Increased Charlson Comorbidity Index Research Articles

305 The Frequency of Point-of-Care Ultrasound Use in the Treatment of Sepsis in the Emergency Department: A Retrospective Cohort Study

A role for point-of-care ultrasound (POCUS) in the care of septic patients has been previously proposed; however, the degree to which POCUS has been integrated into sepsis care in the community emergency department (ED) is unknown. Our aim was to better understand the current role of POCUS in sepsis care by examining its frequency of use and the types of exams performed. This retrospective cohort study analyzed 5, 264 ED visits for sepsis across two community hospitals from January 2014 to December 2018. Patients 18 years or older with an ED diagnosis of sepsis and either lactate ≥4 mmol, a documented mean arterial pressure < 65mmHg, or a systolic blood pressure < 90mmHg were eligible for inclusion. Eligible encounters underwent chart review to determine if POCUS was used during their ED evaluation. Primary outcomes were frequency of POCUS use in the cohort, change in frequency of POCUS use over the study period, and the types of exams performed. Odds ratios (OR), confidence intervals (CI), and p-values (p) were calculated to assess relationships between variables and POCUS use. POCUS was used in 21% of encounters meeting inclusion criteria and was positively correlated with ED arrival year (OR=1.09; 95% CI: 1.04 - 1.15; p=0.001). The most common POCUS exam was for central venous catheter (CVC) placement (37%); however, use of this exam did not increase over the study period. The second and third most common exams performed were cardiac (18%) and inferior vena cava (IVC) exams (11%), respectively. Only the frequency of cardiac, IVC, lung and Focused Assessment with Sonography for Trauma (FAST) exams increased significantly over the study period. Certain patient characteristics, including obese BMI (OR=1.28; 95% CI: 1.10 - 1.49; p=0.002) and increased Charlson comorbidity index (OR=1.03; 95% CI: 1.00 - 1.05; p=0.03), were associated with increased odds of receiving POCUS. A code status of DNR prior to ED arrival conferred lower odds of receiving POCUS (OR=0.74; 95% CI: 0.62 - 0.90; p=0.002). POCUS use increased significantly over time in this cohort of septic patients. This suggests increasing incorporation of ultrasound into sepsis care and a potential role for cardiac, IVC, and lung exams in the evaluation and treatment of septic patients. Further studies are needed to assess the generalizability of these findings, and determine if POCUS use affects treatment decisions or patient outcomes.

Incidence Rates and Case-Fatality Rates of Cerebral Vein Thrombosis: A Population-Based Study.

Cerebral vein thrombosis (CVT) incidence is estimated to be >10 per 1 000 000 per year. Few population-based studies investigating case-fatality rates (CFRs) and pyogenic/nonpyogenic CVT incidence are available. We assessed trends in CVT incidence between 2002 and 2012, as well as adjusted in-hospital CFRs and incidence of hospital admissions for pyogenic/nonpyogenic CVT in a large Northwestern Italian epidemiological study. Primary and secondary discharge diagnoses of pyogenic/nonpyogenic CVT were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes 325, 671.5, and 437.6. Age, sex, vital status at discharge, length of hospital stay, and up to 5 secondary discharge diagnoses were collected. Concomitant presence of intracerebral hemorrhage (ICH) was registered, and comorbidities were assessed through the Charlson comorbidity index. A total of 1718 patients were hospitalized for CVT (1147 females—66.8%; 810 pyogenic and 908 nonpyogenic CVT, 47.1% and 52.9%, respectively), with 134 patients (7.8%) experiencing a concomitant ICH. The overall incidence rate for CVT was 11.6 per 1 000 000 inhabitants with a sex-specific rate of 15.1 and 7.8 per 1 000 000 in females and males, respectively. CVT incidence significantly increased in women during time of observation (P=0.007), with the highest incidence being at 40 to 44 years (27.0 cases per 1 000 000). In-hospital CFR was 3%, with no difference between pyogenic/nonpyogenic CVT. Patients with concomitant ICH had a higher in-hospital CFR compared with patients without ICH (7.5% versus 2.7%; odds ratio, 2.96 [95% CI, 1.45–6.04]). In-hospital CFR progressively increased with increasing Charlson comorbidity index (P=0.003). Age (odds ratio, 1.03 [95% CI, 1.02–1.05]), Charlson comorbidity index ≥4 (odds ratio, 4.33 [95% CI, 1.29–14.52]), and ICH (odds ratio, 3.05 [95% CI, 1.40–6.62]) were independent predictors of in-hospital mortality. In a large epidemiological study, CVT incidence was found to be comparable to the one registered in population-based studies reported after the year 2000. CVT incidence increased among women over time. In-hospital CFR was low, but not negligible, in patients with concomitant ICH. Age, ICH, and a high number of comorbidities were independent predictors of in-hospital mortality. Pyogenic CVT was not a predictor of in-hospital CFR, although its high proportion was not confirmed by internal validation.

