Increased Charlson Comorbidity Index Research Articles

Stone size is a predictor for residual stone and multiple procedures of endoscopic combined intrarenal surgery

Objectives: The aim of this study was to identify the predictors of treatment results after endoscopic combined intrarenal surgery (ECIRS).Materials and methods: A retrospective analysis was conducted of 75 patients with renal stones who underwent ECIRS and a preoperative non-contrast computed tomography (NCCT) examination. The stone-free rate (SFR), number of primary procedures and perioperative complications were investigated, and the predictors contributing to these three outcomes were analyzed. Stone-free status was determined within 3 months postoperatively using NCCT. The number of primary procedures (defined as ECIRS and/or conventional transurethral lithotripsy) and perioperative complications were reviewed using the medical records.Results: The final SFR after further treatment was 69.3% (52/75 cases). About 70% of all cases underwent only one primary procedure, and the average number of primary procedures was 1.41. From multivariate analysis, increasing stone size (p < 0.001), increasing Charlson Comorbidity Index (p = 0.043) and unfavorable nephrostomy tract (p = 0.046) were independent significant predictors of residual stones, and increasing stone size was the only independent significant predictor of two or more primary procedures (p = 0.017). Overall, 24 out of 75 patients (32%) experienced one or more perioperative complications. Based on multivariate analysis, female gender (p = 0.014) and increasing Hounsfield units (p = 0.006) were significantly associated with perioperative complications.Conclusions: Increasing stone size was an independent predictor for residual stone and multiple procedures of ECIRS. In contrast, increasing number of involved calyces was not predictive, which may be responsible for the combined antegrade and retrograde access. Female gender and increasing Hounsfield units of the stone were significantly associated with perioperative complications of ECIRS, and ECIRS for these patients requires careful attention.

Identification and prediction of health-related quality of life trajectories after a prostate cancer diagnosis.

The aim of our study was to identify physical and mental health-related quality of life (HRQoL) trajectories after a prostate cancer diagnosis and systematically characterize trajectories by behaviours and prognostic factors. Prostate cancer survivors (n = 817) diagnosed between 1997 and 2000 were recruited between 2000 and 2002 into a prospective repeated measurements study. Behavioural/prognostic data were collected through in-person interviews and questionnaires. HRQoL was collected at three post-diagnosis time-points, approximately 2 years apart using the Short Form (SF)-36 validated questionnaire. To identify physical and mental HRQoL trajectories, group-based trajectory modelling was undertaken. Differences between groups were evaluated by assessing influential dropouts (mortality/poor health), behavioural/prognostic factors at diagnosis or during the follow-up. Three trajectories of physical HRQoL were identified including: average-maintaining HRQoL (32.2%), low-declining HRQoL (40.5%) and very low-maintaining HRQoL (27.3%). In addition, three trajectories for mental HRQoL were identified: average-increasing HRQoL (66.5%), above average-declining HRQoL (19.7%) and low-increasing HRQoL (13.8%). In both physical and mental HRQoL, dropout from mortality/poor health differed between trajectories, thus confirming HRQoL and mortality were related. Furthermore, increased Charlson comorbidity index score was consistently associated with physical and mental HRQoL group membership relative to average maintaining groups, while behaviours such as time-varying physical activity was associated with physical HRQoL trajectories but not mental HRQoL trajectories. It was possible to define three trajectories of physical and mental HRQoL after prostate cancer. These data provide insights regarding means for identifying subgroups of prostate cancer survivors with lower or declining HRQoL after diagnosis whom could be targeted for interventions aimed at improving HRQoL.

Duty hour restrictions and surgical complications for head and neck key indicator procedures.

Graduate medical education has traditionally required long work hours, allowing trainees little time for adequate rest. Based on concerns over performance deterioration with sleep deprivation and its effect on patient outcomes, duty hour restrictions have been mandated. We sought to characterize complications from otolaryngology key indicator procedures performed before and after duty hour reform. Retrospective cross-sectional analysis of National Inpatient Sample (NIS). The NIS was queried for procedure codes associated with head and neck key indicator groupings for the years 2000-2002 (45,363 procedures) and 2006-2008 (51,144 procedures). Hospitals were divided into three groups: nonteaching hospitals (NTH), teaching hospitals without otolaryngology programs (TH), and teaching hospitals with otolaryngology programs (TH-OTO). Surgical complication rates, length of stay, and mortality rates were analyzed using logistic and linear regression. The number of procedures increased (12.7%), with TH-OTO contributing more in postrestriction years (21% to 30%). Overall complication rates between the two periods revealed no difference, regardless of hospital setting. Subset analysis showed some variation within each complication within each grouping. Length of stay increased at TH-OTO (2.75 to 2.78 days) and decreased at NTH (2.28 to 2.24 days) and TH (2.39 to 2.36 days). Mortality did not increase among the three hospital types (NTH, P < .58; TH, P < .96; TH-OTO, P < .06). During the latter period, TH-OTO procedures showed lower mortality (P < .0038, odds ratio [OR] = 0.45, 95% confidence interval [CI] = 0.27-0.77). Increasing Charlson comorbidity index increased overall mortality rate (P < .0001, OR = 2.63, 95% CI = 2.4-2.89). Overall complication rates did not change for head and neck key indicator procedures. Moreover, concerns about reduced surgical case numbers appear unfounded, especially for otolaryngology programs. 2c Laryngoscope, 127:1797-1803, 2017.

