In-hospital Complications Research Articles

Thoracoabdominal Aortic Aneurysm Repair Using Fenestrated and Branched Endovascular Grafts for High-Risk Patients: Evolving yet Safe

Purpose: The purpose was to investigate outcomes of high-risk patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated or branched endovascular aneurysm repair (F/BEVAR) devices at a single center in Canada. Materials and Methods: A retrospective review of all patients undergoing endovascular TAAA repair with F/BEVAR from June 2007 to July 2020. Imaging and clinical endpoints of interest including death, reintervention, and target vessel patency were reported. Results: Ninety-five consecutive patients underwent endovascular TAAA repair using F/BEVAR stent grafts (63 males, median age 74 [interquartile range 70, 78] years). Repairs included 81 elective and 14 urgent/emergent cases (6 ruptures and 8 symptomatic). Graft deployment was 100% successful. Intraoperative target vessel revascularization was successful in 336/355 (94.6%) vessels with the celiac having the lowest success rate 72/82 (87.8%). In-hospital mortality was 9.5% (7.4% elective and 21.4% urgent/emergent, p=0.125) and permanent paraplegia was 4.2% (3.7% elective and 7.1% urgent/emergent, p=0.458). In-hospital complications included stroke in 5.3%, acute myocardial infarction in 8.4%, and bowel ischemia in 5.3%. No patients required permanent dialysis or tracheostomy during their hospital stay. However, 22 (23.2%) patients required additional unplanned procedures for various indications (branch occlusion, endoleaks, realignment) during their hospital stay. Patients were followed up for a mean of 3.6 ± 3.0 years. Clinical follow-up was 100%, with 80/86 (93%) having surveillance imaging. On follow-up imaging, 43 (50%) patients had at least 1 endoleak identified and 337/341 (98.8%) of the target vessels were found to be patent. At 5 years, cumulative probability of reintervention was 46.3% (95% confidence interval [CI], 36.1-56.4). Survival at 5 and 8 years was 50.1% (95% CI, 38.4-65.4) and 34.4% (95% CI, 22.5-52.8), respectively. Progression of aneurysmal disease leading to rupture on follow-up was confirmed in 1 patient at 10 years. Conclusion: Endovascular TAAA repair provides a safe treatment option with a high technical success rate and low pulmonary and renal complications. Long-term survival is similar to previous literature; however, high rates of secondary reintervention reaffirm the need for ongoing patient follow-up and further technical improvements. Clinical Impact This study demonstrates that endovascular repair of TAAAs can be performed in a high-risk elderly population with acceptable rates of mortality, TALE and SCI, using evolving technology. The incidences of post-operative respiratory failure and renal dysfunction were lower in patients who underwent endovascular repair compared with open repair. Future technical and procedural refinements in addition to increasing surgical experience are expected to lead to further improvements in short- and long-term outcomes exceeding those of open repair.

Sex differences in post-acute neurological sequelae of SARS-CoV-2 and symptom resolution in adults after coronavirus disease 2019 hospitalization: an international multi-centre prospective observational study.

Although it is known that coronavirus disease 2019 can present with a range of neurological manifestations and in-hospital complications, sparse data exist on whether these initial neurological symptoms of coronavirus disease 2019 are closely associated with post-acute neurological sequelae of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2; PANSC) and whether female versus male sex impacts symptom resolution. In this international, multi-centre, prospective, observational study across 407 sites from 15 countries (30 January 2020 to 30 April 2022), we report the prevalence and risk factors of PANSC among hospitalized adults and investigate the differences between males and females on neurological symptom resolution over time. PANSC symptoms included altered consciousness/confusion, fatigue/malaise, anosmia, dysgeusia and muscle ache/joint pain, on which information was collected at index hospitalization and during follow-up assessments. The analysis considered a time to the resolution of individual and all neurological symptoms. The resulting times were modelled by Weibull regression, assuming mixed-case interval censoring, with sex and age included as covariates. The model results were summarized as cumulative probability functions and age-adjusted and sex-adjusted median times to resolution. We included 6862 hospitalized adults with coronavirus disease 2019, who had follow-up assessments. The median age of the participants was 57 years (39.2% females). Males and females had similar baseline characteristics, except that more males (versus females) were admitted to the intensive care unit (30.5 versus 20.3%) and received mechanical ventilation (17.2 versus 11.8%). Approximately 70% of patients had multiple neurological symptoms at the first follow-up (median = 102 days). Fatigue (49.9%) and myalgia/arthralgia (45.2%) were the most prevalent symptoms of PANSC at the initial follow-up. The reported prevalence in females was generally higher (versus males) for all symptoms. At 12 months, anosmia and dysgeusia were resolved in most patients, although fatigue, altered consciousness and myalgia remained unresolved in >10% of the cohort. Females had a longer time to the resolution (5.2 versus 3.4 months) of neurological symptoms at follow-up for those with more than one neurological symptom. In the multivariable analysis, males were associated with a shorter time to the resolution of symptoms (hazard ratio = 1.53; 95% confidence interval = 1.39-1.69). Intensive care unit admission was associated with a longer time to the resolution of symptoms (hazard ratio = 0.68; 95% confidence interval = 0.60-0.77). Post-discharge stroke was uncommon (0.3% in females and 0.5% in males). Despite the methodological challenges involved in the collection of survey data, this international multi-centre prospective cohort study demonstrated that PANSC following index hospitalization was high. Symptom prevalence was higher and took longer to resolve in females than in males. This supported the fact that while males were sicker during acute illness, females were disproportionately affected by PANSC.

