Independent Predictors Of Prolonged Hospital Research Articles

Sex-related differences in the impact of nutritional status on length of hospital stay in atrial fibrillation: a retrospective cohort study.

Nutritional status is related to the length of hospitalization of patients with atrial fibrillation (AF). The aim of this study is to assess the prognostic impact of nutritional status and body mass index on length of hospital stay (LOHS) among patients with AF relative to their sex. A retrospective analysis of the medical records of 1,342 patients admitted urgently with a diagnosis of AF (ICD10: I48) to the Cardiology Department (University Hospital in Wroclaw, Poland) between January 2017 and June 2021. In the study group, women were significantly older than men (72.94 ± 9.56 vs. 65.11 ± 12.68, p < 0.001). In an unadjusted linear regression model, malnutrition risk was a significant independent predictor of prolonged hospitalization in men (B = 1.95, p = 0.003) but not in women. In the age-adjusted linear regression model, malnutrition risk was a significant independent predictor of prolonged hospitalization in men (B = 1.843, p = 0.005) but not in women. In the model adjusted for age and comorbidities, malnutrition risk was a significant independent predictor of prolonged hospitalization in men only (B = 1.285, p = 0.043). In none of the models was BMI score a predictor of LOHS in either sex. The risk of malnutrition directly predicts the length of hospital stays in men but not women. The study did not find a relationship between body mass index and length of hospital stay in both women and men.

Clinical relevance of bronchiectasis in patients with community-acquired pneumonia

BackgroundData regarding the clinical characteristics and treatment outcomes of patients with community-acquired pneumonia (CAP) and bronchiectasis (BE) are rare. This study aims to elucidate the clinical relevance of BE in patients with CAP. MethodsPatients hospitalized with CAP in a single center were retrospectively analyzed and divided into significant BE (BE with ≥ 3 lobes or cystic BE on computed tomography) and control groups. Clinical and microbiological characteristics were compared between the two groups. ResultsIn the final analysis, 2112 patients were included, and 104 (4.9%) had significant BE. The significant BE group exhibited a higher prevalence of sputum production, dyspnea, and complicated parapneumonic effusion or empyema than the control group. Pseudomonas aeruginosa was more frequently isolated in the significant BE group than in the control group, whereas Mycoplasma pneumoniae was less commonly identified. Length of hospital stay (LOS) was significantly longer in the significant BE group than the control group (12 [8–17] days vs. 9 [6–13] days, p < 0.001). In contrast, 30-day and in-hospital mortality rates did not significantly differ between the two groups. Furthermore, significant BE was an independent predictor of prolonged hospitalization in two models based on CURB-65 and pneumonia severity index. ConclusionsSignificant BE occurred in approximately 5% of patients with CAP and was more likely to be associated with sputum, dyspnea, complicated parapneumonic effusion or empyema, and isolation of P. aeruginosa. Significant BE was an independent predictor of LOS in patients with CAP.

Disse index and free fatty acids as markers of insulin resistance and their association with hospital outcomes of coronary bypass surgery in patients with different glycemic status

AIM: to analyze various indices of insulin resistance and plasma free fatty acid (FFA) levels, and their association with the preoperative status and in-hospital complications after coronary artery bypass grafting (CABG) in normoglycemic patients and patients with carbohydrate metabolism disorders (CMD).MATERIALS AND METHODS: The study included 708 patients who underwent CABG. The glycemic status, preoperative parameters, the specifics of surgical intervention, in-hospital complications were analyzed. The patients were divided into 2 groups: Group 1 (n=266) — patients with CMD (type 2 diabetes mellitus (T2DM) and prediabetes); Group 2 (n=442) — patients without CMD. Plasma FFA and fasting plasma insulin levels were determined, the Disse index, the quantitative insulin sensitivity check index (QUICKI), revised QUICKI were estimated in 383 patients.RESULTS: Screening prior to CABG increased the number of patients with T2DM from 15.2% to 24.1%, prediabetes – from 3.0% to 13.4%, with any CMD – from 18.2% to 37.5%.Patients with CMD showed a higher percentage of significant hospital complications (25.2% vs 17.0%, p=0.007), progression of renal failure (6.3% vs 2.9%, p=0.021), multiple organ failure (4.5% vs 1.7%, p=0.039), sternal wound complications (6.3% vs 2.9%, p=0.018), renal replacement therapy (3.7% vs 1.1%, p=0.020), surgery on peripheral arteries (1.5% vs 0%, p=0.039).According to the results of multivariate analysis, the Disse index turned out to be a significant predictor of the end point (hospital stay &gt;10 days or any significant complication CABG) in several regression models (OR 1.060 in one of the models; 95% CI 1.016–1.105; p=0.006). Independent predictors of the end point were: female gender, age, body mass index, cardiopulmonary bypass duration, left atrium size, left ventricular end diastolic dimension, T2DM, FFA levels (OR 3.335; 95% CI 1.076–10.327; p=0.036), average postoperative glycemia on the 1st day after CABG, failure to achieve the target range of perioperative glycemia.CONCLUSION: Screening for CMD prior to CABG can significantly increase the number of patients with diagnosed CMD. Significant in-hospital complications after CABG tend to be more prevalent in patients with CMD compared with normoglycemic patients. Insulin resistance index Disse, FFA, postoperative glycemia are independent predictors of prolonged hospital stay or postoperative complications of CABG.

