Systemic corticosteroids are playing an increasingly important role in elective total knee arthroplasty (TKA) to aid in postoperative recovery. Corticosteroids reduce inflammation that can cause pain, limit range of motion (ROM), and prolong narcotic use following TKA. Dexamethasone and methylprednisolone are corticosteroids used perioperatively during TKA, but, to our knowledge, a comparative analysis assessing pain and narcotic use has not been done. We sought to determine if a difference exists between these two medications in reducing pain and narcotic usage while also assessing clinical outcomes and complications. A nonrandomized prospective cohort study was performed of 350 patients undergoing primary unilateral TKA; 200 patients received an oral dexamethasone, and 150 patients received an oral methylprednisolone taper. The primary outcome measures included pain levels and narcotic consumption recorded by patients over the first 30 days after surgery. Pain scores were implemented utilizing the visual analog scale. Narcotic usage was converted to oral morphine milligram equivalents (MMEs). Lengths of hospital stay, knee ROMs, complications, and hospital readmissions were collected. Patients taking methylprednisolone reported significantly lower pain than patients taking dexamethasone on postoperative days three to seven and nine (all P < 0.05), with no significant differences through day 30. There were no statistically significant differences in MMEs between groups during the first postoperative month. There were no differences in lengths of stay, ROMs, complications, or hospital readmissions. A novel prospective study is presented comparing dexamethasone versus methylprednisolone, assessing narcotic usage and pain scores following TKA. Patients who received methylprednisolone taper reported statistically significantly lower postoperative pain scores compared to those receiving dexamethasone. Narcotic MMEs and complication rates were similar. Methylprednisolone demonstrated similar clinical outcomes and may be preferred for its more controlled tapering profile and greater ease of prescription and patient compliance than dexamethasone.

Periacetabular osteotomy, commonly performed for prearthritic hip dysplasia, was identified as a procedure that could benefit from an enhanced recovery after surgery pathway due to wide variation in multimodal pain management and regional anesthesia practices at our institution. The global aim of this project was to implement an enhanced recovery after surgery pathway for patients undergoing periacetabular osteotomy. Our SMART aim was to achieve greater than 70% compliance for the intraoperative medication bundle elements during the first PDSA cycle. A multidisciplinary pathway was designed and implemented with key stakeholders from the Departments of Evidence Based Practice, Anesthesiology, Orthopedic Surgery, and Perioperative Nursing. Patient data from all patients undergoing periacetabular osteotomy from 2018 to the present were analyzed, which included the baseline cohort as well as outcomes from two Plan-Do-Study-Act cycles. After ERAS implementation and two subsequent Plan-Do-Study-Act cycles, we observed a decrease in hospital length of stay from 3.34 days (95% CI [2.95, 3.72]) to 2.37 days (95% CI [2.00, 2.74]) and an intraoperative medication bundle compliance of 90%. These gains occurred with minimal change in average postoperative pain scores and no hospital readmissions within 30 days of surgery. Multidisciplinary enhanced recovery after surgery pathways continue to play a critical role in standardizing perioperative care, reducing unwarranted variation, and promoting faster recovery across paediatric populations.

Late preterm birth: how big is the problem?

Hospital Readmission in Pediatric Patients Discharged Home with Ventricular Assist Devices

