes included postoperative length of stay in hospital, adverse discharge disposition, readmissions within 30 days and total hospitalization costs.Results:A total of 98 701 episodes of inpatient surgical care occurred among patients aged 18 to 104 years; 928 (0.9%) of these involved Nunavut Inuit, and 97 773 involved non-Inuit patients. Death or postoperative complication occurred more often among Nunavut Inuit than non-Inuit patients (159 [17.2%] v. 15 691 [16.1%]), which was significantly different after adjustment for age, sex, surgical specialty, risk and urgency (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.03–1.51). This association was most pronounced in cases of cancer (OR 1.63, 95% CI 1.03–2.58) and elective surgery (OR 1.58, 95% CI 1.20–2.10). Adjusted rates of readmission, adverse discharge disposition, length of stay and total costs were significantly higher for Nunavut Inuit.Interpretation:Nunavut Inuit had a 25% relative increase in their odds of morbidity and death after surgery at a major quaternary care hospital in Canada compared with non-Inuit patients, while also having higher rates of other adverse outcomes and resource use. An examination of perioperative systems involving patients, Inuit leadership, health care providers and governments is required to address these differences in health outcomes.

Racial and Socioeconomic Disparities in Necrotizing Soft-Tissue Infection

Background: Necrotizing soft-tissue infection (NSTI) is a medical emergency. We investigated the impact of racial, socioeconomic disparities, and comorbidities on mortality, complications, length of stay, and charges in patients with NSTI. Methods: Data were acquired from the National Inpatient Sample from Q4 2015 to 2017. ICD-10, Clinical Modification codes were utilized to identify relevant cases. Logistic regression was used to assess socioeconomic, racial, and health risk factors for adverse outcomes in NSTI patients. Results: Of 16,071,053 cases identified during the study period, 15,078 (0.094%) NSTI cases were recognized. Black patients had increased odds of amputation (OR 1.40 95% CI 1.24–1.58, p < 0.001), prolonged hospital stay (OR 1.40 95% CI 1.24–1.58, p < 0.001), excessive charges (OR 1.22 95% CI 1.03–1.43, p = 0.019), and adverse discharge disposition (OR 1.32 95% CI 1.19–1.46, p < 0.001) compared to white patients. Hispanic patients had increased odds of mortality (OR 1.30 95% CI 1.05–1.60, p = 0.014) and amputation (OR 1.21 95% CI 1.04–1.42, p = 0.016) compared to white patients. Medicare patients had increased odds of mortality (OR 1.35 95% CI 1.09–1.67, p = 0.006), Medicaid patients had increased odd of amputation (OR 1.33 95% CI 1.17–1.51, p < 0.001) and prolonged LOS (OR 1.33 95% CI 1.17–1.51, p < 0.001). Patients in the lower income quartiles had decreased odds of amputation compared to the highest income quartile, including the 26th to 50th income quartile (OR 0.84 95% CI 0.73–0.98, p = 0.022) and 51st to 75th income quartile (OR 0.84 95% CI 0.73–0.98, p = 0.022). Conclusions: Racial and socioeconomic disparities exist for patients being treated for NSTIs.

Abstract TMP51: Predictors Of Severe Disease In Posterior Reversible Encephalopathy Syndrome

Background: Despite its name, posterior reversible encephalopathy syndrome (PRES) is not always fully reversible and there might be residual neurologic sequelae or even mortality in a significant minority of patients. Factors predisposing to severe disease course in PRES are largely unclear. The aim of this study was to evaluate the predictors of in-hospital mortality and adverse discharge disposition in patients hospitalized due to PRES. Methods: Hospitalizations due to the primary diagnosis of PRES with known discharge disposition were identified from the Nationwide Readmissions Database 2016-2018. Survey statistics were used to compute national estimates. Univariate and multivariable logistic regression analyses were used to identify factors associated with the study outcomes. P-value &lt;0.01 was considered significant. Results: There were 9,298 patients with PRES (mean±SD age: 56.2±17.6 years; female: 71.2%). Of these, 207 (2.2%) had in-hospital mortality and 4,002 (43.0%) had adverse discharge disposition, defined as discharge to a short-term hospital, a rehabilitation facility, home with in-home healthcare or hospice. Figure 1 shows the independent predictors of the study outcomes. Advanced age, history of cancer, concurrent sepsis, coma, ischemic stroke, and mechanical ventilation were associated with higher in-hospital mortality. Whereas advanced age, female sex, higher Charlson comorbidity index score, mechanical ventilation, and longer length of hospital stay were associated with a higher likelihood of adverse discharge disposition. Conclusion: Nearly half of the hospitalized patients with PRES have severe disease. This study identifies several clinical predictors of severe disease course in PRES.