Validation of Asian Body Mass Index Cutoff Values for the Classification of Malnutrition Severity According to the Global Leadership Initiative on Malnutrition Criteria in Patients with Chronic Obstructive Pulmonary Disease Exacerbations.

Low body mass index (BMI) is an independent predictor of prolonged hospital stay and mortality in patients with chronic obstructive pulmonary disease (COPD). However, to the best of our knowledge, no studies have examined the validity of Asian BMI cutoff values for classifying severity based on the Global Leadership Initiative on Malnutrition (GLIM) criteria in patients with acute COPD exacerbations. This study sought to validate whether Asian BMI cutoff values can accurately predict 30-day in-hospital mortality, length of stay, and 90-day readmission outcomes for patients with acute COPD exacerbations. The present retrospective cohort study was conducted using a large claims database created by the JMDC. Patients were classified into three groups according to the severity of low BMI assessed using Asian BMI cutoff values. As a result, 624 (29.4%) had severely low BMI, and 444 (20.9%) had moderately low BMI. The severity of low BMI, as assessed by the Asian BMI cutoff values used in the GLIM criteria, was independently associated with 30-day in-hospital mortality (moderately low BMI: HR, 1.87; 95% CI, 1.13-3.08; p = 0.014 and severely low BMI: HR, 2.55; 95% CI, 1.66-3.92; p &lt; 0.001). The Asian BMI cutoff values used to classify the severity of malnutrition in the GLIM criteria are clinically functional for predicting the prognosis of patients with acute COPD exacerbations.

Prognostic value of platelet count-related ratios on admission in patients with pyogenic liver abscess

ObjectiveThe purpose of the current study was to evaluate the association between C-reactive protein-to-platelet ratio (CPR), neutrophil-to-lymphocyte*platelet ratio (NLPR) and fibrinogen-to-platelet ratio (FPR) and the prognoses of pyogenic liver abscess (PLA) patients.MethodsA cohort of 372 patients with confirmed PLA were enrolled in this retrospective study between 2015 and 2021. Laboratory data were collected on admission within 24 h. The demographic characteristics and clinical features were recorded. Risk factors for outcomes of PLA patients were determined via multivariate logistic regression analyses, and optimal cut-off values were estimated by using the receiver operating characteristic (ROC) curve analysis.ResultsOut of 372 patients, 57.8% were men, 80 (21.5%) developed sepsis, and 33 (8.9%) developed septic shock. The levels of CPR, NLPR and FPR were significantly increased in the development of sepsis, and prolonged hospital stays in PLA patients. The multivariate logistic regression analysis indicated that the CPR (OR: 2.262, 95% CI: 1.586–3.226, p < 0.001), NLPR (OR: 1.118, 95% CI: 1.070–1.167, p < 0.001) and FPR (OR: 1.197, 95% CI: 1.079–1.329, p = 0.001) were independent risks of PLA patients with sepsis, and NLPR (OR: 1.019, 95% CI: 1.004–1.046, p = 0.019) was shown to be an independent predictor of prolonged hospital stays. The ROC curve results showed that the three biomarkers had different predictive values, and CPR proved to work best, with a ROC value of 0.851 (95% CI: 0.807–0.896, p < 0.001) for sepsis.ConclusionHigher levels of CPR, NLPR and FPR were associated with a higher risk of poor outcomes. Moreover, a high CPR level performed best when predicting the clinical outcome in PLA patients.

