Early Discharge Research Articles

High in-hospital preoperative anxiety levels are not associated with an increased length of stay or readmission following primary shoulder arthroplasty

BackgroundAnxiety is prevalent in our society, affecting all facets of patients’ lives. There is, however, a paucity of literature exploring how anxiety extends into the orthopedic perioperative setting. We sought to analyze a subset of patients undergoing primary shoulder arthroplasty to determine whether correlations exist between anxiety, patient characteristics, time spent in the hospital, and likelihood of returning to the hospital after discharge. MethodsAfter obtaining institutional review board approval, our hospital prospectively identified and approached all patients undergoing total shoulder arthroplasty between February and June of 2023. Patients completed the Visual Analog Scale for Anxiety (VAS-A) and Amsterdam Preoperative Anxiety and Information Scale (APAIS), two validated tools used to assess preoperative anxiety levels and need for information, in the preoperative holding area before surgery. Patient demographics, hospital length of stay (LOS), and 30-day readmission rate were collected and analyzed. ResultsA total of 79 patients were enrolled. Nineteen percent of patients were found to be anxious using the APAIS tool, while 37.7% of patients were found to be anxious using the VAS-A tool. No significant correlation was found between APAIS or VAS-A anxiety scoring and hospital LOS. No significant correlation was found between APAIS or VAS-A anxiety scoring and 30-day readmission rate. A significant correlation was found between APAIS anxiety scoring and body mass index (BMI), as well as VAS-A scoring and BMI. However, no significant correlation was found between BMI and hospital LOS or between BMI and 30-day readmission rate. ConclusionOur study did not find a statistically significant correlation between immediate preoperative anxiety levels in patients undergoing shoulder arthroplasty and their length of stay or 30-day readmission rate. We did discover a linear relationship between patient BMI and their preoperative anxiety scores; however, no significant direct correlation was found between a patient’s BMI and their length of stay or their 30-day readmission rate. Our findings suggest that higher levels of preoperative anxiety should not preclude a patient from the benefits of consideration of early discharge planning such as same-day total shoulder replacement.

Risk Factors and Treatment of Chylothorax After Minimally Invasive Esophagectomy for Esophageal Cancer.

Background Postoperative chylothorax is a rare but life-threatening complication of esophagectomy. However, due to its rarity, researching the risk factors and selecting appropriate treatment options has been limited. Methods This study included 727 patients with esophageal cancer who underwent minimally invasive esophagectomy at our hospital. To detect the risk factors for chylothorax, we divided the patients into two groups, with and without postoperative chylothorax. We then compared patient characteristics, tumor-specific variables, and operative details. Subsequently, we analyzed the peri-treatment characteristics and outcomes for the three distinct treatment options we had chosen: surgery, conversion (the group that finally underwent surgery after unsuccessful conservative treatment), andconservative. Results Of the 727 patients, 18 (2.5%) developed a chylothorax. The mean BMI was lower (20.3 vs. 21.9, p=0.057), and more cases of thoracic duct resection were found in the chylothorax group (33.3% vs. 6.2%, p=0.001), with statistical significance. Multivariate analysis identified thoracic duct resection as a risk factor (adjusted odds ratio, 6.83). The drainage volume two days after chylothorax was higher in the surgery group, although the difference was not statistically significant (surgery group, 1,405 ml vs. conversion group, 260 ml vs. conservative group, 310 ml; p=0.073). The surgery group had the shortest median postoperative hospital days among these groups (21.5 as compared to 102 and 25.0 days in the conversion and conservative groups, respectively; p<0.001). None of the patients died during their hospital stays. Conclusion Thoracic duct resection during the initial minimally invasive esophagectomy was an independent risk factor for chylothorax. If drainage volume does not decrease on the second day, early surgery may lead to earlier discharge.

