Strong Predictor Of Need Research Articles

Abstract 18044: Valvular Procedures in Pregnant Women With Congenital Heart Disease: The Magee Obstetric Maternal and Infant (MOMI) ACHD Substudy

Introduction: Pregnant women with adult congenital heart disease (ACHD) are at high risk of complications and may require interventions, including valvular surgery, after delivery. However, data on the long-term need for valvular surgery among pregnant women with ACHD are limited. Hypothesis: We hypothesized that increasing ACHD complexity and obstetric history are associated with the need for valvular surgery after delivery. Methods: Data from the University of Pittsburgh Medical Center clinical data warehouse were linked to all deliveries from 2004 to 2020 in pregnant women with ACHD (N=430) and without ACHD (N=876), who were included in the Magee Obstetric Maternal and Infant (MOMI) study. Women were matched at the delivery level for age, delivery year, and race. Valvular procedures were captured using Current Procedural Terminology codes until 8/31/2022. Results: Baseline characteristics and pregnancy outcomes are presented in Table 1 . Prior to index delivery, 8 women (6 with ACHD, 2 controls) had a valve replacement, Table 1. After a median of 5.1 (2.8, 8.8) years, 23 women with ACHD had a total of 25 valve procedures, corresponding to 1.0% per year (95%CI: 0.6 to 1.4). Most procedures were aortic valve (n=11, plus aortic root in 5) and pulmonary valve replacements (n=11), followed by tricuspid (n=5) and mitral (n=1) procedures; some women had >1 valve replaced in the same procedure. There were no valvular interventions among controls. After adjusting for maternal age and race, the strongest predictor of need for valvular interventions was ACHD complexity. Compared to simple lesions; moderate ACHD had a HR of 6.58; 95%CI 1.85 - 23.4; P=0.004 and complex ACHD a HR of 9.35; 95%CI 1.37 - 64.0; P=0.023). The number of previous deliveries (or total pregnancies) was not associated with the need for valvular procedures. Conclusions: Women with moderate or complex ACHD have increased rates of valvular procedures after delivery, but multiple pregnancies do not modify this risk.

Population Perspectives on Impact of the COVID-19 Pandemic on Essential Health Services-Behavioral Insights from the Federation of Bosnia and Herzegovina.

The aim of this study was to analyze the impact of the COVID-19 pandemic on patterns of use of essential health services (EHS), health-seeking behaviors, and population health and wellbeing in the Federation of Bosnia and Herzegovina (FBiH) from the perspective of its adult population. A population-based survey was implemented in the FBiH in December 2020 on a sample of 1068 adults. Overall, 64% of respondents received care, significantly more being women (67% vs. 61%, p = 0.046), those with a chronic disease (CD) (75% vs. 65%, p < 0.001), and of an older age (58% in 18-34 vs. 67% in older, p = 0.031). These groups also postponed care more often (39% in 55+ vs. 31% in 18-34 years old, p = 0.01; 55% with CD vs. 31% without, p < 0.001; and 43% in females vs. 32% males, p < 0.001). Main reasons for postponing care were lack of available appointments and fear of infection. The presence of a CD was the strongest predictor of need, access, and disruptions of health care. Respondents reported increased expenses for medicines (40%) and health services (30%). The findings of the survey add user insights into EHS disruptions to existing health statistics and other data and may be used to inform strategies for mitigating the impact of COVID-19 on the disruption of health care services, strengthening health system preparedness and building resilience for future emergencies.

Paediatric Intussusception: A Clinical Scoring System to Predict the Risk of Operative Intervention.

BackgroundIntussusception is a common cause of obstruction in paediatric patients. Rapid clinical recognition and treatment is important to prevent potentially fatal complications. The present study aims to derive a clinical scoring system for prediction of risk of operative intervention in patients with intussusception.Materials and methodsData of 100 patients with intussusception were analyzed retrospectively, and a score was calculated based on clinical parameters – age, presence/absence of symptoms and signs such as abdominal distention, vomiting, lump abdomen, red currant jelly stools and duration of abdominal pain. The maximum score was 12, and the minimum score was 6. This score was then applied to other 50 consecutive patients with intussusception.ResultsOf 100, 13 patients required operative intervention; 87 patients were managed by hydrostatic reduction. In all, four patients with a score of 12 and five patients with a score of 11 required operative intervention. Seven patients had a score of 10, out of which four (57.14%) required operative intervention. A total of 87 patients who had a score of 10 or less were successfully managed non-operatively by ultrasound-guided hydrostatic reduction. In the next 50 patients, two patients with a score of 9 and all patients with scores of 10 and 11 required operative intervention. Thus, age less than 3 months and more than 2 years, presence of symptoms such as abdominal lump, red currant jelly stools and duration of abdominal pain of 2 or more days were strong predictors of operative intervention.ConclusionThis clinical score helps to predict the risk of operative intervention required in a child with a diagnosis of intussusceptions – duration of abdominal pain of 48 h or more, presence of abdominal distention and lump and red currant jelly stools are strong predictors of need of operative intervention in patients with intussusception. Higher the score (8 or more, as concluded by this study), more the probability of requiring operative intervention in these patients. Though limited, this study could serve as a pilot work to develop a user-friendly score for early surgical decision making in the management of paediatric intussusception.