Predicting Patients at Risk for Prolonged Hospital Stays Following Pediatrics Traumatic Head Injuries in High-Income Developing Country: A Retrospective Cohort Study

Traumatic brain injuries (TBIs) in pediatrics are the most common cause of long-term morbidity and mortality, generating a considerable burden on the health care system. In the current retrospective study, we aimed to identify the predictors that contribute to prolonged hospital stays in pediatric TBI. A retrospective cohort study including all pediatric cases (age younger than 14) who presented to Khoula Hospital with TBI and were seen from January 2015 to December 2019. The multivariate binary logistic regression analysis has been used to determine the independent predictors of prolonged hospital stay. Prolonged hospitalization was defined as mean ± 2 standard deviation days. A total of 866 cases of pediatric TBI were documented. The mean age was 4.33 years. The length of hospital stay ranged from <1 day to 90 days (mean= 3.65, standard deviation= 6.84). Prolonged hospitalization was calculated to be >17 days. Thirty-one patients had prolonged hospital stay out of the studied cohort, with an incidence proportion of prolonged stay= 3.6% (95% CI= 2.4%-5.0%). Prolonged hospitalizations were associated with motor vehicle collision injuries (odds ratio [OR]: 27.028, 95% confidence interval [CI]= 2.744-266.194, P= 0.005); pedestrian injuries (OR= 11.667, 95% CI= 1.017-133.805, P= 0.048), and Glasgow Coma Scale score onarrival of <9 (OR= 8.149, 95% CI= 1.167-56.921, P= 0.034). The current study identified motor vehicle collision and pedestrian injuries, as well as initial Glasgow Coma Scale score of <9 as independent predictors of prolonged hospitalization in pediatrics TBI.

Altered mental status predicts length of stay but not death in a community-based cohort of hospitalized COVID-19 patients

IntroductionAltered Mental Status (AMS) is a common neurological complication in patients hospitalized with the diagnosis of COVID-19 (Umapathi et al., 2020; Liotta et al., 2020). Studies show that AMS is associated with death and prolonged hospital stay. In addition to respiratory insufficiency, COVID-19 causes multi-organ failure and multiple metabolic derangements, which can cause AMS, and the multi-system involvement could account for the prolonged hospital stay and increased mortality. In this study, we built on our previous publication (Chachkhiani et al., 2020) using a new, larger cohort to investigate whether we could reproduce our previous findings while addressing some of the prior study’s limitations. Most notably, we sought to determine whether AMS still predicted prolonged hospital stay and increased mortality after controlling for systemic complications such as sepsis, liver failure, kidney failure, and electrolyte abnormalities. ObjectivesThe primary purpose was to document the frequency of AMS in patients with COVID-19 at the time of presentation to the emergency room. Secondary aims were to determine: 1) if AMS at presentation was associated with worse outcomes as measured by prolonged hospitalization and death; and 2) if AMS remained a predictor of worse outcome after adjusting for concomitant organ failure and metabolic derangements. ResultsOut of 367 patients, 95 (26%) had AMS as a main or one of the presenting symptoms. Our sample has a higher representation of African Americans (53%) than the US average and a high frequency of comorbidities, such as obesity (average BMI 29.1), hypertension (53%), and diabetes (30%). Similar to our previous report, AMS was the most frequent neurological chief complaint. At their admission, out of 95 patients with AMS, 83 (88%) had organ failure or one of the systemic problems that could have caused AMS. However, a similar proportion (86%) of patients without AMS had one or more of these same problems. Age, race, and ethnicity were the main demographic predictors. African Americans had shorter hospital stay [HR1.3(1.0,1.7),p = 0.02] than Caucasians. Hispanics also had shorter hospital stay than non-Hispanics [HR1.6(1.2,2.1), p = 0.001]. Hypoxia, liver failure, hypernatremia, and kidney failure were also predictors of prolonged hospital stay. In the multivariate model, hypoxia, liver failure, and acute kidney injury were the remaining predictors of longer hospital stay, as well as people with AMS at baseline [HR0.7(0.6,0.9), p < 0.02] after adjusting for the demographic characteristics and clinical predictors. AMS at baseline predicted death, but not after adjusting for demographics and clinical variables in the multivariate model. Hypoxia and hyperglycemia at baseline were the strongest predictors of death. ConclusionAltered mental status is an independent predictor of prolonged hospital stay, but not death. Further studies are needed to evaluate the causes of AMS in patients with COVID-19.