Predictors of the timing of interval cytoreduction based on the number of cycles of neoadjuvant chemotherapy: a retrospective cohort

Objectives: To identify pretreatment clinical variables in ovarian cancer patients undergoing neoadjuvant chemotherapy that predict a delayed interval cytoreductive surgery. Methods: We performed an (institutional review board) IRB-approved retrospective cohort study of advanced-stage ovarian cancer patients at a single, academic, tertiary-referral center. Patients from 2008-2017 with stage III or IV disease who received NACT were included in the study. Patients without a pathologic or cytologic diagnosis, those who did not have treatment records, and those who underwent surgery at another institution were excluded. Patients who underwent interval cytoreduction (IDS) prior to their 4th cycle were compared against those who required 4 or more cycles, as our institution's practice is to undergo cytoreduction after 3 cycles if an optimal debulking is achievable. Chi-square and t-tests were used to compare clinical, radiographic, laboratory, and pathologic variables between the groups. Results: A total of 123 patients were included in the study: 70 (56.9%) patients underwent surgery at <4 cycles and 53 (43.1%) required 4 or more cycles. There was no difference in terms of age, renal function, or primary tumor size at time of diagnosis (Table 1) per number of cycles of NACT prior to IDS for either group. Patients also had a similar decrease in their Ca-125 values as measured by pre-op nadir (283.3 vs 356.6, p=0.69). Patients who underwent interval debulking surgery at <4 cycles were more likely to have a lower Charlson Comorbidity index (5.3 compared to 6.3, p=0.007) and a higher albumin (3.33 compared to 3.00, p=0.007). Not surprisingly, patients with IDS after fewer cycles received their chemotherapy in a shorter mean time period (47.2 vs 103.7 days, p<0.0001). Both groups restarted chemotherapy in a similar time frame after IDS. Conclusions: Patients with increased Charlson Comorbidity Index and a lower baseline albumin were more likely to require 4 or more cycles prior to proceeding with surgery after neoadjuvant chemotherapy for ovarian carcinoma. Ongoing assessment of these variables and other variables prior to initiating NACT may provide guidance regarding anticipated patient outcomes. To identify pretreatment clinical variables in ovarian cancer patients undergoing neoadjuvant chemotherapy that predict a delayed interval cytoreductive surgery. We performed an (institutional review board) IRB-approved retrospective cohort study of advanced-stage ovarian cancer patients at a single, academic, tertiary-referral center. Patients from 2008-2017 with stage III or IV disease who received NACT were included in the study. Patients without a pathologic or cytologic diagnosis, those who did not have treatment records, and those who underwent surgery at another institution were excluded. Patients who underwent interval cytoreduction (IDS) prior to their 4th cycle were compared against those who required 4 or more cycles, as our institution's practice is to undergo cytoreduction after 3 cycles if an optimal debulking is achievable. Chi-square and t-tests were used to compare clinical, radiographic, laboratory, and pathologic variables between the groups. A total of 123 patients were included in the study: 70 (56.9%) patients underwent surgery at <4 cycles and 53 (43.1%) required 4 or more cycles. There was no difference in terms of age, renal function, or primary tumor size at time of diagnosis (Table 1) per number of cycles of NACT prior to IDS for either group. Patients also had a similar decrease in their Ca-125 values as measured by pre-op nadir (283.3 vs 356.6, p=0.69). Patients who underwent interval debulking surgery at <4 cycles were more likely to have a lower Charlson Comorbidity index (5.3 compared to 6.3, p=0.007) and a higher albumin (3.33 compared to 3.00, p=0.007). Not surprisingly, patients with IDS after fewer cycles received their chemotherapy in a shorter mean time period (47.2 vs 103.7 days, p<0.0001). Both groups restarted chemotherapy in a similar time frame after IDS. Patients with increased Charlson Comorbidity Index and a lower baseline albumin were more likely to require 4 or more cycles prior to proceeding with surgery after neoadjuvant chemotherapy for ovarian carcinoma. Ongoing assessment of these variables and other variables prior to initiating NACT may provide guidance regarding anticipated patient outcomes.

