Significant Predictor Of Morbidity Research Articles

EVALUATION OF PULMONARY FUNCTION TEST IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE PATIENTS

Chronic obstructive pulmonary disease (COPD) is a progressive inflammatory disease that affects the airways, alveoli, and pulmonary vasculature, leading to irreversible airflow limitation and loss of elastic recoil. This disease is highly prevalent in clinical practice, affecting approximately 10% of adults over 40 years of age, and it is expected to become the third leading cause of death by 2030. The study was conducted on 54 COPD patients diagnosed based on GOLD guidelines. The study observed a statistically significant association between Spirometric staging and the duration of symptoms.The mean value of FEV1/FVC,FEV1 in %,and 6MWD in meters decreased significantly as the grade of GOLD stage increased from stage II to stage III and stage IV. The study showed that COPD is associated with various comorbidities, including hypertension, diabetes mellitus, hypothyroidism, and coronary artery disease. The study concludes that FEV1, BMI, MMRC grading, and the 6-minute walk test are significant predictors of morbidity among COPD patients. The study recommends early detection and management of COPD to prevent its progression and associated morbidity.

Comorbidity and nutritional status in adult with advanced chronic kidney disease influence the decision-making choice of renal replacement therapy modality: A retrospective 5-year study.

Nutritional and inflammation status are significant predictors of morbidity and mortality risk in advanced chronic kidney disease (ACKD). To date, there are a limited number of clinical studies on the influence of nutritional status in ACKD stages 4-5 on the choice of renal replacement therapy (RRT) modality. This study aimed to examine relationships between comorbidity and nutritional and inflammatory status and the decision-making on the choice of RRT modalities in adults with ACKD. A retrospective cross-sectional study was conducted on 211 patients with ACKD with stages 4-5 from 2016 to 2021. Comorbidity was assessed using the Charlson comorbidity index (CCI) according to severity (CCI: ≤ 3 and >3 points). Clinical and nutritional assessment was carried out by prognosis nutritional index (PNI), laboratory parameters [serum s-albumin, s-prealbumin, and C-reactive protein (s-CRP)], and anthropometric measurements. The initial decision-making of the different RRT modalities [(in-center, home-based hemodialysis (HD), and peritoneal dialysis (PD)] as well as the informed therapeutic options (conservative treatment of CKD or pre-dialysis living donor transplantation) were recorded. The sample was classified according to gender, time on follow-up in the ACKD unit (≤ 6 and >6 months), and the initial decision-making of RRT (in-center and home-RRT). Univariate and multivariate regression analyses were carried out for evaluating the independent predictors of home-based RRT. Of the 211 patients with ACKD, 47.4% (n = 100) were in stage 5 CKD, mainly elderly men (65.4%). DM was the main etiology of CKD (22.7%) together with hypertension (96.6%) as a CV risk factor. Higher CCI scores were significantly found in men, and severe comorbidity with a CCI score > 3 points was 99.1%. The mean time of follow-up time in the ACKD unit was 9.6 ± 12.8 months. A significantly higher CCI was found in those patients with a follow-up time > 6 months, as well as higher mean values of eGFR, s-albumin, s-prealbumin, s-transferrin, and hemoglobin, and lower s-CRP than those with a follow-up <6 months (all, at least p < 0.05). The mean PNI score was 38.9 ± 5.5 points, and a PNI score ≤ 39 points was found in 36.5%. S-albumin level > 3.8 g/dl was found in 71.1% (n = 150), and values of s-CRP ≤ 1 mg/dl were 82.9% (n = 175). PEW prevalence was 15.2%. The initial choice of RRT modality was higher in in-center HD (n = 119 patients; 56.4%) than in home-based RRT (n = 81; 40.5%). Patients who chose home-based RRT had significantly lower CCI scores and higher mean values of s-albumin, s-prealbumin, s-transferrin, hemoglobin, and eGFR and lower s-CRP than those who chose in-center RRT (p < 0.001). Logistic regression demonstrated that s-albumin (OR: 0.147) and a follow-up time in the ACKD unit >6 months (OR: 0.440) were significantly associated with the likelihood of decision-making to choose a home-based RRT modality (all, at least p < 0.05). Regular monitoring and follow-up of sociodemographic factors, comorbidity, and nutritional and inflammatory status in a multidisciplinary ACKD unit significantly influenced decision-making on the choice of RRT modality and outcome in patients with non-dialysis ACKD.

Low serum albumin as a risk factor for delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage: eICU collaborative research database analysis.