Predictors of prolonged hospitalization in patients with mild and moderate pancreatitis presenting to the emergency department.

Patients with acute pancreatitis often present to the emergency department (ED) and usually require hospital admission. The aim of this study was to determine predictors of prolonged hospital stays in patients with mild forms of acute pancreatitis. This retrospective cohort study was conducted in patients diagnosed in the ED with mild and moderate acute pancreatitis according to the revised Atlanta classification. Patients with available data between 2007 and 2017 were included and were divided based on their admission duration. Eight days or more was considered along hospitalization. Amultivariate logistic regression model was constructed to determine the independent predictors of prolonged hospital stays. Of the 485 evaluated patients, 335 were included in the analysis. Baseline characteristics, determined by vital signs and laboratory parameters, were similar between the short and long hospitalization groups. However, the long hospitalization group received more intravenous crystalloid in the ED, and this group used more diuretics and more angiotensin-converting enzyme inhibitor and angiotensin-receptor blocker (ACEI/ARB) drugs than the other group. Diuretic use was present in 8patients (4.8%) in the short hospital length of stay group and in 26patients (15.3%) in the long hospital length of stay group. Age, gender, ACEI/ARB use, diuretic use, total amount of intravenous crystalloid administered in the ED, aPTT, BUN, creatinine, and presence of biliary pathology were included in the multivariate analysis. Regarding the final analysis, diuretic use was an independent predictor of prolonged hospitalization (odds ratio 2.89, 95% confidence interval 1.05-8.00, p = 0.041). Diuretic use is an independent predictor of long hospitalization in patients with mild and moderate pancreatitis. Drugs affecting total volume balance may prolong hospital stays in these patients.

Laparoscopic Versus Open Re-operations Within 30 Days After Lower Gastrointestinal Tract Surgery: a Retrospective Comparative Study.

Re-operations within 30days after lower gastrointestinal tract surgery are associated to high morbidity and mortality. Laparoscopic approach has been reported as feasible and safe in selected patients, but comparative data to laparotomy are scarce. The aim of this study was to review our experience in laparoscopic re-operations and compare it to laparotomy. From January 2012 to December 2016, patients undergoing a re-operation within one month after lower gastrointestinal tract surgery were included and divided into laparoscopy and laparotomy groups. The primary endpoint was successful re-operation, defined as recovery without any of the following: conversion to laparotomy, need of further invasive treatments or death. Secondary outcomes were the length of hospital stay and 30-day morbidity and mortality. Demographic, clinical and surgical characteristics were collected and analyzed. Out of 114 patients who underwent a re-operation, 71 met the inclusion criteria. Thirty (42%) patients underwent laparoscopy and 41 (58%) laparotomy. Thirty (42%) patients were male and median age was 72.0years-old. The initial operation was elective in 24 (34%) patients, and 50% of the initial operations were colorectal resections in both groups. Multivariate analyses showed that type of approach did not affect the re-operation success rate. Laparotomy was an independent predictor of prolonged hospital stay (OR 3.582, 95%CI 1.191-10.776, p = 0.023) and mortality (OR 13.123, 95%CI 1.301-131.579, p = 0.029). Re-operations within 30days after lower gastrointestinal tract surgery may be safe in selected patients, as effective as laparotomy, and associated with shorter hospital stay and lower mortality rates.

Early Outcome of Laparotomy Wounds in Pediatric Patients in TASH, Addis Ababa, Ethiopia: A Six-Months Prospective Study.

