Patients Required Hospital Readmission Research Articles

Radical cystectomy in bladder cancer patients previously treated for prostate cancer: Insights from a large European multicentric series

IntroductionPrevious radical prostatectomy (RP) for prostate cancer (PCa) might impair feasibility of radical cystectomy (RC) for bladder cancer (BCa). The current study addressed morbidity, operative time (OT), and length of stay (LOS) of RC, within the largest available series of patients with history of previous RP. Materials and methodsAll patients previously submitted to RP for PCa and subsequently submitted to RC for BCa, at six high-volume European institutions between 2010 and 2019, were identified. Presence of either PCa or BCa metastases, RT as primary treatment for PCa, and palliative RC represented exclusion criteria.The quality criteria for accurate and comprehensive reporting of intra- and post-operative surgical outcomes, recommended by the European Association of Urology guidelines, were fulfilled. Multivariable logistic and Poisson regression analyses were performed. ResultsOverall, 140 RC patients with history of RP were identified. After RP, 69 (49%) patients received radiotherapy (RT) for PCa, either in adjuvant (n = 50, 36%) or salvage setting (n = 19, 13%). Median age-adjusted Charlson comorbidity index was 6 (IQR 5, 7). Median OT, estimated blood loss and LOS were, respectively, 300 min, 500 ml, and 16 days. Intra-operative transfusions rate was 47% (n = 65). One intra-operative complication occurred (EAUiaiC grade 2, perforation of the rectum managed with immediate repair). Eighty-two (59%) patients experienced a total of 107 post-operative complications during the hospital stay, and seven (5%) patients required hospital readmission. In multivariable regression analyses, RT for PCa was associated with higher risk of post-operative complications (odds ratio 1.82, p = 0.039), longer OT (incidence rate ratio 1.09, p < 0.001), and longer LOS (incidence rate ratio 1.24, p < 0.001). ConclusionsRC in patients with history of RP is feasible, albeit burdened by remarkable morbidity, even in centers of excellence. RT after RP for PCa portends worse surgical outcomes.

The Epidemiology of Radial Tunnel Syndrome and Its Overlap With Lateral Epicondylitis

Radial tunnel syndrome (RTS) is characterized by nerve compression affecting the posterior interosseous nerve branch in the forearm, and its symptoms often overlap with those of lateral epicondylitis (LE). The purpose of this study was to examine the epidemiology of RTS, frequency of injections and surgical release, and overlap of RTS with LE. We queried the PearlDiver database to identify RTS in patients older than 18 years. Demographic data, diagnostic or therapeutic injection within 30 days of diagnosis, surgical release within 1 year of diagnosis, and 90-day postoperative complication rates were evaluated. Using International Classification of Diseases, 10th Revision, laterality codes, we also determined the number of patients who had same-side RTS and LE and the proportion of patients who subsequently underwent simultaneous RT release and LE debridement. The prevalence of RTS in a representative United States insurance database was 0.091%, and the annual incidence was 0.0091%. There were 75,459 patients identified with an active RTS diagnosis. The mean age at the time of diagnosis was 52 years (range, 18-81 years), 55% were women, and 1,833 patients (2.4%) underwent RT release within 1 year. Fewer than 3% of the patients received an injection within 30 days of RTS diagnosis. The 90-day postoperative complication rates were low: 5% of the patients required hospital readmission and 2.1% underwent revision surgery. Approximately 5.7% of the patients with RTS also had a diagnosis of LE on the same side within 6 months of RTS diagnosis. In patients with ipsilateral RTS and LE who underwent surgery, 59.1% underwent simultaneous RT release and LE debridement, whereas 40.9% underwent isolated radial tunnel release. The analysis of a large insurance database showed that the diagnosis of RTS is rarely assigned, suggesting that the incidence of this nerve compression is low. Diagnostic III.

Outcomes following parathyroidectomy for secondary hyperparathyroidism in patients with chronic kidney disease: a single-centre study.

Surgical parathyroidectomy may be required for severe and refractory secondary hyperparathyroidism (SHPT) in patients with chronic kidney disease (CKD). Parathyroidectomy is associated with long-term survival benefit despite an increase in short-term morbidity and mortality. Global variation in practice exists, with limited Australian data on outcomes following parathyroidectomy. To evaluate clinical outcomes of patients with chronic kidney disease undergoing surgical parathyroidectomy for secondary hyperparathyroidism. We conducted a retrospective study of patients who underwent parathyroidectomy for SHPT between January 2010 and December 2019 at a single tertiary referral centre in Melbourne, Australia. Biochemical markers and medications were assessed 12 months pre- and post-surgery. Clinical outcomes, including hospital readmission, cardiovascular events and mortality were assessed following surgery. During the 10-year study period, 129 patients underwent parathyroidectomy for SHPT (mean age 50.7 ± 15 years; 109 (85%) on dialysis). Significant immediate post-operative complications were seen in eight (6%) patients, requiring admission to the intensive care unit (n = 6) or return to theatre (n = 2). Within the first 6 months, 24 (19%) patients required hospital readmission. Within 12 months post-parathyroidectomy, 100 (78%) and 103 (80%) patients experienced at least one episode of hypercalcaemia (corrected calcium >2.6 mmol/L) or hypocalcaemia (corrected calcium <2.1 mmol/L) respectively. Over a 12-month period, there were six (5%) deaths and eight (6%) patients experienced a major cardiovascular event. Significant fluctuations in serum calcium levels are common post-parathyroidectomy; however, long-term morbidity and mortality in our cohort were lower than previously reported, highlighting that parathyroidectomy in a carefully selected cohort is safe for severe SHPT refractory to medical treatment.