Pre-anaesthetic assessment is essential for identifying perioperative risk and optimising patient safety. Digital alternatives, including video consultation and structured electronic health record (EHR) review, may improve efficiency, but comparative evidence regarding postoperative safety remains limited. We hypothesise that digital pre-anaesthetic assessment modalities will be associated with low rates of major postoperative complications in selected low-risk patients. This protocol describes a single-centre study with retrospective data collection including adult patients scheduled for elective otorhinolaryngologic, oral or maxillofacial surgery at Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark. Patients underwent preoperative assessment using one of three modalities: in-person consultation (2019-2020), EHR review (2021-2022) or video consultation (2024-2025). The primary outcome is a composite of major postoperative complications within 30 days, including all-cause mortality, admission to the intensive care unit, bleeding requiring transfusion, infection requiring antibiotics, or hospital readmission. Secondary outcomes include number of days spent hospitalised within 30 days after surgery, changes in anaesthesia plan, airway management modifications, delay in surgical start time, intubation attempts and same-day cancellations. Associations between assessment modality and dichotomous outcomes will be examined using multivariable generalised linear models with a log-link function, adjusted for prespecified covariates. Sensitivity analyses will include inverse probability weighting and win ratio analysis. This single-centre cohort study will examine whether digital pre-anaesthetic assessment strategies, such as video consultation and EHR review, are associated with differences in major postoperative complications compared with in-person assessment. The findings may inform the implementation of patient-centred, resource-efficient preoperative assessment strategies within the Danish healthcare system and similar international settings.

The Role of Corticosteroids in the Management of Orbital Cellulitis: A Report by the American Academy of Ophthalmology.

Patients with complications of advanced liver disease experience high rates of hospital readmission after discharge. Transitional care models have improved outcomes in other chronic conditions, but their efficacy in liver disease care remains uncertain. This randomized trial evaluates the effectiveness of a tailored transitional care model-the Transitional Liver Clinic (TLC)-in reducing readmissions, improving quality of life, and enhancing patient satisfaction for patients with advanced liver disease. This is a 45-month, stepped-wedge cluster randomized trial enrolling up to 1000 patients with advanced liver disease across 4 academic medical centers. Each site transitions from usual care to the TLC intervention on a randomized schedule at 9-month intervals. The TLC includes a post-discharge phone call within 2 business days and a hepatology advanced practice provider (APP) visit within 14 days. The primary outcome is 30-day hospital readmission. Secondary outcomes include 90-day readmission, emergency room visits, mortality, days alive out of hospital, quality of life, and patient satisfaction. Quality of life is measured with the PROMIS-29+2 Profile, and patient satisfaction is measured with the Patient Satisfaction Questionnaire-18. Follow-up occurs at 30 and 90 days post-discharge. This multicenter randomized trial will determine whether a structured, APP-led transitional care model can improve outcomes for patients with advanced liver disease. If successful, the TLC could serve as a scalable model for post-discharge care in hepatology.

Physical function in lung transplant recipients: Clinical implications and rehabilitation strategies.

The long-term outcome of lung transplantation remains inferior to that of other solid organ transplants, primarily due to rejection/infection. This pilot study investigates longitudinal changes in the bronchoalveolar lavage (BAL) leukocyte transcriptomes and phenotypes, and their impact on clinical outcomes. BAL samples were collected at baseline and 1-12 mo posttransplantation. Leukocyte phenotypes, activation status, and biomarkers were characterized alongside their gene expression profiles. We identified distinct BAL leukocyte transcriptional signatures associated with allograft rejection across 2 independent cohorts. Alveolar macrophages (AMs) predominated after transplantation, whereas granulocytes increased during the first year. This was associated with decreased expression of CD163, an anti-inflammatory marker, and increased expression of proinflammatory markers CD80 and CD86 on AMs. In a patient subgroup, a unique foamy macrophage (FM) subset with distinct cytology, featuring cytoplasmic lipid-laden vacuoles, was identified and confirmed in lung biopsies. FMs were accompanied by a unique non-FM (no-FM) population and were associated with elevated BAL levels of interleukin (IL)-8, IL-1β, and IL-10 and more frequent hospital readmissions. BAL transcriptomic analysis for patients carrying both FMs and no-FMs showed upregulation of genes linked to lipid metabolism, leukocyte chemotaxis, and inflammatory response pathways. We identified a rejection gene signature and proinflammatory shift in BAL leukocyte phenotypes after lung transplantation. The presence of FMs/no-FMs was associated with proinflammatory changes and worse clinical outcomes as per our data analysis, unadjusted for confounders due to relatively limited sample size. These findings could facilitate further investigations into early detection of lung allograft rejection and help focus on AM-targeted interventions.