Delayed cerebral ischemia (DCI) represents a devastating complication of aneurysmal subarachnoid hemorrhage (aSAH) and is a significant predictor of morbidity and mortality. Recent studies have implicated inflammatory processes in the pathogenesis of DCI. aSAH patient data were retrospectively obtained from the eICU Collaborative Research Database (eICU CRD). Multivariable logistic regression models and receiver operating characteristic (ROC) curve analyses were employed to assess the association between low serum albumin (<3.4 g/dL) and clinical endpoints: DCI and in-hospital mortality. Among 276 aSAH patients included in the analysis, 35.5% (N.=98) presented with low serum albumin levels and demonstrated a higher incidence of DCI (18.4% vs. 8.4%, OR=2.45, 95% CI=1.17, 5.10; P=0.017) and in-hospital mortality (27.6% vs. 16.3%, OR=1.95, 95% CI=1.08, 3.54; P=0.027) compared to patients with normal admission albumin values. In a multivariable model controlling for age and World Federation of Neurosurgical Societies grade, low serum albumin remained significantly associated with DCI (OR=2.52, 95% CI=1.18, 5.36; P=0.017), but not with in-hospital mortality. A combined model for prediction of DCI, encompassing known risk factors in addition to low serum albumin, achieved an area under the curve of 0.65 (sensitivity = 0.55, specificity = 0.75). Serum albumin, a routine and inexpensive laboratory measurement, may potentially aid in the identification of patients with aSAH at risk for the development of DCI.

Secondary School Socioeconomic Status and Athletic Training Practice Characteristics.

Socioeconomic status (SES) is a significant predictor of morbidity and mortality across health outcomes. Limited information exists on how school SES affects athletic training practice when a certified athletic trainer (AT) is present at secondary schools. To describe contact frequencies and service rates provided by ATs for injuries among secondary school student-athletes and how these differ by school SES. Cross-sectional study. The number of athletic training facility (ATF) visit days and AT services were collected from 77 secondary schools. Schools were separated into 3 school SES groups: affluent (n = 31), average (n = 29), and disadvantaged (n = 17). Secondary school student-athletes who participated in ≥1 of 12 boys' or 11 girls' sports, visited the ATF during the 2014-2015 through 2018-2019 academic years, and received athletic or nonathletic injury care. Contact frequencies were expressed as ATF visit days per injury, AT services per injury, and AT services per ATF visit day. Rates for service type used were expressed as the total count over reported athlete-exposures. The ATs documented 1191 services. Affluent and average SES school communities provided more contact frequencies for injury-related care than did disadvantaged school communities, particularly in AT services per injury (7.10 ± 13.08 versus average: 9.30 ± 11.60 and affluent: 9.40 ± 12.20; P = .020). Affluent school communities supplied greater rates of services in 5 of the 11 service groups reported. No differences were observed among school SES groups in therapeutic exercise. Our findings reflect that AT practice characteristics may have differed by school SES, but these differences did not appear to result in less medical care. Given the complexity and widespread effects of SES, future investigators should use a complex method to determine SES and aim to identify how SES may affect secondary school student-athletes in ways other than AT practice characteristics.

Frailty is a stronger predictor than age for postoperative morbidity in Crohn’s disease

BackgroundPatients with Crohn’s disease are particularly susceptible to preoperative frailty owing to the chronic nature of the illness and immunosuppressive therapy. The hypothesis in this study was that frailty would have a greater impact on postoperative outcome than age in older individuals with Crohn’s disease. MethodsData were obtained from the National Surgical Quality Improvement Program (NSQIP) from the years 2012 to 2018. Patients with Crohn’s disease who underwent a bowel resection were identified from diagnostic and procedure codes. Frailty was assessed using the 5-point Simplified Frailty Index (0–not frail, 5–most frail). Age was defined as an ordinal variable with 3 age ranges (18–64, 65–79, >80 years). Aggregate morbidity was classified according to the standard NSQIP definitions. Simplified Frailty Index was evaluated as a potential predictor of morbidity and mortality using covariate-adjusted logistic regression modeling. ResultsA total of 9,023 patients underwent bowel resection for Crohn’s disease during the study period. Patient Simplified Frailty Index ranged from 0 to 3 (Simplified Frailty Index = 0, 82%; 1, 15%; 2, 2.5%; 3, 0.1%), and higher Simplified Frailty Index was associated with increased age (P < .01). In multivariate regression, a Simplified Frailty Index was significantly associated with postoperative morbidity (Simplified Frailty Index ≥ 2: odds ratio = 2.59, 95% confidence interval [1.84–3.63], P < .0001). In contrast, age was not found to be a significant predictor of morbidity when adjusted for Simplified Frailty Index and other covariates (P > .05). ConclusionFrailty is a stronger predictor than age for morbidity in Crohn’s-related bowel resection. Functional assessments and vulnerability screening should be used to determine surgical candidacy rather than age alone.