Survival outcomes of TAVR and self-expanding versus balloon-expandable valves in patients with advanced cardiac dysfunction.

There is a growing body of literature on long-term outcomes post-transcatheter aortic valve replacement (TAVR), but to our knowledge, few research have focused on patients with advanced cardiac dysfunction. This challenging category of patients was excluded from the Partner 3 clinical trial. There are no data to guide the choice of valve type in patients with severely depressed ejection fraction. This study evaluates the safety, efficacy, and outcomes of TAVR in patients with severe aortic stenosis and left ventricular ejection fraction (LVEF)≤35%. It compares post-TAVR survival outcomes with self-expanding (SEV) versus balloon-expandable (BEV) valves in the context of cardiac dysfunction. A retrospective cohort was conducted on 977 patients who underwent TAVR at Toulouse University Hospital between January 2016 and December 2020. The study population included two groups: LVEF≤35% (N=157) and LVEF≥50% (N=820). The group of LVEF≤35% was divided into two subgroups according to the type of implanted device: self-expanding (N=66) versus balloon-expandable (N=91). The living status of each of study's participants was observed in December 2022. Patients with low ejection fraction were younger (82 vs. 84.6years) and commonly males (71.3% vs. 45.6%). Procedural success was almost 98% in both study groups (97.5% vs. 97.9%). The prevalence of all in-hospital post-TAVR complications [acute kidney injury (3.8% vs. 2.2%), major bleeding events (2.5% vs. 3.2%), stroke (1.3% vs. 1.6%), pacemaker implantation (10.2% vs. 10.7%), major vascular complication (4.5% vs. 4.5%), new onset atrial fibrillation (3.2% vs. 3.4%), and in-hospital death (3.2% vs. 2.8%)] were similar between groups (LVEF≤35% vs. LVEF≥50%). No difference in long-term survival has been revealed over 3.4years (P=0.268). In patients with LVEF≤35%, except for post-TAVR mean aortic gradient (7.8±4.2 vs. 10.2±3.6), baseline and procedural characteristics were comparable between SEV versus BEV subgroups. An early improvement in LVEF (from 29.2±5.5 to 37.4±10.8) was observed. In patients with LVEF≤35%, the all-cause mortality rate was significantly higher in BEV than that in SEV subgroups, respectively (40.7% vs. 22.7%, P=0.018). Kaplan-Meier curve showed better survival outcomes after SEV implantation (P=0.032). A Cox regression identified BEV as independent predictor of mortality [HR=3.276, 95% CI (1.520-7.060), P=0.002]. In the setting of low LVEF, TAVR remains a safe and effective procedure not associated with an increased risk of complications and mortality. SEV implantation may likely result in superior survival outcomes in patients with advanced cardiac dysfunction.

Trends and benefits of early hip arthroplasty for femoral neck fracture in China: a national cohort study.

Limited studies have examined the benefits of early arthroplasty within 48h from admission to surgery for femoral neck fractures (FNFs). Using the national inpatient database, the authors aimed to investigate the trends in early arthroplasty within 48h for FNFs in China and to assess its effect on in-hospital complications and 30-day readmission patterns. This was a retrospective cohort study. Patients receiving primary total hip arthroplasty (THA) or hemiarthroplasty (HA) for FNFs in the Hospital Quality Monitoring System between 2013 and 2019 were included. After adjusting for potential confounders with propensity score matching, a logistic regression model was performed to compare the differences in in-hospital complications [i.e. in-hospital death, pulmonary embolism, deep vein thrombosis (DVT), wound infection, and blood transfusion], rates and causes of 30-day readmission between early and delayed arthroplasty. During the study period, the rate of early THA increased from 18.0 to 19.9%, and the rate of early HA increased from 14.7 to 18.4% ( P <0.001). After matching, 11731 pairs receiving THA and 13568 pairs receiving HA were included. Compared with delayed THA, early THA was associated with a lower risk of pulmonary embolism [odds ratio (OR) 0.51, 95% CI: 0.30-0.88], DVT (OR 0.59, 95% CI: 0.50-0.70), blood transfusion (OR 0.62, 95% CI: 0.55-0.70), 30-day readmission (OR 0.82, 95% CI: 0.70-0.95), and venous thromboembolism-related readmission (OR 0.50, 95% CI: 0.34-0.74). Similarly, early HA was associated with a lower risk of DVT (OR 0.70, 95% CI: 0.61-0.80) and blood transfusion (OR 0.74, 95% CI: 0.68-0.81) than delayed HA. Despite a slight increase, the rate of early arthroplasty remained at a low level in China. Given that early arthroplasty can significantly improve prognosis, more efforts are needed to optimize the procedure and shorten the time to surgery.

Selective aneurysmal sac neck-targeted embolization during endovascular repair of abdominal aortic aneurysm with hostile neck anatomy.