Systematic review and meta-analysis. To explore the impact of preoperative cannabis use on perioperative outcomes of spinal fusion procedures. Opioid use disorder is a growing problem, especially in the United States. Cannabis use is increasingly being adopted as an alternative method of pain management. However, it remains unclear how a history of preoperative cannabis use impacts opioid consumption, length of hospitalization, or perioperative complications in spinal fusion procedures. The authors searched PubMed, Scopus, Web of Science, and Cochrane Library for studies where outcomes of spinal fusion were compared between patients preoperatively exposed and nonexposed to active cannabis use. A total of 7 retrospective studies and 1920 patients (386 cannabis users) were included. Significant increase in in-hospital opioid use (MD 58.84 MME; 95% CI: 29.75-87.93; P <0.01), readmission (OR 1.70; 95% CI: 1.01-2.87; P =0.045), and reoperation (OR 3.78; 95% CI: 2.06-6.94; P <0.001) was observed in the cannabis group. Studies showed no significant increase in surgical complications. A history of preoperative cannabis use may be associated with poorer surgical outcomes, including increased perioperative opioid utilization and a higher rate of postoperative hospital readmissions. Patients should be informed in detail about these risks, and clinicians should screen for them. Counsel patients to cease or at least reduce the use of cannabis before a spinal fusion procedure, in order to minimize surgical complications.

Most hospital admissions are for older patients, who are more likely to be medically complex. Primary care risks after hospital discharge and readmission trajectories are relatively unexplored. To estimate the frequency and nature of errors and harms linked to discharge summary processing in general practice for patients aged ≥65 years; and to explore associations with readmission and healthcare utilisation, using a novel primary care data source. Retrospective cohort study using electronic health records (EHRs) from seven purposively sampled general practices in the West Midlands, UK. EHRs of patients aged ≥65 years discharged between October 2022 and October 2023 were reviewed. Outcomes included post-discharge healthcare utilisation and costs, frequency and type of discharge actions, error rates (failures to complete requested actions), harms (severity, attribution, and preventability), and 90-day readmissions. Multivariable logistic regression identified predictors of errors, harms, and readmission. Within the cohort of 263 discharged patients, 186 (70.7%) accessed post-discharge care; with 47 out of the 263 patients (17.5%; 95% confidence interval = 13.7 to 23.0) having related readmissions within 90 days. In total, 551 actions were requested in 160 discharge summaries. For those patients who required an action, 20.6% experienced error and 4.4% experienced harm. Most harms resulted in hospital readmission and three out of eight were preventable in primary care. Error and harm disproportionately affected patients who had dementia or a recorded carer. General practice should review their processes for responding to patient discharge information in order to improve patient safety post-discharge. Further research into tools to assist practices with transitions is warranted.

IntroductionHospital readmissions in the US place a considerable burden on patients and their caregivers. Our study will investigate whether spiritual intervention during a patient's hospital stay contributes to lower rates of readmissions 30days after hospital discharge.MethodsTwo hundred patients receiving palliative care will be randomized into control (n = 100) and intervention groups (n = 100). The control group will receive a standard spiritual support visit, while the intervention group will receive a spiritual intervention consisting of active listening, compassionate presence, assessment of post-discharge resources, and a supportive phone call 5 to 7days after discharge. The primary outcome will be hospital readmission within 30days of discharge. Board-certified chaplains will be allowed to use their individual skillsets but within the standardized ACA spiritual care model. Training chaplains to assess patients in the same way will help with this discrepancy as the same form will be used.DiscussionWe hypothesize that patients who receive spiritual intervention with a supportive phone call will experience fewer hospital readmissions. Spiritual intervention will instill.confidence in those patients at risk of readmission by assuring them that the hospital staff remain concerned about their well-being even after discharge.

