Risk Severity Score Research Articles

What Is the Risk of Irrigation and Debridement Following Foot and Ankle Surgery? Development of a Risk Severity Scoring System.

Surgical site infection (SSI) after foot and ankle surgery has serious negative effects on patient health and quality of life. While previous studies have looked at predisposing factors for SSI, to our knowledge, no study has proposed a risk severity score. Can a risk severity score, based on patient demographic characteristics and surgical variables, be developed for preoperative use in patients undergoing foot and ankle surgery that will calculate the risk of an irrigation and debridement (I&D) procedure within 90 days of surgery utilizing data from previous surgeries? A retrospective chart study was performed on patients undergoing foot and ankle surgery. Data on demographic characteristics including age, sex, and BMI were recorded. Data on patient factors including diabetes and smoking history were also recorded. Surgical details including length of surgery, procedure type, surgeon, antibiotic delivery time, antibiotic type, and antibiotic dose were analyzed. Of 2979 procedures, 1% (36) of I&Ds were performed within 90 days. The mean age at surgery was 49 ± 17 years, and 57% (1702) of patients were female. The mean BMI was 28 ± 6 kg/m2. The primary outcome was I&D within 90 days postoperatively. Descriptive statistics of differences in patient characteristics between those who underwent I&D and those who did not were examined using chi-square tests and t-tests (p < 0.05 was taken as significant). Significant variables from a simple regression analysis were included in a multiple logistic regression model with a forward stepwise procedure for variable selection. We required all data in the model to be categorical; thus, continuous variables such as time were dichotomized. We factored odds ratios determined by multiple regression for significant variables into the final risk severity score, and an easy-to-use tool based on this risk severity score was created in Excel (Microsoft). Current tobacco use, diabetes, and longer operative times were the only factors associated with I&D within 90 days postoperatively. A risk severity score was developed using current tobacco use, diabetes, and length of surgery greater than 60 minutes as factors. A patient with a severity score of 0 (no risk factors) had a 0.6% chance of I&D within 90 days, while a severity score of 1 indicated a 1.1% chance, a score of 2 indicated a 2.1% chance, a score of 3 indicated a 4.0% chance, and a score of 4 (all risk factors) indicated a 7.5% chance of I&D within 90 days. A spreadsheet that can be used at the point of care was created based on these findings. Our risk severity score may help inform preoperative patient guidance and operative planning. Calculating the score in the office setting during preoperative visits can also improve communication between physician and patient. Future research should focus on validation of this risk severity score at multiple institutions. Level III, prognostic study.

Risk Stratification Model for Severe COVID-19 Disease: A Retrospective Cohort Study.

Risk stratification models have been developed to identify patients that are at a higher risk of COVID-19 infection and severe illness. Objectives To develop and implement a scoring tool to identify COVID-19 patients that are at risk for severe illness during the Omicron wave. This is a retrospective cohort study that was conducted in Israel's second-largest healthcare maintenance organization. All patients with a new episode of COVID-19 between 26 November 2021 and 18 January 2022 were included. A model was developed to predict severe illness (COVID-19-related hospitalization or death) based on one-third of the study population (the train group). The model was then applied to the remaining two-thirds of the study population (the test group). Risk score sensitivity, specificity, and positive predictive value rates, and receiver operating characteristics (ROC) were calculated to describe the performance of the model. A total of 409,693 patients were diagnosed with COVID-19 over the two-month study period, of which 0.4% had severe illness. Factors that were associated with severe disease were age (age > 75, OR-70.4, 95% confidence interval [CI] 42.8-115.9), immunosuppression (OR-4.8, 95% CI 3.4-6.7), and pregnancy (5 months or more, OR-82.9, 95% CI 53-129.6). Factors that were associated with a reduced risk for severe disease were vaccination status (patients vaccinated in the previous six months OR-0.6, 95% CI 0.4-0.8) and a prior episode of COVID-19 (OR-0.3, 95% CI 0.2-0.5). According to the model, patients who were in the 10th percentile of the risk severity score were considered at an increased risk for severe disease. The model accuracy was 88.7%. This model has allowed us to prioritize patients requiring closer follow-up by their physicians and outreach services, as well as identify those that are most likely to benefit from anti-viral treatment during the fifth wave of infection in Israel, dominated by the Omicron variant.