The Impact of Diabetes and African American Race in COVID-19 Severity

Introduction: COVID-19, an illness caused by the novel coronavirus usually presents as a mild to moderate flu like illness, but can lead to pneumonia, acute respiratory distress syndrome and death in some patients. Since the onset of the COVID-19 pandemic there has been special attention towards patients with diabetes. Not only is diabetes highly prevalent in patients with COVID-19, but diabetes has been reported as a significant predictor of morbidity and mortality. Furthermore, race seems to be a predictor of severity with black people dying at 2.3 times the rate of white people. Methods: Here we performed a retrospective study of 524 cases of COVID-19 at an academic center in Chicago between March 2020 until August 2020. Data were obtained from patients that consented to the study to examine the relationship between diabetes, BMI, age, and race with degree of COVID-19 severity. Not all patients had all clinical and demographic data available. COVID-19 severity was determined using a severity index obtained from the measured SpO2 divided by the FiO2/fraction of inspired oxygen times 100. Numbers ≥ 315 mmHg were defined as low severity with patients generally requiring outpatient care, while 235–314 mm Hg were classified as moderate severity generally requiring inpatient care and≤ 234 mm Hg indicated high severity generally requiring intubation/ICU care. The Pearson correlation coefficient was used for linear correlation analyses. Proportion for categorical values were compared using the Chi squared test, the means for continuous variables were compared using two-tailed t tests or one way ANOVA (with Tukey post-test) for comparisons involving more than two conditions. A multiple linear regression model was used to assess the contribution of different variables. Differences were considered statistically significant at p<0.05 Results: Among 120 patients with an A1c, 55 (46%) patients had diabetes and 65 (54%) did not have diabetes. More patients with a high severity index were seen in the cohort with diabetes compared to those without diabetes (72% compared to 28% p=0.004). Univariate analyses revealed statistically significant positive correlations with higher COVID-19 severity and older age, BMI, and African American race. ANOVA analysis revealed a statistically significant difference between increasing BMI and worse severity category with a BMI mean of 29.3 kg/m2 in the low severity category compared to 34.9 kg/m2 in the moderate severity category (p=0.006). A multi-variate analysis adjusting for all variables revealed that A1c, older age and race were positively associated with higher COVID-19 severity. Conclusion: Increased A1c, older age and race are positively and independently associated with a higher COVID-19 severity index. Further research regarding the relationship between COVID-19 and these associations is urgently needed.

The Impact of Frailty on Outcomes of Sling Surgery with and without Prolapse Repair.

Frailty has emerged as a significant predictor of morbidity in urological surgery, but its impact on outcomes of sling surgery for stress incontinence remains unclear. The purpose of this study is to describe the prevalence of frailty among women undergoing sling surgery and determine the association of frailty with 30-day postoperative outcomes. We analyzed data from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP®) in 2013-2016 to identify patients undergoing sling placement using Current Procedural Terminology, 10th edition, code 57288. Patients were categorized into 2 groups based on whether they underwent isolated sling placement or had a sling with concomitant prolapse surgery. Frailty was assessed using the 5-factor Modified Frailty Index (mFI-5) developed for use with the NSQIP data set. Patients were considered frail if 2 or more factors from the mFI-5 were present. Outcomes and complications within 30 days were captured from the NSQIP data and logistic regression models used to adjust for age, race/ethnicity, body mass index and frailty. We identified 25,887 women who underwent sling placement, 15,087 of whom underwent isolated sling placement (Group 1) and 10,800 of whom underwent sling with concomitant prolapse repair surgery (Group 2). Frailty was present in 9.3% of patients in Group 1 and 10.2% of patients in Group 2 (p=0.0122). Among those who underwent isolated sling placement, frailty was associated with increased length of hospital stay (OR 1.2, 95% CI 1.1-1.4, p=0.0008) and 30-day hospital readmission (OR 1.7, 95% CI 1.1-2.5, p=0.0093). Older patients undergoing isolated sling placement were more likely to have longer operation time (OR 1.2, 95% CI 1.1-1.3, p <0.0001) and hospital length of stay (OR 1.3, 95% CI 1.2-1.4, p <0.0001). Frailty was also associated with increased 30-day hospital readmission in patients who underwent sling with concomitant prolapse repair (OR 1.8, 95% CI 1.3-2.6, p=0.0003), while age was not (OR 0.9, 95% CI 0.7-1.1, p=0.29). We found that frailty was present in relatively few patients undergoing sling surgery. Adverse postoperative outcomes and complications were low overall. Increased age and frailty were both associated with longer length of stay. Frailty, but not age, was significantly associated with increased likelihood of hospital readmission within 30 days following surgery. Our findings provide insight into the preoperative characteristics of women undergoing sling surgery in a large national sample, suggesting the need for preoperative identification of the frail patient.

