Comorbidity Index Research Articles

Intergenerational Occurrence of Premature Birth and Reproductive Health in Prematurely-Born Women in the Women’s Health Initiative

ObjectiveTo compare reproductive history and postmenopausal health by birth status (preterm vs. full term) in a U.S. longitudinal study of postmenopausal women. Birth status was examined according to region of residence, household, and neighborhood socioeconomic status (SES).MethodsIn the Women’s Health Initiative Observational Study, 2271 women were born prematurely (< 37 weeks). ANOVA and Chi-square determined birth status differences of reproductive history, pregnancy, and postmenopausal health. Odds ratios were calculated using either binary logistic or multinomial logistic regression. SES and U.S. region of residence were examined as potential effect modifiers.ResultsPreterm-born women compared to term-born women had higher risk of delivering a premature infant (aOR 1.68, 95% CI [1.46, 1.93]), higher odds of later-age first pregnancy (aOR 1.27 95% CI [1.02, 1.58]), longer duration to become pregnant (> 1 year to pregnancy) (aOR 1.10 95% CI [1.01, 1.21]), more miscarriages (aOR 1.23 95% CI [1.11, 1.37]), and more pregnancy complications including hypertension (aOR 1.58 95% CI (1.13, 2.21)], preeclampsia (aOR 1.64 95% CI [1.24, 2.16]), and gestational diabetes (aOR 1.68 95% CI [1.11, 2.53]). Preterm-born women had higher odds of menopause before age 50 (aOR 1.09 95% CI [1.05, 1.14]). Post-menopause, they had higher rates of diabetes (p = .01), hypertension (p = .01), hysterectomy (p = .045), and higher Charlson Comorbidity Index scores (p = .01).ConclusionsPreterm-born women had higher reproductive and pregnancy risks which when coupled with early menopause, may indicate a shorter childbearing period than term-born women. Guidelines for integration of preterm history in women’s health care across the life course are needed to identify and manage their higher risk.

Retrograde open mesenteric stenting and outcomes for acute mesenteric ischemia.

Data regarding retrograde open mesenteric stenting (ROMS) for urgent mesenteric ischemia is limited to small single center and case series, with variable utilization across patient populations and ill-defined outcomes. We aimed to evaluate characteristics and outcomes of patients with acute mesenteric ischemia requiring urgent surgical intervention. Retrospective cohort study of patients with mesenteric ischemia requiring urgent surgical intervention from 2018 to 2020 was queried from the National Inpatient Sample (NIS) database. Study groups were defined as those requiring an open bypass (BYPASS), an open superior mesenteric artery embolectomy (OPEN), or ROMS. Descriptive statistics were used to report variables. Comparisons were mad using t test, chi-squares tests, and multivariate regression reported as odds ratio (OR), 95% confidence interval (CI) where appropriate. 898 patients with mesenteric ischemia requiring urgent surgical intervention were included: Bypass: 284, OPEN: 363, ROMS: 251. There was no difference in gender or race between groups. Patients requiring ROMS were more likely to be older 70.2 + 11.3versus Bypass 66.81 + 11.6 and OPEN 67.17 + 14.5, p = 0.0035. ROMS patients had the highest Charlson Comorbidity Index (CCI) 2.9 versus 2.5 Bypass and 2.6 OPEN, p = 0.0292 with the most frequent comorbidities: Diabetes 37% (p = 0.01), renal disease 24.3% (p = 0.5), and previous preoperative myocardial infarction 9.2%, p = 0.05; however, the lowest mortality rate was seen within this Group 15.9% versus bypass 19.7%, OPEN 34.5%, p < 0.0001. Patients requiring bypass were more likely to have chronic pulmonary disease 34.5% versus OPEN 24.2% and ROMS 31.5%, p = 0.013, peripheral vascular disease (PVD) 38% versus OPEN 16%, and ROMS 29.9%, p < 0.0001. On multivariate regression, ROMS was associated with 50% decreased incidence of mortality (OR 0.45, 95% CI 0.27-0.75). Open SMA embolectomy was associated with nearly 2x mortality rate compared to bypass procedures OR 2.0, 95% CI 1.3-3.0, p < 0.001. Previous MI was also associated with nearly 2x incidence of mortality (OR 1.9, 95% CI 1.01-3.6), while pre-existing PVD conferred a protective effect (OR 0.56, 95% CI 0.36-0.89). Higher CCI and age were associated with slightly increased risk for mortality OR 1.2 and 1.03, p < 0.05 for both. In patients with acute mesenteric ischemia, ROMS demonstrated a significant mortality benefit compared to traditional open procedures. Advanced age, history of MI, and open SMA embolectomy were associated with increased mortality. Little data exists regarding ROMS in a real-world population evaluating ROMS, which is a newer technique. These data suggest that ROMS may be a superior alternative to restore mesenteric flow in the acute setting and further prospective studies evaluating ROMS to other procedural types in urgent and elective settings are needed.

Outcomes following two-level Cervical Disc Arthroplasty Relative to two-level Anterior Cervical Discectomy.