Therapeutic coma for status epilepticus: Differing practices in a prospective multicenter study.

Our aim was to analyze and compare the use of therapeutic coma (TC) for refractory status epilepticus (SE) across different centers and its effect on outcome. Clinical data for all consecutive adults (>16 years) with SE of all etiologies (except postanoxic) admitted to 4 tertiary care centers belonging to Harvard Affiliated Hospitals (HAH) and the Centre Hospitalier Universitaire Vaudois (CHUV) were prospectively collected and analyzed for TC details, mortality, and duration of hospitalization. Two hundred thirty-six SE episodes in the CHUV and 126 in the HAH were identified. Both groups were homogeneous in demographics, comorbidities, SE characteristics, and Status Epilepticus Severity Score (STESS); TC was used in 25.4% of cases in HAH vs 9.75% in CHUV. After adjustment, TC use was associated with younger age, lower Charlson Comorbidity Index, increasing SE severity, refractory SE, and center (odds ratio 11.3 for HAH vs CHUV, 95% confidence interval 2.47-51.7). Mortality was associated with increasing Charlson Comorbidity Index and STESS, etiology, and refractory SE. Length of stay correlated with STESS, etiology, refractory SE, and use of TC (incidence rate ratio 1.6, 95% confidence interval 1.22-2.11). Use of TC for SE treatment seems markedly different between centers from the United States and Europe, and did not affect mortality considering the whole cohort. However, TC may increase length of hospital stay and related costs. This study provides Class III evidence that for patients with SE, TC does not significantly affect mortality. The study lacked the precision to exclude an important effect of TC on mortality.

Risk Factors for Infection After Knee Arthroscopy: Analysis of 595,083 Cases From 3 United States Databases

To identify and quantify patient- and procedure-related risk factors for post-arthroscopic knee infections using a large dataset. An administrative health care database including 8years of records from 2 large commercial insurers and Medicare (a 5% random sample) was queried to identify all knee arthroscopies performed on patients aged at least 15years using Current Procedural Terminology (CPT) codes. Each CPT code was designated as a high- or low-complexity procedure, with the former typically requiring accessory incisions or increased operative time. Deep infections were identified by a CPT code for incision and drainage within 90days of surgery. Superficial infections were identified by International Classification of Diseases, Ninth Revision infection codes without any record of incision and drainage. Patients were compared based on age, sex, body mass index, tobacco use, presence of diabetes, and Charlson Comorbidity Index. A total of 526,537 patients underwent 595,083 arthroscopic knee procedures. Deep postoperative infections occurred at a rate of 0.22%. Superficial infections occurred at a rate of 0.29%. Tobacco use and morbid obesity were the largest risk factors for deep and superficial infections, respectively (P < .001; relative risk of 1.90 and 2.19, respectively). There were also higher infection rates among patients undergoing relatively high-complexity arthroscopies, men, obese patients, diabetic patients, and younger patients (in order of decreasing relative risk). Increased Charlson Comorbidity Index was associated with superficial and total infections (P < .001). Post-arthroscopic knee infections were more frequent among morbidly obese patients, tobacco users, patients undergoing relatively complex procedures, men, obese patients, diabetic patients, relatively young patients, and patients with increased comorbidity burdens in this study population. This knowledge may allow more informed preoperative counseling, aid surgeons in patient selection, and facilitate infection prevention by targeting individuals with higher inherent risk. Level IV, cross-sectional study.

Predictors of early postoperative voiding dysfunction and other complications following a midurethral sling