Disparities in refusal of surgery for gynecologic cancer

<h3>Objectives:</h3> To characterize socioeconomic and clinical factors associated with refusal of gynecologic cancer surgery. <h3>Methods:</h3> The National Cancer DataBase (NCDB) was surveyed for patients with uterine, cervical, or ovarian cancer treated at participating Commission on Cancer sites between 2004 and 2017. Demographic and clinical data were abstracted, descriptive statistics and Pearson's chi squared tests performed. Univariate and multivariate logistic regression were performed to examine the association between variables and refusal of surgery, with the threshold for two-sided significance set at p<0.05. <h3>Results:</h3> Of the 938 773 patients with gynecologic cancer included in the NCDB, 5875 patients (0.6%) did not undergo surgery and had documented refusal. On univariate analysis, age, race, Hispanic ethnicity, rural residence, lower median household income, regional high school graduation rate, facility type (academic vs community), geographic location and distance to treating hospital, disease site, stage, and increasing Charlson comorbidity index were all associated with refusal of surgery (p<0.05).On multivariate analysis, patients who refused surgery were older at diagnosis (72.3 ±16.1 vs 60.8 ±13.7 years, p<0.001), more likely Black (OR 1.86 95% CI 1.72-2.01), Native Hawaiian or Pacific Islander (OR 3.24 95% CI 2.24-4.70) or Native American (OR 1.66 95% CI 1.05-2.61). Refusal of surgery was associated with uninsured status (OR 2.40 95% CI 2.09-2.76), Medicare as primary payer (OR 1.43 95% CI 1.32-1.55), and residence in an area in the lowest national quartile of high school graduation (OR 1.17 95% CI 1.05-1.30). Treatment location <10 miles from primary residence was associated with refusal as receiving treatment (OR 2.46 95% CI 2.02-3.01), as was treatment in the Northeast (OR 1.24 95% CI 1.13-1.36), and at a community hospital (OR 2.2 95% CI 2.0-2.38). Patients who refused surgery were more likely to have ovarian or primary peritoneal cancer (OR 1.38 95% CI 1.25-1.51), and more likely to have advanced stage disease (OR 2.88 95% CI 2.64-3.15) or a Charlson comorbidity index >3 (OR 1.34 95% CI 1.16-1.56). Clinical trial enrollment was not associated with refusal. <h3>Conclusions:</h3> Multiple social, racial, economic, and systematic factors that impact marginalized members of society are independently associated with refusal of NCCN guideline-indicated surgery. Refusal of surgery is more common in underserved patients and may represent another aspect of healthcare disparity that deserves closer attention.

Case Characteristics, Resource Utilisation, and In-Hospital Mortality of 13,503 COVID-19 Patients Admitted to 566 Hospitals in Japan: An Observational Study

Background: Studies of in-hospital mortality of COVID-19 patients among high-income countries with low infection rates with a nationwide database are scarce. We aimed to describe and gain comprehensive insight regard to in-hospital mortality, medical resource use of mechanical ventilators and ICU admission, and patient characteristics from COVID-19 patients in Japan. Method: This is a retrospective observational study using the nationwide insurance claims data of the DPC database in Japan. The study cohort included hospitalized patients aged 18 years or older with a diagnosis of COVID-19, based on patient data with completing hospital course from January 1, 2020 to September 30, 2020. Multivariate analysis using restricted cubic spline curves showed the relationships between in-hospital mortality and age, male sex, increased body mass index, decreased Barthel Index for activities of daily living, comorbidities based on Charlson comorbidity index and its score. Findings: During the study period, 13503 of the patients admitted for COVID-19 completed hospital course. The overall in-hospital mortality was 4·1%, and 3·0% (393 of 13005) in the non-ventilated group and 31·5% (157 of 498) in the ventilated group. The age-specific in-hospital mortality was higher in the older age, with in-hospital mortality of 31·0% in aged 80 years and more in the early pandemic period of March 2020, and declined to 14·9% even in the second pandemic in August 2020. 13005 patients (96·3%) completed their course without mechanical ventilation and 498 patients (3·7%) with mechanical ventilation. The overall median age was 50 years (IQR 33–68). The milder the COVID-19, the younger the median age tended to be: median 44 years (IQR 29–59) without any respiratory support, median 69 years (IQR 55–80) in the supplemental oxygen group, and median 69 years (IQR 58–78) in the ventilated group. In the multivariate analysis, an older age, male sex, increased body mass index, increased Charlson Comorbidity Index score and decreased Barthel Index were associated with the risk of in-hospital mortality. Interpretation: The in-hospital mortality rate for patients hospitalized with COVID-19 in Japan during the study period was considerably lower than that reported in previous studies using nationwide databases in other countries. This may reflect the low infection rate in Japan and the fact that the burden on medical resources did not exceed capacity. In the context of a pandemic, controlling the burden on medical resources is one of the important key factors for improving in-hospital mortality in patients with COVID-19. Funding Information: Ministry of Health, Labour and Welfare, Japan.Declaration of Interests: We declare no competing interests.Ethics Approval Statement: The study was conducted following the Ethical Guidelines for Medical Research Involving Human Subjects established by the Ministry of Health, Labour and Welfare, and was approved by the Ethics Committee of Tokyo Medical and Dental University (Research Ethics Committee No. M2000-788).

The Association of Psoriatic Arthritis With All-cause Mortality and Leading Causes of Death in Psoriatic Arthritis.