Retrospective cohort study. To evaluate postoperative adverse events, readmissions, and five-year survival to reoperation for two-level cervical disc arthroplasty (CDA) relative to two-level anterior cervical discectomy and fusion (ACDF). CDA and ACDF are both treatment options for degenerative cervical spine pathology. Relative to ACDF, CDA is a relatively novel treatment option, and limited research exists comparing outcomes between two-level CDA and two-level ACDF. Patients undergoing two-level CDA or two-level ACDF were isolated from the PearlDiver M165Ortho database. These two cohorts were matched 1:1 based on patient age, sex, and Elixhauser Comorbidity Index (ECI) scores. The odds of 90-day postoperative adverse events were compared between the two groups by multivariable analysis. Overall cost-of-care for the first 90-days postoperatively, and five-year survival to cervical spine reoperation were then assessed. Of the two-level cases identified, only 3.9% had CDA and the rest had ACDF. After matching, there were 4,224 patients in each of the study groups. With controlling for patient age, sex, and ECI on multivariable analysis, two-level CDA patients had significantly lower odds of experiencing 90-day dysphagia (OR 0.60, P<0.0001 driving aggregated any adverse event [OR 0.65, P<0.0001]) and readmission (OR 0.69, P=0.0002). Median 90-day cost of care was greater for two-level ACDF patients ($4,776.00 vs. $3,191.00, P<0.0001). No significant difference in five-year survival to cervical spine reoperation was identified (P=0.7). Relative to two-level ACDF patients, two-level CDA patients were found to have significantly lower odds of 90-day readmissions and minor adverse events (dysphagia), while rates of major adverse events (pulmonary embolism, deep vein thrombosis, sepsis, etc.) were comparable between the groups. Further CDA patients had lower cost of overall care, but no difference in five-year survival to cervical spine reoperation. Thus, it may be appropriate to further consider CDA when two-level surgery is pursued.

One- versus Three-- Level Fusion in Patients Undergoing Multilevel Lumbar Decompression: Relative Perioperative Risks and Five-year Revisions.

Retrospective cohort study. To assess relative odds of perioperative complications, readmissions, and five-year survival to reoperation for three-level lumbar decompression patients who undergo three-level fusion relative to one-level fusion. Patients undergoing multilevel lumbar decompression may be indicated for fusion at one or more levels. The question of fusing only one level with indications such as spondylolisthesis or fusing all levels decompressed is of clinical interest in both the short and longer term. Patients undergoing three-level lumbar decompression were extracted from the PearlDiver M165Orto database. The subset of these patients undergoing concomitant three-level and one-level lumbar fusion were identified and matched 1:1 based on patient age, sex, and Elixhauser Comorbidity Index (ECI) scores. The incidence and odds of 90-day postoperative adverse events were compared between the two groups by multivariable analysis, and comparative five-year survival to lumbar spinal reoperation was determined. After matching, 28,276 patients were identified as undergoing three-level lumbar decompression with three-level fusion and the same for those undergoing three-level decompression with one-level fusion. Controlling for patient age, sex, and ECI, three-level fusion patients had significantly greater odds ratio (OR) of many 90-day adverse events and aggregated any (OR 1.42), serious (OR 1.44), and minor (OR 1.42) adverse events, as well as readmissions (OR 1.51) (P<0.0001 for all). Five-year survival to reoperation was significantly lower for those undergoing three-level decompression with three-level fusion (P<0.0001). Three-level lumbar decompression patients who underwent three-level fusion were found to be at significantly greater odds of 90-day postoperative adverse events, readmissions, and five-year reoperations relative to those undergoing one-level fusion. The current data support the concept of limiting fusion to the levels with specific indications in the setting of multi-level lumbar decompressions and not needing to match the decompression and fusion levels.

Assessing the Effect of Electronic Health Record Data Quality on Identifying Patients With Type 2 Diabetes: Cross-Sectional Study.