The rates reported for postoperative urinary retention following midurethral sling procedures are highly variable. Determining which patients have a higher likelihood of failing a voiding trial will help with preoperative counseling prior to a midurethral sling. The objective of the study was to identify preoperative predictors for failed voiding trial following an isolated midurethral sling. A retrospective, multicenter, case-control study was performed by including all isolated midurethral sling procedures performed between Jan. 1, 2010 to June 30, 2015, at 6 academic centers. We collected demographics, medical and surgical histories, voiding symptoms, urodynamic evaluation, and intraoperative data from the medical record. We excluded patients not eligible for attempted voiding trial after surgery (eg, bladder perforation requiring catheterization). Cases failed a postoperative voiding trial and were discharged with an indwelling catheter or taught intermittent self-catheterization; controls passed a voiding trial. We also recorded any adverse events such as urinary tract infection or voiding dysfunction up to 6 weeks after surgery. Bivariate analyses were completed using Mann-Whitney and Pearson χ2 tests as appropriate. Multivariable stepwise logistic regression was used to determine predictors of failing a voiding trial. A total of 464 patients had an isolated sling (70.9% retropubic, 28.4% transobturator, 0.6% single incision); 101 (21.8%) failed the initial voiding trial. At follow-up visits, 90.4% passed a second voiding trial, and 38.5% of the remainder passed on the third attempt. For the bivariate analyses, prior prolapse or incontinence surgery was similar in cases vs controls (31% vs 28%, P= .610) as were age, race, body mass index, and operative time. Significantly more of the cases (32%) than controls (22%) had a Charlson comorbidity index score of 1 or greater (P= .039). Overactive bladder symptoms of urgency, frequency, and urgency incontinence were similar in both groups as was detrusor overactivity in those with a urodynamic evaluation (29% vs 22%, P= .136), but nocturia was reported more in the cases (50% vs 38%, P= .046). Mean (SD) bladder capacity was similar in both groups (406 [148] mL vs 388 [122] mL, P= .542) as was maximum flow rate with uroflowmetry and pressure flow studies. Cases were significantly more likely to have a voiding type other than detrusor contraction: 37% vs 25%, P= .027, odds ratio, 1.79 (95% confidence interval, 1.07-3.00). There was no difference in voiding trial failures between retropubic and transobturator routes (23.1% vs 18.9%, P= .329). Within 6 weeks of surgery, the frequency of urinary tract infection in cases was greater than controls (20% vs 6%, P < .001; odds ratio, 3.51 [95% confidence interval, 1.82-6.75]). After passing a repeat voiding trial, cases were more likely to present with acute urinary retention (10% vs 3%, P= .003; odds ratio, 4.00 [95% confidence interval, 1.61-9.92]). For multivariable analyses, increasing Charlson comorbidity index increased the risk of a voiding trial failure; apart from this, we did not identify other demographic information among the patients who did not undergo urodynamic evaluation that reliably forecasted a voiding trial failure. The majority of women will pass a voiding trial on the first attempt after an isolated midurethral sling. Current medical comorbidities are predictive of a voiding trial failure, whereas other demographic/examination findings are not. Patients failing the initial voiding trial are at an increased risk of postoperative urinary tract infection or developing acute retention after passing a subsequent voiding trial.

Factors Associated With 20-Year Cumulative Risk of Infection After Aseptic Index Revision Total Knee Arthroplasty

BackgroundThe purpose of this study was to calculate the cumulative risk of periprosthetic joint infection (PJI) after aseptic index knee revisions and to identify the surgical, perioperative, and medical comorbidity risk factors associated with deep infection. MethodsWe retrospectively reviewed 1802 aseptic index revision total knee arthroplasties performed at our institution from 1970 to 2000. From this cohort, there were 60 reoperations performed for deep infection. ResultsThe cumulative risk of infection at 1, 5, 10, and 20 years after index revision was 1%, 2.4%, 3.3%, and 5.6%, respectively. ConclusionsMale gender, use of constrained implants, increased operative times, increased Charlson Comorbidity Index, and a history of liver disease were all significantly associated with PJI. The development of cardiovascular disease, endocrine disorders, and renal disease were also associated with PJI.

Crystalloid administration among patients undergoing liver surgery: Defining patient- and provider-level variation

Fluid administration among patients undergoing liver resection is a key aspect of perioperative care. We sought to examine practice patterns of crystalloid administration, as well as potential factors associated with receipt of crystalloid fluids. Patients who underwent liver resection between 2010 and 2014 were identified. Data on clinicopathologic variables, operative details, and perioperative fluid administration were collected and analyzed using univariable and multivariable analyses; variation in practice of crystalloid administration was presented as coefficient of variation (COV). Among 487 patients, median crystalloid administered at the time of surgery was 4,000mL. After adjusting for body size and operative duration, median corrected crystalloid was 30.0mL kg(-1) m(2) h(-1), corresponding with a COV of 35%. Patients who received <30 mL kg(-1) m(2) h(-1) crystalloids were more likely to be younger (58 vs 60years), white (79% vs 74%), and have a higher body mass index (BMI; 28.2 vs 25.4kg/m(2); all P<.001). On multivariable analysis, increasing Charlson comorbidity index, BMI, estimated blood loss, and each additional hour of surgery were all associated with increased crystalloid administration (all P<.05). Corrected crystalloid administration varied among providers with a corrected COV ranging from 14% to 61%. When overall variation in crystalloid administration was assessed, 80% of the variation occurred at the patient level, and 20% occurred at the provider level (surgeon, 3% vs anesthesiologist, 17%). There was wide variability in crystalloid administration among patients undergoing liver resection. Although the majority of variation was attributable to patient factors, a large amount of residual variation was attributable to provider-level differences.