Early Discharge after Enhanced Recovery Colectomy does Not Increase ED Visits and Readmissions: A Single Institution Analysis

Background: With continued advancements in Enhanced Recovery Pathway (ERP) protocols, we have noticed a significant decrease in colorectal surgery emergency department (ED) visits and readmissions. When considering same-day discharge after colorectal surgery in ERP patients, it would be important to know if early discharge is associated with increased ED visits and readmissions. This study is to determine if discharge on postoperative days (POD) one or two is associated with increased rates of ED visits and hospital readmissions after left and right colectomy. Methods: This is a single institution analysis of a prospectively maintained institutional colorectal surgery database between 07/01/2018 and 07/15/2022. The primary outcomes were ED visit and readmission rates for enhanced recovery open and minimally invasive right and left colectomy using logistic regressions models. Results: 820 patients met inclusion criteria; mean age 62.8 years; 47.4% ASA-3, and 83.2% had a minimally invasive surgical approach. Hospital length-of-stay decreased over the study period. There were significant differences in discharge-day by diagnosis - 58.5% of patients with Crohn’s disease were discharged on POD≥4 and 21.6% of those with benign colon neoplasia were discharged on POD 0-1 (p &lt; 0.001). ED visits occurred in 12.9% of the study population and were not significantly different between discharge-day groups (p=0.096). Overall readmission rate was 8.5% and significantly different between discharge-day groups (0% POD-0 vs 8.3% POD-1 vs 5.8% POD-2 vs 6.9% POD-3 vs 12.9% POD≥4, p=0.041). Logistic regression showed that ED visits and readmissions for longer discharge-days (POD-2, POD-3, POD≥4) were not significantly different than POD-0-1. Readmission diagnoses for the study population were higher for ileus (17.1%) and SSI III (22.9%) than for AKI (1.4%) and SSI I/II (1.4%). Readmissions were not related to discharge day of the week (p=0.494). Conclusions: Early discharge after left and right colectomy is not associated with increased rates of ED visits and readmissions. Same-day discharge may be feasible in selected enhanced recovery patients. Risks and benefits associated with same-day discharge require further investigation.

Safety of Early Discharge After Coronary Artery Bypass Grafting: A Nationwide Readmissions Analysis

BackgroundWe determined the safety of early discharge after coronary artery bypass grafting (CABG) in patients with uncomplicated postoperative courses and compared outcomes with routine discharge in a national cohort. We identified preoperative factors associated with readmission after early discharge after CABG. MethodsThe Nationwide Readmissions Database was queried to identify patients undergoing CABG from January 2016 to December 2018. Patients were stratified based on length of stay (LOS) as early (≤4 days) vs routine (5-10 days) discharge. Patients were excluded with hospital courses indicative of complicated stays (emergent procedures, LOS >10 days, discharge to extended care facility or with home health, index hospitalization mortality). Propensity score matching was performed to compare outcomes between cohorts. Multivariable logistic regression models were used to identify factors associated with readmission after early discharge. ResultsDuring the study period, 91,861 patients underwent CABG with an uncomplicated postoperative course (∼20% of CABG population). Of these, 31% (28,790 of 91,861) were discharged early, and 69% (63,071 of 91,861) were routinely discharged. After propensity score matching, patients discharged early had lower readmission rates at 30 days, 90 days, and up to 1 year (P < .001 for all). The index hospitalization cost was lower with early discharge ($26,676 vs $32,859; P < .001). Early discharge was associated with a lower incidence of nosocomial infection at the index hospitalization (0.17% vs 0.81%, P < .001) and readmission from infection (14.5% vs 18%, P = .016). ConclusionsEarly discharge after uncomplicated CABG can be considered in a highly selective patient population. Early-discharge patients are readmitted less frequently than matched routine-discharge patients, with a lower incidence of readmission from infection. Appropriate postdischarge processes to facilitate early discharge after CABG should be further pursued.

Safety of an Early Discharge Strategy (≤48 h) after ST-Elevation Myocardial Infarction.