Increasing and substantial reliance on electronic health records (EHRs) and data types (ie, diagnosis, medication, and laboratory data) demands assessment of their data quality as a fundamental approach, especially since there is a need to identify appropriate denominator populations with chronic conditions, such as type 2 diabetes (T2D), using commonly available computable phenotype definitions (ie, phenotypes). To bridge this gap, our study aims to assess how issues of EHR data quality and variations and robustness (or lack thereof) in phenotypes may have potential impacts in identifying denominator populations. Approximately 208,000 patients with T2D were included in our study, which used retrospective EHR data from the Johns Hopkins Medical Institution (JHMI) during 2017-2019. Our assessment included 4 published phenotypes and 1 definition from a panel of experts at Hopkins. We conducted descriptive analyses of demographics (ie, age, sex, race, and ethnicity), use of health care (inpatient and emergency room visits), and the average Charlson Comorbidity Index score of each phenotype. We then used different methods to induce or simulate data quality issues of completeness, accuracy, and timeliness separately across each phenotype. For induced data incompleteness, our model randomly dropped diagnosis, medication, and laboratory codes independently at increments of 10%; for induced data inaccuracy, our model randomly replaced a diagnosis or medication code with another code of the same data type and induced 2% incremental change from -100% to +10% in laboratory result values; and lastly, for timeliness, data were modeled for induced incremental shift of date records by 30 days to 365 days. Less than a quarter (n=47,326, 23%) of the population overlapped across all phenotypes using EHRs. The population identified by each phenotype varied across all combinations of data types. Induced incompleteness identified fewer patients with each increment; for example, at 100% diagnostic incompleteness, the Chronic Conditions Data Warehouse phenotype identified zero patients, as its phenotypic characteristics included only diagnosis codes. Induced inaccuracy and timeliness similarly demonstrated variations in performance of each phenotype, therefore resulting in fewer patients being identified with each incremental change. We used EHR data with diagnosis, medication, and laboratory data types from a large tertiary hospital system to understand T2D phenotypic differences and performance. We used induced data quality methods to learn how data quality issues may impact identification of the denominator populations upon which clinical (eg, clinical research and trials, population health evaluations) and financial or operational decisions are made. The novel results from our study may inform future approaches to shaping a common T2D computable phenotype definition that can be applied to clinical informatics, managing chronic conditions, and additional industry-wide efforts in health care.

Implementing routine collection of EQ-5D-5L in a breast cancer outpatient clinic.

A cross-sectional study was conducted to investigate the feasibility of implementing routine collection of the Euro-Qol 5 dimensions (EQ-5D) questionnaire, to inform drug and health technology reimbursement decision making. Women with breast cancer were recruited during scheduled clinic visits to an academic cancer centre. EQ-5D-5L was self-administered using electronic tablets. Diagnostic and treatment data were abstracted from patient charts. Feasibility was assessed primarily by the proportion of patients who fully completed EQ-5D-5L and by their willingness to complete the instrument at each clinic visit. 588 women were approached for study participation, 341 were enrolled. Fully completed EQ-5D-5L questionnaires were obtained in 323 participants (95% of participants, 95% CI 92-97%). Median time for EQ-5D-5L completion was 1.5 minutes (range:0.35 to 14.7). Mean age of participants was 58 years old. Most women who completed EQ-5D were White, born outside Canada and presented a high education level; one-quarter had metastatic disease. Most participants reported "No problems" in all EQ-5D-5L dimensions. Mean EQ-5D-5L index and mean EQ-5D-5L VAS values for all participants were respectively 0.83 (SD 0.13) and 75.7 (SD 17.45), with patients with metastatic disease scoring the lowest values. Seventy-eight percent of participants were willing to complete EQ-5D-5L at each clinic visit; lower Charlson comorbidity index and higher education level were predictors of willingness to continue to answer EQ-5D-5L. Tablet-based collection of EQ-5D-5L in the context of routine clinical practice proved to be feasible. However, many patients declined study participation or reported being in full health, raising concerns about whether this method of collecting EQ-5D adequately represents the health status of all breast cancer patients.

Risk Factors for Adverse In-Hospital Outcomes in Patients With Traumatic Blunt Thoracic Aortic Injuries Undergoing Thoracic Endovascular Aortic Repair (TEVAR): An Analysis of the US Nationwide Inpatient Sample.

Thoracic endovascular aortic repair (TEVAR) is a treatment for traumatic blunt thoracic aortic injury (BTAI) with good survival rates and safety. However, there is limited study on the risk factors for in-hospital mortality and complications. This study aimed to identify risk factors associated with poor in-hospital outcomes after TEVAR. This is a population-based, retrospective observational study. Data of adults ≥20 years admitted for BTAI who received TEVAR were extracted from the Nationwide Inpatient Sample (NIS) database 2005 to 2018. The primary outcome was in-hospital mortality, and the secondary outcomes were length of stay (LOS) and unfavorable discharge (ie, non-routine discharge, including nursing homes or long-term care facilities). Associations between study variables and in-hospital outcomes were determined using univariate and multivariable logistic and linear regression analyses. Data of 1095 participants (representing 5360 hospitalized patients in the United States) were analyzed. Multivariable analysis revealed that older age (adjusted odds ratio [aOR]=1.02) and having at least 1 perioperative complication (aOR=4.01) were significantly associated with increased risk for in-hospital mortality. Patients with at least 1 perioperative complication (aOR=11.19) had significantly increased odds for prolonged LOS. Risk for unfavorable discharge was significantly increased by older age (aOR=1.02), household income at quartile 2 (aOR=1.58), Charlson Comorbidity Index (CCI) 2 to 3 (aOR=1.66), and having at least 1 complication (aOR=3.94). Complications including perioperative cerebrovascular accident (CVA) (aOR=2.75), venous thromboembolism (VTE) (aOR=2.87), pneumonia (aOR=3.93), sepsis (aOR=4.69), infection (aOR=4.49), respiratory failure (aOR=4.55), mechanical ventilation (aOR=3.27), and acute kidney injury (AKI) (aOR=3.09) significantly predicted prolonged LOS. In adults with traumatic BTAI undergoing TEVAR, advanced age and perioperative complications are risk factors for poor in-hospital outcomes. Acute kidney injury, CVA, respiratory failure, and sepsis are strong predictors of prolonged LOS, unfavorable discharge, and in-hospital mortality. The study identifies advanced age and perioperative complications as key risk factors for poor in-hospital outcomes in patients undergoing TEVAR for BTAI. Clinicians should be vigilant in managing these patients, particularly those with comorbidities, to mitigate risks. The findings suggest a need for tailored perioperative care strategies to improve survival rates and reduce complications. This research highlights the critical importance of early identification and intervention in high-risk patients, offering an innovative approach to refining TEVAR protocols and enhancing patient outcomes in trauma care.