Rapid implementation of an outpatient arthroplasty care pathway: a COVID-19-driven quality improvement initiative

BackgroundHip and knee total joint arthroplasty (TJA) procedures are two of the most common inpatient surgical procedures worldwide. Outpatient TJA has emerged as a feasible option. COVID-19 caused significant constraints...

S184: preoperative sarcopenia is associated with worse short-term outcomes following transanal total mesorectal excision (TaTME) for rectal cancer.

Malnutrition and deconditioning impact postoperative morbidity and mortality. Computed tomography (CT) body composition variables are used as markers of nutritional status and sarcopenia. The objective of this study is to evaluate the impact of sarcopenia, using CT variables, on postoperative outcomes following transanal total mesorectal excision (TaTME) for rectal cancer. This was an institutional retrospective cohort analysis of consecutive rectal cancer patients who underwent TaTME between April 2014 and May 2020. Psoas muscle index (PMI) was calculated from diagnostic CT scans. Based on previous studies, patients in the lowest PMI tertile by gender were considered sarcopenic. Fisher's exact and Mann-Whitney U test were used to compare categorical and continuous variables, respectively. Readmission rates and postoperative complications were compared between groups. Backward stepwise logistic regression was used to determine the association between sarcopenia and 30-day postoperative complications. 85 patients were analyzed, of which 63% were male, with a median age of 59 (IQR: 51-65), and median BMI of 28 (IQR: 24-32). Of the entire cohort, 34% (n = 29) were sarcopenic (median PMI 5.39 IQR: 4.49-6.71). No significant difference in baseline characteristics between sarcopenic and nonsarcopenic patients were observed. 55% of sarcopenic patients experienced a complication within 30 days compared to 24% of nonsarcopenic patients (p = 0.01). 41% of sarcopenic patients required hospital readmission within 30 days compared to 17% of their nonsarcopenic counterparts (p = 0.014). Sarcopenic patients also experienced significantly higher rates of post-operative small bowel obstruction (10% vs. 0%, p = 0.04). Multivariable analyses identified that sarcopenic patients have a fourfold increase in odds of experiencing a 30-day postoperative complication (OR: 4.44, 95%CI: 1.6-12.4, p < 0.05) after adjusting for gender. Preoperative sarcopenia is associated with increased 30-day postoperative complications following TaTME for rectal cancer. Postoperative complications can have serious oncologic implications by delaying adjuvant chemotherapy. Therefore, preoperative recognition of sarcopenia prior to undergoing TaTME for rectal cancer may provide an opportunity for early intervention with prehabilitation programs.

Inhaled high dose nitric oxide is a safe and effective respiratory treatment in spontaneous breathing hospitalized patients with COVID-19 pneumonia

BackgroundInhaled nitric oxide (NO) is a selective pulmonary vasodilator. In-vitro studies report that NO donors can inhibit replication of SARS-CoV-2. This multicenter study evaluated the feasibility and effects of high-dose inhaled NO in non-intubated spontaneously breathing patients with Coronavirus disease-2019 (COVID-19). MethodsThis is an interventional study to determine whether NO at 160 parts-per-million (ppm) inhaled for 30 min twice daily might be beneficial and safe in non-intubated COVID-19 patients. ResultsTwenty-nine COVID-19 patients received a total of 217 intermittent inhaled NO treatments for 30 min at 160 ppm between March and June 2020. Breathing NO acutely decreased the respiratory rate of tachypneic patients and improved oxygenation in hypoxemic patients. The maximum level of nitrogen dioxide delivered was 1.5 ppm. The maximum level of methemoglobin (MetHb) during the treatments was 4.7%. MetHb decreased in all patients 5 min after discontinuing NO administration. No adverse events during treatment, such as hypoxemia, hypotension, or acute kidney injury during hospitalization occurred.In our NO treated patients, one patient of 29 underwent intubation and mechanical ventilation, and none died. The median hospital length of stay was 6 days [interquartile range 4–8]. No discharged patients required hospital readmission nor developed COVID-19 related long-term sequelae within 28 days of follow-up. ConclusionsIn spontaneous breathing patients with COVID-19, the administration of inhaled NO at 160 ppm for 30 min twice daily promptly improved the respiratory rate of tachypneic patients and systemic oxygenation of hypoxemic patients. No adverse events were observed. None of the subjects was readmitted or had long-term COVID-19 sequelae.