Determinants of outcomes following resection for pancreatic cancer – An Australian population-based study

s / Pancreatology 15 (2015) S1eS141 S85 Patients & methods: Data were collected manually from patient records in two states of Australia for all patients diagnosed with pancreatic cancer between July 2009 and June 2011. Determinants of attempted resectionwere estimated using multivariable logistic regression analyses. Results: Of the cohort 740 patients had stage I-III disease. Of these 38 (5%) declined surgery and 320 (43%) had an attempted resection. Patient factors associated with likelihood of surgery were being male (adjusted odds ratio (AOR) 1.48; 95% confidence interval (CI) 1.00 e 2.18), decreasing performance status (AOR 0.38, 95% CI 0.29 to 0.50), age (AOR 0.93, 95% CI 0.91 to 0.95 per year of age) and increasing Charlson co-morbidity index (AOR 0.79, 95% CI 0.64 to 0.97). Patients seen initially in the private system were more likely to undergo surgery (AOR 1.48, 95% CI 1.00 to 2.19). Being first seen in a facility that admittedmore pancreatic cancer cases increased the likelihood of receiving an attempted resection (AOR 1.47, 95% CI 1.08 to 2.01). Conclusion: Health service and patient factors are determinants of attempted resection for patients with non-metastatic pancreatic cancer.

Contemporary 90-day mortality rates after radical cystectomy in the elderly

IntroductionExisting radical cystectomy (RC) perioperative mortality estimates may underestimate the contemporary rates due to more advanced age, more baseline comorbidities and potentially broader inclusion criteria for RC, relative to past criteria. MethodsWithin the most recent Surveillance, Epidemiology, and End Results (SEER)-Medicare database we identified clinically non-metastatic, muscle-invasive (T2–T4a) urothelial carcinoma of the urinary bladder (UCUB) patients, who underwent RC between 1991 and 2009. Mortality at 30- and 90-day after RC was quantified. Multivariable logistic regression analyses tested predictors of 90-day mortality. ResultsWithin 5207 assessable RC patients 30- and 90-day mortality rates were 5.2 and 10.6%, respectively. According to age 65–69, 70–79 and ≥80 years, 90-day mortality rates were 6.4, 10.1 and 14.8% (p < 0.001). Additionally, 90-day mortality rates increased with increasing Charlson Comorbidity Index (CCI, 0, 1, 2 and ≥3): 6.3, 10.3, 12.6 and 15.9% (p < 0.001). 90-day mortality rate in unmarried patients was 13.0 vs. 9.3% in married individuals (p < 0.001). In multivariable logistic regression analyses, advanced age, higher CCI, low socioeconomic status, unmarried status and non organ-confined stage were independent predictors of 90-day mortality (all p < 0.05). ConclusionsThe contemporary SEER-Medicare derived 90-day mortality rates are substantially higher than previously reported estimates from centers of excellence, and even exceed previous SEER reports. More advanced age, higher CCI score, and other patient characteristics that distinguish the current population from others account for these differences.

Results of Ventricular Septal Myectomy and Hypertrophic Cardiomyopathy (from Nationwide Inpatient Sample [1998–2010

Ventricular septal myomectomy (VSM) is the primary modality for left ventricular outflow tract gradient reduction in patients with obstructive hypertrophic cardiomyopathy with refractory symptoms. Comprehensive postprocedural data for VSM from a large multicenter registry are sparse. The primary objective of this study was to evaluate postprocedural mortality, complications, length of stay (LOS), and cost of hospitalization after VSM and to further appraise the multivariate predictors of these outcomes. The Healthcare Cost and Utilization Project's Nationwide Inpatient Sample was queried from 1998 through 2010 using International Classification of Diseases, Ninth Revision, procedure codes 37.33 for VSM and 425.1 for hypertrophic cardiomyopathy. The severity of co-morbidities was defined using the Charlson co-morbidity index. Hierarchical mixed-effects models were generated to identify independent multivariate predictors of in-hospital mortality, procedural complications, LOS, and cost of hospitalization. The overall mortality was 5.9%. Almost 9% (8.7%) of patients had postprocedural complete heart block requiring pacemakers. Increasing Charlson co-morbidity index was associated with a higher rate of complications and mortality (odds ratio 2.41, 95% confidence interval 1.17 to 4.98, p=0.02). The mean cost of hospitalization was $41,715 ± $1,611, while the average LOS was 8.89 ± 0.35days. Occurrence of any postoperative complication was associated with increased cost of hospitalization (+$33,870, p <0.001) and LOS (+6.08days, p <0.001). In conclusion, the postoperative mortality rate for VSM was 5.9%; cardiac complications were most common, specifically complete heart block. Age and increasing severity of co-morbidities were predictive of poorer outcomes, while a higher burden of postoperative complications was associated with a higher cost of hospitalization and LOS.