Abstract WMP106: Acute Ischemic Stroke Treatments And Outcomes In Patients With Hematological Malignancies

Background: There is limited evidence to guide treatment decisions in patients with acute ischemic stroke (AIS) who have concurrent hematological malignancies. In this study, we aimed to evaluate the impact of acute stroke interventions and clinical outcomes in this patient population. Methods: Hospitalizations with primary diagnosis of AIS were identified from the Nationwide Readmissions Database 2016-2018. Hospital records with age&lt;18 or with concomitant diagnosis of solid organ malignancy were excluded. Logistic regression was used to compare the differences in acute stroke interventions and clinical outcomes in patients with and without hematological malignancies. Survival analysis was used to evaluate recurrent AIS after discharge. Results: There were 1347150 hospitalizations due to AIS (mean±SD age 70.3±14.1 years, female 50.2%). Of these, 11863 (0.9%) had a concurrent diagnosis of hematological malignancy. Patients with malignancy were older and were less likely to have comorbid cerebrovascular risk factors, except atrial fibrillation. Patients with malignancy were less likely to receive intravenous thrombolysis (tPA) but the rates of endovascular thrombectomy (ET) did not differ between the two groups. After adjustment for baseline differences, patients with malignancy had higher in-hospital mortality [odds ratio (OR): 1.2, 95% confidence interval (CI): 1.0-1.3] but other outcomes like intracranial hemorrhage and discharge disposition were comparable between the two groups. Sub-group analysis according to the type of malignancy (leukemia, lymphoma, plasma cell neoplasms, histiocytic/other) showed that only patients with leukemias had higher mortality and adverse discharge disposition. Among the subgroups of patients treated with tPA or ET, the clinical outcomes were comparable between patients with and without malignancy. Further, the overall risk of readmission due to recurrent ischemic stroke was also similar between patients with and without malignancy (hazards ratio: 1.0, 95% CI: 0.9-1.1). Conclusion: Acute reperfusion in ischemic stroke is safe in patients with hematological malignancies. While patients with malignancy have higher in-hospital mortality, they are not at an increased risk of stroke recurrence.

Abstract WMP57: Acute Stroke Interventions And Clinical Outcomes In Patients With Solid Organ Malignancies

Background: There is limited data regarding the safety of acute ischemic stroke (AIS) treatments in patients with solid organ malignancy (SOM). We aimed to evaluate the nationwide use of acute stroke interventions and clinical outcomes in this patient population. Methods: Adult hospitalizations with primary diagnosis of AIS were identified from the Nationwide Readmissions Database 2016-2018. Logistic regression was used to compare the differences in interventions and clinical outcomes in patients with and without SOM. Survival analysis was used to evaluate recurrent AIS after discharge. Results: There were 1385840 hospitalizations due to AIS (mean±SD age 70.4±14.0 years, female 50.2%). Of these, 50553 (3.7%) had a concurrent diagnosis of SOM. Patients with SOM were older, more likely to be male, and had a lower prevalence of comorbid cerebrovascular risk factors, except atrial fibrillation and tobacco use. The five most common malignancies were of lung, prostate, breast, pancreas, and colorectal origins. After adjustment for baseline differences, patients with SOM were more likely to have intraparenchymal hemorrhage (IPH) [odds ratio (OR): 1.1, 95% confidence interval (CI): 1.0-1.2], in-hospital mortality (OR: 2.1, 95% CI: 2.0-2.2), and discharge disposition other than to home (OR: 1.6, 95% CI: 1.6-1.7). The risk of IPH was higher only in pancreatic cancer, in-hospital mortality in all types except prostate cancer, and adverse discharge disposition in all types except prostate and breast cancers. Patients with SOM were less likely to receive intravenous thrombolysis (tPA) but more likely to undergo endovascular thrombectomy (ET). Among the subgroups of patients treated with tPA or ET, outcomes were comparable between patients with and without SOM, except patients with lung cancer remained at a higher risk of mortality and adverse disposition despite these interventions. Patients with SOM had higher risk of readmission due to recurrent AIS within 1 year of discharge (hazards ratio: 1.2, 95% CI: 1.1-1.3), and this risk was entirely driven by lung and pancreatic cancers. Conclusion: Clinical outcomes of AIS in the setting of SOM vary according to the malignancy site. Acute stroke interventions when performed, appear to be safe in most patients with SOM.