To examine the association between psoriatic arthritis (PsA) and all-cause mortality from a large population-based database. Patients with PsA from the Clalit Health Services database were identified between 2003-2018 and matched to 4 controls by age, sex, ethnicity, and index date. Patient demographics, comorbidities, and treatments were extracted. Mortality data were obtained from the Israeli Notification of Death certificate. The proportionate mortality rate (PMR) of the leading causes of death was calculated and compared to that of the general population. Cox proportional hazard regression models were used to estimate the crude and the multivariate adjusted HR for the association between PsA and all-cause mortality and for factors associated with mortality within the PsA group. There were 5275 patients with PsA and 21,011 controls included and followed for 7.2 ± 4.4 years. The mean age was 51.7 ± 15.4 years, and 53% were females. Among patients with PsA, 38.2% were on biologics. Four hundred seventy-one (8.9%) patients died in the PsA group compared to 1668 (7.9%) in the control group. The crude HR for the association of PsA and all-cause mortality was 1.16 (95% CI 1.04-1.29) and 1.02 (95% CI 0.90-1.15) on multivariate analysis. Malignancy was the leading cause of death (26%), followed by ischemic heart disease (15.8%); this is in keeping with the leading causes of death in the general population. Older age, male sex, lower socioeconomic status, increased BMI, increased Charlson comorbidity index scores, and history of psoriasis or hospitalization in 1 year prior to entry were positive predictors for mortality. No clinically relevant increase in mortality rate was observed in patients with PsA, and specific PMRs were similar to those of the general population.

Risk factors and associated outcomes of acute kidney injury in hip fracture patients

PurposeTo assess risk factors and associated outcomes of acute kidney injury (AKI) in hip fracture patients. MethodsRisk factors for AKI were identified by multivariate logistic regression. AKI patients were matched to patients who did not experience AKI using a validated trauma triage score. Comparative analyses between matched groups were performed. ResultsRisk factors of AKI included increasing Charlson Comorbidity Index and use of anticoagulation medications. AKI was associated with increased likelihood of medical complications and longer, more costly hospital stays. DiscussionPatients with identified risk factors for AKI may benefit from consultation with nephrology and closer lab monitoring.

Transfusion timing relative to surgery does not impact outcomes in hip fracture patients.

The purpose of this study is to determine the effects of blood transfusion timing in hip fracture patients. A consecutive series of hip fracture patients 55years and older who required a blood transfusion during hospitalization were reviewed for demographic, injury, clinical outcome, and cost information. A validated risk predictive score (STTGMA) was calculated for each patient. Patients were stratified to preoperative, intraoperative, or postoperative first transfusion cohorts. The intraoperative and postoperative cohorts were matched by STTGMA, sex, and procedure to the preoperative cohort. Baseline patient characteristics and outcomes were compared before and after matching. Prior to matching, the preoperative cohort was more often male (p < 0.001) with increased Charlson comorbidity index (p = 0.012), ASA class (p < 0.002), STTGMA (p < 0.001), total transfused volume (p = 0.002), incidence of inpatient mortality (p = 0.045), myocardial infarction (p = 0.005) and cardiac arrest (p = 0.014). After matching, the preoperative cohort had increased total transfused volume (p = 0.015) and decreased pneumonia incidence (p = 0.040). Matching STTGMA score, sex, and procedure results in non-inferior outcomes among hip fracture patients receiving preoperative first blood transfusions compared to intraoperative and postoperative transfusions.

The impact of COVID-19 on breast cancer stage at diagnosis.

528 Background: During the SARS-CoV-2 pandemic, routine screening mammography (SM) was stopped and diagnostic mammography (DM) was limited for several months across the United States in order to reduce patient exposure and redeploy medical personnel. We hypothesized that this delay would result in patients presenting with later-stage disease following the initial shutdown. Methods: Patients diagnosed with invasive breast cancers from 2016-2020 were identified using the Beth Israel Deaconess Medical Center Cancer Registry. Baseline patient characteristics, demographics, and clinical information were gathered and cross-referenced with our electronic medical record. Late-stage disease was defined as initial anatomic stage III-IV disease in the AJCC 8th edition staging system. The control cohort consisted of patients diagnosed from 2016-2019; patients diagnosed in 2020 were the test cohort. Chi-squared analysis was used to compare monthly distributions in stage at diagnosis between the control and test cohorts. Multivariate analysis was performed using a logistic regression model. Results: There were 1597 patients diagnosed with invasive breast cancer between 2016-2019 and 333 in 2020. Median age at diagnosis was 60 years; 99% were female, and 69.1% were white. Mammography was limited from 3/16/20-6/8/20, with 90% reduction in volume during this time. The number of screening studies performed in March, April, May, and June of 2020 were 987, 1, 4, and 721 compared to 2042, 2141, 2241, and 2142 in 2019. The volume of new diagnoses per month decreased substantially during the shutdown (see table). The proportion of patients diagnosed with late-stage disease was 6.6% in the control cohort compared to 12.6% in the 2020 test cohort (p &lt; 0.001); 92.9% of late-stage diagnoses in 2020 occurred from June to December following the shutdown period. On multivariate analysis, year of diagnosis (2020 vs 2016-2019; OR = 4.25 95% CI 0.035-0.095, p &lt; 0.001), lower income (&lt;200% of the federal poverty level; OR = 2.73 95% CI 0.016-0.099, p = 0.006) and increased Charlson Comorbidity Index (OR = 12.01 95% CI 0.037-0.052, p &lt; 0.001) were associated with later stage at diagnosis. Conclusions: Patients were more likely to be diagnosed with late-stage breast cancer following the global shutdown due to the SARS-CoV-2 pandemic. Patients with lower income and medical comorbidities were disproportionately affected. These data raise significant concerns regarding the impact of SARS-CoV-2 on cancer diagnoses and long-term outcomes, especially in vulnerable patient populations.[Table: see text]