To evaluate the efficacy and safety of selective aneurysmal sac neck-targeted embolization in endovascular aneurysm repair (EVAR) in patients with a hostile neck anatomy (HNA). Between October 2020 and June 2022, patients with an abdominal aortic aneurysm (AAA) and HNA who underwent EVAR with a low-profile stent graft and a selective aneurysmal sac neck-targeted embolization technique were analysed. An HNA was defined by the presence of any of the following parameters: infrarenal neck angulation > 60°; neck length < 15mm; conical neck; circumferential calcification ≥ 50%; or thrombus ≥ 50%. Before occluding the entire aneurysm during the procedure, a buddy wire was loaded prophylactically into the sac through the contralateral limb side. If a type Ia endoleak (ELIa) occurred and persisted despite adjunctive treatment such as balloon moulding or cuff extension, this preloaded wire could be utilized to enable a catheter to reach the space between the stent graft and sac neck to perform coil embolization. In the absence of ELIa, the wire was simply retracted. The primary outcome of this study was freedom from sac expansion and endoleak-related reintervention during the follow-up period; secondary outcomes included technical success and intraoperative and in-hospital postoperative complications. Among the 28 patients with a hostile neck morphology, 11 (39.5%) who presented with ELIa underwent intraprocedural treatment involving sac neck-targeted detachable coil embolization. Seventeen individuals (60.7%) of the total patient population did not undergo coiling. All patients in the coiling group underwent balloon moulding, and 2 patients additionally underwent cuff extension. In the noncoiling group, 14 individuals underwent balloon moulding as a treatment for ELIa, while 3 patients did not exhibit ELIa during the procedure. The coiling group showed longer operating durations (81.27 ± 11.61 vs. 70.71 ± 7.17min, P < 0.01) and greater contrast utilization than the noncoiling group (177.45 ± 52.41 vs. 108.24 ± 17.49ml, P < 0.01). In the entire cohort, the technical success rate was 100%, and there were no procedure-related complications. At a mean follow-up of 18.6 ± 5.2months (range 12-31), there were no cases of sac expansion (19 cases of sac regression, 67.86%; 9 cases of stability, 32.14%) or endoleak-related reintervention. Selective aneurysmal sac neck-targeted embolization for the treatment of ELIa in AAA patients with an HNA undergoing EVAR is safe and may prevent type Ia endoleak and related sac expansion after EVAR.

Abstract TP173: Differential Outcomes and Treatment in Vertebral versus Carotid Artery Dissections: A National Inpatient Sample Study

Introduction: Cervical artery dissection (CAD) involves the carotid (CCAD) or vertebral artery (VCAD). However, limited studies have compared their clinical features and outcomes. Our study utilized a comprehensive nationwide database to discern these differences. Method: We examined non-traumatic CAD-diagnosed patients from the U.S. National Inpatient Sample (2005-2019) using ICD-9 and ICD-10 codes. The evaluation included patient demographics, comorbidities, in-hospital complications, treatment, and costs. Differences between CCAD and VCAD were assessed using survey-weighted stepwise backward logistic regression, followed by propensity score matched adjusted regressions for outcomes. Result: From 2005 to 2019, we identified 157,086 CAD admissions, of which 79.9% (125,477) were spontaneous CADs, with CCAD outnumbering VCAD (67,671 vs. 57,806). Compared to VCAD, CCAD was significantly associated with older age (54 [44-66] vs. 49 [37-62]), Black race (12.6% vs. 8.7%), atrial fibrillation (6.1% vs. 3.7%), hypertension (58.0% vs. 53.9%), fewer concurrent acute ischemic strokes (AIS) (22.1% vs. 24.7%), higher NIHSS (mean NIHSS 7 [2-16] vs. 2 [0-5]), extended stays (4 days [2-8] vs. 4 days [2-7]) and increased hospitalization charges ($52,005 [$25,759-$118,806] vs. $43,199 [$24,116-$85,701]); all P&lt;0.05. Within the concurrent AIS group, the CCAD group also exhibited an increased likelihood for IV thrombolysis (10.7% vs. 5.7%) and mechanical thrombectomy (14.9% vs. 3.7%). After propensity score matching for NIHSS and age, the CCAD group was associated with less death (adjusted odds ratio [aOR] 0.41, 95% CI 0.26-0.65, P&lt;0.001) but a similar home discharge rate (aOR 1.15, 95% CI 0.78-1.69, P=0.480) (Figure). Conclusion: Our study underscores distinct comorbidity profiles and treatment patterns between CCAD and VCAD groups. These findings advocate for tailored treatment strategies based on dissection type to optimize patient outcomes.

Clinical characteristics and outcomes of traumatic brain injury in patients admitted to surgical ward of Jimma Medical Center, Southwest Ethiopia: a prospective observational follow-up study

ObjectiveTo assess the Clinical Characteristics and Outcomes of Traumatic Brain Injury in Patients Admitted to the Surgical Ward of Jimma Medical Center, Southwest Ethiopia from January to July 2022.Design and...

The relationship between inflammatory cytokines and in-hospital complications of acute pancreatitis.