SARS-CoV-2 infection and diabetes mellitus: A North Eastern Romanian experience.

As it spread globally, the new SARS-CoV-2 virus was first confirmed in Romania in February 2020, inevitably infecting individuals with diabetes mellitus (DM) along the way. Diabetes is known to affect the response of the body to pathogens and, according to studies conducted in the last 3 months, it appears that diabetic patients are at a higher risk for developing severe forms of the disease and multiple complications. We performed a retrospective study in order to assess the patients with SARS-CoV-2 infection and DM admitted to 'Sf. Parascheva' Clinical Hospital of Infectious Diseases from March 4th until June 30th, 2020. Of the total 1,080 patients admitted during this period, 85 patients (7.87%) had underlying DM, mostly type 2 (82 cases, 96.46%); the mean age of these patients was 62, and 42 were men (49.41%). Chest CTs revealed indicative SARS-CoV-2 images for all patients and their treatment included individually tailored administration of hydroxychloroquine/lopinavir + ritonavir/enoxaparin sodium/tocilizumab/antibiotherapy according to the then national and international guidelines. In total, 70 patients (82.35%) were cured and 15 succumbed to MODS and/or associated neoplasia, bringing the fatality rate to 17.64%. Although advanced age and DM have been associated with aggravated forms of SARS-CoV-2 infection, over 80% of the patients included in the present study were cured. Nonetheless, diabetes appears to be a significant predictor of morbidity and mortality in the SARS-CoV-2 infection.

Granulomatous interstitial nephritis in a patient with SARS-CoV-2 infection

BackgroundAcute kidney injury (AKI) associated with severe coronavirus disease 19 (COVID-19) is common and is a significant predictor of morbidity and mortality, especially when dialysis is required. Case reports and autopsy series have revealed that most patients with COVID-19 – associated acute kidney injury have evidence of acute tubular injury and necrosis - not unexpected in critically ill patients. Others have been found to have collapsing glomerulopathy, thrombotic microangiopathy and diverse underlying kidney diseases. A primary kidney pathology related to COVID-19 has not yet emerged. Thus far direct infection of the kidney, or its impact on clinical disease remains controversial. The management of AKI is currently supportive.Case PresentationThe patient presented here was positive for SARS-CoV-2, had severe acute respiratory distress syndrome and multi-organ failure. Within days of admission to the intensive care unit he developed oliguric acute kidney failure requiring dialysis. Acute kidney injury developed in the setting of hemodynamic instability, sepsis and a maculopapular rash. Over the ensuing days the patient also developed transfusion-requiring severe hemolysis which was Coombs negative. Schistocytes were present on the peripheral smear. Given the broad differential diagnoses for acute kidney injury, a kidney biopsy was performed and revealed granulomatous tubulo-interstitial nephritis with some acute tubular injury. Based on the biopsy findings, a decision was taken to adjust medications and initiate corticosteroids for presumed medication-induced interstitial nephritis, hemolysis and maculo-papular rash. The kidney function and hemolysis improved over the subsequent days and the patient was discharged to a rehabilitation facility, no-longer required dialysis.ConclusionsAcute kidney injury in patients with severe COVID-19 may have multiple causes. We present the first case of granulomatous interstitial nephritis in a patient with COVID-19. Drug-reactions may be more frequent than currently recognized in COVID-19 and are potentially reversible. The kidney biopsy findings in this case led to a change in therapy, which was associated with subsequent patient improvement. Kidney biopsy may therefore have significant value in pulling together a clinical diagnosis, and may impact outcome if a treatable cause is identified.

Molecualr Association of Coronavirus with Diabetes Mellitus Type 2 in Pakistan

Patients with COVID-19 who have elevated blood sugar levels without a previous diagnosis of diabetes may be at a high risk of death and an increased risk of severe complications from the infectious disease, a new study says. We aimed to briefly review the general characteristics of the novel coronavirus (SARSCoV-2) and provide a better understanding of the coronavirus disease (COVID-19) in people with diabetes, and its management. We searched for articles in PubMed and Google Scholar databases till 02 April 2020, with the following keywords: “SARS-CoV-2”, “COVID-19”, “infection”, “pathogenesis”, “incubation period”, “transmission”, “clinical features”, “diagnosis”, “treatment”, and “diabetes”, with interposition of the Boolean operator “AND”. The clinical spectrum of COVID-19 is heterogeneous, ranging from mild flu-like symptoms to acute respiratory distress syndrome, multiple organ failure and death. Older age, diabetes and other comorbidities are reported as significant predictors of morbidity and mortality. Chronic inflammation, increased coagulation activity, immune response impairment, and potential direct pancreatic damage by SARS-CoV-2 might be among the underlying mechanisms of the association between diabetes and COVID-19. No conclusive evidence exists to support the discontinuation of angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers or thiazolidinedione’s because of COVID-19 in people with diabetes. Caution should be taken to potential hypoglycemic events with the use of chloroquine in these subjects. Patient tailored therapeutic strategies, rigorous glucose monitoring and careful consideration of drug interactions might reduce adverse outcomes. Suggestions are made on the possible pathophysiological mechanisms of the relationship between diabetes and COVID-19, and its management. No definite conclusions can be made based on current limited evidence. Further research regarding this relationship and its clinical management is warranted