Heart failure accounts for more than one million US hospitalizations annually, with 30-day all-cause readmission approaching 25% and triggering CMS Hospital Readmissions Reduction Program penalties. The 2022 ACC/AHA/HFSA guideline and the 2023 ESC focused update elevated SGLT2 inhibitors to Class I therapy for heart failure with reduced ejection fraction (HFrEF) [1, 2]. The DAPA ACT HF-TIMI 68 prespecified meta-analysis demonstrated reductions in cardiovascular death or worsening heart failure (HR 0.71) and all-cause mortality (HR 0.57). Real-world prescribing patterns and 30-day readmission outcomes in the post-guideline US era are not well characterized. The relative contribution of clinical stability variables versus co-prescribed guideline-directed medical therapy (GDMT) to confounding has not been directly quantified in this setting. We conducted a retrospective cohort study at four NYU Langone Health hospitals from January 2023 to January 2026. Adults with a primary heart failure discharge diagnosis were included. The prespecified primary analysis was in the HFrEF subgroup (LVEF ≤ 40%). The primary outcome was 30-day all-cause readmission. Stabilized inverse probability of treatment weighting (IPTW) was the primary adjustment, with overlap weighting (ATO) as sensitivity analysis. Hierarchical logistic regression decomposed the confounding contribution of clinical stability parameters relative to GDMT. The E-value assessed robustness to unmeasured confounding. Among 438 patients, 122 (27.9%) received in-hospital SGLT2 inhibitor initiation. The HFrEF rate was 41.6%, a sixfold increase from 6.6% reported in INSIGHT-HF (2020-2021). Patients with prior heart failure hospitalization received SGLT2 inhibitors at 11.4% versus 29.7% in those without (p < 0.001). In HFrEF (n = 221), 30-day readmission was 12.1% versus 31.8% (crude OR 0.29, 95% CI 0.14-0.61). The primary IPTW estimate was OR 0.34 (95% CI 0.13-0.91, p = 0.032). Sensitivity analyses were directionally consistent. Clinical stability parameters contributed only 9.3% confounding attenuation; GDMT was the dominant confounder. In a contemporary US post-guideline cohort, in-hospital SGLT2 inhibitor initiation reached 41.6% in HFrEF but remained low in patients with recent heart failure hospitalization. In-hospital SGLT2 inhibitor initiation was associated with lower 30-day all-cause readmission, though initiation was strongly bundled with discharge GDMT optimization and cannot be distinguished from a GDMT optimization effect with this study design. These findings should be considered hypothesis-generating. Because short-term safety events and post-discharge persistence were not systematically captured, these findings should not be interpreted as establishing the benefit-risk profile of inpatient SGLT2 inhibitor initiation. The prescribing gap in high-risk patients is an actionable quality-improvement target.

ABSTRACT National rates of homelessness are rising, creating challenges in providing care for homeless populations after hospital discharge. Without intermediary care solutions, people experiencing homelessness are at higher risk for condition exacerbation and poor health outcomes. Using a naturalistic approach of assignment, this preliminary study compared subsequent healthcare utilization by 95 individuals experiencing homelessness and who were referred and admitted to a medical respite program in the Western United States against those who were not admitted due to lack of bed space. Using a retrospective cohort design, a secondary data analysis on deidentified medical records collected between January 2023 and December 2024, which had been shared between the medical respite program and a large academic medical center in the Mountain West, examined emergency department utilization, non-emergency room treatment utilization, and all-cause 90-day hospital readmissions. Despite statistical limitations due to sample size, results showed possible clinically meaningful differences, such as a 22.9% reduction in emergency room utilization. Nonetheless, the lack of statistical power limits the generalizability of the findings. Preliminary findings suggest that medical respite programs have a meaningful, practical, and clinically significant impact on costs and medical utilization, justifying continued funding and support of the program.