Resource utilization and survival among Medicare patients with advanced liver disease.

The prevalence of advanced liver disease and its complications may be on the rise within the Medicare population. The study aim was trend assessment for prevalence, mortality and resource utilization of patients with advanced liver disease. A retrospective, cross-sectional design was used to analyze a national sample of non-institutionalized Medicare in/outpatients from 2005 to 2009. Cases were ascertained by International Classification of Diseases, 9th Edition. Outcomes were overall mortality (within 1 year) and resource utilization [hospital length of stay (LOS/days) and institutional costs to Medicare]. Multivariate analyses were used to estimate the odds ratios for mortality predictors; linear regression was used for resource utilization predictors. A total of 21,913 beneficiaries with advanced liver disease were identified in the Medicare inpatient and outpatient administrative data sets from 2005 to 2009. Over 70 % of the beneficiaries with advanced liver disease died during study time period with 17 % dying while hospitalized. Predictors of mortality were: admission to the intensive care unit (ICU) and increasing Charlson Comorbidity Index. Predictors for increased LOS and cost were: ICU admission and having a thoracentesis procedure (both indicators of the levels of illness). Advanced liver disease and its related complication are increasing in the Medicare population and are associated with very high mortality. Further study is warranted to understand the drivers of the increased prevalence of advanced liver disease for earlier identification and treatment.

Do physicians with diabetes have differences in dialysis use and survival than other patients with diabetes

AimsTo assess whether the increased knowledge and resources available to physicians led to differences in dialysis and survival rates between physicians and non-physician patients with diabetes. MethodsAll newly diagnosed (1997–2009) type 2 diabetes patients aged ≥35 years from the National Health Insurance Program of Taiwan database were included. After propensity score matching (1:10), we estimated the relative risk of dialysis and death using Cox proportional hazards model adjusted for demographic characteristics and comorbidities. ResultsPhysicians with diabetes were more likely to start dialysis than general patients, with a 48% increased hazard risk (HR) (P=0.006). Physicians with diabetes had significantly lower risk of death (HR: 0.88; P=0.025). However, those requiring dialysis had a non-significant increased risk of death (HR: 1.19). There was an increased HR for death in older physicians (HR: 1.81; P<0.001) and those with cancer or catastrophic illness. The HR of dialysis (7.89; P<0.0001) increased dramatically with increasing Charlson Comorbidity Index scores. ConclusionsPhysicians with DM survived longer than other patients with diabetes, likely benefiting from their professional resources in disease control and prevention. Nonetheless, they displayed no advantage from their medical backgrounds compared with the general patients if they developed end stage renal disease.

Nationwide shoulder arthroplasty rates and revision burden in Germany: analysis of the national hospitalization data 2005 to 2006

The aim of this study was to provide nationwide shoulder arthroplasty rates in Germany based on the national hospitalization file and to estimate the revision burden for shoulder arthroplasty and its determinants. We analyzed the nationwide, population-based, German diagnosis-related groups data from the years 2005 and 2006. Procedure codes and diagnosis were analyzed for each hospitalization. Overall, 16,488 primary shoulder arthroplasties and 1302 revisions were performed during the study period. Age-standardized rates, age-specific rates, rates by indication, and revision burden were calculated. The age-standardized hemiarthroplasty (HA) rates were 3.6 per 100,000 person-years (standard error [SE], 0.1) for men and 9.3 per 100,000 person-years (SE, 0.1) for women and clearly exceeded the age-standardized total shoulder arthroplasty (TSA) rates of 1.7 per 100,000 person years (SE, 0.1) for men and 3.7 per 100,000 person-years (SE, 0.1) for women. The revision burden was 4.7% for HA and 15.0% for TSA. Multivariable-adjusted analysis showed increasing age was associated with a lower relative burden of revision, and an increased Charlson comorbidity index and male gender were associated with a higher relative burden of revision. The adjusted relative burden of revision was considerably higher for TSA than for HA (adjusted relative burden of revision, 2.89; 95% confidence interval, 2.60-3.22). We found more than 2-fold higher primary rates for HA than for TSA and up to 3-fold higher shoulder arthroplasty rates for women than for men. TSA had a 3-fold higher relative burden of revision than HA.