TLM Outcomes in Elderly Patients with Glottic Pre-Malignancy and Early Malignancy; A 12-Year Retrospective Study.

UK population ageing and associated cancer risk predicts an increase in the prevalence of laryngeal cancer in elderly patients. Whilst trans-oral laser microsurgery (TLM) has been demonstrated to achieve excellent control of early disease with few complications, data specifically related to its safety and efficacy in older patients is lacking. We report the largest series to date. To assess the safety and efficacy of TLM in elderly patients with glottic pre-malignancy and early malignancy. A retrospective review and statistical analysis of the clinical records of patients aged 70 or over undergoing TLM for early and premalignant glottic disease. The records of 106 patients over the age of 70 were identified. Thirteen records were excluded, 4 due to failure to meet the inclusion criteria (stage I/II disease, primary site of lesion in the glottis) and 9 due to incomplete follow up data capture. Most surgeries (>70%) were performed as a day case or overnight admission, with only 2 admissions >2 days. One patient required hospital readmission with dysphagia, resulting in an altered diet. No patients required tracheostomy or tube feeding. No treatment related deaths or intensive care admissions were observed. Ten patients had recurrent disease within 5 years; 1 received radiotherapy, 1 underwent salvage laryngectomy, the remainder had further TLM without complication. Five-year disease specific survival rates were >90%. Our results demonstrate that TLM is safe and effective for elderly patients, with outcomes comparable to those reported in large, non-age selected cohorts. Although our patients underwent more conservative cordectomy types (I-III) than those with similar disease stages reported elsewhere, our recurrence rates were not higher. This supports the oncological effectiveness of surgery whilst reducing the risk of associated functional compromise.

SIMULTANEOUS LAPAROSCOPIC INGUINAL HERNIA REPAIR AND CHOLECYSTECTOMY: DOES IT CAUSE MESH INFECTION?

ABSTRACT Background: Repair of inguinal hernia concomitant with cholecystectomy was rarely performed until more recently when laparoscopic herniorrhaphy gained more adepts. Although it is generally an attractive option for patients, simultaneous performance of both procedures has been questioned by the potential risk of complications related to mesh, mainly infection. Aim:To evaluate a series of patients who underwent simultaneous laparoscopic inguinal hernia repair and cholecystectomy, with emphasis on the risk of complications related to the mesh, especially infection. Methods: Fifty patients underwent simultaneous inguinal repair and cholecystectomy, both by laparoscopy, of which 46 met the inclusion criteria of this study. Results: In all, hernia repair was the first procedure performed. Forty-five (97,9%) were discharged within 24 h after surgery. Total mean cost of the two procedures performed separately ($2,562.45) was 43% higher than the mean cost of both operations done simultaneously ($1,785.11). Up to 30-day postoperative follow-up, seven (15.2%) presented minor complications. No patient required hospital re-admission, percutaneous drainage, antibiotic therapy or presented any other signs of mesh infection after three months. In long-term follow-up, mean of 47,1 months, 38 patients (82,6%) were revaluated. Three (7,8%) reported complications: hernia recurrence; chronic discomfort; reoperation due a non-reabsorbed seroma, one in each. However, none showed any mesh-related complication. Satisfaction questionnaire revealed that 36 (94,7%) were satisfied with the results of surgery. All of them stated that they would opt for simultaneous surgery again if necessary. Conclusion: Combined laparoscopic inguinal hernia repair and cholecystectomy is a safe procedure, with no increase in mesh infection. In addition, it has important advantage of reducing hospital costs and increase patient’ satisfaction.

The Use of Periorbital Steroids to Reduce Postoperative Swelling in Fronto-orbital Advancement: An Analysis of Outcomes