Background: Early discharge following ST-segment-elevation myocardial infarction (STEMI) confers notable advantages for both patients and healthcare systems. However, the adoption of a very early discharge strategy for selected patients remains limited due to safety considerations. We aimed to provide some insight into the safety of a discharge program with a hospital stay lasting <48 h after a primary percutaneous coronary intervention (PCI). Methods: Using a registry of 1105 patients undergoing primary PCI for STEMI in our hospital between January 2015 and October 2023, we enrolled all the patients who had a hospital stay ≤48 h, according to a prespecified institutional protocol. The primary objective was a combined rate of non-fatal stroke, non-fatal acute myocardial infarction, or cardiovascular death within 30 days of discharge. Emergency department visits or hospitalizations due to cardiovascular causes, along with the all-cause mortality, were measured during the same period. Results: A total of 453 (41%) patients were discharged ≤48 h after admission for a STEMI. The mean age was 62.4 (±12.5 years), 24.3% were women, and 17.9% were people with diabetes. Up to 96% of the procedures had been performed through radial artery access, and there were no major vascular complications. Regarding the primary endpoint, there was one event (0.2%; one patient suffered a non-fatal myocardial infarction). There were no cardiovascular deaths or deaths from other causes. Only five patients (1.1%) were re-hospitalized or visited the emergency department due to cardiovascular causes. Conclusions: An early discharge strategy for patients within 48 h of experiencing STEMI and undergoing primary PCI appears feasible and safe.

Clinical efficacy and economic impact of an enhanced recovery after cardiac surgery program for early discharge

Clinical efficacy and economic impact of an enhanced recovery after cardiac surgery program for early discharge

Real-life experience with IV dalbavancin in Canada; results from the CLEAR (Canadian LEadership on Antimicrobial Real-life usage) registry

We report the use of IV dalbavancin in Canadian patients using data captured by the national CLEAR registry. The CLEAR registry uses the web-based data management program, REDCap™ (online survey https://rcsurvey.radyfhs.umanitoba.ca/surveys/?s=TPMWJX98HL) to facilitate clinicians entering details associated with their clinical experiences using IV dalbavancin. Data were available for 40 patients. The most common infections treated were acute bacterial skin and skin structure infection (ABSSSI) (62.5% of patients), bone/joint infection (22.5%), bloodstream/vascular infection (7.5%) and endocarditis (5.0%). Dalbavancin was used as directed (75.0%) and empiric therapy (25.0%). MRSA was the most common identified pathogen (70.0%). Dalbavancin was used both in outpatient (e.g., emergency department) (65.0%), and inpatient treatment settings (e.g., hospital ward) (35.0%). Dalbavancin was used due to the convenience of a single dose treatment (77.5%) as well as to facilitate hospital discharge (7.5%). Dalbavancin was primarily used alone (90.0%), and most commonly using a single 1500 mg dose (77.5%). Microbiological success (pathogen eradicated or presumed eradicated) occurred in 88.2% of known cases, while clinical success (cure and/or improvement) occurred in 93.3% of known cases. No adverse events were reported. In Canada, IV dalbavancin is used as both directed and empiric therapy to treat ABSSSI as well as off-label (bone/joint, bacteremia/vascular, endocarditis, device-related) infections. It is used in both outpatient and inpatient settings due primarily to its convenience as a single-dose treatment regimen and to facilitate early hospital discharge. Dalbavancin use is associated with high microbiological and clinical cure rates along with an excellent safety profile.

What Makes Effective Acute Geriatric Care? - A mixed Methods Study From Aotearoa New Zealand

Structured Objectives Current policies for older patients do not adequately address the barriers to effective implementation of optimal care models in New Zealand, partly due to differences in patient definitions and the in-patient pathway they should follow through hospital. This research aims to: (a) synthesise a definition of a complex older patient; (b) identify and explore primary and secondary health measures; and (c) identify the primary components of a care model suitable for a tertiary hospital in the midland region of the North Island of New Zealand.MethodThis mixed-methods study utilised a convergence model, in which qualitative and quantitative data were investigated separately and then combined for interpretation. Semi-structured interviews (n=11) were analysed using a general inductive method of enquiry to develop key codes, categories and themes. Univariate data analysis was employed using six years of routinely collected data of patients admitted to the emergency department and inpatient units (n=261,773) of the tertiary hospital.ResultsA definition of a complex older patient was determined that incorporates chronic conditions, comorbidities and iatrogenic complications, functional decline, activities of daily living, case fatality, mortality, hospital length of stay, hospital costs, discharge destination, hospital readmission and emergency department revisit and age – not necessarily over 65 years old. Well-performing geriatric care models were found to include patient-centred care, frequent medical review, early rehabilitation, early discharge planning, a prepared environment and multidisciplinary teams.ConclusionsThe findings of this New Zealand study increase understanding of acute geriatric care for complex older patients by filling a gap in policies and strategies, identifying potential components of an optimal care model and defining a complex geriatric patient.Implications for Public HealthThe findings of this study present actionable opportunities for clinicians, managers, academics and policymakers to better understand a complex older patient in New Zealand, with significant relevance also for international geriatric care and to establish an effective acute geriatric care model that leads to beneficial health outcomes and provides safeguard mechanisms.