Prevalence of polypharmacy in the older adult population within primary care in Portugal: a nationwide cross-sectional study.

Polypharmacy is commonly defined as the simultaneous use of five or more medications; however, there is a lack of consensus regarding the most appropriate definition. It is a significant predictor of morbidity and mortality. The aim of this study was to determine the prevalence of polypharmacy in the population of older adults attending primary care in Portugal and to identify associated sociodemographic and clinical factors. We conducted a cross-sectional, analytical study in primary care centres from the five Portuguese healthcare administrative regions and the two autonomous regions. We used a random sample of 757 older adult patients provided by the information department of the ministry of health (SPMS) and family doctors from the autonomous regions. Data collection occurred in March 2018. The variables utilised were sociodemographic characteristics, clinical profile and medication. For each patient, polypharmacy was measured either by the concurrent use of ≥ 5 drugs or by the median number of drugs at the time of data collection. Logistic regression analyses were performed to determine associations between polypharmacy and other variables. Polypharmacy (≥ 5 drugs) was present in 77% of the sample. A cut-off of over the median number of drugs was present in 55%. The likelihood of having polypharmacy increased significantly with age (OR = 1.05 (1.02-1.08)), number of chronic health problems (OR = 1.24 (1.07-1.45)) and number of prescribers (OR = 4.71 (3.42-6.48)). Cardiovascular, metabolic and musculoskeletal medications were the most commonly involved in polypharmacy. Polypharmacy was a very common occurrence in Portugal. Future primary healthcare policies should address polypharmacy.

Frailty predicts mortality and complications in chronologically young patients with traumatic orthopaedic injuries

BackgroundAs morbidity and mortality from traumatic orthopaedic injuries continues to rise, increased research is being conducted on how to best predict complications in at risk patients. Recently, frailty indices have been validated in a variety of surgical subspecialties as predictors of morbidity and mortality. However, the vast majority of research has been conducted on geriatric patient populations, with little evidence on patients who are chronologically young. The purpose of this study was to evaluate the role of a modified frailty index (mFI) in predicting mortality and complications after pelvis, acetabulum, and lower extremity trauma in patients of all ages. MethodsThe American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried from 2005 to 2014 for all patients who underwent surgery for pelvis, acetabulum, and lower extremity trauma. The sample size was divided into geriatric (age ≥ 60) and young (age < 60) cohorts. The mFI score was calculated for each patient. Bivariate analysis was performed using logistic regression and a chi-square test to determine the relationship between mFI and both primary and secondary outcomes while adjusting for age. Univariate analysis and multivariate analyses were performed. All analyses were done using SAS 9.4 (Cary, NC) and a p < 0.05 was considered significant. Results56,241 patients were identified to have undergone surgery for pelvis, acetabulum, or lower extremity trauma. 28% of patients were identified under the age of 60. In the young cohort, mFI was a strong predictor of thirty-day mortality (OR 11.02, 95% CI 6.26–19.39, p < 0.001). With regards to Clavien-Dindo grade IV complications, MFI is also a strong predictor in the young cohort (OR 28.82, 95% CI 16.05–51.77, p < 0.001). Conclusion and relevanceThe mFI score was a significant predictor of morbidity and mortality in chronologically young orthopaedic trauma patients. The use of the mFI score can provide an individualized risk assessment to interdisciplinary teams for perioperative counseling and to improve outcomes.