Surgical Site Infection (SSI) and wound dehiscence are two early complications of laparotomy causing significant morbidity and mortality. This study was conducted to determine the prevalence and risk factors of SSI and wound dehiscence in pediatric surgical patients. We performed a prospective observational study of all pediatric surgical patients who underwent laparotomy at Tikur Anbessa Specialized Hospital, Ethiopia, from December 2017 to May 2018. Data collected included demographics, operative indication, nutritional status, prophylactic antibiotics administration, and duration of operation. Primary outcome was SSI; secondary outcomes were hospital stay and other postoperative complications, including wound dehiscence and mortality. Data were analyzed using SPSS, Version 23. Fisher's exact and Chi-squared tests used to report outcomes. Multivariable logistic regression was used to identify variables associated with SSI, wound dehiscence and other outcomes. Of 114 patients, median age was 46 months [range: 1day-13 years]; 77(67.5 %) were males. Overall SSI rate was 21.05%. Nine (7.9%) developed wound dehiscence while 3(2.6%) had abdominal contents evisceration. Overall mortality rate was 2.6%. In multivariate analysis, prophylactic antibiotics administration (AOR=13.05, (p=0.006)), duration of procedure (AOR=8.62, (p=0.012)) and wound class (AOR=16.63, (p=0.034)) were independent risk factors for SSI while SSI was an independent predictor of prolonged hospital stay, >1 week (AOR=4.7, p=.003,) and of wound dehiscence (AOR=33. 96, p=0.003). Age (p=0.004) and malnutrition (p<0.001) were significantly associated with wound dehiscence. SSI and wound dehiscence are common in this setting. Wound contamination, antibiotics administration >1 hour before surgery and operative time >2 hours are independent predictors of SSI.

Medicare coverage is an independent predictor of prolonged hospitalization after primary total joint arthroplasty.

The purpose of this study was to investigate the association between insurance type and length of stay (LOS) in primary total joint arthroplasty. A retrospective review of 848 patients was performed. Patients were divided into 3 groups based on their insurance type: Medicare, Medicaid, or commercial coverage. Medicare patients had a significantly higher rate of LOS > 2 days than the Medicaid and commercial groups (P < .0001). The effect of Medicare coverage on LOS remained significant even after controlling for baseline differences among the study groups. There were no differences in the rates of 90-day emergency room visits and readmissions between the 3 groups (P > .05). Arthroplasty surgeons not experienced with outpatient surgery should not be pressured to default to outpatient admission in Medicare patients.

Speckle Tracking Strain Echocardiography: On Its Way into the Operating Room

The purpose of this review is to introduce the basic concepts of strain as well as its applicability to intraoperative echocardiography. In the operating room, strain literature is in its infancy. The majority of the strain literature is based on TTE studies. Currently, there are no published guidelines on the normal values of strain with TEE. Early strain literature has shown there is correlation between TTE and TEE values. Reduction in intraoperative left ventricular strain with TEE has been shown to be an independent predictor of prolonged hospitalization, postoperative atrial fibrillation, and low cardiac output syndrome in certain cardiac surgeries. Reduction in intraoperative right ventricular strain with TEE has been shown to be associated with hemodynamic instability following cardiac surgery. Understanding the limitations of intraoperative strain analysis is important. They include high frame rates required for analysis, vendor-to-vendor variability, and the limited availability of right ventricular strain software. The intraoperative use of strain echocardiography with TEE is growing because of its availability and ease of use. The application of intraoperative strain echocardiography in everyday practice has the potential to actively guide intraoperative clinical decision-making and risk stratify patients in the operating room, but further work needs to be done to validate early studies.

Psychological Distress Independently Predicts Prolonged Hospitalization After Primary Total Hip and Knee Arthroplasty

BackgroundThe purpose of this study was to investigate the effect of psychological distress on hospital length of stay (LOS) in joint arthroplasty (TJA). MethodsA retrospective review of 863 patients who underwent primary, unilateral TJA at a single tertiary academic center was performed. Two groups were compared: patients with or without psychological distress defined using the Short Form-12 mental component summary. The primary outcome was the rate of hospital LOS exceeding 2 days. Secondary outcomes were rates of in-hospital complications and 90-day emergency room visits and readmissions. Univariate and multivariate logistic regression analyses were performed. ResultsThe prevalence of psychological distress was 23%. The mean LOS was 2.44 days. Patients with psychological distress were younger (P < .0001) and more likely to have depression (P < .0001), lower educational attainment (P < .0001), smoke tobacco (P = .003), be Hispanic/Latino (P = .001), live alone (P = .001), and have higher rates of nonprimary osteoarthritis (P < .0001). After adjusting for these differences, psychological distress was an independent predictor of LOS > 2 days (P = .049 and .006 for total hip arthroplasty [THA] and total knee arthroplasty [TKA], respectively). There were no differences in the rates of in-hospital complications (P = .913 and .782 for THA and TKA, respectively), emergency room visits (P = .467 and .355 for THA and TKA respectively), or readmissions (P = .118 and .334 for THA and TKA, respectively). ConclusionPsychological distress is an independent predictor of prolonged hospitalization after primary TJA. The Short Form-12 mental component summary is a good screening tool for identifying patients with poor mental health who may not be appropriate candidates for outpatient surgery. Efforts to address psychological distress before surgery are warranted.