PURPOSE: Marked facial swelling is a known consequence following fronto-orbital advancement (FOA), which can result in prolonged eye closure, patient discomfort, and postoperative hospitalization. There are limited reports on the efficacy and safety of periorbital steroids to help reduce facial swelling in craniofacial surgery, which has become standard practice at some centers. The purpose of this study is to compare outcomes with and without the use of periorbital steroids in patients undergoing FOA. METHODS: A retrospective chart review of patients who underwent FOA at Seattle Children’s Hospital between January 2012 and December 2019 was completed. All procedures were performed by 2 senior surgeons (R.A.H. and C.B.B.) in conjunction with a pediatric neurosurgeon. All patients received pre-, intra-, and postoperative care via a standardized clinical care pathway. In the periorbital steroid cohort, triamcinolone was administered as an injection into the subcutaneous tissues or soaked in gelfoam and placed in the frontal/periorbital region before closure of the scalp. Statistical significance between outcomes measures was determined using a 2-tailed unpaired Student’s t test or chi-square test as appropriate. RESULTS: A total of 167 patients were included in this study (80 control, 87 periorbital steroid). The majority of these patients underwent FOA for isolated metopic synostosis (52.1%) followed by multisuture synostosis (23.9%) and isolated unicoronal synostosis (18%). 15.6% of patients had craniosynostosis as part of a diagnosed craniofacial syndrome. The average postoperative length of stay following FOA was 4.3 ± 2.0 days. Criteria for discharge including adequate PO intake, appropriate pain control, removal of the surgical drain, and improvement in facial swelling with opening of at least 1 eye. The use of periorbital steroids resulted in a statistically significant decrease in the hospital length of stay (LOS) compared with controls for isolated metopic (12.5 hours; P = 0.031) and unicoronal (12 hours; P = 0.015) craniosynostosis; there was no statistically significant difference in LOS for multisuture craniosynostosis (5.2 hours; P = 0.329). There was a significantly higher rate of surgical site infection in patients who received periorbital steroids compared to controls (10.2% versus 2.5%; P = 0.041). All of these complications represented scalp wound infections requiring operative intervention. Ninety-one percent of patients required hospital readmission with an average LOS of 17.6 days and 36% required subsequent revision cranioplasty. There was no association between specific suture involvement, craniofacial syndrome, or age at FOA with infectious complications. CONCLUSIONS: The use of periorbital steroids has been reported in the literature to reduce facial swelling and shorten convalescence following FOA. This study demonstrates that there is a statistically significant decrease in hospital LOS with the use of periorbital steroids in isolated suture craniosynostosis. However, it is associated with a significantly higher rate of infectious complications requiring operative intervention, extended hospital readmissions, prolonged antibiotic therapy, and secondary reconstruction.

Remote Monitoring of Patients with COVID-19 after Hospital Discharge with Connected Health Platform: Outcomes and Quality of Life

Background: Telemonitoring with applications and connected devices facilitates a more accessible and efficient attention. Its implementation has been accelerated thanks to the pandemic by COVID-19, where they have allowed the continuity of care. Objective: To evaluate the efficacy of a remote monitoring platform for the outpatient follow-up after hospital discharge by COVID-19. Methods: Prospective observational study of patients discharged from the hospital with COVID-19 infection between March 23 and May 25, 2020, who were followed for one month with the Connected Health telemonitoring platform. The mobile phone application connected to a pulse oximeter, allowed to measure vital signs and answer health questionnaires (EQ5D3L and CAT) daily, and alert the medical team that could be contacted by video consultation. Results: 95 patients (64% male) with a mean age of 54 (SD 26-81) years were included. The application allowed the detection of alerts for pain (80% of patients) and a decrease in oxygen saturation (12%). No patient required hospital readmission or presented complications. The application allowed strict monitoring of symptoms and quality of life. The main symptom was severe pain (59% of patients) followed by anxiety or depression (25%). The average state of health was 65 (SD 20-100). COVID-19 caused a low impact on the quality of life of 62% of the patients, although 8% reported a significant limitation, due to shortness of breath and leaving the house. Conclusion: telemonitoring allows a safe remote monitoring of patients after hospital discharge by COVID-19. The Connected Health application has allowed the measurement of oxygen saturation, symptoms and quality of life, and the detection and management of alerts by the medical team through video consultation.

Paracentese de alívio no domicílio

Introdução: A ascite é definida como um acúmulo de líquido na cavidade peritoneal e, em 75% dos casos, é causada por cirrose e hipertensão da veia porta de várias etiologias. Seu tratamento inclui restrição de fluidos, diurese e paracentese de grande volume. A paracentese de alívio é o procedimento de remoção de fluido ascítico da cavidade peritoneal com a finalidade de reduzir a pressão intra-abdominal e aliviar sintomas associados como dispneia, dor e desconforto abdominal. É uma técnica simples e segura que pode ser realizada em ambiente hospitalar e ambulatorial. A expansão dos Serviços de Atenção Domiciliar (SAD) no país oportunizou a realização de procedimentos de maior complexidade no domicílio podendo contribuir com o bem-estar de pacientes em cuidado paliativo domiciliar. Objetivo: Descrever o perfil de pacientes submetidos à paracentese de alívio em um SAD. Métodos: Estudo transversal, incluindo pacientes consecutivos que realizaram paracentese de alívio no domicílio entre os anos 2009 e 2017. Os dados foram coletados em prontuário. Para a análise descritiva dos dados estatísticos utilizou-se o Software Statistical Package for the Social Sciences v. 18.0 (SPSS). Resultados: A amostra foi composta por 15 pacientes, apresentando uma média do Índice de Comorbidade de Charlson de 8,1 (3-15). As neoplasias foram as principais causas de ascite nos pacientes acompanhados (80,2%). No período do estudo foram realizadas 48 paracenteses de alívio. Seis pacientes apresentaram sintomatologia clínica com necessidade de visita domiciliar (VD) não programada. Em relação às complicações do procedimento de paracentese, um paciente apresentou sangramento no local da punção. Todas as situações acima foram manejadas no domicílio. Em relação aos desfechos do atendimento no SAD, 53% dos pacientes necessitaram de reinternação hospitalar por piora clínica. Conclusões: A paracentese de alívio no domicílio mostra-se como uma prática segura, reduzindo idas desnecessárias a serviços de urgência/emergência e com bons índices de satisfação relatados pelos pacientes, desde que os profissionais sejam devidamente capacitados para realização do procedimento, com rotina e técnica instituída pelo SAD.