Targeted intraoperative radiation therapy (TARGIT-IORT) is a promising alternative to standard external radiation for the treatment of early-stage breast cancer. However, American Society for Radiation Oncology guidelines have limited its use. We aimed to present our long-term results with the use of TARGIT-IORT in a very restricted population. The electronic records of a tertiary medical center were retrospectively searched for women diagnosed with invasive ductal carcinoma from 2014 to 2023. Inclusion criteria were age >50 years, unifocal disease, tumor size <3 cm, and clinical subtype estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-non-amplified. Those with a favorable pathology after completion of lumpectomy and sentinel lymph node biopsy (SLNB) underwent TARGIT-IORT consisting of delivery of a single high dose of radiation (20 Gy) to an applicator inserted into the tumor bed using low-energy X-rays (50 Kv) over 22-29 minutes. Follow-up consisted of clinical examination every 6 months in the first 2 years and then mammography and breast ultrasound annually. The cohort included 219 patients with a median age of 66 years (range 50-83). During a median follow-up of 85 months, there was one case each (0.45%) of ipsilateral breast tumor recurrence, axillary lymph node recurrence, and isolated liver metastasis. In total, 20 patients (9.1%) had minor wound complications, and three (1.4%) had fat necrosis, self-limiting in all cases, with no need for hospital readmission. TARGIT-IORT is associated with excellent local control, very high survival rates, and a very low toxicity profile for low-risk early breast cancer, consistent with the TARGIT-A trial and should be offered to patients when suitable.

Enabling community management of patients with heart failure: the impact of a specialist nurse-facilitated shared-care model

Whether sedative prescriptions after hospital admissions are associated with poor patient outcomes is unknown. We sought to determine the incidence and risk of adverse events associated with sedatives in older adults within 30 days after hospital discharge. We conducted a population-based cohort study involving older adults (age ≥ 66 yr) discharged alive from hospital in Ontario (2003 to 2023). We assessed the association of sedative prescriptions (benzodiazepines, antidepressant sedatives, or antipsychotics) filled within 7 days after discharge with falls (with or without fracture), emergency department (ED) visits, and hospital readmission. We used cause-specific proportional hazard regression for outcomes other than death and Cox proportional hazard models for death to assess the association between a sedative prescription filled after discharge and the outcomes. Because of an interaction with prehospital sedative prescription, we stratified results for prehospital sedative-naive and sedative-exposed status. Among 1 868 484 older adults (mean age 77 yr, 52.1% female), 13.2% filled a sedative prescription after discharge; of these patients, 31.0% were sedative naive before hospital admission. Falls occurred in 1.6% (n = 30 626), ED visits in 21.3% (n = 397 402), hospital readmissions in 12.4% (n = 231 191), and death in 3.8% (n = 70 661). The adjusted hazard ratio (HR) for all outcomes was increased among those who filled a sedative prescription after discharge (v. no filled prescription) and were sedative naive before hospital admission (fall: 1.20, 95% confidence interval [CI] 1.13 to 1.26; ED visit 1.20, 95% CI 1.19 to 1.22; hospital readmission: 1.20, 95% CI 1.17 to 1.22; and death: 1.78, 95% CI 1.73 to 1.83). For those who were exposed to sedatives before their hospital admission, there was an increased hazard of death (adjusted HR 1.08, 95% CI 1.05 to 1.11), but not for the other outcomes. For sedative-naive older adults, benzodiazepines were associated with an increased hazard of all outcomes, antipsychotics were associated with an increased hazard of falls and death, and antidepressant sedatives were associated with a decreased hazard of falls. New sedative prescriptions filled within 7 days after discharge were associated with increased hazards of a fall, ED visit, hospital admission, and death within 30 days after discharge, with differences based on the sedative class. These findings have important implications for in-hospital medication review and falls-risk assessment for older adults in Canada.