Outcomes of Older Patients with Resectable Colorectal Liver Metastases Cancer (CRLM): Single Center Experience.

Surgery is the only potential curative option of CRLM if resectable. The curative approach in patients over 70 years old is challenging mainly because of comorbidities and other geriatric syndromes. Herein, we report outcomes of older patients with resectable CRLM in our center. We retrospectively analyzed characteristics and outcomes of older patients with CRLM operated at “Centre Hospitalier de l’Université de Montréal” (CHUM) between 2010 and 2019. We identified 210 patients aged ≥70 years with a median age of 76 (range: 70–85). CRLM were synchronous in 56% of patients. Median disease-free survival (DFS) was 41.3 months. Median overall survival (OS) was 62.2 months and estimated 5-year survival rate was 51.5% similar to those of younger counterparts. Patients with metachronous CRLM had a trend to a higher OS compared to those with synchronous disease (67.2 vs. 58.7 months; p = 0.42). Factors associated with lower survival in the multivariate analysis were right-sided tumors and increased Charlson Comorbidity index (CCI). Survival outcomes of patients aged ≥70 years were comparable to those of younger patients and those reported in the literature. Age should not be a limiting factor in the curative management of older patients with resectable CRLM.

Geriatric emergency department revisits after discharge with Potentially Inappropriate Medications: A retrospective cohort study.

To determine whether Potentially Inappropriate Medications (PIMs) prescribed in an academic emergency department (ED) are associated with increased ED revisits in older adults. A retrospective chart review of Medicare beneficiaries 65 years and older, discharged from an academic ED (January 2012 - November 2015) with any PIMs versus no PIMs. PIMs were defined using Category 1 of the 2015 Updated Beers criteria. Primary outcomes, obtained from a Medicare database linked to hospital ED subjects, were ED revisits 3 and 30 days from index ED discharge. Adjusted multiple logistic regression was used with entropy balance weighted covariates: Age in years, Gender, Race, Number of discharge medications, Charlson Comorbidity Index (CCI) score, Emergency Severity Index scores (ESI), Chief Complaint, Medicaid status, and prior 90 Day ED visits. Over the study period, there were a total of 7,591 Medicare beneficiaries 65+ discharged from the ED with a prescription; 1,383 (18%) received one or more PIMs. ED revisits in 30 days were fewer for the PIMs cohort (12% PIMs vs 16% no PIMs, OR 0.79, 95% CI 0.65 - 0.95, P value <0.005). Hospital admissions in 30 days were fewer for the PIMs cohort (4 PIMs vs 7% no PIMs, OR 0.75, 95% CI 0.56 - 1.00, P value <0.005). In addition to PIMs, covariate risk factors associated with ED revisits in 30 days included comorbidity severity, history of prior ED revisits, chief complaint, and Medicaid status. Risk factors associated with hospitalization in 30 days included those plus age and emergency severity index, but not race nor ethnicity. Patients discharged from the ED receiving potentially inappropriate medications as defined by Category 1 of the 2015 updated Beers criteria had lower odds of revisiting the ED within 30 days of index visit. Sociodemographic factors such as gender and race did not predict ED revisits or hospital admissions. Clinical characteristics predicted ED revisits and hospital admissions, the strongest risk being increasing Charlson Comorbidity Index score followed by triage acuity and chief complaint. Future studies are needed to delineate the implications of our findings.

Long-Term Health-Related Quality of Life (HRQoL) After Redo-Fundoplication

BackgroundWe aim to shed light on long-term subjective outcomes after re-operations for failed fundoplication.Methods1809 patients were operated on for hiatal hernia and/or gastroesophageal reflux disease (GERD) at the Helsinki University Hospital between 2000 and 2017. 111 (6%) of these had undergone a re-operation for a failed antireflux operation. Overall, HRQoL was assessed in 89 patients at the latest follow-up using the generic 15D© instrument. The results were compared to a sample of the general population, weighted to reflect the age and gender distribution of patients. Disease-specific HRQoL was assessed using the GERD-HRQoL questionnaire. We studied variation in the overall HRQoL with respect to disease-specific HRQoL and known patients' parameters using univariate and multivariable linear regression models.ResultsThe median postoperative follow-up period was 9.3 years. All patients were operated on laparoscopically (6% conversion rate), and 87% were satisfied with the re-operation. Postoperative complications were minimal (5%). Twelve patients (11%) underwent a second re-operation. The median GERD-HRQoL score was nine. In multivariable analysis, four variables were independently associated with the 15D score, suggesting a decrease in the 15D score with increasing GERD-HRQoL score, increasing Charlson Comorbidity Index (CCI) and the presence of chronic pain syndrome (CPS) and depression.ConclusionRe-do LF is a safe procedure in experienced hands and may offer acceptable long-term alleviation in patients with recurring symptoms after antireflux surgery. Decreased HRQoL in the long run is related to recurring GERD and co-morbidities.