Salvage Resection for Isolated Local and/or Regional Failure of Head/Neck Cancer Following Definitive Concurrent Chemoradiotherapy Case Series and Review of the Literature

Primary management of advanced head/neck cancers involves concurrent chemoradiotherapy . Subsequently, regional and local failures are managed with resection but there have been few reports that describe the morbidity and disease control outcomes of surgical salvage in this setting. Retrospective analysis describes complications, survival, and patterns of failure after salvage resection of isolated local and/or regional failures of head/neck cancer following definitive concurrent chemoradiotherapy. Sixteen patients were identified for inclusion: laryngectomy in 11 patients, oral cavity/oropharynx resection in 2 patients, and neck dissection alone in 4 patients. Ten patients required graft tissue reconstruction (6 pedicle and 4 free flap). Median post-operative hospitalization was 7 days (range 3-19), and 4 patients required hospital re-admission. At a median survivor follow-up of 15.8 months (range 4.3-34.9), 10 patients were alive (6 without evidence of disease). Seven patients experienced disease recurrence at a median 6.7 months (range 0-12.6) following salvage resection (2 with isolated distant failures). Estimated 2-year local/regional control, freedom from failure, and overall survival were 58%, 39%, and 58%, respectively. Surgical salvage after primary definitive concurrent chemoradiotherapy is feasible with toxicity and outcomes similar to prior radiotherapy alone or sequential chemotherapy and radiation. Local andregional recurrence remains the predominant pattern of failure.

Disease Progression, Treatment Patterns, Hospitalization, and Clinical Outcomes of Patients with Acute Graft-Versus-Host Disease (aGVHD) after Allogeneic Hematopoietic Stem Cell Transplant (HSCT): A Multicenter Chart Review

Introduction aGVHD is a significant cause of morbidity and mortality following allogeneic HSCT. Objectives To describe the clinical course, treatments, hospitalizations, and clinical outcomes of patients who developed aGVHD after HSCT. Methods A multicenter retrospective chart review was conducted at 11 large US academic and community transplant centers to identify patients with first allo HSCT from 1/1/2014–6/30/2016 who subsequently developed grade II–IV aGVHD. Changes in aGVHD grade or organs involved, aGVHD recurrence, inpatient resource utilization, all-cause mortality, and 12-month overall and nonrelapse mortality (NRM) based on Kaplan-Meier estimates were reported. Results Data were collected for 475 patients (mean age, 52 years; 57% male). Median (interquartile range [IQR]) time from transplant to aGVHD diagnosis was 32 (22–48) days. At time of diagnosis, most (63%) patients had grade II disease (Figure 1), and 33% had ≥2 organs involved. Among all patients, 29% had an increase in their aGVHD grade, with a median time of 19 days from diagnosis to max grade. At max aGVHD grade, 46% had ≥2 organs involved (Figure 2). Overall, an increase in grade, new organ involvement, and progression by either organ or grade was experienced by 29%, 27%, and 40% of patients, respectively. Among patients with grade II–IV at diagnosis (n=431), 73% (314) received systemic corticosteroids (CS) as initial therapy, and median (IQR) time from diagnosis to initiation of systemic CS was 0 (0–2) days. Median starting dose was 1.0 mg/kg (79 mg/day) for prednisone and 2.1 mg/kg (190 mg/day) for methylprednisolone. During follow-up (median [IQR] 524 [165–954] days from aGVHD diagnosis to death/last visit), 23% of patients had CS dose increases, and 44% were unable to taper below 10 mg/day. Upon tapering CS, aGVHD recurred in 199 of 475 (42%) and was managed in 51% by increasing CS doses. 89 patients received additional systemic therapy for GVHD; 42% increased CS dose before additional therapy. Overall, 55% of patients required hospital readmission(s) within 100 days post-HSCT (mean length of stay, 27.5 days). Relapse of the underlying malignancy was reported in 110 (23%) patients. The 12-month overall mortality and NRM rates were 35% and 26%, respectively. Overall, 53% of patients died at a median (IQR) of 213 (77–430) days from aGVHD diagnosis (Figure 3). Conclusion 40% of patients with aGVHD experienced progression of GVHD despite systemic treatment; 27% with grade II progressed to higher grade. Approximately half of all patients required readmissions for inpatient stays of almost a month. Half of those patients died within 7 months of aGVHD onset. Although patients with grade III–IV aGVHD had the worst outcomes, patients with grade II at onset also had high mortality rates (51%). These data indicate the need for effective and tolerable treatments administered early in the disease course, even for grade II aGVHD.