Impact of a colorectal enhanced recovery program implementation on clinical outcomes and institutional costs: A prospective cohort study with retrospective control

BackgroundThe enhanced recovery program for perioperative care of the surgical patient reduces postoperative metabolic response and organ dysfunction, accelerating functional recovery. The aim of this study was to determine the impact on postoperative recovery and cost-effectiveness of implementing a colorectal enhanced recovery program in an Italian academic centre. Materials and methodsA prospective series of consecutive patients (N = 100) undergoing elective colorectal resection completing a standardized enhanced recovery program in 2013–2015 (ERP group) was compared to patients (N = 100) operated at the same institution in 2010–2011 (Pre-ERP group) before introducing the program. The exclusion criteria were: >80 years old, ASA score of IV, a stage IV TNM, and diagnosis of inflammatory bowel disease. The primary outcome was hospital length of stay which was used as a proxy of functional recovery. Secondary outcomes included: postoperative complications, 30-day readmission and mortality, protocol adherence, nursing workload, cost-effectiveness, and factors predicting prolonged hospital stay. The ERP group patient satisfaction was also evaluated. ResultsHospital stay was significantly reduced in the ERP versus the Pre-ERP group (4 versus 8 days) as well as nursing workload, with no increase in postoperative complications, 30-day readmission or mortality. ERP group protocol adherence (81%) and patient satisfaction were high. Conventional perioperative protocol was the only independent predictor of prolonged hospital stay. Total mean direct costs per patient were significantly higher in the Pre-ERP versus the ERP group (6796.76 versus 5339.05 euros). ConclusionsImplementing a colorectal enhanced recovery program is feasible, efficient for functional recovery and hospital stay reduction, safe, and cost-effective. High patient satisfaction and nursing workload reduction may also be expected, but high protocol adherence is necessary.

CT Predictors of Unfavorable Clinical Outcomes of Acute Right Colonic Diverticulitis.

The purpose of this study was to retrospectively assess CT predictors of unfavorable outcomes of medical treatment in patients with right colonic diverticulitis. Of 394 patients with right colonic diverticulitis diagnosed on the basis of CT findings from January 2010 through August 2013, we included 328 (190 men, 138 women; mean age, 41.3 ± 12.6 years) who had undergone medical treatment as inpatients. Two radiologists retrospectively reviewed the following CT findings associated with diverticulitis: number of diverticula per 10 cm of colon; length and thickness of affected colonic wall; diameter of inflamed diverticulum and abscess; presence of pericolic fluid collection, spilled feces, and contained air; and extent of fatty infiltration. Logistic regression analysis and the Cox proportional hazards regression model were used to determine significant variables predictive of unfavorable outcomes, including surgery after failed medical treatment, recurrence, and prolonged hospital stay. Of the 328 patients, nine underwent surgery after failed medical treatment. Of the other 319 patients, 35 had recurrence and 49 had a prolonged hospital stay. The spilled feces sign (adjusted odds ratio [OR], 111; p < 0.001) and serum WBC count (adjusted OR, 1.3; p = 0.047) were independent predictors of the need for surgery. More than five multiple diverticula per 10 cm of colon was significantly associated with recurrence (adjusted hazard ratio, 4.1; p < 0.001). Abscess larger than 4 cm (adjusted OR, 18.2; p = 0.01) and inflamed diverticulum larger than 2 cm (adjusted OR, 3.7; p = 0.001) were independent predictors of prolonged hospital stay. Some specific CT findings can be useful predictors of unfavorable clinical outcomes of right colonic diverticulitis.