Polymyxin B vs. colistin: the comparison of neurotoxic and nephrotoxic effects of the two polymyxins

BackgroundThe study aimed to compare polymyxin B with colistimethate sodium (CMS) regarding neurotoxicity, nephrotoxicity and 30-day mortality in patients with MDR Gram-negatives.MethodsAll adult patients who received polymyxin B or CMS for at least 24 h for the treatment of MDR microorganisms were evaluated retrospectively.ResultsAmong 413 initially screened patients, 147 patients who were conscious and able to express their symptoms were included in the neurotoxicity analysis. 13 of 77 patients with polymyxin B and 1 of 70 with CMS had neurotoxic adverse events, mainly paresthesias. All events were reversible after drug discontinuation. Among 290 patients included in nephrotoxicity analysis, the incidence of acute kidney injury (AKI) was 44.7% and 40.0% for polymyxin B and CMS, respectively (p = 0.425). AKI occurred two days earlier with colistin than polymyxin B without statistical significance (median (IQR): 5 (3–11) vs. 7 (3–12), respectively, p = 0.701). Polymyxin therapy was withdrawn in 41.1% of patients after AKI occurred and CMS was more frequently withdrawn than polymyxin B (p = 0.025). AKI was reversible in 91.6% of patients with CMS and 79% with polymyxin B after the drug withdrawal. Older age, higher baseline serum creatinine and the use of at least two nephrotoxic drugs were independent factors associated with AKI (OR 1.05, p < 0.001; OR 2.99, p = 0.022 and OR 2.45, p = 0.006, respectively). Septic shock, mechanical ventilation, presence of a central venous catheter and Charlson comorbidity index (OR 2.13, p = 0.004; OR 3.37, p < 0.001; OR 2.47, p = 0.004 and OR 1.21, p p < 0.001, respectively) were the independent predictors of mortality. The type of polymyxin was not related to mortality.ConclusionsNeurotoxicity is a relatively common adverse event that leads to drug withdrawal during polymyxins, particularly polymyxin B. Nephrotoxicity is very common during polymyxin therapy and the two polymyxins display similar nephrotoxic events with high reversibility rates after drug withdrawal. Close monitoring of AKI is crucial during polymyxin therapy, particularly, for elderly patients, patients who have high baseline creatinine, and using other nephrotoxic drugs.

Diabetes, frailty and burden of comorbidities among older Malaysians with stroke

Abstract Background Stroke is a global health challenge. The increasing prevalence of diabetes and the ageing population further add to the complexities of stroke care. Objective This study aims to (1) describe the prevalence of diabetes in older patients with stroke and (2) compare the burden of comorbidities among patients with diabetes and frailty compared to those without these conditions. Methods This was a cross-sectional study in older patients aged ≥ 65 years with stroke. Comorbidities were assessed using the Charlson Comorbidity Index (CCI). Frailty assessments were done using the Clinical Frailty Scale. Participants were classified into four groups: Group 1, frail and diabetic; Group 2, non-frail and diabetic; Group 3, frail and non-diabetic; and Group 4, non-frail and non-diabetic. Results There were 384 participants (mean age 81.11 ± 6.37). Diabetes was present in 45.1%. The mean CCI was highest for the frail and diabetic group (6.97 ± 1.97), followed by non-frail and diabetic (6.00 ± 2.02), frail and non-diabetic (5.49 ± 1.79) and non-frail and non-diabetic (4.74 ± 1.68), p &lt; 0.001. The non-frail and diabetic group had a significantly higher prevalence of hypertension (96.9%) and ischaemic heart disease (34.4%) compared to the other three groups. Conclusions There was a high prevalence of diabetes among older patients with stroke. While the frail and diabetic group had the highest overall burden of comorbidities, the non-frail and diabetic group had the most significant cardiovascular disease burden. These findings highlight the urgent need for integrated and personalized management approaches to enhance the overall well-being and quality of life for older stroke survivors with diabetes.