Acute necrotic collection (ANC), acute peripancreatic fluid collection (APFC), pleural effusion, and ascites are common early complications of acute pancreatitis. This study aimed to investigate the relationship between 12 serum cytokines and the early complications and severity of acute pancreatitis (AP). We retrospectively analyzed the clinical data of 307 patients with AP, and divided them into severe group and mild-to-moderate group according to the revised Atlanta classification. Propensity score matching was used to control for confounding factors. Binary logistic regression analysis was used to explore the relationship between cytokine levels and early complications of AP. Serum levels of interleukin (IL)-1β, IL-5, IL-6, IL-8, IL-10, IL-17, and tumor necrosis factor-α were significantly higher in the severe acute pancreatitis (SAP) group than in the non-SAP group (p < .05). After adjusting for confounding factors, the upper quartiles of IL-6, IL-8, and IL-10 were associated with an increased risk of ANC compared with those in the lowest quartile (IL-6: quartile 3, odds ratio [OR] = 3.99, 95% confidence interval [CI] = 1.95-8.16; IL-8: quartile 4, OR = 2.47, 95% CI = 1.27-4.84; IL-10: quartile 2, OR = 2.22, 95% CI = 1.09-4.56). APFC was associated with high serum levels of IL-6 (quartile 3, OR = 1.32, 95% CI = 1.02-1.72), pleural effusions were associated with high serum levels of IL-1β, IL-6, IL-8, and IL-10 (IL-1β: quartile 4, OR = 2.36, 95% CI = 1.21-4.58; IL-6: quartile 3, OR = 4.67, 95% CI = 2.27-9.61; IL-8: quartile 3, OR = 2.95, 95% CI = 1.51-5.79; IL-10: quartile 4, OR = 3.20, 95% CI = 1.61-6.36), and high serum levels of IL-6 and IL-10 were associated with an increased risk of ascites (IL-6: quartile 3, OR = 3.01, 95% CI = 1.42-6.37; IL-10: quartile 3, OR = 2.57, 95% CI = 1.23-5.37). Serum cytokine levels, including IL-1β, IL-6, IL-8, and IL-10 may be associated with the occurrence of early complications of AP. In daily clinical practice, IL-6 may be the most worthwhile cytokine to be detected.

Impact of Frailty on Short-Term Outcomes of Hepatic Lobectomy in Patients with Intrahepatic Cholangiocarcinoma: Evidence from the US Nationwide Inpatient Sample 2005–2018

Introduction: This study aimed to evaluate associations between frailty and outcomes in patients with intrahepatic cholangiocarcinoma (ICC) undergoing hepatic lobectomy using a large, nationally representative sample. Methods: This population-based, retrospective observational study extracted the data of adults ≥20 years old with ICC undergoing hepatic lobectomy from the US Nationwide Inpatient Sample database between 2005 and 2018. Frailty was assessed by the validated Hospital Frailty Risk Score (HFRS). Associations between frailty and surgical outcomes were analyzed using logistic regression analyses. Results: After exclusions, 777 patients were enrolled, including 427 frail and 350 non-frail. Patients’ mean age was 64.5 (±0.4) years and the majority were males (51.1%) and whites (76.5%). Frailty was significantly associated with increased odds of in-hospital mortality (aOR: 18.51, 95% CI: 6.70, 51.18), non-home discharge (aOR: 3.58, 95% CI: 2.26, 5.66), prolonged LOS (aOR: 5.56, 95% CI: 3.87, 7.99), perioperative cardiac arrest/stroke (aOR: 5.44, 95% CI: 1.62, 18.24), acute respiratory distress syndrome (ARDS)/respiratory failure (aOR: 3.88, 95% CI: 2.40, 6.28), tracheostomy/ventilation (aOR: 3.83, 95% CI: 2.23, 6.58), bleeding/transfusion (aOR: 1.67, 95% CI: 1.24, 2.26), acute kidney injury (AKI) (aOR: 14.37, 95% CI: 7.13, 28.99), postoperative shock (aOR: 4.44, 95% CI: 2.54, 7.74), and sepsis (aOR: 11.94, 95% CI: 6.90, 20.67). Discussion/Conclusion: Among patients with ICC undergoing hepatic lobectomy, HFRS-defined frailty is a strong predictor of worse in-patient outcomes, including in-hospital death, prolonged LOS, unfavorable discharge, and complications (perioperative cardiac arrest/stroke, ARDS/respiratory failure, tracheostomy/ventilation, bleeding/transfusion, AKI, postoperative shock, and sepsis). Study results may help stratify risk in frail patients undergoing hepatic resection for ICC.

Thirteen Years of Impactful, Minimally Invasive Coronary Surgery: Short- and Long-Term Results for Single and Multi-Vessel Disease

Objectives: Minimally invasive coronary surgery (MICS) via lateral thoracotomy is a less invasive alternative to the traditional median full sternotomy approach for coronary surgery. This study investigates its effectiveness for short- and long-term revascularization in cases of single and multi-vessel diseases. Methods: A thorough examination was performed on the databases of two cardiac surgery programs, focusing on patients who underwent minimally invasive coronary bypass grafting procedures between 2010 and 2023. The study involved patients who underwent either minimally invasive direct coronary artery bypass grafting (MIDCAB) for the revascularization of left anterior descending (LAD) artery stenosis or minimally invasive multi-vessel coronary artery bypass grafting (MICSCABG). Our assessment criteria included in-hospital mortality, long-term mortality, and freedom from reoperations due to failed aortocoronary bypass grafts post-surgery. Additionally, we evaluated significant in-hospital complications as secondary endpoints. Results: A total of 315 consecutive patients were identified between 2010 and 2023 (MIDCAB 271 vs. MICSCABG 44). Conversion to median sternotomy (MS) occurred in eight patients (2.5%). The 30-day all-cause mortality was 1.3% (n = 4). Postoperative AF was the most common complication postoperatively (n = 26, 8.5%). Five patients were reoperated for bleeding (1.6%), and myocardial infarction (MI) happened in four patients (1.3%). The mean follow-up time was six years (±4 years). All-cause mortality was 10.3% (n = 30), with only five (1.7%) patients having a confirmed cardiac cause. The reoperation rate due to graft failure or the progression of aortocoronary disease was 1.4% (n = 4). Conclusions: Despite the complexity of the MICS approach, the results of our study support the safety and effectiveness of this procedure with low rates of mortality, morbidity, and conversion for both single and multi-vessel bypass surgeries. These results underscore further the necessity to implement such programs to benefit patients.