Surgical management of esophageal diverticulum: a review of the Nationwide Inpatient Sample database

BackgroundEsophageal diverticulum is rare in the United States. The mainstay treatment of symptomatic esophageal diverticulum is surgical correction. Much of the available information regarding esophageal diverticulum and its surgical management has been derived from small studies and institutional reviews. Our study objective was to investigate the demographics, perioperative conditions, and predictors of outcomes after surgical treatment of acquired esophageal diverticulum using a nationally representative database. MethodsA retrospective review using the Nationwide Inpatient Sample database from 2000–2009 was performed for patients with acquired esophageal diverticulum. The patients were stratified into Zenker's diverticulum (ZD) or non-Zenker’s diverticulum (NZD) subgroups. The covariates retrieved included age, gender, ethnicity, insurance type, and Charlson comorbidity index. A multivariate analysis was performed to determine the predictors of postoperative morbidity. Discharge-level weights were applied. ResultsOverall, a total of 4253 patients met our inclusion criteria, 3197 (75%) with ZD and 1056 (25%) with NZD. In the ZD group, the mean age was 73 ± 12.3 y, and most were men (55%) and white (67%). The mean length of stay was 5.82 ± 8.08 d, and the mortality rate was 1.2%. The most common complication was septicemia or sepsis (2.0%). The black patients had higher odds of postoperative morbidity than the white patients (odds ratio [OR] 2.29, 95% confidence interval [CI] 1.02–5.17). The risk of overall postoperative morbidity was 52% greater for women (OR 1.52, 95% CI 1.01–2.29). An increasing Charlson comorbidity index was an independent predictor of morbidity. In the NZD group, the mean age was 69 ± 13.9 y, and most were also men (51%) and white (63%). The mean length of stay was 8.13 ± 10.56 d, and the mortality rate was 1.6%. The most common complication was air leak (3.1%). The black and Hispanic patients had higher odds of postoperative morbidity than the white patients (OR 1.97, 95% CI 1.05–3.72 and OR 2.37, 95% CI 1.06–5.30, respectively). An increasing Charlson comorbidity index was an independent predictor of morbidity. Compared with laparoscopy, the risk of developing postoperative morbidity was higher with the thoracotomy procedure (OR 7.45, 95% CI 1.11–50.18). ConclusionsUsing a nationally representative database, our study found that female gender, black race, and the presence of comorbidities were associated with increased postoperative morbidity among patients with ZD. Among the patients with NZD, black and Hispanic patients had worse postoperative morbidity than the white patients, and the presence of comorbidities was associated with increased postoperative morbidity. Thoracotomy for the correction of NZD was associated with increased postoperative morbidity compared with the laparoscopic approach.

Persistent nasal methicillin-resistant staphylococcus aureus carriage in hemodialysis outpatients: a predictor of worse outcome

BackgroundNasal colonization with methicillin-resistant Staphylococcus aureus (MRSA) is a well defined risk factor for subsequent bacteremia and death in various groups of patients, but its impact on outcome in patients receiving long-term hemodialysis (HD) is under debate.MethodsThis prospective interventional cohort study (performed 2004 to 2010) enrolled 289 HD outpatients of an urban dialysis-unit. Nasal swab cultures for MRSA were performed in all patients upon first admission, at transfer from another dialysis facility or readmission after hospitalisation. Nasal MRSA carriers were treated in a separate ward and received mupirocin nasal ointment. Concomitant extra-nasal MRSA colonization was treated with 0.2% chlorhexidine mouth rinse (throat) or octenidine dihydrochloride containing antiseptic soaps and 2% chlorhexidine body washes (skin). Clinical data and outcome of carriers and noncarriers were systematically analyzed.ResultsThe screening approach identified 34 nasal MRSA carriers (11.7%). Extra-nasal MRSA colonization was observed in 11/34 (32%) nasal MRSA carriers. History of malignancy and an increased Charlson Comorbidity Index were significant predictors for nasal MRSA carriers, whereas traditional risk factors for MRSA colonization or markers of inflammation or malnutrition were not able to discriminate. Kaplan-Meier analysis demonstrated significant survival differences between MRSA carriers and noncarriers. Mupirocin ointment persistently eliminated nasal MRSA colonization in 26/34 (73.5%) patients. Persistent nasal MRSA carriers with failure of this eradication approach had an extremely poor prognosis with an all-cause mortality rate >85%.ConclusionsNasal MRSA carriage with failure of mupirocin decolonization was associated with increased mortality despite a lack of overt clinical signs of infection. Further studies are needed to demonstrate whether nasal MRSA colonization represents a novel predictor of worse outcome or just another surrogate marker of the burden of comorbid diseases leading to fatal outcome in HD patients.