Risk Factors for Postoperative Delirium in Thoracic Surgery Patients – A Prospective Cross-sectional Study

Background: Postoperative delirium (POD) is a common complication that affects the prognosis and outcome. The risk factors of different surgical types have significance in preventing POD. Still, there are few studies on the risk factors for this complication of thoracic surgery, and further research and exploration are necessary. Method: This study intends to conduct a prospective cross-sectional study, including patients undergoing elective thoracic surgery. The primary outcome is the incidence of POD 1-7 days after surgery or before discharge. The essential information on patients, surgery, anesthesia, and postoperative details are gathered for statistical analysis. We are exploring the potential relationship between anesthesia-related factors and POD. Result: One hundred seventy-five patients were included in this study, and 17 (9.7%) patients developed POD. Univariate analysis showed that age-adjusted Charlson Comorbidity Index (aCCI), educational attainment, blood transfusion, artificial blood vessel replacement, and indwelling urinary catheter were statistically different. Logistic regression results showed that the aCCI index (OR 1.811, 95% CI 1.058-3.103; P=0.030), the ambulation time (OR 12.303, 95% CI 2.670-56.686; P=0.001) increased POD risk. In patients undergoing thoracotomy, blood transfusion (RR 16.875, 95% CI 2.149-132.508; P=0.012) was statistically different between POD and non-POD groups. Conclusion: The results of this study showed that the higher the aCCI index, the later the ambulation time is the risk factor for POD in thoracic surgery patients. The risk of POD may be heightened in thoracic surgery patients who require a blood transfusion. However, additional research is warranted to confirm these findings.

Relationship between functional status and fatigue after COVID-19 infection: a multicenter study from Türkiye.

Symptoms of COVID-19 may persist for months. One of the persistent symptoms of COVID-19 is fatigue, which reduces functional status. The relationship between fatigue, functional status, and various other factors has received little attention, which this study aims to address.. Patients with COVID-19 infection were included in this multicenter cross-sectional study. Age, sex, body mass index (BMI), marital status, smoking status, presence and duration of chronic disease, comorbidity index, regular exercise habits, time since COVID-19 diagnosis, hospitalization status, length of hospital stay, intubation status, home oxygen therapy after discharge, participation in a pulmonary rehabilitation program, presence of dyspnea, presence of cough, presence of sputum, and modified Medical Research Council, Post-COVID Functional Status (PCFS), Fatigue Severity Scale (FSS), and EQ-5D-5L Questionnaire scores were recorded. We enrolled 1095 patients, including 603 (55%) men and 492 (45%) women with a mean age of 50 ± 14 years. The most common chronic lung disease was COPD (11%) and 266 (29%) patients had nonpulmonary disease. The median time elapsed since COVID-19 diagnosis was 5 months; the hospitalization rate was 47%. The median PCFS grade was 1 (0-4) and the median FSS score was 4.4 (1-7). The PCFS and FSS were positively correlated (r = 0.49, p < 0.01; OR: 1.88, 95% CI: 1.68-2.10). Both functional status and fatigue were associated with quality of life, which was lower in older patients, those with higher BMI, those with systemic disease, those not exercising regularly, and those with more severe COVID-19 infection (defined by dyspnea, pneumonia as indicated by computed tomography, hospitalization, length of stay, ICU admission, intubation, and the need for home oxygen after discharge). Fatigue may cause poorer functional status regardless of the time since COVID-19 diagnosis. In this study, patients with FSS scores of >4.78 showed moderate to severe functional limitations. It is important to address modifiable patient risk factors and reduce the severity of COVID-19 infection.

Prospective comparative study of medial parapatellar and medial subvastus approaches in total knee arthroplasty

Introduction Total knee arthroplasty (TKA) is the treatment of end-stage osteoarthritis in patients who failed to respond to conservative treatment in providing significant pain relief and improving joint function. The medial parapatellar approach (MPP) allows adequate patellar eversion and sufficient knee flexion to expose the knee joint, but the incision through the quadriceps tendon may impair the extensor mechanism of the knee post-operatively. The subvastus approach (SV) completely spares both the quadriceps tendon and muscle and provides adequate exposure of the knee joint for the replacement procedure, SV maintains integrity of the patellar blood supply and reduces post-operative pain resulting in shorter hospital stay.The aim of this prospective study was to compare the results of the medial parapatellar and subvastus approaches in primary total knee arthroplasty (TKA) regarding postoperative pain, recovery of muscle strength, range of knee motion and return to regular daily activities.Materials and Methods Sixty patients underwent TKA at El-Hadara university hospital in Alexandria. The medial parapatellar apphroach (MPP) was performed in 30 patients while the subvastus approach (SV) was used for the other 30 patients. The choice of approach was randomly assigned.Results The statistical analysis of the results at the end of a 6-month follow-up showed that there were no significant differences between the patients in group 1 (MPP) and group 2 (SV) with respect to age, gender, comorbidity, side operated or body mass index (BMI). Regarding the functional knee scores (IKDC, WOMAC), there were no differences at 4 weeks, 3 months and 6 months postoperatively between the two groups. However, we found better outcomes in the SV group regarding the VAS score during the first five postoperative days, earlier quadriceps recovery by assessment of Straight Leg Raising test (SLR), while the operative time was longer in the SV group with less blood collected postoperatively in hemovac drain in the same group.Discussion In our study during the operation via the MPP approach, the index suture positioned at the superomedial border of the patella and the opposite suture on the medial retinacular flap had enabled the surgeon to avoid patellar maltracking during closure of the wound. In the SV group, the L-shaped incision of the medial capsule was considered an efficient landmark for accurate soft tissue closure avoiding the patellar maltracking.Conclusion The subvastus approach offers the advantage of keeping the integrity of quadriceps muscle and the extensor mechanism remains intact post-surgery. It causes less pain and less blood loss postoperatively than the regular parapatellar approach. The patient could recover the knee function in a shorter time with fewer complications, which is greatly in line with the concept of ERAS (Enhanced Recovery After Surgery).