DIFFERENCE IN HEALTHCARE OUTCOMES BETWEEN TEACHING AND NON-TEACHING HOSPITALS FOR PATIENTS ADMITTED WITH CROHN'S DISEASE

Abstract BACKGROUND The physician workforce at teaching hospitals differs compared to non-teaching hospitals, and data suggest that patient outcomes may also be dissimilar. Crohn’s disease (CD) is a costly disorder among hospitalized patients. Its complications often require endoscopic interventions, surgery, and advance levels of care, for which approaches are not standardized. METHODS We queried the National Inpatient Sample (NIS)[GS1] 2016-2019 using ICD10-PCS codes. Patients were subsequently divided based on the concomitant diagnosis of CD and subcategorized between teaching and non-teaching institutions. In-hospital mortality, total hospital cost, length of stay, and in-hospital complications were evaluated. Multivariate logistic regression analysis was conducted to adjust for confounders. RESULTS A total of 141,865 discharges with diagnosis of CD were identified, of which 108,735 (76.6%) were admitted to a teaching institution and 33,130 (23.4%) to a non-teaching institution. Those admitted to a teaching hospital were most likely to be black (10.0% vs 15.1%; P&amp;lt;0.01), Hispanic (4.4% vs 5.6%; P&amp;lt;0.01), have a Charlson score of ≥3 (27.1% vs 31.3%; P&amp;lt;0.01), belong to the highest income bracket (17.8% vs 24.7%; P&amp;lt;0.01), have private insurance (43.7% vs 51.3%; P&amp;lt;0.01), and be located in the northeastern U.S. (14.9% vs 23.8%; P&amp;lt;0.01). Those admitted to a teaching institution were more likely to have fistulizing disease (7.8% vs 15.6%; P&amp;lt;0.01), require parenteral nutrition (3.0% vs 6.1%; P&amp;lt;0.01), have severe malnutrition (4.8% vs 8.3%; P&amp;lt;0.01), undergo colonoscopy (10.4% vs 12.8%; P&amp;lt;0.01), and undergo bowel resection including large bowel (6.4% vs 11.4%; P&amp;lt;0.01) and small bowel (1.6% vs 2.4%; P&amp;lt;0.01), and were more likely to require conversion from laparoscopy to open laparotomy (0.8% vs 1.9%) during surgery. On multivariate analysis, there was no significant difference in mortality [aOR 0.84; (P=0.59)] between teaching and nonteaching institutions. However, we found worse outcomes within teaching institutions such as a prolonged mean length of stay (4.5 days vs 5.6 days; P&amp;lt;0.01), more likely to need surgical bowel resection including small [aOR 1.39; (P&amp;lt;0.01)] and large [aOR 1.66; (P&amp;lt;0.01)], to develop venous thromboembolism [aOR 1.97; (P&amp;lt;0.01)], and to require conversion to open surgery during laparoscopy [aOR 2.3; (P&amp;lt;0.01), and ileus (aOR 1.18; (P&amp;lt;0.01)], they were less likely to require endotracheal intubation [aOR 0.63; (P=0.02)]. CONCLUSIONS Institutional designs impact outcomes in CD, albeit no difference in mortality. In general, complication rates and resource utilization are higher in teaching centers when compared to non-teaching.