Making a case for outpatient parenteral antimicrobial therapy (OPAT).

In the wake of the COVID-19 pandemic, and its negative impact on both acute and elective care and decline in available inpatient resources, there is an imperative to maximize safe and effective alternatives to inpatient hospital care. Properly governed outpatient parenteral antimicrobial therapy (OPAT) services embed the principles of antimicrobial stewardship (AMS) (including use of early oral therapy) and support admission avoidance and early discharge for a growing range of patient groups with complex infections through well-organized multidisciplinary team working. Expansion of OPAT aligns with the UK's national strategy to deliver care closer to home and cost-effectively maximize use of inpatient resources. OPAT serves as an exemplar to other ambulatory services and presents opportunities for developing and assuring AMS strategies within the rapidly developing hospital-at-home and virtual ward environments.

Early discharge after enhanced recovery rectal resection does not increase emergency department visits and readmissions: a single institution analysis.

Same-day discharge after colectomy in enhanced recovery pathways has been shown to be feasible. It is not clear how early patients with rectal resections may be safely discharged. The study aim was to determine if patients discharged ≤ 3 days after rectal resections are associated with increased rates of emergency department (ED) visits and hospital readmissions. Retrospective analysis of enhanced recovery low anterior resection, abdominoperineal resection, and proctocolectomy patients in a prospectively maintained single institution colorectal surgery database from 01/01/2018 to 07/15/2022. Clinic visits were scheduled within 4-7 days and at 30 days after discharge, and every 1-2 weeks for stoma patients until no longer needed. Logistic regression models were used to analyze the association of discharge on postoperative days (POD)-1-3, POD-4-5, and POD ≥ 6dayswith incidence of ED visits and readmissions. A total of 118 patients met inclusion criteria, 76 with stomas. Median postoperative length of stay was 5 [IQR 6.5] days. Mean age was 58.6 years; 59.3% were ASA-3; and 69.5% had a minimally invasive surgical approach. ED visits were not significantly different between discharge-day groups (p = 0.096). No patients were discharged same-day, one without a stoma was discharged on POD-1, ten patients (2 with stomas) on POD-2, and twenty-four patients (13 with stomas) on POD-3. ED visits were lowest for the POD-1-3 group (14.3%) but not significantly different than later discharge groups (p = 0.166). Readmission rate was also lowest for the POD-1-3 group (11.4%) and also not significantly different than later discharge groups (p = 0.261) and this was confirmed with logistic regression. Complication rate was lowest in the POD-1-3 group (p < 0.001). Early discharge after enhanced recovery partial or complete proctectomy is not associated with increased ED visits and readmissions. Follow up studies should identify post-discharge resources that allow safe early discharge and that may be standardized and generalizable.

Optimization of a home hospitalization program for hematopoietic stem cell transplantation with ehealth integration and clinical pharmacist involvement.