The effect of an Enhanced Recovery Program in elective retroperitoneal abdominal aortic aneurysm repair

Enhanced Recovery Programs (ERPs) have been introduced to accelerate postoperative recovery and are mainly focused on decreasing the surgical stress response. Limited data are available regarding the implementation of ERPs in patients who undergo abdominal aortic aneurysm (AAA) repair using the retroperitoneal approach. The aims of this study were: (1) to evaluate the implementation of an ERP in patients who underwent elective retroperitoneal AAA repair; and (2) to define independent predictors of prolonged hospital length of stay (LOS) in these patients. This was a retrospective cohort study on 221 patients who underwent elective AAA repair via a retroperitoneal approach from 2005 through 2013 at an Italian university hospital. Patients who received surgery from 2008 through 2013 and enrolled in an ERP (n= 130) were compared with those who received surgery from 2005 through 2007 and managed with traditional perioperative care (n= 91). Patient characteristics were comparable between groups. Intensive care unit admissions were prevalent among patients who received traditional care vs patients in the ERP (P< .01). ERP patients had fewer major (P< .01) and minor (P= .019) complications, and mortality was similar between groups. Complete functional recovery was achieved earlier in ERP patients vs controls (P< .01). Patients in the ERP group left the hospital earlier than controls (P< .01). No readmission ≤30days were reported in the ERP group. Age ≥65years and being in a conventional care protocol were found to be independent predictors of prolonged hospital LOS. The implementation of an ERP after elective AAA repair using a retroperitoneal approach reduced postoperative intensive care unit admission, accelerated functional recovery, and decreased morbidity and LOS with no readmission ≤30days. Age ≥65years and conventional perioperative care were the only independent predictors of prolonged LOS.

Hyperglycaemia in patients with no history of diabetes presenting to Internal Medicine Departments.

Stress hyperglycaemia during hospitalisation may be the first sign of diabetes mellitus (DM). Most hospitals routinely measure blood glucose, which may enable early diagnosis. This study measured the prevalence of hyperglycaemia in hospitalised adults with no history of diabetes, and whether the discharge summary recommended work-up. Files with at least one random blood glucose (RBG) sample were included and reviewed for specific discharge recommendations concerning elevated blood glucose. Hyperglycaemia was defined as serum glucose > 200 mg/dl. Length of stay, in-hospital mortality and 3-year mortality were examined. Among 5274 discharged patients, 1479 had DM. They were older and had a higher incidence of cerebrovascular risk factors. Among 3714 patients without known DM, 211 (5.7%) had at least one RBG > 200 mg/dl. Of these patients, 31 died and 24 left against medical advice. Of the remaining 156, 25(16%) files included instructions to the family physician. These patients were younger, more overweight and less frequently diagnosed with dementia or other mental illness. Patients with RBG > 200 mg/dl had prolonged hospital stay (6.5 ± 5.3 vs. 4.0 ± 4.8; p < 0.001). In-hospital mortality and 3-year mortality were increased by 5.1 and 1.89, respectively (p < 0.001 for both parameters) compared to those without RBG ≤ 200 mg/dl. RBG > 200 mg/dl emerged as a significant, independent predictor of prolonged hospital stay and death. Random blood glucose > 200 mg/dl is common in medical departments and is associated with increased in-hospital and 3-year out-hospital mortality.

Early discharge after pancreatoduodenectomy: what helps and what prevents?

Shorter hospital stay after pancreatoduodenectomy (PD) is a desired goal. Implementation of enhanced recovery after surgery (ERAS) protocols can possibly help in achieving this target. We aimed to determine the factors influencing the successful implementation of ERAS protocols by analyzing their relation to the surrogate marker of enhanced recovery, namely, duration of hospital stay. A retrospective analysis of a prospectively maintained ERAS database of 208 consecutive patients who underwent PD at a tertiary referral care center was done. Two hundred eight patients underwent a classical PD with a median duration of hospital stay of 8 days (range, 4-52 days) with an overall morbidity rate of 34.5% and a mortality rate of 3.8%. The 30-day readmission rate was 4% (8 patients). An elevated body mass index (relative risk, 1.098; 95% confidence interval, 1.015-1.188; P = 0.02) and respiratory comorbidities (relative risk, 8.024; 95% confidence interval, 2.018-31.904; P = 0.003) were independent factors resulting in a longer (>8 days) hospital stay. Being overweight or obese and respiratory comorbidities are independent predictors of prolonged hospital stay despite the implementation of ERAS protocol. Hypoalbuminemia does not have a direct effect on hospital stay but may predispose the patient to the development of complications.