DIFFERENCE IN HEALTHCARE OUTCOMES BETWEEN PUBLIC AND PRIVATE PAYERS FOR PATIENTS ADMITTED WITH CROHN'S DISEASE

Abstract BACKGROUND In countries where health coverage is not universal, there is ample evidence of disparities in healthcare, often associated with insurance. Crohn’s disease (CD) is a complex chronic disease with potential for significant morbidity if the content or delivery of healthcare is suboptimal. However, the literature related to primary payers and CD remains lacking. METHODS We queried the National Inpatient Sample (NIS)from 2016-2019 using ICD10-CM/PCS codes to identify hospital discharges with a diagnosis of CD. Patients were subsequently stratified based on insurance (Medicare, Medicaid, Private, and No insurance). Observations were categorized into two groups, private and public (Medicare and Medicaid) insurance. Patients without insurance were excluded from the study. In-hospital mortality, total hospital cost, length of stay, and in-hospital complications were evaluated. Multivariate logistic regression analysis was conducted to adjust for confounders. RESULTS A total of 135,075 discharges with diagnosis of CD were identified with a primary payer insurance, of which 70,275(52.1%) had private insurance and 64,800 (47.9%) public. Patients with private insurance were more likely to be white (68.9% vs 78.4%; P&amp;lt;0.01), have lower Charlson score (46.1% vs 59.1%; P&amp;lt;0.01), belong to the higher income bracket (16.7% vs 29.6%; P&amp;lt;0.01), be admitted to a teaching institution (74.2% vs 79.4%; P&amp;lt;0.01), and be in an urban setting (92.2% vs 95.5%; P&amp;lt;0.01). Patients with private insurance were less likely to require parenteral nutrition (5.9% vs 5.3%; P=0.04), have severe malnutrition (8.8% vs 6.4%; P&amp;lt;0.01), abuse EtOH (1.7% vs 0.8%; P&amp;lt;0.01), use tobacco (1.4% vs 1.1%; P&amp;lt;0.01), use cannabis (4.2% vs 2.3%; P&amp;lt;0.01), have iron deficiency anemia (13.4% vs 11.6%; P&amp;lt;0.01), and die during hospitalization (0.4% vs 0.1%; P&amp;lt;0.01). On multivariate analysis, there was lower mortality in patients with a private primary payer [0.28; (P&amp;lt;0.01)], shorter LOS (5.8 vs 4.9 days mean days; P&amp;lt;0.01), and lower healthcare charges [ -3,903 US$; (P&amp;lt;0.01)]. Overall, those with private insurance had lower in-hospital complications such as respiratory failure [aOR 0.75; (P=0.05)], endotracheal intubation [aOR 0.50; (P&amp;lt;0.01)], prolonged mechanical ventilation [aOR 0.36;(P&amp;lt;0.01)], hemodialysis [aOR 0.34; (P&amp;lt;0.01)], acute kidney injury [aOR 0.72; (P&amp;lt;0.01)], and venous thromboembolism [aOR 0.54; (P&amp;lt;0.01)]. However, they had higher rates of surgical interventions including small bowel resection [aOR 1.57; (P&amp;lt;0.01)], large bowel resection [aOR 1.58; (P&amp;lt;0.01)], laparoscopic surgery [aOR 2.44; (P&amp;lt;0.01)], and to require conversion to open surgery [aOR 1.55; (P&amp;lt;0.01)]. CONCLUSIONS Our findings suggest that primary public payers were independently associated with higher morbidity and mortality in patients admitted with CD.

Predictors and outcomes of discharge to long-term acute care facilities after cardiac surgery

ObjectiveAn increasing number of patients with significant comorbidities present for complex cardiac surgery, with a subgroup requiring discharge to long-term acute care facilities. We aim to examine predictors and mortality after discharge to a long-term acute care facility. MethodsFrom January 1, 2015, to April 30, 2021, all adult cardiac surgeries were queried and patients discharged to long-term acute care facilities were identified. Baseline characteristics, procedures, and in-hospital complications were compared between long-term acute care facility and non–long-term acute care facility discharges. Random forest analysis was conducted to establish predictors of discharge to long-term acute care facilities. Kaplan–Meier survival analysis was used to determine probability of survival over 7 years. Multivariate regression modeling was used to establish predictors of death after long-term acute care facility discharge. ResultsOf 29,884 patients undergoing cardiac surgery, 324 (1.1%) were discharged to a long-term acute care facility. The long-term acute care facility group had higher rates of urgent/emergency operation (54% vs 23%; 10% vs 3%, P < .001) and longer mean cardiopulmonary bypass (167 vs 110 minutes, P < .001). By random forest analysis, emergency/urgent status, longer cardiopulmonary bypass duration, redo surgery, endocarditis, and history of dialysis were the most predictive of discharge to a long-term acute care facility. Although the non–long-term acute care facility group demonstrated greater than 95% survival at 6 months, Kaplan–Meier survival analysis showed 28% 6-month mortality in the long-term acute care facility cohort. Random forest analysis demonstrated that chronic lung disease and postoperative respiratory complications were significant predictors of death at 6 months after discharge to a long-term acute care facility. ConclusionsPatients with chronic lung and kidney disease undergoing prolonged procedures are at higher risk to be discharged to long-term acute care facilities after surgery with worse survival. Efforts to minimize postoperative respiratory complications may reduce mortality after discharge to long-term acute care facilities.

Surgical Outcomes in Octogenarians with Central Cord Syndrome: A Propensity-Score Matched Analysis

IntroductionCentral cord syndrome (CCS) is a traumatic cervical spine injury that is treated with surgical decompression. In octogenarians (80-89), surgeons often opt for conservative management instead due to fears of postoperative complications and prolonged recovery times. This study aims to assess the in-hospital complications and outcomes in octogenarians undergoing surgery compared to those undergoing non-surgical management for CCS. MethodsThe National Trauma Data Bank was queried from 2017 to 2019 for octogenarians with CCS. Patients who received surgical fusion or decompression were divided into the surgery group and the remaining into the non-surgical group. The surgery group was sampled and propensity score matched with the non-surgery group. Student’s t-tests and Pearson’s chi-squared tests were used to test for group differences. ResultsA total of 759 octogenarians with CCS were identified. Following sampling and propensity score matching, 225 patients were identified in each group. The surgery group experienced longer ICU (6.8 days vs. 3.21 days, p < 0.001) and hospital (13.79 days vs. 7.8 days, p < 0.001) lengths of stay (LOS) and higher rates of deep vein thrombosis (4.89% vs. 0.44%, p = 0.02) and ventilator-associated pneumonia (4% vs. 0%, p = 0.02). Patients did not otherwise differ in mortality rate, other hospital complications, and discharge disposition. ConclusionOctogenarians undergoing surgery for CCS experience longer LOS and complications consistent with prolonged hospitalization, but otherwise have similar mortality, hospital complications, and discharge disposition compared to non-surgical treatment. Given the relative lack of short-term drawbacks, surgery should be considered first-line management when the long-term benefits are substantive.