National health disparities in incisional hernia repair outcomes: An analysis of the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS) 2012-2014

BackgroundIncisional hernias represent an acquired defect from failed healing of an abdominal facial incision and are therefore distinct from primary hernias. While literature regarding incisional hernia incidence, risk factors, and treatment are abundant, no study has examined national health disparities specific to incisional hernia repair. The objective of this study was to analyze national health disparities unique to surgical incisional hernia repair procedures. MethodsPatient data queried from the Healthcare Cost and Utilization Project National Inpatient Sample from 2012 to 2014 using International Classification of Diseases 9th revision procedure codes for incisional hernia repair were used to generate univariate and multivariate models including demographics, socioeconomic factors, admission status, and hospital characteristics. Primary outcomes were nonelective admission status, in-hospital mortality, surgical complications, and extended duration of stay. ResultsWe estimated that 89,258 incisional hernia repair procedures occurred annually from 2012 to 2014, incurring $6.3 billion in hospital charges. By multivariate analysis, multiple risk factors contribute to significantly increased odds of nonelective repair. These include age over 65, female sex, non-White race, nonprivate insurance, obesity, and increased Charlson comorbidity index. Nonelective incisional hernia repair was strongly correlated with worse outcomes including in-hospital mortality (odds ratio [95% confidence interval] 3.01 [2.51, 3.61]), postoperative complications (odds ratio 1.2 [1.14, 1.25]), and extended duration of stay (odds ratio 2.96 [2.81, 3.12]). After controlling for admission status, other disparities persisted including extended duration of stay for Black individuals (odds ratio 1.21 (1.12, 1.31]). ConclusionProviders should be aware of these significant health disparities in incisional hernia repair status and outcomes especially for elderly, non-White, nonprivate insurance, and obese/comorbid patients. Management strategies that increase access to elective repair and that prevent incisional hernia should be expanded to address these disparities.

Predictors for 30-Day Readmissions After Traumatic Brain Injury.

To examine predictors for 30-day readmission post-onset of traumatic brain injury (TBI) after initial trauma hospitalization. Retrospective cohort. In total, 5284 patients with an acute TBI admitted from January 1, 2006, through December 31, 2015. Demographic and clinical data after initial TBI onset were extracted from the local trauma registry and matched with the Dallas-Fort Worth Hospital Council registry. Multiple logistic regression analysis was used to determine factors significantly associated with 30-day readmission. Top diagnosis codes for 30-day readmission were also described. Patients were primarily male (64.6%), non-Hispanic White (47.6%), uninsured (35.4%), and aged 46.1 ± 23.3 years. In total, 448 patients (8.5%) had a 30-day readmission. Median cumulative charges for each readmitted subject was $34 313. Factors significantly associated with 30-day readmission were falling as the cause of injury, having increased Charlson Comorbidity Index and Injury Severity Score, and discharging to a skilled nursing facility or long-term acute care. Being uninsured was associated with decreased odds of a 30-day readmission. Top diagnosis codes among the readmission visits included cardiac codes (57.7%), fluid and acid-base disorders (54.8%), and hypertension (50.1%). These data highlight those at risk for 30-day readmission across a diverse population of TBI at a large medical center. Interventions such as health literacy education or patient navigation may help mitigate 30-day readmission for at-risk patients.

Serum potassium as a predictor of adverse clinical outcomes in patients with increasing comorbidity burden.

AimsThe aim of this study was to establish whether patients with multiple comorbidities may be at elevated risk of hyperkalaemia (HK), a potentially life-threatening electrolyte imbalance, and the associated adverse clinical outcomes.Methods and resultsThis was a retrospective, observational cohort study using UK primary and secondary care data. Adult patients with at least one of: resistant hypertension, chronic kidney disease stage 3+, dialysis, heart failure (HF), and diabetes, were eligible for inclusion. According to their diagnoses, patients were grouped into overlapping cohorts that were updated as multimorbidity progressed. Outcomes of interest were incident HK, all-cause mortality (ACM), and major adverse cardiovascular events (MACE). A total of 673 686 patients met the eligibility criteria, 36.3% of whom developed multimorbidity during the study period. A consistent U-shaped association was observed between serum K+ level and adjusted incidence of ACM and MACE. Hyperkalaemia was progressively more common with increasing Charlson Comorbidity Index (CCI). Relative to a CCI <3, scores of ≥3 to <6, and ≥6 were associated with 2.9- and 6.2-fold increases, respectively, in crude HK (serum K+ ≥5.0 mmol/L) incidence rate. In all condition-based cohorts except for HF, there was a clear correlation between increasing CCI and the risk of ACM and MACE associated with hypokalaemia and HK.ConclusionPatients with a higher CCI are at an increased risk of developing HK and appear more prone to adverse clinical outcomes associated with abnormal serum K+ levels, warranting additional routine clinical monitoring.