Predictors of prolonged hospitalisation in childhood pneumonia in a rural health centre

Background. Pneumonia is a major cause of morbidity and mortality in under-5 children. Caring for children with pneumonia, especially in the case of prolonged hospitalisation, is a daunting task in resource-poor countries where caregivers are required to pay for treatment ‘out of pocket’ at the point of care. These children are often discharged against medical advice with incomplete treatment, with a consequent high rate of re-admission and complications. Objective. To determine factors that predict prolonged hospitalisation among under-5 children with severe pneumonia admitted to a compre h ensive health centre in rural Gambia. Methods. We prospectively assessed 420 consecutive under-5 admissions with severe pneumonia, diagnosed using World Health Organization criteria, for factors in patient history, examination or investigations that could predict a hospital stay longer than 5 full days. Results. Over the 6-month study period, pneumonia accounted for 27.6% of the total number of under-5 admissions. The mean age of children with pneumonia was 18.0 months (standard deviation (SD) ±13.7), there was a male to female ratio of 1.2:1, and 40.0% of the children were infants. Their mean hospital stay was 4.5 (SD ±3.0) days and 105 (25.0%) of the children had a prolonged hospital stay. Head nodding (odds ratio (OR) 1.929; 95% confidence interval (CI) 1.124 - 3.414; p=0.018), the presence of oedematous protein-energy malnutrition (OR 5.813; CI 1.060 - 3.616; p=0.006), severe wasting (OR 2.071; CI 1.047 - 3.241; p=0.034) and hypoxaemia at presentation (OR 2.220; CI 1.097 - 3.405; p=0.023) were independent predictors of prolonged hospital stay. Conclusion. Caregivers of children hospitalised with pneumonia and severe wasting, head nodding, oedema or hypoxaemia should be counselled at admission about the possibility of prolonged hospitalisation.

Cardiovascular diseases in older patients with osteoporotic hip fracture: prevalence, disturbances in mineral and bone metabolism, and bidirectional links

BackgroundConsiderable controversy exists regarding the contribution of mineral/bone metabolism abnormalities to the association between cardiovascular diseases (CVDs) and osteoporotic fractures.Aims and methodsTo determine the relationships between mineral/bone metabolism biomarkers and CVD in 746 older patients with hip fracture, clinical data were recorded and serum concentrations of parathyroid hormone (PTH), 25-hydroxyvitamin D, calcium, phosphate, magnesium, troponin I, parameters of bone turnover, and renal, liver, and thyroid functions were measured.ResultsCVDs were diagnosed in 472 (63.3%) patients. Vitamin D deficiency was similarly prevalent in patients with (78.0%) and without (82.1%) CVD. The CVD group had significantly higher mean PTH concentrations (7.6 vs 6.0 pmol/L, P < 0.001), a higher prevalence of secondary hyperparathyroidism (SPTH) (PTH > 6.8 pmol/L, 43.0% vs 23.3%, P < 0.001), and excess bone resorption (urinary deoxypyridinoline corrected by creatinine [DPD/Cr] > 7.5 nmol/μmol, 87.9% vs 74.8%, P < 0.001). In multivariate regression analysis, SHPT (odds ratio [OR] 2.6, P = 0.007) and high DPD/Cr (OR 2.8, P = 0.016) were independent indictors of CVD. Compared to those with both PTH and DPD/Cr in the normal range, multivariate-adjusted ORs for the presence of CVD were 17.3 (P = 0.004) in subjects with SHPT and 9.7 (P < 0.001) in patients with high DPD/Cr. CVD was an independent predicator of SHPT (OR 2.8, P = 0.007) and excess DPD/Cr (OR 2.5, P = 0.031). CVD was predictive of postoperative myocardial injury, while SHPT was also an independent predictor of prolonged hospital stay and in-hospital death.ConclusionSHPT and excess bone resorption are independent pathophysiological mediators underlying the bidirectional associations between CVD and hip fracture, and therefore are important diagnostic and therapeutic targets.