Renal Function as a Predictor of Reamputation After Initial Transmetatarsal Amputation in the Perioperative Period

Category: Midfoot/Forefoot Introduction/Purpose: With increasing rates of patients being newly diagnosed with diabetes mellitus, foot complications are becoming more common, which often lead to amputation. Compared to major lower extremity amputations, transmetatarsal amputations (TMA) are associated with lower cost, better function, and more aesthetically satisfactory results for patients. Renal failure has been shown to be a significant predictor of morbidity and mortality in lower extremity amputations at various levels. However, previous reports examining the effect of renal function on reamputation rates after TMA have been mixed. As a result, the purpose of this study was to evaluate renal dysfunction as a risk factor for reamputation after initial TMA during the 30-day perioperative period in a large population database. Methods: Patients under 90 years of age who underwent a TMA between 2012 and 2015 were retrospectively identified in the prospectively collected American College of Surgeons-National Surgical Quality Improvement Program® (ACS-NSQIP®) database using the Current Procedure Terminology (CPT) code 28805. Failure of the initial TMA was defined as reamputation in the 30-day perioperative period through corresponding CPT codes. From these criteria, a total of 1,775 patients were identified. More than 150 unique patient factors were included in the study, but glycated hemoglobin (HbA1C) was not reported by the ACS-NSQIP® database. Diabetes status was categorized into four groups: “Insulin” dependent, “Non-Insulin” dependent, or “None.” Filtration rate was estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, and patients were categorized into stages of chronic kidney disease (CKD). Results: Over the 30-day perioperative period, the rate of reamputation after TMA was 6.5%. No statistical differences in age, gender, race, body-mass index, or level of pre-operative functional status were found between groups. Reamputation rates after TMA was significantly correlated with higher white blood cell counts (p&lt;.00001), greater serum creatinine (p=.021), higher blood urea nitrogen (p=.021), type of glycemic control (p=.002), stage of CKD (p=.003), dialysis (p=.001), and pre-operative blood transfusion (p=.042). Stage IV-V CKD was associated with 75% increased odds of reamputation (OR=1.75, 95% CI=1.12-2.73), and higher stage of CKD was associated with greater reamputation rates (p=.003) where stage II CKD had the lowest reamputation rate (3.6%) and stage V with the highest reamputation rate (10.9%). A similar trend was seen with 30-day mortality (p&lt;.00001). Conclusion: In the current study, CKD was significantly correlated with reamputation rates after TMA as well as 30-day mortality. In contrast to a previous report, dialysis was also associated with TMA failure and need for reamputation. Our findings corroborate previous findings correlating dialysis-dependent renal failure and mortality. Whether patients in certain stages of CKD would achieve better outcomes with higher-level amputation rather than a TMA should be investigated in future studies.

Acute Kidney Injury After Total Arch Replacement Combined With Frozen Elephant Trunk Implantation: Incidence, Risk Factors, and Outcome

Acute kidney injury (AKI) is common after thoracic aortic surgery and is a significant predictor of morbidity and mortality. Total arch replacement (TAR) combined with frozen elephant trunk (FET) implantation has been reported to produce satisfactory clinical outcomes, whereas several features of the surgical procedure may induce postoperative AKI. The authors aimed to clarify the incidence of and risk factors for postoperative AKI and the association of AKI with short-term outcomes. This study was a retrospective analysis of a prospectively collected cohort. A multivariate logistic regression model was used to identify predictors of postoperative AKI. Single center. Clinical data were analyzed for 553 consecutive patients who underwent TAR combined with FET implantation between 2013 and 2016. None MEASUREMENTS AND MAIN RESULTS: Postoperative AKI was defined using the Kidney Disease Improving Global Outcomes criteria. Postoperative AKI occurred in 77.6% of the whole cohort. Patients in stage 3 AKI were associated with a higher incidence of major adverse events and in-hospital and 90-day mortality (p < 0.001, p < 0.05, p < 0.01, respectively). In the multivariate analysis, male sex (odds ratio [OR] 1.94; 95% confidence interval [95% CI] 1.22-3.18; p = 0.005); older age (per 10 years) (OR 1.37; 95% CI 1.14-1.67; p = 0.001); elevated body mass index (per 5 kg/m2) (OR 1.41; 95% CI 1.08-1.87; p = 0.01); and prolonged cardiopulmonary bypass duration (per 30 minutes) (OR 1.17; 95% CI 1.01-1.37; p = 0.03) were identified as independent predictors of postoperative AKI. TAR combined with FET implantation carries a high-risk for postoperative AKI compared with other types of thoracic aortic surgeries. Cardiopulmonary bypass duration was identified as the only modifiable predictor of AKI, and patients may benefit from moderate hypothermic circulatory arrest instead of deep hypothermic circulatory arrest.