Impact of multiple comorbidities on long-term mortality in older patients following transcatheter aortic valve replacement

BackgroundOlder candidates for transcatheter aortic valve replacement (TAVR) frequently present with both cardiac and noncardiac comorbidities. There are few risk scores that evaluate a wide range of comorbidities. MethodsPatients who underwent TAVR for severe aortic stenosis were retrospectively evaluated. A new prediction model (Cardiac and nonCardiac Comorbidities risk score: 3C score) was determined based on coefficient in the multivariate Cox regression analysis for two-year all-cause mortality. C-statistics were assessed to compare the predictive abilities of the 3C score, the Charlson Comorbidities Index (CCI) score, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, and the Model for End-stage Liver Disease eXcluding International normalized ratio (MELD-XI) score. ResultsThe present study included 226 patients (age, 86 ± 5 years; males, 38 %). The values of the CCI score, EuroSCORE II, and MELD-XI score were 2 (1–3), 3.36 (2.12–4.58), and 5.35 (3.05–8.55), respectively. Multivariate Cox regression analysis identified two cardiac (left ventricular ejection fraction [LVEF] <40 % [2 points]; pulmonary hypertension [1 point]) and three noncardiac comorbidities (hepatobiliary system impairment [3 points]; estimated glomerular filtration rate <30 ml/min/1.73 m2 [1 point]; cachexia [1 point]). The C-statistics of the 3C score, EuroSCORE II, MELD-XI score, and CCI score were 0.767 (0.666–0.867), 0.610 (0.491–0.729), 0.580 (0.465–0.696), and 0.476 (0.356–0.596), respectively (p < 0.001). ConclusionsAmong cardiac and noncardiac comorbidities, special attention should be given to hepatobiliary system impairment and reduced LVEF in older patients following TAVR. The 3C score may contribute to the risk stratification.

Treatment differences and long-term outcomes in adults and children with Ewing sarcoma

IntroductionEwing sarcoma is an aggressive malignancy primarily affecting children and adolescents. Limited research is available on treatment practices, clinical course, and survival in adults. MethodsA multi-institution retrospective cohort study of all adults (>18 years) and children (≤18 years) with Ewing sarcoma treated in British Columbia, Canada between January 01, 2000 and December 31, 2018. ResultsOne-hundred seven individuals (66 adults, 41 children) were included in the analysis. 5-year OS was 58 % in adults and 75 % in children. For individuals with local disease, 5-year OS was 74 % in adults and 84 % in children. Adult status was associated with impaired PFS (HR, 1.8; 95 % CI, 1.0 – 3.1, p=0.04) and OS (HR, 1.8; 95 % CI, 0.9 – 3.5; p=0.088). A Charlson Comorbidity Index (CCI) ≥3 was associated with impaired survival in adults and children (HR, 3.9, 95 % CI, 2.0 – 7.5; p=<0.001); baseline CCIs were not significantly different between groups. Most adults (61/66; 92 %) and all children (41/41; 100 %) received systemic treatment with no significant difference in mean lines of therapy, treatment modalities or agents. Most children received interval-compressed chemotherapy (35/41; 85 %) compared to adults (19/61; 29 %; p=<0.001). Interval-compression was not significantly associated with improved survival in adults with local disease (HR, 0.51; 95 % CI 0.1 – 2.3; p=0.373). Children more often initiated treatment within 28 days of diagnosis (31/33; 94 %) compared to adults (41/64; 64 %, p=0.001). Treatment within 28 days was associated with improved survival in the entire cohort (HR, 2.04 95 % CI, 1.1 – 3.9; p = 0.03). This association was preserved in subanalysis of individuals with local disease (HR, 5.4; 95 % CI, 1.9 – 15; p = 0.001) and only adults (HR, 5.3, 95 % CI, 1.7 – 17; p = 0.005). DiscussionSurvival for adults with Ewing sarcoma is inferior to children despite similarities in presentation, tumour characteristics and treatments. Further studies on the value of interval-compression in adults are required. Timely initation of treatment should be a priority for this disease.