Home hospitalization represents an alternative to traditional hospitalization, providing comparable clinical safety for hematological patients. At-home therapies can range from the delivery of intravenous antibiotics to more complex scenarios, such as the care during the early period after hematopoietic stem cell transplantation and chimeric antigen receptor T-cell therapy. Early discharge from conventional hospitalization is feasible and helps reduce hospital resources and waiting lists. The coordinated efforts of multidisciplinary teams, including hematologists, nurses, and pharmacists, ensure patient safety and continuity of care. The traditional model of home hospitalization relies on home visits and telephone consultations with physicians and nurses. However, the use of eHealth technologies, such as MY-Medula, can enhance communication and monitoring, and thereby improve patient outcomes with no additional costs. The active involvement of a clinical pharmacist in home hospitalization programs is essential, not only for the proper logistical management of the medication but also to ensure its appropriateness, optimize treatment, address queries from the team and patients, and promote adherence. In conclusion, the implementation of hematopoietic stem cell transplantation and chimeric antigen receptor T-cell therapy home hospitalization programs that use both an eHealth tool and a multidisciplinary care model can optimize patient care and improve quality of life without increasing healthcare costs.

Predictors of mortality among low birth weight neonates after hospital discharge in a low-resource setting: A case study in Uganda.

Most neonatal deaths occur among low birth weight infants. However, in resource-limited settings, these infants are commonly discharged early which further exposes them to mortality. Previous studies on morbidity and mortality among low birth weight infants after early discharge mainly focused on very low birth weight infants, and none described post-discharge neonatal mortality. This study aimed to determine the proportion and predictors of mortality among low birth weight neonates discharged from the Special Care Baby Unit at Mulago National Referral Hospital in Uganda. This was a prospective cohort study of 220 low birth weight neonates discharged from the Special Care Baby Unit at Mulago National Referral Hospital. These were followed up to 28 completed days of life, or death, whichever occurred first. Proportions were used to express mortality. To determine the predictors of mortality, Cox hazards regression was performed. Of the 220 enrolled participants, 216 (98.1%) completed the follow-up. The mean gestational age of study participants was 34 ±3 weeks. The median weight at discharge was 1,650g (IQR: 1,315g -1,922g) and 46.1% were small for gestational age. During follow-up, 14/216 (6.5%) of neonates died. Mortality was highest (7/34, 20.6%) among neonates with discharge weights less than 1,200g. The causes of death included presumed neonatal sepsis (10/14, 71.4%), suspected aspiration pneumonia (2/14, 14.3%), and suspected cot death (2/14, 14.3%). The median time to death after discharge was 11 days (range 3-16 days). The predictors of mortality were a discharge weight of less than 1,200g (adj HR: 23.47, p <0.001), a 5-minute Apgar score of less than 7 (adj HR: 4.25, p = 0.016), and a diagnosis of neonatal sepsis during admission (adj HR: 7.93, p = 0.009). Post-discharge mortality among low birth weight neonates at Mulago National Referral Hospital is high. A discharge weight of less than 1,200g may be considered unsafe among neonates. Caregiver education about neonatal danger signs, and measures to prevent sepsis, aspiration, and cot death should be emphasized before discharge and during follow-up visits.

The Impact of Silent Liver Disease on Hospital Length of Stay Following Isolated Coronary Artery Bypass Grafting Surgery.

Objectives: Risk assessment models for cardiac surgery do not distinguish between degrees of liver dysfunction. We have previously shown that preoperative liver stiffness is associated with hospital length of stay following cardiac surgery. The authors hypothesized that a liver stiffness measurement (LSM) ≥ 9.5 kPa would rule out a short hospital length of stay (LOS < 6 days) following isolated coronary artery bypass grafting (CABG) surgery. Methods: A prospective observational study of one hundred sixty-four adult patients undergoing non-emergent isolated CABG surgery at a single university hospital center. Preoperative liver stiffness measured by ultrasound elastography was obtained for each participant. Multivariate logistic regression models were used to assess the adjusted relationship between LSM and a short hospital stay. Results: We performed multivariate logistic regression models using short hospital LOS (<6 days) as the dependent variable. Independent variables included LSM (< 9.5 kPa, ≥ 9.5 kPa), age, sex, STS predicted morbidity and mortality, and baseline hemoglobin. After adjusting for included variables, LSM ≥ 9.5 kPa was associated with lower odds of early discharge as compared to LSM < 9.5 kPa (OR: 0.22, 95% CI: 0.06-0.84, p = 0.03). The ROC curve and resulting AUC of 0.76 (95% CI: 0.68-0.83) suggest the final multivariate model provides good discriminatory performance when predicting early discharge. Conclusions: A preoperative LSM ≥ 9.5 kPa ruled out a short length of stay in nearly 80% of patients when compared to patients with a LSM < 9.5 kPa. Preoperative liver stiffness may be a useful metric to incorporate into preoperative risk stratification.