Incidence and Risk Factors of Recurrent Clostridioides difficile Infection in Patients With Cirrhosis.

INTRODUCTION:Clostridioides difficile infection (CDI) is common in patients with cirrhosis and is associated with poor outcomes. CDI risk factors in this population have been well characterized; however, risk factors of recurrent CDI (R-CDI) after treatment have not been explored. We sought to estimate the incidence of R-CDI and its associated risk factors in patients with cirrhosis.METHODS:We performed a cohort study of patients with cirrhosis hospitalized with CDI between 2012 and 2016. We collected patient characteristics, including detailed information on the CDI, features of the underlying liver disease, and outcomes including R-CDI, hospital readmission, and mortality. R-CDI was defined as CDI occurring 2–8 weeks after the initial episode. Cox proportional hazards model was used to identify variables independently associated with the outcomes.RESULTS:A total of 257 hospitalized patients with cirrhosis and CDI were included. CDI was community associated in 22.6%. The incidence of R-CDI was 11.9%. R-CDI was not significantly associated with medications at hospital admission or discharge. Independent risk factors of R-CDI included increased Charlson Comorbidity Index (hazard ratio [HR] 1.30; 95% confidence interval [CI]: 1.09–1.55) and use of lactulose (HR 2.58; 95% CI: 1.09–6.09). The 30-day readmission rate was 37%, and readmission was associated with increased Charlson Comorbidity Index (HR 1.12; 95% CI: 1.03–1.23) and Model for End-Stage Liver Disease score (HR 1.04; 95% CI: 1.01–1.07). The 90-day mortality was 22.8%.DISCUSSION:In patients with cirrhosis, R-CDI is associated with comorbidity burden and lactulose use. Attention to these factors might aid clinicians in efforts to prevent R-CDI and improve outcomes in this population.

Characteristics and outcomes among a hospitalized patient cohort with Streptococcus pneumoniae infection.

Infection due to Streptococcus pneumoniae (SP) requiring hospitalization is common. However, recent clinical studies describing patient characteristics and outcomes for SP infection in adults requiring hospitalization are lacking. Our goal was to evaluate patient characteristics, contemporary antibiotic resistance, and clinical outcomes among hospitalized adults with SP infections.A retrospective cohort study was conducted at Barnes-Jewish Hospital (1350 beds) in St. Louis, Missouri, USA for years 2012 through 2016. During the study period, 358 hospitalized adults, excluding those with meningitis, were identified with SP infection. Forty-four patients (12.3%) died within 30 days of the identification of their infection. Among these infections, 99 (27.7%) were assessed to be hospital-acquired and 259 (72.3%) were community-onset infections. The majority of infections involved the respiratory tract (88.5%). Azithromycin resistance was the most common antibiotic resistance at 51.4%, followed by enteral penicillin resistance (45.3%), trimethoprim-sulfamethoxazole (34.1%), second-generation cephalosporin (cefuroxime) (30.7%), and meropenem (22.6%). There were 70 isolates (19.6%) classified as multidrug resistant. Independent predictors of hospital mortality included increasing weight in 1-kilogram increments (adjusted odds ratio [AOR], 1.02; 95% CI, 1.01 – 1.02; P = .048), increasing Charlson Comorbidity Index scores (AOR, 1.31; 95% CI, 1.21 – 1.42; P = .001), and the presence of septic shock (AOR, 3.89; 95% CI, 2.31 – 6.57; P = .009). The median [interquartile range] hospital length of stay was 8.1 days [4.5 days, 16.8 days].Hospitalized patients with infection attributed to SP have significant 30-day mortality and use of hospital resources. Antibiotic resistance is common among isolates associated with infection. Determinants of mortality are primarily severity of illness, underlying comorbidities and increasing patient weight. Efforts to improve the treatment and prevention of SP infections are needed.

Patient and surgery factors associated with the incidence of failed and difficult intubation.