Seasonal Variations in Stroke and a Comparison of the Predictors of Unfavorable Outcomes among Patients with Acute Ischemic Stroke and Cardioembolic Stroke.

We investigated the seasonal variations in stroke in 4040 retrospectively enrolled patients with acute ischemic stroke (AIS) admitted between January 2011 and December 2022, particularly those with cardioembolic (CE) stroke, and compared predictors of unfavorable outcomes between AIS patients and CE stroke patients. The classification of stroke subtypes was based on the Trial of ORG 10172 in Acute Stroke Treatment. Stroke occurrence was stratified by seasons and weekdays or holidays. Of all AIS cases, 18% were of CE stroke. Of all five ischemic stroke subtypes, CE stroke patients were the oldest; received the most thrombolysis and thrombectomy; had the highest initial National Institutes of Stroke Scale (NIHSS) and discharge modified Rankin Scale (mRS) scores; and had the highest rate of in-hospital complications, unfavorable outcomes (mRS > 2), and mortality. The highest CE stroke prevalence was noted in patients aged ≥ 85 years (30.9%); moreover, CE stroke prevalence increased from 14.9% in summer to 23.0% in winter. The main predictors of death in patients with CE stroke were age > 86 years, heart rate > 79 beats/min, initial NIHSS score > 16, neutrophil-to-lymphocyte ratio (NLR) > 6.4, glucose > 159 mg/dL, cancer history, in-hospital complications, and neurological deterioration (ND). The three most dominant factors influencing death, noted in not only patients with AIS but also those with CE stroke, are high initial NIHSS score, ND, and high NLR. We selected the most significant factors to establish nomograms for predicting fatal outcomes. Effective heart rhythm monitoring, particularly in older patients and during winter, may help develop stroke prevention strategies and facilitate early AF detection.

Transcatheter Paravalvular Leak Closure With Covered Stent Tract and Vascular Plug: Tootsie Roll Technique

BackgroundTranscatheter closure of transcatheter heart valve (THV)–related paravalvular leak (PVL) is associated with a high failure rate with available devices due to the complex interaction of THV and aortic/mitral annulus. ObjectivesThis study reports on novel transcatheter techniques to treat PVL after THV. MethodsThe authors describe consecutive patients who underwent PVL closure after transcatheter aortic valve replacement (TAVR) or transcatheter mitral valve replacement (TMVR). A covered self-expanding stent (Viabahn) was deployed in the defect to create a seal between the THV and annulus. A vascular plug (Amplatzer Vascular Plug 2 [AVP2] or AVP4) was then deployed inside the covered stent to obliterate PVL. ResultsEight patients with THV-related PVL were treated using this method (aortic [3 SAPIEN, 1 Evolut], mitral [2 SAPIEN-in-MAC (mitral annular calcification), 2 M3 TMVR). Various combinations of stents and plugs were used (5 mm × 2.5 cm Viabahn + 6 mm AVP4 [n = 2], 8 mm × 2.5 cm Viabahn + 10 mm AVP2 [n = 5], and 10 mm × 5.0 cm Viabahn + 12 mm AVP2 [n = 1]). All had technical success with immediate elimination of target PVL, without in-hospital complications. None had signs of postprocedure hemolysis. All patients were discharged alive (median 3.5 days [Q1-Q3: 1.0-4.8 days]). No residual PVL was seen at discharge, except for 1 patient with mild regurgitation due to another untreated PVL location. One patient died before 30 days due to complication of valve-in-MAC TMVR. In remaining patients, none had recurrence of PVL at 30 days. Symptoms decreased to NYHA functional class I/II in 6 patients. NYHA functional class III symptoms remained in 1 patient with mitral regurgitation awaiting subsequent valve replacement procedure. ConclusionsThe technique of sequential deployment of a covered stent and vascular plug may effectively treat THV-related PVL.

Influencing Factors on the Quality of Lymph Node Dissection for Stage IA Non-Small Cell Lung Cancer: A Retrospective Nationwide Cohort Study.

Lymphadenectomy is an essential part of complete surgical operation for non-small cell lung cancer (NSCLC). This retrospective, multicenter cohort study aimed to identify factors that influence the lymphadenectomy quality. Data were obtained from the Polish Lung Cancer Study Group Database. The primary endpoint was lobe-specific mediastinal lymph node dissection (L-SMLND). The study included 4271 patients who underwent VATS lobectomy for stage IA NSCLC, operated between 2007 and 2022. L-SMLND was performed in 1190 patients (27.9%). The remaining 3081 patients (72.1%) did not meet the L-SMLND criteria. Multivariate logistic regression analysis showed that patients with PET-CT (OR 3.238, 95% CI: 2.315 to 4.529; p < 0.001), with larger tumors (pT1a vs. pT1b vs. pT1c) (OR 1.292; 95% CI: 1.009 to 1.653; p = 0.042), and those operated on by experienced surgeons (OR 1.959, 95% CI: 1.432 to 2.679; p < 0.001) had a higher probability of undergoing L-SMLND. The quality of lymphadenectomy decreased over time (OR 0.647, 95% CI: 0.474 to 0.884; p = 0.006). An analysis of propensity-matched groups showed that more extensive lymph node dissection was not related to in-hospital mortality, complication rates, and hospitalization duration. Actions are needed to improve the quality of lymphadenectomy for NSCLC.