Automation of Macular Degeneration Classification in the AREDS Dataset, Using a Novel Neural Network Design.

To create an ensemble of Convolutional Neural Networks (CNNs), capable of detecting and stratifying the risk of progressive age-related macular degeneration (AMD) from retinal photographs. Retrospective cohort study. Three individual CNNs are trained to accurately detect 1) advanced AMD, 2) drusen size and 3) the presence or otherwise of pigmentary abnormalities, from macular centered retinal images were developed. The CNNs were then arranged in a "cascading" architecture to calculate the Age-related Eye Disease Study (AREDS) Simplified 5-level risk Severity score (Risk Score 0 - Risk Score 4), for test images. The process was repeated creating a simplified binary "low risk" (Scores 0-2) and "high risk" (Risk Score 3-4) classification. There were a total of 188,006 images, of which 118,254 images were deemed gradable, representing 4591 patients, from the AREDS1 dataset. The gradable images were split into 50%/25%/25% ratios for training, validation and test purposes. The ability of the ensemble of CNNs using retinal images to predict an individual's risk of experiencing progression of their AMD based on the AREDS 5-step Simplified Severity Scale. When assessed against the 5-step Simplified Severity Scale, the results generated by the ensemble of CNN's achieved an accuracy of 80.43% (quadratic kappa 0.870). When assessed against a simplified binary (Low Risk/High Risk) classification, an accuracy of 98.08%, sensitivity of ≥85% and specificity of ≥99% was achieved. We have created an ensemble of neural networks, trained on the AREDS 1 dataset, that is able to accurately calculate an individual's score on the AREDS 5-step Simplified Severity Scale for AMD. If the results presented were replicated, then this ensemble of CNNs could be used as a screening tool that has the potential to significantly improve health outcomes by identifying asymptomatic individuals who would benefit from AREDS2 macular supplements.

The Risk Calculation of Hazardous Zones Created By Flammable And Explosive Chemicals, LPG Tank Example

The determining of hazardous areas created by flammable and explosive chemicals is important to obtain a safe working environment. Taking precautions and prevent explosions require detailed investigations and accurate calculations instead of superficial and personal experience. In this context, possible leakages and leaks occurring around the LPG tank and its connections in a real enterprise were evaluated and the border of possible explosive atmosphere areas was calculated by the ALOAH program according to the TS 60079-10-1 standard. Based on the secondary discharge of the LPG from the bottom of the tank, the discharge characteristics were calculated as 4.946578 3.926692 m3/s at sonic and subsonic conditions respectively, and region radii, 10.8 m. The explosive atmosphere of the LPG tank was concluded that matched well the definition of Zone 2. The risk severity score of explosive atmospheres was calculated as 12 by using the risk assessment method of matrix system with approximations, possible in a week (3P), and the effect that could cause serious injury (4P). Serious threats and devastating effects were fictionalized clearly by explosion scenarios of the LPG tank. The calculations of explosive borders for flammable chemicals are necessary to prevent explosions, fires, and toxic effects of leaked chemicals by taking measurements on time. It is also necessary to calculate explosive areas and possible sceneries for each chemical separately for accurate results and effective control.

Abstract P675: Cardiovascular and Cerebrovascular Events in Status Migrainosus and Migraine With Aura- A National Estimate