Disease Progression, Hospital Readmissions, and Clinical Outcomes of Patients with Steroid-Refractory Acute Graft-Versus-Host Disease: A Multicenter Chart Review

Background: Acute graft-versus-host disease (aGVHD) post allogeneic hematopoietic stem cell transplantation (HCT) has a significant impact on morbidity and mortality. The standard first-line therapy for grade II-IV aGVHD is systemic corticosteroids (CS), which provide effective control in 40%-60% of patients. Patients may be unable to taper steroids due to new organ involvement or aGVHD flares. The objective of this retrospective multicenter study was to describe the clinical course, outcomes, and hospital readmissions for patients with aGVHD who were refractory to or dependent on systemic CS. Methods: A multicenter retrospective chart review was conducted at 11 large US academic and community transplant centers to identify patients who had their first HCT between Jan 1, 2014, and June 30, 2016, and subsequently developed grade II-IV aGVHD (defined by International Bone Marrow Transplant Registry Severity Index). Patients who participated in a GVHD prophylaxis trial or used Janus kinase inhibitors were excluded. Steroid dependence (SD)/steroid refractory (SR) was defined as the use of additional systemic anti-GVHD therapy, inability to taper high-dose steroids (≥1 mg/kg) by ≥25%, or tapering of CS dose by ≥25% but not &lt;10 mg/day. Clinical outcomes included changes in aGVHD grade or organs involved, aGVHD reoccurrence, and all-cause mortality. Results: Patient (N=168) mean age was 55 years, and 64% were male. The stem cell source was peripheral blood for 74% of patients. Median time from transplant to aGVHD diagnosis was 30 days (interquartile range [IQR]: 21-49). At the time of aGVHD diagnosis, most patients had grade I or II (65%; Figure 1) disease: 39% had skin involvement only; 38% had lower gastrointestinal (GI) involvement; and 37% had ≥2 organs involved (Figure 2). At the time of maximum aGVHD grade, most patients (66%) had grade III-IV disease: 25% had skin involvement only; 54% of patients had lower GI involvement; and 54% had ≥2 organs involved. Between the time of diagnosis and maximum aGVHD grade, 54% of patients had new organ involvement or an increase in aGVHD grade. Median time from diagnosis to maximum grade was 6.0 days. Of the 146 patients with grade II-IV aGVHD at diagnosis, 82% (119/146) were given systemic CS as first-line therapy, and 49% (72/146) initiated systemic CS on the day of diagnosis. Among the 119 patients, the average starting daily dose was 77 mg (0.9 mg/kg) for prednisone and 166 mg (1.8 mg/kg) for methylprednisolone. During follow-up (median 194 days from aGVHD diagnosis to death/last visit, IQR: 58-720), 36% of patients had an increase in steroid dose, and 88% were unable to taper below 10 mg/day. aGVHD recurred in 42% of patients (70/168) and was managed by increasing the CS dose in 79% of these patients. Over half of patients (53%; 89/168) received additional systemic anti-GVHD therapy; of those, 41% had an increase in CS dose before receiving additional therapy. Median time from CS initiation to additional therapy was 21 days. Frequently used additional therapies included sirolimus (19%), polyclonal antibodies (antithymocyte globulin/antilymphocyte globulin; 18%), mycophenolate mofetil (17%), tocilizumab (16%), extracorporeal photopheresis, and etanercept (both 13%). 26% (23/89) used ≥2 additional therapies. Overall, 57% of patients (95/168) required hospital readmission(s); 24% had ≥2 readmissions within 100 days post-HCT, with a mean inpatient length of stay of 50 days. Half (51%) of patients experienced an infection within the first 100 days post-HCT. Relapse of the underlying malignancy was reported in 35 patients (21%). Overall, 70% of patients (118/168) died at a median of 118 days (IQR: 62.0-234.1) from aGVHD diagnosis; 82% of patients with aGVHD progression died at a median of 116.0 days (IQR: 49-223), and 80% of patients with maximum grade III-IV aGVHD died at a median of 80 days (IQR: 42-216). Additionally, 86% of patients with lower GI aGVHD died at a median of 74.0 days (IQR: 44-174) (Figure 3). Conclusions: The majority of patients with aGVHD had severe and rapidly progressing disease. These findings indicate that clinical outcomes were poor among patients with SR and SD, with a mortality rate of 70% within 4 months of aGVHD diagnosis. Most patients required hospital readmission with an extended length of stay. The rapidly worsening clinical course further emphasizes the need for effective and tolerable therapies that prevent or reverse disease progression. Disclosures Yu: Incyte: Employment, Equity Ownership. Hanna:Asclepius Analytics: Employment. Paranagama:Incyte: Employment, Equity Ownership. Tang:Asclepius Analytics: Employment. Naim:Incyte: Employment, Equity Ownership. Galvin:Incyte: Consultancy.