Estimates of the rate and risk-factors for difficult airway rarely include a denominator for the number of anaesthetics. Approaches such as self-reporting and crowd-sourcing of airway incidents may help identify specific lessons from clinical episodes, but the lack of denominator data, biased reporting and under-reporting does not allow a comprehensive population-based assessment. We used an established state-wide dataset to determine the incidence of failed and difficult intubations between 2015 and 2017 in the state of Victoria in Australia, along with associated patient and surgical risk-factors. A total of 861,533 general anaesthesia episodes were analysed. Of these, 4092 patients with difficult or failed intubation were identified; incidence rates of 0.52% (2015-2016) and 0.43% (2016-2017), respectively. Difficult/failed intubations were most common in patients aged 45-75 and decreased for older age groups, with risk being lower for patients aged>85 than patients aged 35-44. The risk for failed/difficult intubation increased significantly for: patients undergoing emergency surgery (OR 1.80); obese patients (OR 2.48); increased ASA physical status; and increased Charlson Comorbidity Index. Across all age groups, procedures on the nervous system (OR 1.92) and endocrine system (OR 2.03) had the highest risk of failed/difficult intubation. The relative reduced risk for failed/difficult intubations in the elderly population is a novel finding that contrasts with previous research and may suggest a 'compression of morbidity' effect as a moderator. Administrative databases have the potential to improve understanding of peri-operative risk of rare events at a population level.

Risk Factors for Unplanned Admission to the Intensive Care Unit After Elective Total Joint Arthroplasty

BackgroundDespite improved surgical and anesthesia techniques, as well as advances in perioperative protocols, a number of patients undergoing total joint arthroplasty (TJA) are at risk of serious medical complications that require intensive care unit (ICU) admission. With the recent move toward performing TJA in ambulatory surgical centers and on an outpatient basis, it is important to recognize patients that may require intensive care in the postoperative period. This study aimed to identify risk factors for ICU admission following elective total hip (THA) and knee (TKA) arthroplasty. MethodsWe evaluated 12,342 THA procedures, with 132 ICU admissions, and 10,976 TKA procedures, with 114 ICU admissions from 2005 to 2017. Demographic, preoperative, and surgical variables were collected and compared between cohorts using both univariate and logistic regression analysis. ResultsFor THA, logistic regression analysis demonstrated older age, bilateral procedure, revision surgery, increased Charlson comorbidity index, general anesthesia, increased estimated blood loss, decreased preoperative hemoglobin, and increased preoperative glucose level were independently associated factors for increased risk of ICU admission. For TKA, increased age, increased body mass index, bilateral procedure, revision surgery, increased Charlson comorbidity index, increased estimated blood loss, general anesthesia, and increased preoperative glucose were independently significantly associated with ICU admission. ConclusionIn this study, we identify a number of critical independent risk factors which may place patients at increased risk of ICU admission following THA and TKA. Identification of these risk factors may help surgeons safely select those TJA candidates appropriate for surgery at facilities that do not have ICUs readily available.

P129 INPATIENT OUTCOMES OF SEPSIS IN INFLAMMATORY BOWEL DISEASE PATIENTS: A 2016 NATIONWIDE INPATIENT SAMPLE ANALYSIS

Abstract Introduction Patients with inflammatory bowel disease are at increased risk of infections due to the immunosuppressive drugs used for its treatment and by the virtue of the disease itself. The risk of infection is further exacerbated by decreased host response to vaccines. Objective The objective of this study is to determine the outcomes of sepsis in patients with Inflammatory bowel disease (IBD). Methods The 2016 National Inpatient Sample database was used to identify patients admitted with primary diagnosis of sepsis using ICD 10 code. The subgroup analysis was done to identify patients with IBD. IBD patients were further subdivided into Ulcerative colitis and Crohn’s disease. We analyzed inpatient demographics using chi-square. Predictors of inpatient mortality were calculated using univariate and multivariable regression models. Results 1,899,169 patients were admitted for sepsis in 2016. 10,485 UC and 13,879 CD patients with sepsis were identified. UC patients admitted with sepsis had a higher mortality (47.9%) compared to CD patients (37.8%). After adjusting for potential confounders, CD was associated lower odds of mortality as compared to UC (aOR 0.77, 95% CI 0.60–0.97, P=0.031). Independent predictors of mortality were Age (aOR 1.02, 95% CI 0.60–0.97, P=0.031) and increased Charlson comorbidity index (aOR 1.76, 95%CI 1.27–2.44 P=0.001). Acute renal failure patients requiring inpatient hemodialysis (aOR 2.8, 95% CI 1.9–4.1,P=0.000) and patients with septic shock requiring pressor support(aOR 1.6 95% CI 1.01–2.51, P=0.044) were also associated with higher odds of mortality. Severe malnourishment (aOR 0.005, 95% CI 1.18–2.62, P=0.005) and patients who developed obstruction (aOR 1.9, 95% CI 1.3–2.7, P=0.001) were also associated independent predictors of mortality on multivariate logistic regression. Conclusions Sepsis admissions in CD patients had better outcomes compared with UC patients. Age, Charlson comorbidity index, renal function and nutritional status of patient were useful tools to predict mortality. Further, research is needed to identify other predictors and to determine the mechanisms of underlying clinical differences.