Objective: Primary aim of this study is to compare the prevalence of vascular events [VEs - acute ischemic stroke (AIS), transient ischemic attack (TIA), acute myocardial infarction (AMI) and angina] among patients with status migrainosus and intractable migraine (SM), migraine with aura (MWA), migraine without aura (MWOA) and non-migraineurs. Secondary aim of this study is to evaluate the linkage of VEs and associated disability with different migraine subtypes. Methods: A cross-sectional study was performed using National Inpatient Sample [2016-2017] for adult hospitalizations. We extracted a cohort of secondary diagnoses of specific migraine subtypes amongst which primary diagnoses of VEs were identified using ICD 10 code. Weighted analysis using chi-square and multivariable survey logistic regression was performed to identify prevalence of VEs and evaluate relationship and disability (using APRDRG Risk Severity Score) between VEs and migraine subtypes. Results: Out of total 58,259,589 US hospitalizations, 0.1%, 0.08% and 0.03% had SM, MWA and MWOA, respectively. Prevalence of AIS (5.5 vs 0.96 vs 1.96 vs 1.71%) and TIA (3.99 vs 1.07 vs 0.49 vs 0.38%) was higher amongst MWA in comparison with SM, MWOA and non-migraineurs, respectively. (p&lt;.0001) Prevalence of AMI was lower amongst migraineurs (SM:0.40 vs MWA:0.86 vs MWOA:0.86 vs non-migraineurs:2.15%) but prevalence of angina was higher amongst MWOA (0.01 vs 0.07 vs 0.21 vs 0.06%). (p&lt;.0001) MWA and MWOA were associated with higher odds of AIS [MWA - aOR 3.7; 95%CI 3.4-4.1; MWOA - 1.7 (1.3-2.1)] and TIA [MWA - 11.8 (10.5-13.1); MWOA - 4.0 (2.9-5.6)] compared to non-migraineurs. Angina was associated with MWOA [3.0 (1.4-6.8)]. AIS hospitalization with SM had 52% [1.52 (1.2-1.9)] higher odds of extreme/severe disability compared to MWA. TIA patients with SM had higher odds of disability compared to MWA [3.0 (2.1-4.3)] and non-migraineurs [1.9 (1.4-2.6)]. Angina with MWOA had a significant disability [1.5 (1.04-2.2)] compared to non-migraineurs. Conclusion: SM and MWA had a significant role not only to predict AIS, TIA and angina but also increase disability. Early identification and management of these migraine subtypes may prevent VEs and mitigate disability associated with them.

Validation of a previously published risk severity score predicting surgical site infection after spinal deformity surgery in patients with cerebral palsy utilizing a large, separate cohort

Validation of a previously published risk severity score predicting surgical site infection after spinal deformity surgery in patients with cerebral palsy utilizing a large, separate cohort

Plastic Multilayered Closure in Pediatric Nonidiopathic Scoliosis Is Associated With a Lower Than Expected Incidence of Wound Complications and Surgical Site Infections

ObjectiveTo compare the incidence of surgical site infection (SSI) and wound complications between standard and plastic multilayered closure (PMC) in patients with pediatric nonidiopathic scoliosis undergoing primary or revision instrumentation or fusion. Study DesignRetrospective cohort study. Summary of Background DataAlthough PMC has been used for adult spine patients as well as infected spinal wound closure, it has not been reported as routine closure in the pediatric nonidiopathic scoliosis population. MethodsPatients with nonidiopathic scoliosis undergoing primary or revision instrumentation or fusion between 2013 and 2016 were enrolled. Clinical charts and operative reports were reviewed. Following September 2015, all patients with nonidiopathic scoliosis received PMC closure by plastic or orthopedic surgery. The SSI and wound complication incidence in patients undergoing PMC was compared to standard closure. The mean Risk Severity Score (RSS) for SSI, which uses patient characteristics to calculate the excepted SSI probability, was compared to the observed (actual) incidence. The CDC definition of SSI (infection ≤90 days of surgery) was used. Results115 patients were identified, including 56 standard closure and 59 PMC (mean age of 10.6 years; 54.8% female; mean preoperative major curve = 57.5°). There was no significant difference in age, sex, race, preoperative major curve, BMI, hemoglobin, blood loss, mean RSS score, or etiology between both groups (p > .05). Following PMC implementation, the observed incidence of wound complications decreased significantly from 19.6% in standard closures to 5.1% in the PMC group (p = .02), and the SSI incidence decreased from 8.9% to 1.7% (p = .11). The overall change in the observed (actual) incidence versus expected (RSS score) incidence of SSI indicated a 7.1% reduction following PMC. ConclusionUtilizing PMC in patients undergoing spinal surgery for nonidiopathic scoliosis significantly decreases the incidence of wound complications. Surgeons should consider using PMC in patients with nonidiopathic scoliosis. Level of EvidenceLevel II.