The Association of Frailty with Outcomes after Cancer Surgery: A Systematic Review and Metaanalysis

Cancer is common in older adults, who often have concurrent frailty. Frailty is a strong predictor of adverse outcomes in surgical patients. Our objective is to systematically review the association of frailty with postoperative mortality and other adverse outcomes in adult patients who have undergone nonemergency cancer surgery. After registration (CRD42020171163), we systematically reviewed PubMed, MEDLINE, EMBASE, and CINAHL databases to identify all studies reporting an association between a preoperative frailty measurement and a relevant outcome (primary: all-cause mortality in-hospital or within 30 days of surgery; secondary outcomes: postoperative complications, length of stay, discharge disposition, mortality between 30 days and 1 year, postoperative function, and delirium). All stages of the review were completed in duplicate. Risk of bias was assessed using the Quality in Prognostic Studies (QUIPS) tool. Metaanalysis was used to pool effect estimates using random-effects models. A total of 2877 studies were identified, and 71 were included. Frailty was significantly associated with mortality within 30 days (adjusted odds ratio (OR) 3.02, 95% confidence interval (CI) 1.77-5.15), adverse discharge disposition (adjusted OR 2.14, 95% CI 1.52-3.02), postoperative complications (adjusted OR 2.39, 95% CI 1.64-3.49), longer-term mortality (unadjusted OR 4.32, 95% CI 2.15-8.67), and length of stay (mean difference 2.30, 95% CI 1.10-3.50). The number of studies presenting adequately adjusted estimates was small. Findings may be limited due to publication bias. In adults having elective cancer surgery, frailty is strongly associated with adverse health outcomes. Preoperative frailty assessment should be considered in prognostication.

Is Preoperative Serum Albumin Predictive of Adverse Surgical Outcomes in Maxillofacial Fracture Repair?

Malnutrition has been recognized as a predictor of postoperative adverse outcomes across many surgical subspecialties. The purpose of this study was to evaluate the relationship between serum albumin and adverse outcomes in patients undergoing operative repair of maxillofacial fractures. The authors utilized the 2011 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases to identify patients with facial fractures undergoing operative repair. The primary predictor variable was preoperative serum albumin level. Outcome variables included complications and other adverse outcomes occurring within 30 days of the index operation. Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between serum albumin and adverse outcomes. During the study period 1211 subjects underwent operative repair of a facial fracture and had a documented serum albumin level. Of these subjects, 1037 (85.6%) had normal albumin levels and 174 (14.4%) had hypoalbuminemia. A total of 90 subjects experienced a complication (7.43%), although albumin level was not associated with surgical complications or any complication. In bivariate analysis, subjects with hypoalbuminemia were significantly more likely to have an extended length of stay (P ≤ .001), adverse discharge disposition (P ≤ .001), and be readmitted (P=.002). In multivariate analysis, hypoalbuminemia was an independent predictor of an extended length of stay (P ≤ .001, 95% CI 2.50 to 7.62), adverse discharge disposition (P=.048, 95% CI 1.01 to 3.75), and readmission (P=.041, 95% CI 1.03 to 3.47). Serum albumin was not an independent predictor of complications after maxillofacial trauma repair. However, it was an independent predictor of other adverse outcomes including extended length of stay, adverse discharge disposition, and readmission. Targeted nutritional optimization may represent an opportunity to improve outcomes in this demographic.

Does Preoperative Estimated Glomerular Filtration Rate (eGFR) Predict Short-Term Surgical Outcomes in Patients Undergoing Pancreatic Resections?