Assessment of pre-, peri-, and post-surgical practices for elective colorectal patients in a model 4 hospital in Ireland

IntroductionThe ERAS protocol is a set of international guidelines established to expedite patients’ discharge after colorectal surgery. It does this by aiming to prevent postoperative complications early, and return the patient to normal function allowing earlier discharge. Complications such as PONV, DVT, ileus and pain are common after surgery to name a few, and delay discharge. Early treatment and prevention of these complications however is suggested to aid a patients’ return to home at earlier rates than traditional practice.MethodsA prospective chart review and questionnaire was performed on patients undergoing colorectal surgery in UHL in a 6-month period from February to September 2023. Patients were approached on the 3rd day postoperatively and informed about the project. Exclusion criteria included patients who went to HDU or ICU postoperatively.ResultsIn total, 33 patients were recruited. A target of greater than 70% compliance was reached for a variety of the elements of the ERAS protocol such as laparoscopic surgery, preoperative assessments, nutritional drinks, LMWH, oral intake within 24 h of surgery, and intraoperative antiemetics. Unsatisfactory compliance was found with documentation of postoperative antibiotics use of preoperative gabapentin.ConclusionUHL has a satisfactory compliance of over 70% with a large variety of elements of the ERAS protocol. Areas of improvement required include postoperative antibiotic and preoperative gabapentin usage. With the collective effort of the multidisciplinary team, along with education, the ERAS protocol can successfully be applied and implemented in a model 4 hospital in Ireland.

Leveraging User-Friendly Mobile Medical Devices to Facilitate Early Hospital Discharges in a Pediatric Setting: A Randomized Trial Study Protocol.

Mobile technology is increasingly prevalent in healthcare, serving various purposes, including remote health monitoring and patient self-management, which could prove beneficial to early hospital discharges. This study investigates the transitional care program experience facilitating early discharges in a pediatric setting through the use of an easy-to-use mobile medical device (TytoCare™, TytoCare Ltd., Natanya, Israel). This study aims to assess the effectiveness of telehomecare in achieving complete resolution of diseases without readmission, compare the length of stay between intervention and standard care groups, and gather user and professional experiences. A randomized open-label, controlled pilot study enrolled 102 children, randomly assigned to the telehomecare (TELE) group (n = 51, adopting early hospital discharge with continued home monitoring) or the standard-of-care (STAND) group (n = 51). Primary outcomes include complete disease resolution without readmission. Secondary objectives include recording a shorter length of stay in the intervention group. Surveys on user and professional experiences were conducted. A group of 51 children declining telemedicine services (NO-TELE) was also included. In the TELE group, 100% of children achieved complete disease resolution without readmission, with a median duration of stay of 4 days, significantly shorter than the 7 days in the STAND group (p = 0.01). The telemedicine system demonstrated efficient performance and high satisfaction levels. The NO-TELE group showed no significant differences in demographics or digital technology competence. Perceived benefits of telemedicine included time and cost savings, reduced hospital stays, and technology utility and usability. This study demonstrates that user-friendly mobile medical devices effectively facilitate early hospital discharges in a pediatric setting. These devices serve as a bridge between home and hospital, optimizing care pathways.

Evaluating the Baby@Home program: Early discharge strategies for (pre)term infants are safe and benefit health outcomes.