Development of a Risk Severity Score for Surgical Site Infection: Identifying High-Risk Non-Idiopathic Patients Undergoing Spinal Fusion and Instrumentation

Purpose: Surgical site infection (SSI) following pediatric spinal fusion and instrumentation is a well-recognized complication with an incidence that varies depending on patient diagnosis. The aim of this study was to develop a risk severity score (RSS) reflecting the risk of developing a SSI within 90 …

Development of a Risk Severity Score for Surgical Site Infection: Identifying High-Risk Non-Idiopathic Patients Undergoing Spinal Fusion and Instrumentation

Development of a Risk Severity Score for Surgical Site Infection: Identifying High-Risk Non-Idiopathic Patients Undergoing Spinal Fusion and Instrumentation

Development of a Risk Severity Score (RSS) Predicting Surgical Site Infection in Early Onset Scoliosis: Identifying High-Risk Patients

The RSS was developed to quantify the risk of SSI when considering operative intervention in patients with early onset scoliosis undergoing spinal surgery. The tool includes neuromuscular etiology, myelomeningocele, spinal muscular atrophy, endocrine comorbidity, gastrointestinal comorbidity, pulmonary comorbidity, developmental delay, urinary incontinence, and ventriculoperitoneal shunt as predictive variables. The RSS can improve shared decision making with patients and families during preoperative counseling and aid policy makers and administrators in determining reliable and valid risk-adjusted outcome measures.

Perceived discrimination and drug involvement among black primary care patients who use drugs

Perceived discrimination has been associated with disparities for Black patients on a variety of health outcomes. Studies have suggested that perceived discrimination is associated with drug use in Blacks, but they have been limited by use of samples with little drug use and single measures of drug involvement. The current study examined the association between perceived discrimination and multiple measures of drug involvement among a sample of 203 Black adult primary care patients who were participants in a randomized trial of screening and brief intervention for drug use. The main independent variable was everyday perceived discrimination. The three outcomes were frequency of drug use in the past ninety days, drug-related consequences, and total drug involvement risk severity score from the Alcohol, Smoking, and Substance Involvement Test [ASSIST]. Analyses were conducted using negative binomial regression models for frequency and consequence outcomes and median regression models for drug involvement risk. Greater perceived discrimination was not significantly associated with frequency of use, but was associated with more drug-related consequences and a higher drug use risk level. These findings suggest that perceived discrimination may be an important variable to consider when selecting drug intervention approaches for Black primary care patients.

A novel risk severity score to predict pediatric spine surgical site infection in patients with cerebral palsy ranges from 0.88% to 23.3%

A novel risk severity score to predict pediatric spine surgical site infection in patients with cerebral palsy ranges from 0.88% to 23.3%

Paper #31 Development of a Risk Severity Score Predicting Surgical Site Infection in Early Onset Scoliosis

The aim of this case-control study was to develop a RSS to predict SSI in patients with EOS undergoing repetitive lengthening utilizing traditional growth instrumentation. 171 patients with an average age of 4.7 years at surgery were enrolled. The SSI rate was 22.8%. Syndromic etiology, pulmonary comorbidity, major curve magnitude >90, non-ambulatory status, high BMI, and pelvic instrumentation were prognostic of SSI. The models predictive ability was 74.0%, indicating this model’s utility in evidence-based guidance regarding surgical risks.

The aggregate effects of multiple comorbid risk factors on cognition among HIV-infected individuals

This study developed and then cross-validated a novel weighting algorithm based on multiple comorbid risk factors (stimulant use, vascular disease, hepatitis C, HIV disease severity, cognitive reserve) to predict cognitive functioning among 366 HIV+ adults. The resultant “risk severity score” was used to differentially weight, as a function of age, the impact and magnitude of multiple risk factors on cognition. Among older adults (≥50 years) the risk severity index was differentially predictive of learning/memory and verbal fluency, whereas among younger adults it was linked to working memory and executive function. Cognitive reserve was found to be the most robust predictor of neurocognition.

Hypercoagulability in Pediatric Patients with Sickle Cell Disease and Correlation to Transcranial Doppler and Disease Severity