Incidence and outcomes of delayed intracranial hemorrhage: a population-based cohort study

Head trauma is a common reason for emergency department (ED) visits. Delayed intracranial hemorrhage (ICH) in patients with minor head trauma is a major concern, but controversies exist regarding the incidence of delayed ICH and discharge planning at the ED. This study aimed to determine the incidence of delayed ICH in adults who developed ICH after a negative initial brain computed tomography (CT) at the ED and investigate the clinical outcomes for delayed ICH. This nationwide population cohort study used data from the National Health Insurance Service of Korea from 2013 to 2019. Adult patients who presented to an ED due to trauma and were discharged after a negative brain CT examination were selected. The main outcomes were the incidence of ICH within 14 days after a negative brain CT at initial ED visit and the clinical outcomes of patients with and without delayed ICH. The study patients were followed up to 1 year after the initial ED discharge. Cox proportional hazard regression analysis was used to estimate the hazard ratio for all-cause 1-year mortality of delayed ICH. During the 7-year study period, we identified 626,695 adult patients aged 20 years or older who underwent brain CT at the ED due to minor head trauma, and 2666 (0.4%) were diagnosed with delayed ICH within 14 days after the first visit. Approximately two-thirds of patients (64.3%) were diagnosed with delayed ICH within 3 days, and 84.5% were diagnosed within 7 days. Among the patients with delayed ICH, 71 (2.7%) underwent neurosurgical intervention. After adjustment for age, sex, Charlson Comorbidity Index, and insurance type, delayed ICH (adjusted hazard ratio, 2.15; 95% confidence interval, 1.86–2.48; p < 0.001) was significantly associated with 1-year mortality. The incidence of delayed ICH was 0.4% in the general population, with the majority diagnosed within 7 days. These findings suggest that patient discharge education for close observation for a week may be a feasible strategy for the general population.

Outpatient vs. inpatient designation in total hip arthroplasty: can we predict who will require hospitalization?

Following removal of total hip arthroplasty (THA) from the inpatient only (IPO) list by the Center for Medicare Services (CMS), arthroplasty surgeons face increased pressure to perform procedures on an outpatient (OP) basis. The purposes of the present study were to compare patients booked for THA as OP who required conversion to IP status postoperatively, to patients who were booked as, and remained OP, and to identify factors predictive of conversion from OP to IP status. We retrospectively reviewed all patients who underwent a primary THA at our institution between January 1, 2020 and April 26, 2022. All patients included were originally scheduled for OP surgery and were separated based on conversion to IP status postoperatively. Multiple regression analyses were used to determine the significance of all perioperative variables. Modeling via binary logistic regressions were used to determine factors predictive of status conversion. Of 1,937 patients, 372 (19.2%) designated as OP preoperatively required conversion to IP status postoperatively. These patients had significantly higher facility discharge rates (P < 0.001) and 90-day readmission rates (P = 0.024). Patients aged 65 and older (P < 0.001), females (P < 0.001), patients with Black/African American race (P = 0.027), with a recovery room arrival time after 12pm (P < 0.001), with a BMI > 30kg/m2 (P = 0.001), and with a Charlson Comorbidity Index (CCI) ≥ 4 (P = 0.013) were Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation more likely to require conversion to IP designation. Marital status and time of procedure were also significant factors, as patients who were married (P < 0.001) and who were the first case of the day (P < 0.001) were less likely to be converted to IP. Several factors were identified which could help determine appropriate hospital designation status at the time of surgical booking to ultimately avoid insurance claim denials. These included BMI, certain demographic factors, CCI ≥ 4, and patients 65 or older. Retrospective Cohort Study.

Emergency Department Length of Stay Classification Based on Ensemble Methods and Rule Extraction.

This study employs machine learning techniques to identify factors that influence extended Emergency Department (ED) length of stay (LOS) and derives transparent decision rules to complement the results. Leveraging a comprehensive dataset, Gradient Boosting exhibited marginally superior predictive performance compared to Random Forest for LOS classification. Notably, variables like triage acuity and the Elixhauser Comorbidity Index (ECI) emerged as robust predictors. The extracted rules optimize LOS stratification and resource allocation, demonstrating the critical role of data-driven methodologies in improving ED workflow efficiency and patient care delivery.

External validation and comparison of four prediction scores for severe maternal morbidity

BackgroundSevere maternal morbidity (SMM) is increasing in the United States. Several tools and scores exist to stratify an individual's risk of SMM. ObjectiveWe sought to examine and compare the validity of four scoring systems for predicting SMM. Study DesignThis was a retrospective cohort study of all individuals in the Consortium on Safe Labor dataset, which was conducted from 2002 to 2008. Individuals were excluded if they had missing information on risk factors. SMM was defined based on the Centers for Disease Control and Prevention excluding blood transfusion. Blood transfusion was excluded due to concerns regarding the specificity of International Classification of Diseases codes for this indicator and its variable clinical significance. Risk scores were calculated for each participant using the Assessment of Perinatal Excellence (APEX), California Maternal Quality Care Collaborative (CMQCC), Obstetric Comorbidity Index (OB-CMI), and modified OB-CMI. We calculated the probability of SMM according to the risk scores. The discriminative performance of the prediction score was examined by the areas under receiver operating characteristic curves and their 95% confidence intervals (95% CI). The area under the curve for each score was compared using the bootstrap resampling. Calibration plots were developed for each score to examine the goodness-of-fit. The concordance probability method was used to define an optimal cutoff point for the best-performing score. ResultsOf 153, 463 individuals, 1115 (0.7%) had SMM. The CMQCC scoring system had a significantly higher area under the curve (95% CI) (0.78 [0.77–0.80]) compared to the APEX scoring system, OB-CMI, and modified OB-CMI scoring systems (0.75 [0.73–0.76], 0.67 [0.65–0.68], 0.66 [0.70–0.73]; P<.001). Calibration plots showed excellent concordance between the predicted and actual SMM for the APEX scoring system and OB-CMI (both Hosmer–Lemeshow test P values=1.00, suggesting goodness-of-fit). ConclusionThis study validated four risk-scoring systems to predict SMM. Both CMQCC and APEX scoring systems had good discrimination to predict SMM. The APEX score and the OB-CMI had goodness-of-fit. At ideal calculated cut-off points, the APEX score had the highest sensitivity of the four scores at 71%, indicating that better scoring systems are still needed for predicting SMM.