Prolonged hospitalisation in the neonatal intensive care unit (NICU) can emotionally tax newborn infants and their families, resulting in developmental adversities and inadequate parent-infant bonding. This study aimed to assess the feasibility and value of the Baby@Home program in reducing prolonged hospital stays. This is a retrospective cohort study of 26 infants from a tertiary neonatology department, using qualitative data (gathered through interviews with parents (n = 15) and professionals (n = 5)) and quantitative data (retrieved from medical records and the Luscii application). Our study included 26 newborn infants. 76% were premature, born at an average term of 35 weeks and 2 days. During the study period, all infants thrived, and only two adverse events occurred (an allergic reaction and respiratory incident necessitating readmission). Interviews were conducted based on six major themes concerning the feasibility and value of the program. Despite the challenges of application utilisation, the program's overall value was evident. The Baby@Home program effectively facilitated early discharge, promoted family reunification, and yielded favourable safety and health outcomes. Innovative solutions such as Baby@Home have the potential to pave the way for more sustainable and patient-centred care models.

Causes and risk factors for same-day discharge failure after total hip and knee arthroplasty: a meta-analysis

In recent decades, the trend toward early same-day discharge (SDD) after surgery has dramatically increased. Efforts to develop adequate risk stratification tools to guide decision-making regarding SDD versus prolonged hospitalization after total hip arthroplasty (THA) remain largely incomplete. The purpose of this report is to identify the most frequent causes and risk factors associated with SDD failure in patients undergoing THA and total knee arthroplasty (TKA). A systematic search following PRISMA guidelines of four bibliographic databases was conducted for comparative studies between patients who were successfully discharged on the same day and those who failed. Outcomes of interests were causes and risk factors associated with same-day discharge failure. Odds ratios (OR) were calculated for dichotomous variables, whereas mean differences (MD) were calculated for continuous variables. Meta-analysis was performed using RevMan software. Random effects were used if there was evidence of heterogeneity. Eight studies with 3492 patients were included. The most common cause of SDD failure was orthostatic hypotension, followed by inadequate physical condition, nausea/vomiting, pain, and urinary retention. Female sex was a risk factor for failure (OR 0.77, 95% CI 0.63–0.93), especially in the THA subgroup. ASA score IV (OR 0.33, 95% CI 0.14–0.76) and III (OR 0.72, 95% CI 0.52–0.99) were risk factors, as were having > 2 allergies and smoking patients. General anesthesia increased failure risk (OR 0.58, 95% CI 0.42–0.80), while spinal anesthesia was protective (OR 1.62, 95% CI 1.17–2.24). The direct anterior and posterior approaches showed no significant differences. In conclusion, orthostatic hypotension was the primary cause of SDD failure. Risk factors identified for SDD failure in orthopedic surgery include female sex, ASA III and IV classifications, a higher number of allergies, smoking patients and the use of general anesthesia. These factors can be addressed to enhance SDD outcomes.

Nonlinear storage–discharge dynamics of forested headwater catchment: A hysteresis index approach

AbstractThe relationship between catchment storage and discharge is nonlinear. The dynamicity of this relationship is dependent on the distance of the storage measurement from the stream, the depth of the soil moisture (SM) measurement, antecedent SM storage, and precipitation characteristics. Understanding the relative influence of these factors is critical for interpreting runoff generation processes and predicting discharge. In this study, we used a hysteresis index approach and analysed the nonlinear dynamics of catchment storage–discharge relationship across points, hillslope and catchment scales, and their controlling factors. A small headwater forested catchment located in the southern part of the Sierra Nevada region, California, was selected as a case study. In this Mediterranean catchment, the anticlockwise class IV hysteresis loop, indicating an earlier discharge peak than SM, was observed as a prevalent hysteresis class across all the scales, irrespective of seasons (i.e., dry vs. wet) and years (i.e., normal vs. drought). A few clockwise hysteresis loops were observed at the shallow depths (10 and 30 cm) of upslope and lower slope topographic positions. Further, we found a shorter lag time between SM peak to discharge peak at 60 and 90 cm soil depths during the wet season, and during the drought period. The shorter lag at the deeper depth was due to the presence of subsurface flow during high antecedent SM storage conditions and preferential flow through the soil pores during the drought periods. The variability in hysteresis at catchment and hillslope scales was controlled by peak rainfall intensity and antecedent SM storage. However, rainfall characteristics (intensity and depth) were major governing factors for most of the point scale locations. Overall, the current study highlighted the role of SM sensor's location in characterizing storage–discharge behaviour.