Comparative Analysis of Patterns of Infectious Complications of Outpatient Vs. Inpatient Care Following Intensive Induction Chemotherapy for Adults with Acute Myeloid Leukemia (AML) or Other High-Grade Myeloid Neoplasms

Comparative Analysis of Patterns of Infectious Complications of Outpatient Vs. Inpatient Care Following Intensive Induction Chemotherapy for Adults with Acute Myeloid Leukemia (AML) or Other High-Grade Myeloid Neoplasms

One-Year Outcomes Following Tracheostomy for Acute Respiratory Failure.

Tracheostomy utilization has dramatically increased recently. Large gaps exist between expected and actual outcomes resulting in significant decisional conflict and regret. We determined 1-year patient outcomes and healthcare utilization following tracheostomy to aid in decision-making and resource allocation. Retrospective cohort study. All California hospital discharges from 2012 to 2013 with follow-up through 2014. Nonsurgical patients who received a tracheostomy for acute respiratory failure. None. Our primary outcome was 30-day, 90-day, and 1-year mortality. We also determined hospitals readmissions rates and healthcare utilization in the first year following tracheostomy. We identified 8,343 tracheostomies during the study period. One-year mortality following tracheostomy was high, 46.5%. Older adults (≥ 65 yr) had significantly higher mortality compared with younger patients (< 65 yr) (54.7% vs 36.5%; p < 0.0001). Median survival for older adults was 175 days (95% CI, 150-202 d) compared with greater than 1 year for younger adults (adjusted hazard ratio, 1.25; 95% CI, 1.14-1.36). Within 1 year of tracheostomy, 60.3% of patients required hospital readmission. Older adults were more likely to be readmitted in the first year after tracheostomy compared with younger adults (66.1% vs 55.2%; adjusted hazard ratio, 1.19; 95% CI, 1.09-1.29). Total short-term acute care hospital costs (index and readmissions) in the first year after tracheostomy were high (mean, $215,369; SD, $160,874). Long-term outcomes following tracheostomy are extremely poor with high mortality, morbidity, and healthcare resource utilization especially among older patients. Some subsets of younger patients may have better outcomes compared with the general tracheostomy population. Short-term acute care costs were extremely high in the first year following tracheostomy. If extended to the entire U.S. population, total short-term acute care hospital costs approach $11 billion dollars per year for tracheostomy-related to acute respiratory failure. These findings may aid families and surrogates in the decision-making process.

Long-term outcomes after acute hypercapnic COPD exacerbation : First-ever episode of non-invasive ventilation.

SummaryBackgroundNon-invasive ventilation (NIV) is used to treat acute hypercapnic respiratory failure (AHRF) in patients with chronic obstructive pulmonary disease (COPD); however, long-term outcomes following discharge are largely unknown. This study aimed to characterize long-term outcomes and identify associated markers in patients with COPD after surviving the first episode of HRF requiring NIV.MethodsThis study retrospectively analyzed 122 patients, mean age 62 ± 8 years, 52% female and forced expiratory volume in 1 s (FEV1) predicted 30 ± 13%, admitted with an acute hypercapnic exacerbation of COPD and receiving a first-ever NIV treatment between 2000 and 2012.ResultsA total of 40% of the patients required hospital readmission due to respiratory reasons within 1 year. Persistent hypercapnia leading to the prescription of domiciliary NIV, older age and lower body mass index (BMI) were risk factors for readmission due to respiratory reasons. Survival rates were 79% and 63% at 1 and 2 years after discharge, respectively. A shorter time to readmission and recurrent hypercapnic failure, lower BMI and acidemia on the first admission, as well as hypercapnia at hospital discharge were correlated with a decreased long-term survival.ConclusionPatients with COPD surviving their first episode of AHRF requiring NIV are at high risk for readmission and death. Severe respiratory acidosis, chronic respiratory failure and a lower BMI imply shorter long-term survival.Electronic supplementary materialThe online version of this article (10.1007/s00508-018-1364-6) contains supplementary material, which is available to authorized users.