AbstractAbstract 3221Children with sickle cell disease (SCD) are at high risk for thrombotic stroke. Transcranial doppler ultrasound (TCD) is utilized to predict children at highest risk. Anemia and and vessel occlusion are assocated with elevated TCD velocities and risk of stroke. There is increasing evidence that a prothrombotic state contributes to the complications of SCD including stroke. We hypothesized that increased thrombin generation and platelet activation are associated with increased TCD velocities. We conducted a cross-sectional cohort study of children with SCD at Duke University Medical Center. Children had been clinically well for at least 2 weeks, had not been transfused for at least 3 months, and had TCD performed at study enrollment (n= 28) or within the prior 6 months (n=7). TCD time-averaged mean velocities (TAMV) were calculated for each patient and used for analysis. Blood was collected at the time of study entry per study protocol. Thrombin generation was measured utilizing: D-dimer; thrombin antithrombin (TAT); and calibrated automated thrombography (CAT) which evaluates phases of thrombin production including lag phase, time to peak thrombin, endogenous thrombin potential (ETP), and peak thrombin. Platelet activation was assessed by measurement of soluble glycoprotein V (sGPV). Clinical data were abstracted from the medical record including confirmation of SS genotype, use of hydroxyurea, prior sickle cell-related clinical events, and hematological data including hemoglobin, platelets and white blood cell count. SCD severity scores were calculated to classify patients as either high risk or low/moderate risk (van den Tweel et al, 2010). Linear regression analyses were conducted to assess correlation. Children with high risk severity scores were compared to children with low/moderate risk severity scores. Statistical analysis was performed using Graphpad 5.0; p<0.05 was considered significant. We evaluated 35 patients (median age 10 years, range 3 – 17). Linear regression revealed a correlation between the TCD velocities for TAT (r2=0.147, p=0.03), ETP (r2=0.13, p=0.049), and peak thrombin (r2=0.12, p=0.05). There was no significant correlation between TCD velocity and D-dimer, lag phase or time to peak thrombin. There also was no correlation between TCD velocities and hemoglobin, platelets or sGPV. Patients taking hydroxyurea were found to have lower thrombin generation (D-dimer: 882 ± 93 ng/ml vs. 1679 ± 428, p<0.0001) and TAT (6.8 ± 0.67 ng/ml vs. 10.59 ± 2.22, p<0.0001). There were 8 (23%) patients classified as high risk and 27 (77%) classified as low/moderate risk. Comparison of comparison of D-dimer, TAT, and each phase of thrombin generation between patients with low/moderate severity scores and those classified as high severity revealed no significant differences. In summary, increased TAT, ETP, and peak thrombin levels correlated with increased TCD velocities. Markers of thrombin generation were lower in children taking hydroxyurea. The lag phase and time to peak thrombin which both reflect the ‘thrombin burst', were not predictive of TCD velocities. In addition, hematological values and platelet activation did not correlate with TCD velocities. Further studies are warranted to understand the contribution of thrombin generation to stroke risk, to determine if markers of thrombin generation are independent markers of stroke risk, and determine if hydroxyurea can ameliorate this risk. Disclosures:Shah:Adventrx: Consultancy; Eisai: Research Funding. Off Label Use: Hydroxyurea for use in pediatric sickle cell disease. Ortel:Eisai: Research Funding; Glaxo SmithKline: Research Funding; Pfizer: Research Funding; Instrumentation Laboratory, Inc: Consultancy, Research Funding; Boehringer Ingelheim: Consultancy.

The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission

We determined the additional cost of an extended emergency department (ED) length of stay for chest pain patients awaiting non-ICU, monitored (telemetry) beds. This was a prospective cohort study of all ED chest pain patients aged 24 years or older and admitted to a telemetry bed in an urban university hospital during a 12-month period. Structured ED data collection included demographics, chest pain presentation, medical history, and laboratory test and ECG results. Hospital course was monitored daily, followed by a 30-day telephone follow-up. Risk severity scores (Goldman, Acute Cardiac Ischemia-Time-Insensitive Predictive Instrument, and Charlson) were calculated. Hospital charges, real costs, and revenues were obtained at discharge and 2 years later. The main outcome measure was risk-adjusted additional cost to the hospital of a delayed ED admission. Clinical outcome was a secondary measure. Of the 817 patients with chest pain presenting to the ED during the study period, there were 904 hospitalizations. Of these, 825 patients waited more than 3 hours for their bed (91%). There were 21 patient visits with a final diagnosis of acute myocardial infarction. ED length of stay was not associated with total hospital length of stay (r =0.01), hospital costs, or hospital or professional charges, revenues, or collection rates. The annual opportunity cost in lost hospital revenue for chest pain patients was 168,300 US dollars (204 US dollars per patient waiting >3 hours for a hospital bed). Extended ED length of stay demonstrated no association with total hospital costs or revenues or total hospital length of stay but imposed substantial ED opportunity costs, with decreased potential revenue. Interventions that reduce ED delays in hospital admissions have the potential to significantly increase hospital revenues.