Virtual Medicine Wards and Hospital-at-Home Programs

What Is the Issue? In 2021, the occupancy rate of acute care hospital beds in Canada was 86.7%. High occupancy rates without turnover to accommodate all hospitalization needs is an indicator of potential bed shortages and health system pressure. Patients have historically remained in hospital beds until their treatment or recovery is complete. Some patients may be well enough to continue their treatment or recovery at home sooner if provided with the right supports. What Are the Technologies? Virtual wards, also known as hospital-at-home programs, support the provision of inpatient-level acute medical care in a patient’s home. There are 2 main models of these programs: admission avoidance and supported early discharge. This report focuses on the latter type. Many of these programs are technology-enabled and incorporate remote monitoring devices to record the patient’s vital signs and tablets or web portals to facilitate data sharing. Video calls with the clinical team are also used in combination with in-person visits by health care providers. What Is the Potential Impact? Hospital beds can be freed up more quickly to provide space for newly admitted patients with more acute care needs. The safety and effectiveness of virtual ward programs have been examined in several systematic reviews in the existing clinical literature. Factors evaluated include mortality, length of stay, hospital readmissions, and costs as outcomes. Both admission avoidance and early supported discharge via hospital-at-home programs had lower or similar mortality and hospital admission outcomes as inpatient care after completion of care. Patients, caregivers, and health care providers appear to be generally satisfied with their participation in virtual ward programs. Comfort and satisfaction can be improved by allowing patients to receive treatment in a familiar and comfortable environment without compromising patient outcomes. However, increased caregiver burden, lack of sufficient training for participants and staff, and difficulties recruiting health care providers were identified as challenges associated with virtual ward programs. What Else Do We Need to Know? The level of technological support required by patients, caregivers, and staff participating in these programs should be considered when developing a program. Adequate training about how to use provided equipment and other tasks needed to manage care in the home (e.g., drug administration, symptom monitoring, communication with health care professionals) is required for patients and caregivers. There should also be provision of all necessary equipment with supports to overcome any barriers (e.g., visual impairment, physical limitations) to ensure comfort and proficiency. Care coordination and communication among the multidisciplinary care team, the patient, and their caregivers is important. Canadian cost data were not identified, but it is generally accepted that virtual ward programs are associated with reduced costs when compared with traditional in-hospital care. The inclusion of digital monitoring and record keeping technologies as part of virtual ward programs may disproportionately exclude people from some groups, including older people, people living in social housing or without housing, people with lower incomes, people who are unemployed, people living with disabilities, and people who live in rural areas without access to such programs. Key recommendations for development of virtual ward programs in Canada include using a single remote patient-monitoring platform that connects with the hospital’s electronic health record system, choosing a technology to connect patients and providers that best fits the needs of the virtual ward program, and ensuring data security, confidentiality, and data management protocols are in place.

Management of complications of chimeric antigen receptor T-cell therapy: a report by the European Society of Blood and Marrow Transplantation.

CAR-T cells are in standard clinical use to treat relapsed or refractory hematologic malignancies, such as non-Hodgkin's lymphoma, multiple myeloma and acute lymphoblastic leukemia. Owing to the rapidly progressing field of CAR-T cell therapy and the lack of generally accepted treatment guidelines, we hypothesized significant differences between European centers in prevention, diagnosis and management of short- and long-term complications. To capture the current CAR-T cell management among EBMT centers and to determine the medical need and specific areas for future clinical research the EBMT Transplant Complications Working Party performed a survey among 227 EBMT CAR-T cell centers. We received complete servey answers from 106 centers (47%) addressing questions in the areas of product selection, CAR-T cell logistics, management of cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome as well as management in later phases including prolonged cytopenias. We identified common patterns in complication management, but also significant variety in clinical management of the centers in important aspects. Our results demonstrate a high medical need for treatment harmonization and future clinical research in the following areas: treatment of steroid-refractory and very severe CRS/neurotoxicity, treatment of cytopenia, early discharge and outpatient management, as well as immunoglobulin substitution.