IntroductionPreoperative eGFR has been found to be a reliable predictor of post-operative outcomes in patients with normal creatinine levels who undergo surgery. The aim of our study was to evaluate the impact of preoperative eGFR levels on short-term post-operative outcomes in patients undergoing pancreatectomy. MethodsThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) pancreatectomy file (2014–2017) was queried for all adult patients (age ≥ 18) who underwent pancreatic resection. Patients were stratified into two groups based on their preoperative eGFR (eGFR < 60 mL/min/1.73m2 and eGFR ≥ 60 mL/min/1.73m2). Outcome measures included post-operative pancreatic fistula, discharge disposition, hospital length of stay, 30-day readmission rate, and 30-day morbidity and mortality. Multivariate logistic regression analysis was performed. ResultsA total of 21,148 were included in the study of which 12% (n = 2256) had preoperative eGFR < 60 mL/min/1.73m2. Patients in the eGFR < 60 group had prolonged length of stay, were less likely to be discharged home, had higher minor and major complication rates, and higher rates of mortality. On logistic regression analysis, lower preoperative eGFR (< 60 mL/min/1.73m2) was associated with higher odds of prolonged length of stay [aOR: 1.294 (1.166–1.436)], adverse discharge disposition [aOR: 1.860 (1.644–2.103)], minor [aOR: 1.460 (1.321–1.613)] and major complications [aOR: 1.214 (1.086–1.358)], bleeding requiring transfusion [aOR: 1.861 (1.656–2.091)], and mortality [aOR: 2.064 (1.523–2.797)]. ConclusionPreoperative decreased renal function measured by eGFR is associated with adverse outcomes in patients undergoing pancreatic resection. The results of this study may be valuable in improving preoperative risk stratification and post-operative expectations.

Isolated Intracranial Hemorrhage in Elderly Patients With Pre-Injury Anticoagulation: Is Full Trauma Team Activation Necessary?

Traumatic intracranial hemorrhage (ICH) is a highly morbid injury, particularly among elderly patients on preinjury anticoagulants (AC). Many trauma centers initiate full trauma team activation (FTTA) for these high-risk patients. We sought to determine if FTTA was superior compared with those who were evaluated as a trauma consultation (CON). Patients aged ≥55 on preinjury AC who presented from January 2015 to December 2019 with blunt isolated head injury (non-head AIS ≤2) and confirmed ICH were identified. CON patients and FTTA patients were matched by age and head AIS. Cox proportional hazard model was used to assess patient and injury characteristics with mortality and survivor discharge disposition. There were 45 CON patients and 45 FTTA patients. Mean age was 80 years in both groups. Fall was the most common mechanism (98% CON vs. 92% FTTA). Glasgow Coma Score (GCS) was lower in FTTA (14 vs. 15, p<0.01). CON had a significantly longer time from arrival to CT scan (1.3 vs. 0.4 hrs, p<0.01). Hospital days were similar (CON: 3.9 vs. FTTA: 3.7 days). However, CON had increased ventilator use (p=0.03). Lower admission GCS was the only factor associated with increased risk of death. Among survivors, only head AIS increased the risk of discharge to a level of care higher than that of preinjury (p=0.01). There was no difference in mortality or adverse discharge disposition between FTTA and CON, although FTTA was associated with a more rapid evaluation and diagnosis. Any alteration in GCS was strongly associated with mortality and should prompt evaluation by FTTA.

Adult sports-related traumatic spinal injuries: do different activities predispose to certain injuries?

Sports injuries are known to present a high risk of spinal trauma. The authors hypothesized that different sports predispose participants to different injuries and injury severities. The authors conducted a retrospective cohort analysis of adult patients who experienced a sports-related traumatic spinal injury (TSI), including spinal fractures and spinal cord injuries (SCIs), encoded within the National Trauma Data Bank from 2011 through 2014. Multiple imputation was used for missing data, and multivariable linear and logistic regression models were estimated. The authors included 12,031 cases of TSI, which represented 15% of all sports-related trauma. The majority of patients with TSI were male (82%), and the median age was 48 years (interquartile range 32-57 years). The most frequent mechanisms of injury in this database were cycling injuries (81%), skiing and snowboarding accidents (12%), aquatic sports injuries (3%), and contact sports (3%). Spinal surgery was required during initial hospitalization for 9.1% of patients with TSI. Compared to non-TSI sports-related trauma, TSIs were associated with an average 2.3-day increase in length of stay (95% CI 2.1-2.4; p < 0.001) and discharge to or with rehabilitative services (adjusted OR 2.6, 95% CI 2.4-2.7; p < 0.001). Among sports injuries, TSIs were the cause of discharge to or with rehabilitative services in 32% of cases. SCI was present in 15% of cases with TSI. Within sports-related TSIs, the rate of SCI was 13% for cycling injuries compared to 41% and 49% for contact sports and aquatic sports injuries, respectively. Patients experiencing SCI had a longer length of stay (7.0 days longer; 95% CI 6.7-7.3) and a higher likelihood of adverse discharge disposition (adjusted OR 9.69, 95% CI 8.72-10.77) compared to patients with TSI but without SCI. Of patients with sports-related trauma discharged to rehabilitation, one-third had TSIs. Cycling injuries were the most common cause, suggesting that policies to make cycling safer may reduce TSI.