The “Bundle Busters”: Incidence and Costs of Postacute Complications Following Total Joint Arthroplasty

BackgroundRecently, a bundled payment model was implemented in the United States to improve quality and reduce costs. While hospitals may be rewarded for lowering costs, they may be financially exposed by high cost complications, the so-called bundle busters. We aimed at determining the incidence, etiology, and costs of postacute complications after total joint arthroplasty (TJA). MethodsA retrospective study was conducted using a prospectively collected database of patients who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) from January 2015 to April 2016. Nurse navigators performed postoperative surveillance to identify patients with complications and unplanned clinical events in the 90-day postoperative period. This was combined with episode-of-care costs provided by third-party payers to derive the mean and per capita costs of postacute complications and clinical events. ResultsAmong 3018 THA and 5389 TKA patients, 3.35% of THA and 2.62% of TKA patients sought emergency department or urgent care services, 2.62% of THA and 3.69% of TKA patients required hospital readmission, and 3.99% of TKA patients required manipulation. Joint-related complications were more common following THA, whereas medical complications were more frequent after TKA. The most costly complications after THA were periprosthetic fracture, dislocation, and myocardial infarction, compared to deep infection, myocardial infarction, and pulmonary embolism after TKA. ConclusionJoint-related complications were among the most costly events after TJA, and given their higher incidence after THA, had a larger impact on per capita costs. Medical complications were more common after TKA and more costly. Despite these events, postacute complications made up less than 5% of the total 90-day costs of TJA.

Management of paediatric high-grade blunt renal trauma: a 10-year single-centre UK experience.

To report the management and outcome of paediatric patients sustaining high-grade blunt renal trauma. Medical records were examined for all American Association for the Surgery of Trauma (AAST) grade III-V blunt renal trauma cases admitted to a paediatric trauma centre from 2005 to 2015. Data collected and analysed included: demographics, imaging modalities, management, length of hospital stay (LOS), complications, and follow-up outcomes. In all, 18 children (12 boys, six girls) with mean (range) age 11 (4-15) years were included. According to the AAST grading criteria, 39% (seven of 18) of the patients had grade III, 50% (nine of 18) grade IV, and 11% (two of 18) grade V injuries; 44% (eight of 18) had concomitant injuries. Most of the patients were managed conservatively (89%, 16 of 18), although two of the 16 subsequently needed JJ-stent insertion during inpatient stay for symptomatic urinoma(s). In all, 11% (two of 18) of the patients required interventional radiology service(s), involving selective embolisation for life-threatening renal tract haemorrhage. Blood transfusion for renal injury exclusively was required in 11% (two of 18) of the patients. In all, 89% (16 of 18) of the patients had at least one follow-up imaging study before hospital discharge; most (13 of 16) had ultrasonography and three required computed tomography. The median (range) LOS was 11 (4-31) days. In all, 17% (three of 18) of the patients required hospital re-admission within 30 days for complications and all required interventional procedures: JJ stent for urinoma (one), embolisation of renal arterio-venous fistula (one), and embolisation for a post-traumatic pseudoaneurysm (one). Overall, the median (range) follow-up was 6 (2-60) months. In all, 78% (14 of 18) of the patients had dimercaptosuccinic acid studies, with 11 showing reductions in renal function (range 3-44%). This study supports a care pathway strategy advocating conservative management of high-grade renal injuries in children. However, patients may experience a relative decline in renal function with higher grade injuries indicating the need for monitoring and follow-up.

Identifying Risk Factors Leading to Unanticipated Postoperative Readmission

Unanticipated postoperative readmissions are a grading metric directly linked to both the quality of patient care and physician reimbursement. However, little data exist to define factors responsible for these readmissions in the plastic surgery patient population. This study aims to identify patient risk factors contributing to unanticipated postoperative readmissions to optimize perioperative patient care and mitigate negative financial impact upon providers. We present an institutional review board-approved study retrospective review of 819 plastic surgery patients undergoing operative procedures performed at our institution between January 1, 2013, and December 31, 2014. All unanticipated readmissions within 30 days of an operation were identified and subjected to statistical analysis in an effort to determine whether these readmissions were associated with identifiable patient risk factors. One hundred forty-nine (18.1%) of the 819 investigated patients underwent readmission, reoperation, or both within 30 postoperative days. Seventy-four (9%) patients required hospital readmission, alone; 55 (6.7%) underwent readmission with operative intervention; and 20 (2.4%) required outpatient operative intervention without readmission. Readmitted patients were significantly more likely to have a positive smoking history (P = 0.009), hypertension (P = 0.0008), congestive heart failure (P = 0.0015), chronic obstructive pulmonary disease (P = 0.023), a higher mean age (P = 0.0001), and a higher Charlson Comorbidity Score (P = 0.0001). These results identify risk factors associated with unanticipated postoperative readmissions specific to a plastic surgery patient population. With this information, practitioners can allocate appropriate perioperative resources and planning for patients at increased risk for readmission, thereby improving delivery of patient care and satisfying quality metrics linked to practitioner reimbursement.