Stress hyperglycemia ratio and its influence on mortality in elderly patients with severe community-acquired pneumonia: a retrospective study

BackgroundCommunity-acquired pneumonia (CAP) is a significant health issue among the elderly, with severe cases (SCAP) having high mortality rates. This study assesses the predictive significance of the stress hyperglycemia ratio (SHR) in elderly SCAP patients and its impact on outcomes in both diabetic and non-diabetic patients.Methods and materialsThis retrospective study included 406 SCAP patients aged 65 or older from the Second People’s Hospital of Lianyungang (January 2020 to December 2023). Data collected included demographics, medical history, vital signs, and lab results. SHR was calculated from initial blood glucose and estimated average glucose (HbA1c). Statistical analyses, including Cox regression and Kaplan-Meier analysis, evaluated SHR’s impact on mortality. Mediation models explored the effects of neutrophil-lymphocyte ratio (NLR) and SHR.ResultsThe 28-day mortality rate was 21.67%. Deceased patients had higher age, Charlson Comorbidity Index, procalcitonin, NLR, glucose, and SHR levels compared to survivors (P < 0.05). Both SHR and NLR significantly increased mortality risk, particularly in non-diabetic patients. Combining NLR and SHR improved ROC AUC to 0.898, with 89.80% sensitivity and 81.10% specificity. Kaplan-Meier analysis showed higher cumulative survival for SHR < 1.14, regardless of diabetes status (P < 0.05). NLR mediated 13.02% of the SHR-survival relationship, while SHR mediated 14.06% of the NLR-survival relationship.ConclusionElevated SHR is a significant mortality risk factor in elderly SCAP patients, independent of diabetes status. Stringent glucose control and careful monitoring of SHR may improve outcomes in elderly patients with acute respiratory conditions.

Eosinophilic Bronchiectasis: Prevalence, Severity, and Associated Features-A Cohort Study.

Background: Bronchiectasis (BE) has been traditionally associated with neutrophilic inflammation, but eosinophilic bronchiectasis (EB) has recently emerged. Data about prevalence, clinical features, and disease severity are lacking. This study aimed to assess the EB prevalence, compare EB with non-EB, evaluate the Type-2 (T2) high endotype in BE (T2-high EB) versus non-T2-high EB, and identify EB predictors. Methods: We conducted a prospective study involving 153 BE patients. The data collected included clinical, radiological, and microbiological findings. BE severity was assessed using the bronchiectasis severity index (BSI), FACED and E-FACED scores, and the bronchiectasis etiology and comorbidity index (BACI). EB was defined as a blood eosinophil count (BEC) ≥ 300 cells/μL, and T2-high EB as BEC ≥ 300 cells/μL with fractional exhaled nitric oxide (FeNO) ≥ 25 ppb. Results: Prevalence was 27% for EB and 20% for T2-high EB. EB patients exhibited poorer lung function and more severe radiologic features, with significantly higher severity scores [BSI, FACED, E-FACED, BACI (p < 0.05)], and a higher median exacerbation rate [4 (2-5) in EB vs. 2 (1-4) in non-EB, p = 0.0002], compared with non-EB patients. T2-high EB patients showed higher severity scores [BSI, FACED, E-FACED (p < 0.05)], as well as worse lung function parameters [FEV1%, FVC%, FEF 25-75% (p < 0.05)] compared with non-T2-high EB patients. In our study, patients with EB exhibited notably worsened lung function and higher BE severity scores compared with their non-EB counterparts, with exacerbations playing a major role in these differences. We found statistically significant positive correlations between BEC and disease severity scores, such as BSI, FACED, and mMRC, as well as an inverse relationship with pulmonary function. The likelihood of EB being present was significantly higher in association with mMRC ≥ 1 (OR = 2.53; 95% CI, 1.26-5.64), exacerbations/year ≥ 1 (OR = 1.27; 95% CI, 1.0-1.63), and chronic PA colonization (OR = 3.9; 95% CI, 1.08-15.8). Conclusions: EB is a distinct endotype. Dyspnea, exacerbations, and PA colonization may be predictive of EB, emphasizing the importance of early detection for improved outcomes. BEC could serve as a useful biomarker of disease severity to consider when diagnosing EB.