Study Design Retrospective Cohort Study. Objectives To compare mortality and downstream morbidity after early operative versus nonoperative management of isolated Type II dens fractures in octogenarians. Methods TriNetX was queried to identify patients aged 80 years and older with a new diagnosis of Type II dens fracture. Patients with spinal cord injury, traumatic brain injury, or other major traumatic injuries were excluded. Patients were stratified by early operative intervention, defined as surgical fixation within 14 days, versus nonoperative management, defined as no surgical fixation after diagnosis. The primary outcome was mortality. Propensity score matching was performed 1:1 using demographic and clinical variables. Mortality was assessed at 9 months, 1 year, 2 years, and 3 years. Secondary outcomes included hospital readmission and long-term post-injury opioid use between 6 months and 3 years. Results After matching, 156 patients were included in each cohort. No significant differences in mortality were observed between cohorts at 9 months, 1 year, 2 years, or 3 years. Early operative intervention was associated with lower 90-day readmission (7.1% vs 17.9%; OR 0.35, 95% CI 0.17–0.73; p = 0.0036), lower 6-month readmission (9.0% vs 21.2%; OR 0.37, 95% CI 0.19–0.72; p = 0.0026), and lower long-term post-injury opioid use (16.0% vs 26.9%; OR 0.52, 95% CI 0.30–0.90; p = 0.0191). Conclusions In octogenarians with isolated Type II dens fractures, early surgery was not associated with improved long-term mortality, but was associated with lower readmission and reduced long-term post-injury opioid use.

Biologic and targeted immune-modulating agents are increasingly used to manage autoimmune diseases like rheumatoid arthritis, psoriasis, and inflammatory bowel disease. As more patients receiving these therapies undergo elective breast augmentation and implant-based reconstruction, the effect of biologic exposure on postoperative outcomes remains unclear. This study evaluated whether preoperative use of biologic or immune-modulating agents is associated with increased complications following reconstructive and aesthetic breast surgery procedures. A retrospective cohort analysis was performed using the TriNetX database. Patients who underwent breast reconstruction or augmentation were identified by Current Procedural Terminology codes and stratified by preoperative exposure to biologic or immune-modulating agents within six months of surgery. Agents included tumor necrosis factor-α, interleukin, Janus kinase, mammalian target of rapamycin, and calcineurin inhibitors, among others. Propensity score matching (1:1) controlled for demographic and clinical covariates. Postoperative complications were assessed at 30-days, 90-days, and 6-months and included wound dehiscence, infection, seroma or hematoma, implant revision, and hospital readmission. Among 211,105 patients, 4,024 had biologic exposure and 207,081 were controls. After propensity score matching, 3,980 patients remained in each cohort. Complication rates were comparable between groups at all timepoints (p > 0.05). Biologic exposure was not associated with increased risk of wound, infectious, implant revision, or hospital readmission complications. Preoperative biologic or immune-modulating therapy was not associated with a significant increase in postoperative surgical complications after breast reconstruction or augmentation procedures. Continuing these therapies in appropriate patients appears safe and may reduce unnecessary treatment interruptions.

IntroductionCoronary heart disease (CHD) is a leading cause of mortality affecting millions of people worldwide. The prevalence and incidence of CHD are increasing due to traditional and emerging risk factors. Despite advancements in CHD management, improving patient outcomes remains a challenge. Self-care practices can improve patient outcomes. This paper summarises a longitudinal cohort protocol to investigate self-care needs, determinants and outcomes in patients with CHD.Methods and analysisThis study employed a prospective longitudinal cohort design and will be conducted in a tertiary care hospital in Islamabad during 1 May 2024 to 30 December 2024. A total of 354 patients with confirmed CHD will be enrolled. Data collection will occur at baseline and 3 months later, employing validated instruments to measure self-care, self-efficacy, anxiety, depression and comorbidities. This study will examine person-related factors (age, sex and education), problem-related factors (comorbidities, anxiety and depression) and environment-related factors (residence, religious engagement and resources). The outcomes are hospital readmissions, emergency department visits and unscheduled clinic visits. To estimate the self-care predictors on outcomes, the following data analysis will be conducted: descriptive statistics and logistic regression.Ethics and disseminationThe study was approved by the institutional review board and the ethics committee of Shifa International Hospital, Islamabad. Permission was obtained from the department head. Informed consent will be taken from patients. Participation in the study will be voluntary. The data will be collected anonymously. The results of this study will be disseminated through presentations at national and international conferences, peer-reviewed manuscripts and digital social media platforms.