73 PATIENT COMORBIDITY STRATIFIED BY CHARLSON INDEX IS PREDICTIVE OF MEDICAL COMPLICATIONS FOLLOWING PARTIAL NEPHRECTOMY

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-Based Medicine & Outcomes (II)1 Apr 201373 PATIENT COMORBIDITY STRATIFIED BY CHARLSON INDEX IS PREDICTIVE OF MEDICAL COMPLICATIONS FOLLOWING PARTIAL NEPHRECTOMY Jay Simhan, Marc Smaldone, Kevin Tsai, Tianyu Li, Daniel Canter, Anthony Corcoran, Serge Ginzburg, Steven Sterious, Zachary Piotrowski, Rosalia Viterbo, David Chen, Richard Greenberg, Alexander Kutikov, and Robert Uzzo Jay SimhanJay Simhan Philadelphia, PA More articles by this author , Marc SmaldoneMarc Smaldone Philadelphia, PA More articles by this author , Kevin TsaiKevin Tsai Philadelphia, PA More articles by this author , Tianyu LiTianyu Li Philadelphia, PA More articles by this author , Daniel CanterDaniel Canter Philadelphia, PA More articles by this author , Anthony CorcoranAnthony Corcoran Philadelphia, PA More articles by this author , Serge GinzburgSerge Ginzburg Philadelphia, PA More articles by this author , Steven SteriousSteven Sterious Philadelphia, PA More articles by this author , Zachary PiotrowskiZachary Piotrowski Philadelphia, PA More articles by this author , Rosalia ViterboRosalia Viterbo Philadelphia, PA More articles by this author , David ChenDavid Chen Philadelphia, PA More articles by this author , Richard GreenbergRichard Greenberg Philadelphia, PA More articles by this author , Alexander KutikovAlexander Kutikov Philadelphia, PA More articles by this author , and Robert UzzoRobert Uzzo Philadelphia, PA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2013.02.1451AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The impact of comorbidity on adverse events following partial nephrectomy (PN) is poorly characterized. Our objective was to assess the association between patient comorbidity stratified by Charlson Comorbidity Index (CCI) and complication rates following PN. METHODS We queried our prospectively maintained institutional kidney cancer database for all patients undergoing PN from 2007-2011. Postoperative complications within 30 days of PN, determined using the Clavien-Dindo classification system (CCS), were classified as medical or surgical in type and further stratified by minor (CCS I-II) and major (III-V) severity. Patient and tumor characteristics were compared between complication groups using Wilcoxon and Chi-square tests. The relationship between CCI and any complication, medical/surgical complications, and medical/surgical complications stratified by severity were assessed using logistic regression analyses controlling for age, race, gender, CCI, body mass index, estimated blood loss (EBL), ECOG score, ASA score, nephrometry score (NS), operative time, and surgical approach. RESULTS 512 patients (median age 59yrs, 64.3% male) underwent PN (median NS 8.0, median tumor size 3.0cm) with median follow-up of 23 months (range 5-48mo). All patients were stratified into cohorts developing any complication (35.2%), any medical (18.4%)/surgical (23.4%) complication, and patients sustaining major/minor medical (2.5%/16.8%) or surgical (8.8%/17.6%) complications after surgery. Compared to patients with no complications, those who incurred any complication tended to have greater NS (p<0.001), ASA score (p<0.005), EBL (p<0.001), operative time (p<0.001), and preoperative tumor size (p<0.001). Controlling for patient and clinical characteristics, increasing CCI was associated with the development of any complication (OR 1.11, CI 1.01-1.21), any medical complication (OR 1.14, CI 1.01-1.28), and any major medical complication (OR 1.66, CI 1.25-2.21) following PN. In contrast, no associations between CCI and surgical complications (in aggregate or stratified by severity) were demonstrated. CONCLUSIONS In our cohort, increasing Charlson Comorbidity Index is an independent predictor of the development of any Clavien graded medical complication and any major medical complication following PN. This association should be objectified in published reports and integrated into the decision-making and counseling of patients with competing medical risks that present with localized renal tumors. © 2013 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 189Issue 4SApril 2013Page: e30 Advertisement Copyright & Permissions© 2013 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jay Simhan Philadelphia, PA More articles by this author Marc Smaldone Philadelphia, PA More articles by this author Kevin Tsai Philadelphia, PA More articles by this author Tianyu Li Philadelphia, PA More articles by this author Daniel Canter Philadelphia, PA More articles by this author Anthony Corcoran Philadelphia, PA More articles by this author Serge Ginzburg Philadelphia, PA More articles by this author Steven Sterious Philadelphia, PA More articles by this author Zachary Piotrowski Philadelphia, PA More articles by this author Rosalia Viterbo Philadelphia, PA More articles by this author David Chen Philadelphia, PA More articles by this author Richard Greenberg Philadelphia, PA More articles by this author Alexander Kutikov Philadelphia, PA More articles by this author Robert Uzzo Philadelphia, PA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Complications in acute phase hospitalization of traumatic spinal cord injury