The frail fail: Increased mortality and post-operative complications in orthopaedic trauma patients

ObjectiveThe burgeoning elderly population calls for a robust tool to identify patients with increased risk of mortality and morbidity. This paper investigates the utility of the MFI as a predictor of morbidity and mortality in orthopaedic trauma patients. DesignRetrospective review of the NSQIP database to identify patients age 60 and above who underwent surgery for pelvis and lower extremity fractures between 2005 and 2014. Main outcomes and measuresFor each patient, an MFI score was calculated using NSQIP variables. The relationship between the MFI score and 30-day mortality and morbidity was determined using chi-square analysis. MFI was compared to age, American Society of Anesthesiologists physical status classification, and wound classifications in multiple logistic regression. ResultsStudy sample consisted of 36,424 patients with 27.8% male with an average age of 79.5 years (SD 9.3). MFI ranged from 0 to 0.82 with mean MFI of 0.12 (SD 0.09). Mortality increased from 2.7% to 13.2% and readmission increased from 5.5% to 18.8% with increasing MFI score. The rate of any complication increased from 30.1% to 38.6%. Length of hospital stay increased from 5.3days (±5.5days) to 9.1days (±7.2days) between MFI score 0 and 0.45+. There was a stronger association between 30-day mortality and MFI (aOR for MFI 0.45+: 2.6, 95% CI: 1.7–3.9) compared to age (aOR for age: 1.1, 95% CI: 1.1-1.1) and ASA (aOR 2.5, 95% CI: 2.3–2.7). Conclusions and relevanceMFI was a significant predictor of morbidity and mortality in orthopaedic trauma patients. The use of MFI can provide an individualized risk assessment tool that can be used by an interdisciplinary team for perioperative counseling and to improve outcomes.

No Difference in Antibody Responses to Tetanus Vaccine Among HIV-Exposed and -Unexposed Infants in Botswana

BackgroundIn Botswana, more than 10% of HIV-exposed, uninfected infants (HEU) are hospitalized or die in the first 6 months of life, largely due to infectious causes. Vaccine responses can act as a marker of the immune response to infectious antigens. Previous studies of antibody responses to vaccines in HEU have had conflicting results. We compared antibody titers to tetanus vaccine between HEU and HIV-unexposed infants (HUU), and explored whether tetanus antibody titers predicted risk of hospitalization in the first 2 years of life among HEU.Methods443 HIV-infected and 451 HIV-uninfected mothers and their 453 HEU / 457 HUU live-born infants were followed in a prospective observational study in Botswana (“Tshipidi”). Quantitative tetanus toxoid IgG was measured in plasma samples from 18-month-old infants. Geometric mean antibody titers (GMT) were compared between HEU and HUU infants, and between HEU infants who were or were not hospitalized by age 2.ResultsPlasma was available at 18 months for 39 HEU and 42 HUU infants. Within this subset, there were 15 hospitalizations (12 in HEU) [RR of hospitalization among HEU = 1.34 (P = 0.009)]. 73% of hospitalizations overall, and 83% in HEU, were due to infection (primarily pneumonia/bronchiolitis and gastroenteritis). Among infants who had received 3 or 4 doses of tetanus vaccine by 18 months, there were no significant differences in tetanus GMT between HEU and HUU (Fig A). Among HEU who had received 3 or 4 doses of tetanus vaccine by 18 months, there were no significant differences in tetanus GMT between infants who were hospitalized and infants who were not (Fig B).ConclusionIn this small sample of infants from Botswana, we did not identify differences in antibody responses to tetanus vaccine between HEU and HUU. Although HEU demonstrated an increased risk of hospitalization, response to tetanus vaccine did not appear to be a significant predictor of morbidity. It is possible that cell-mediated immune defects play a larger role than humoral immune defects in the increased susceptibility to infection among HEU.Disclosures All authors: No reported disclosures.

Patient Function and the Value of Surgical Care for Kidney Cancer

Frailty and functional status have emerged as significant predictors of morbidity and mortality for patients undergoing cancer surgery. To articulate the impact on value (ie quality per cost), we compared perioperative outcomes and expenditures according to patient function for older adults undergoing kidney cancer surgery. Using linked SEER (Surveillance, Epidemiology and End Results)-Medicare data, we identified 19,129 elderly patients with kidney cancer treated with nonablative surgery from 2000 to 2009. We quantified patient function using function related indicators (claims indicative of dysfunction and disability) and measured 30-day morbidity, mortality, resource use and cost. Using multivariable, mixed effects models to adjust for patient and hospital characteristics, we estimated the relationship of patient functionality with both treatment outcomes and expenditures. Of 19,129 patients we identified 5,509 (28.8%) and 3,127 (16.4%) with a function related indicator count of 1 and 2 or greater, respectively. While surgical complications did not vary (OR 0.95, 95% CI 0.86-1.05), patients with 2 or more indicators more often experienced a medical event (OR 1.22, 95% CI 1.10-1.36) or a geriatric event (OR 1.55, 95% CI 1.33-1.81), or died within 30 days of surgery (OR 1.43, 95% CI 1.10-1.86) compared with patients with no baseline dysfunction. These patients utilized significantly more medical resources and amassed higher acute care expenditures (p <0.001). During kidney cancer surgery, patients in poor functional health can face a more eventful medical recovery at elevated cost, indicating lower value care. Greater consideration of frailty and functional status during treatment planning and transitions may represent areas for value enhancement in kidney cancer and urology care.