Patterns of firearm related injury in the elderly: A single institution analysis

BackgroundFirearm-related violence (FRV) is a public health crisis in the United States that impacts individuals across the lifespan. This study sought to investigate patterns of injury and outcomes of firearm-related injury (FRI) in elderly victims and the impact of social determinants of health on this age demographic. MethodsA retrospective review of the trauma registry at a large Level I center was performed from 2016–2021. Patients over age 18 were included and FRI was defined by ICD 9 and 10 codes. Comparisons were then made between elderly (age > 65 years) and non-elderly (age 18–64 years) victims. The primary outcome was mortality. Secondary outcomes included hospital and intensive care unit length of stay, in-hospital complications and the impact of distressed community index (DCI) and insurance status on discharge disposition. Results23,975 patients were admitted for traumatic injury and 4,133 (6 %) were elderly. Of these, 134 had penetrating injuries and 72 (54 %) were FRI. The elderly patients had a median age of 69y and they were predominantly black (50 %) males (85%). Over 75 % had some form of government insurance compared to less than 20% in non-elderly (p<0.001). 33 % of elderly FRIs were self-inflicted compared to only 4 % in the non-elderly cohort and their overall mortality rate was 25 % versus 15 % in non-elderly with FRI (p = 0.038). The median DCI for the non-elderly victims was 72.3 [IQR 53.7–93.1] compared to 63.7 [IQR 33.2–83.6] in the elderly (p < 0.001), however, over 50 % of elderly victims were living in “at risk” or “distressed” communities. ConclusionFRV is a public health crisis across the lifespan and elderly individuals represent a vulnerable subset of patients with unique needs and public health considerations. While many interventions target youth and young adults, it is imperative to not overlook the elderly in injury prevention efforts, particularly self-directed violence. Additionally, given most elderly victims were on government funded insurance and had a higher likelihood of requiring more costly discharge dispositions, new policies should take into consideration the potential financial burden of FRV in the elderly.

Pediatric Esophageal Foreign Bodies: The Role of Socioeconomic Status in Ingestion Patterns.

Pediatric esophageal foreign bodies (EFBs) are common and can result in serious complications. Little is known about the influence of socioeconomic status (SES) on EFB ingestion in children. The goal was to study SES as a risk factor for dangerous foreign body ingestion and in-hospital complications in children. This was a retrospective cohort study of children presenting to a tertiary care pediatric hospital with an esophageal foreign body from 2010 to 2021. SES was assessed for each patient by linking their postal code to the Ontario Marginalization Index to determine a quintile score across four dimensions of deprivation: residential instability, material deprivation, dependency, and ethnic concentration. Dangerous EFBs were defined as magnets, batteries, sharp objects, or bones. In-hospital complications included: intensive care unit admission, prolonged length of stay, and postoperative sequelae. A total of 680 patients were included. Dangerous EFB ingestion was higher for children with increased residential instability (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.2-3.6) and increased material deprivation (OR, 2.2; CI, 1.9-2.8), which was similarly true for odds of complications. Odds of dangerous EFB ingestion were higher in older children (OR, 1.1; CI, 1.0-1.1) and odds of complications were higher in children with comorbidities (OR, 1.1; CI, 1.0-1.3). Higher levels of housing instability and material deprivation are associated with dangerous EFB ingestion and complications related to EFB ingestion. These findings emphasize the role that SES plays on child health outcomes and the need for initiatives to mitigate these disparities. 3 Laryngoscope, 134:2945-2953, 2024.

Time and Risk Factors of Trauma-Related Mortality: A 5-Year Retrospective Analysis From a National Level I Trauma Center.

Background: We aimed to analyze in-hospital timing and risk factors for mortality in a level 1 trauma center. Methods: This is a retrospective analysis of all trauma-related mortality between 2013 and 2018. Patients were divided and analyzed based on the time of mortality (early (≤48 h) vs late (>48 h)), and within different age groups. Multivariate regression analysis was performed to predict in-hospital mortality. Results: 8624 trauma admissions and 677 trauma-related deaths occurred (47.7% at the scene and 52.3% in-hospital). Among in-hospital mortality, the majority were males, with a mean age of 35.8 ± 17.2 years. Most deaths occurred within 3-7 days (35%), followed by 33% after 1 week, 20% on the first day, and 12% on the second day of admission. Patients with early mortality were more likely to have a lower Glasgow coma scale, a higher shock index, a higher chest and abdominal abbreviated injury score, and frequently required exploratory laparotomy and massive blood transfusion (P < .005). The injury severity scores and proportions of head injuries were higher in the late mortality group than in the early group. The severity of injuries, blood transfusion, in-hospital complications, and length of intensive care unit stay were comparable among the age groups, whereas mortality was higher in the age group of 19 to 44. The higher proportions of early and late in-hospital deaths were evident in the age group of 24 to 29. In multivariate analysis, the shock index (OR 2.26; 95%CI 1.04-4.925; P = .04) was an independent predictor of early death, whereas head injury was a predictor of late death (OR 4.54; 95%CI 1.92-11.11; P = .001). Conclusion: One-third of trauma-related mortalities occur early after injury. The initial shock index appears to be a reliable hemodynamic indicator for predicting early mortality. Therefore, timely hemostatic resuscitation and appropriate interventions for bleeding control may prevent early mortality.