Optimal timing of surgery after a traumatic spinal cord injury (SCI) is one of the most controversial subjects in spine surgery. We assessed the relationship between surgical timing and the occurrence of nonneurologic postoperative complications during acute hospital stay for patients with a traumatic SCI. A retrospective cohort study was performed in a single institution. Four hundred thirty-one cases of traumatic SCI were reviewed, and postoperative complications were recorded from the medical charts. Patients were compared using two different surgical timing cutoffs (24 hours and 72 hours). Logistic regression analyses were modeled for complication occurrence. The effect of surgical timing on complication rate was adjusted for potential confounding variables such as the level of injury, American Spinal Injury Association (ASIA) grade, Injury Severity Score (ISS), age, sex, Charlson Comorbidity Index, and Surgical Invasiveness Index. Patients operated on earlier were younger, had less comorbidity, had a higher ISS, and were more likely to have a cervical lesion and a complete injury (ASIA A). A reduction in the global rate of complications as well as in the rate of pneumonias and pressure ulcers were predicted by surgery performed earlier than 72 hours and 24 hours. Increasing age, more severe ASIA grade, and cervical lesion as well as increased Charlson Comorbidity Index, ISS, and SII were also statistically related to the occurrence of complications. This study showed that a shorter surgical delay after a traumatic SCI decreases the rate of complications during the acute phase hospitalization. We suggest that patients with traumatic SCI should be promptly operated on earlier than 24 hours following the injury to reduce complications while optimizing neurologic recovery. If medical or practical reasons preclude timing less than 24 hours, efforts should still be made to perform surgery earlier than 72 hours following the SCI. Prognostic study, level III; therapeutic/care management study, level IV.

Physiology, Not Chronology, Dictates Outcomes after Esophagectomy for Esophageal Cancer: Outcomes in Patients 80 Years and Older

To assess short and long-term outcomes for patients aged ≥80 years undergoing esophagectomy for malignancy. All patients undergoing esophagectomy for cancer between 1991 and 2011 had information prospectively entered into a database; patients were divided into elderly (≥80 years) and younger (<80 years) groups. Of the 500 patients included, 32 (6.4%) were ≥80 years of age. Octogenarians had increased Charlson comorbidity index and were less likely to receive neoadjuvant chemoradiotherapy (6.3 vs. 39.7%). Analysis of operative time, estimated blood loss, and length of intensive care unit and hospital stay revealed no significant differences between the groups. Patients ≥80 years old had increased total postoperative morbidity (68.8 vs. 44.9%), specifically arrhythmia (31.3 vs. 16.7%) and pneumonia (18.8 vs. 8.3%). There were no in-hospital mortalities in patients ≥80 years (0 vs. 0.4%), and there was no significant difference in overall survival between the groups (53.2 ± 9.1 vs. 77.6 ± 4.8 months; P = 0.58). Subset analysis demonstrated similar morbidity and length of hospital stay for patients between 70 and 79 years (n = 132) and those ≥80 years. Elderly patients undergoing esophagectomy are at greater risk of postoperative complications. However, there were no significant differences in other major parameters, including length of hospital stay, mortality, and survival, indicating that selected patients ≥80 years old can and should be assessed by an experienced surgeon.

Multidisciplinary Care and Pursuit of Active Surveillance in Low-Risk Prostate Cancer

Multidisciplinary clinics offer a unique approach to the management of patients with cancer. Yet, limited data exist to show that such clinics affect management. The purpose of this study was to determine whether consultation at a multidisciplinary clinic is associated with selection of active surveillance in patients with low-risk prostate cancer. The study comprised 701 men with low-risk prostate cancer managed at three tertiary care centers in Boston, MA in 2009. Patients either obtained consultation at a multidisciplinary prostate cancer clinic, at which they were seen by a combination of urologic, radiation, and medical oncologists in a concurrent setting, or they were seen by individual practitioners in sequential settings. The primary outcome was selection of active surveillance. Crude rates of selection of active surveillance in patients seen at a multidisciplinary clinic were double that of patients seen by individual practitioners (43% v 22%), whereas the proportion of men treated with prostatectomy or radiation decreased by approximately 30% (P < .001). On multivariate logistic regression, older age (odds ratio [OR], 1.09; 95% CI, 1.05 to 1.12; P < .001), unmarried status (OR, 1.66; 95% CI, 1.01 to 2.72; P = .04), increased Charlson comorbidity index (OR, 1.37; 95% CI, 1.06 to 1.77; P = .02), fewer positive cores (OR, 0.92; 95% CI, 0.90 to 0.94; P < .001), and consultation at a multidisciplinary clinic (OR, 2.15; 95% CI, 1.13 to 4.10; P = .02) were significantly associated with pursuit of active surveillance. Multidisciplinary care is associated with increased selection of active surveillance in men with low-risk prostate cancer. This finding may have an important clinical, social, and economic impact.