Perioperative Strokes and Early Outcomes in Mitral Valve Surgery: A Nationwide Analysis

To demonstrate the role of perioperative stroke as an independent risk factor for in-hospital morbidity and mortality after mitral valve surgery and review the trends in the early outcomes of mitral valve surgery over the past decade. Using data from the National Inpatient Sample database for analysis, all patients who underwent isolated mitral valve procedures were identified using International Classification of Diseases-Ninth Revision codes. Univariate and multivariate analyses of risk factors of in-hospital mortality and morbidity were performed. Multi-institutional. The study comprised patients who underwent mitral valve procedures from 1999 to 2011. Mitral valve repair or replacement. Data on 21,821 patients showed an in-hospital mortality of 5.5% and morbidity of 63.30% (p<0.05). Perioperative strokes were experienced by 3.89% of the cohort after isolated mitral valve surgery (p<0.05). Independent predictors of adverse outcomes were age, female sex, emergency surgery, arrhythmias, hypertension, renal failure, coagulopathy, neurologic disorders, weight loss, anemia, postoperative cardiac arrest, and myocardial infarction. Perioperative strokes were found to be the strongest risk factor for postoperative mortality (odds ratio 2.34, 95% confidence interval 1.83-2.98) and morbidity (odds ratio 4.53, 95% confidence interval 3.34-6.15). Age, female sex, emergency surgery, arrhythmias, hypertension, renal failure, coagulopathy, neurologic disorders, weight loss, fluid and electrolyte imbalance, anemia, postoperative cardiac arrest, and myocardial infarction were found to be significant predictors of morbidity and mortality after mitral valve surgery, with perioperative strokes posing the strongest risk. The trends in the last 10 years indicated a decrease in mortality and an increase in morbidity. Preoperative risk stratification and intraoperative identification for impending strokes appear warranted.

Risk factors for increased resource utilization and critical care complications in patients undergoing hepaticojejunostomy for biliary injuries

BackgroundThis project aimed to study resource utilization and surgical outcomes after hepaticojejunostomy (HJ) for biliary injuries utilizing data from ACS NSQIP. MethodsData from the Participant Use Data File containing surgical patients submitted to the ACS NSQIP during the period of 1/1/2005–12/31/2014 were analyzed. ResultsDuring the study period, 320 patients underwent HJ. Mean age was 50 years, and 109 (34%) were male. Forty-four percent of patients met criteria for ASA class III–V. Forty patients (12.5%) developed one or more critical care complications (CCC). Eighty-one patients (25%) experienced morbidity with a perioperative mortality rate of 1.9%. The mean age of these patients was 52 years, and 62% were male. Age and preoperative elevated alkaline phosphatase were independent predictors of CCC (p < 0.001 and 0.042, OR 1.035, OR 4.337, respectively). Patients ASA class III, age, and preoperative hypoalbuminemia were found to increase risk for prolonged LOS (OR 1.87, p = 0.041, OR 1.02, p = 0.049, OR 2.63, p = 0.001). DiscussionThe most significant predictors of morbidity and increased resource utilization after HJ include increasing age, ASA class III or above, and preoperative hypoalbuminemia. Age and ASA class are the strongest predictors of CCC in these patients.

Does Living Arrangement Affect Work Status, Morbidity, and Treatment Seeking of the Elderly Population? A Study of South Indian States

The well-being of the elderly population in India is of prime importance in the context of a weak social security system, breakdown of family structure, and increasing noncommunicable diseases. In this context, this study aims to understand the linkages of the living arrangements of the elderly with their work status, morbidity, and treatment-seeking behavior in four states in South India. This study was based on cross-sectional secondary data from the 60th round of National Sample Survey (NSS) on “Morbidity, Health Care and the Condition of the Aged” conducted in India in 2004. A subsample of 7,853 elderly from four demographically advanced states in South India formed the study population. Results showed that most of the elderly were working as unpaid workers in their later ages. A significant number of the elderly with primary or more education and living with their children without spouse or with other relatives worked as unpaid workers. Multivariate analyses suggest that those elderly living with their children were less likely to suffer from any morbidity and more likely to seek treatment. Economic well-being and usual activity status are significant predictors of morbidity and treatment-seeking behavior. Those elderly who lived alone were more vulnerable to poor health and more likely to work for their livelihood. Irrespective of the living arrangement, treatment seeking among the elderly was relatively higher in Kerala compared with the rest of the states. Thus, the family plays a significant role in elderly care, and living arrangement affects the work status and morbidity condition of the elderly population in the states of South India.