Functional status as a marker of need for hospital admission following outpatient hernia repair.

The careful selection of patients for hernia repair in ambulatory surgery centres is critical to prevent unanticipated inpatient admissions. The aim of this study was to evaluate risk factors associated with inpatient admission. A multivariable logistic regression was performed utilising the ACS NSQIP database from 2007 to 2016. The primary outcome was same-day hospital discharge. The primary exposure variable was preoperative functional status. Additional covariates included sex, obesity, age, smoking status, steroid use, dyspnoea, diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, hypertension, bleeding disorder, dialysis-dependence and American Society of Anesthesiologists classification score. A total of 194,822 patients underwent hernia repair in the outpatient setting; 8705 (4.5%) required hospital admission. The variables with the most significantly increased odds for hospital admission were partially dependent and totally dependent preoperative functional status. A non-independent baseline functional status is the strongest predictor of need for admission following outpatient hernia repair.

A nationwide analysis of re-operation after kidney transplant.

We aimed to report the rate and short-term outcomes of patients undergoing re-operation following kidney transplant in the U.S. The Nationwide Inpatient Sample (NIS) database was used to examine the clinical data of patients undergoing kidney transplant and re-operation during same the hospitalization from 2002-2012. Multivariate regression analysis was performed to compare outcomes of patients with and without re-operation. We sampled a total of 35 058 patients who underwent kidney transplant. Of these, 770 (2.2%) had re-operation during the same hospitalization. Re-operation was associated with a significant increase in mortality (30.4% vs. 3%; adjusted odds ratio [AOR] 4.62; p<0.01), mean total hospital charges ($249 425 vs. $145 403; p<0.01), and mean hospitalization length of patients (18 vs. 7 days; p<0.01). The most common day of re-operation was postoperative Day 1. Hemorrhagic complication (64.2%) was the most common reason for re-operation, followed by urinary tract complications (9.9%) and vascular complications (3.6%). Preoperative coagulopathy (AOR 3.35; p<0.01) was the strongest predictor of need for re-operation, hemorrhagic complications (AOR 3.08; p<0.01), and vascular complications (AOR 2.50; p<0.01). Also, hypertension (AOR 1.26; p<0.01) and peripheral vascular disorders (AOR 1.25; p=0.03) had associations with hemorrhagic complications. Re-operation after kidney transplant most commonly occurs on postoperative Day 1 and occurs in 2.2% of cases. It is associated with significantly increased mortality, hospitalization length, and total hospital charges. Hemorrhage is the most common complication. Preoperative coagulopathy is the strongest factor predicting the need for re-operation, vascular complications, and hemorrhagic complications.

Evaluation of the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator in Gynecologic Oncology Patients Undergoing Minimally Invasive Surgery

Study ObjectiveTo evaluate the ability of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator to predict discharge to postacute care and perioperative complications in gynecologic oncology patients undergoing minimally invasive surgery (MIS). DesignA retrospective chart review (Canadian Task Force classification II-1). SettingA university hospital. PatientsAll patients undergoing MIS on the gynecologic oncology service from January 1, 2009, to December 30, 2013. InterventionsSurgical procedures were reviewed, and appropriate Common Procedural Terminology codes were assigned. Twenty-one preoperative risk factors were abstracted from the chart and entered into the ACS NSQIP surgical risk calculator. The predicted risk of discharge to postacute care and 8 additional postoperative complications were calculated and recorded. Actual postoperative complications were abstracted from the medical record. The association between the calculated risk and the actual outcome was determined using logistic regression. The ability of the calculator to accurately predict a particular event was assessed using the c-statistic and Brier score. Measurements and Main ResultsOf the 876 patients reviewed, a majority underwent hysterectomy (71.6%), with almost half of those patients undergoing additional cancer staging procedures (34.8%). Although the calculator was a poor predictor of postoperative complications, it was a strong predictor for discharge to postacute care (c-statistic = 0.91, Brier score = 0.02) with an odds ratio of 2.31 (95% confidence interval, 1.65–3.25; p < .0001). ConclusionThe ACS NSQIP surgical risk calculator does not accurately predict postoperative complications or length of stay in gynecologic oncology patients undergoing MIS. Although it was a strong predictor of need for discharge to postacute care, it vastly overestimated the number of patients requiring this service. Therefore, the calculator's risk score for discharge to postacute care may be considered during preoperative counseling but should not be a predictor of whether or not the patient should proceed with surgery.

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Factors associated with resistance to disopyramide in obstructive hypertrophic cardiomyopathy

Background: Disopyramide (DISO) lowers resting LV outflow gradients in symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM). Some of these patients are resistant to DISO and require surgical myectomy. Our objective was to identify factors associated with DISO resistance. Methods: From a cohort of 737 patients with HCM we analyzed 113 clinical and echo variables in 73 patients with resting gradients ≥30mmHg receiving DISO for symptoms and gradients resistant to beta-blocker and verapamil. Non-response was defined as resting gradient ≥30mmHg post-DISO. Results: There were 26% non-responders. Non-responders were younger (55±18 vs. 63±15 years, p=0.04); had longer anterior mitral leaflets (18±3 vs. 15±1.9 mm/m2, p 88mmHg were non-responders (p<0.00001, fig 1). At 5-years follow-up 40% of all patients required myectomy (31.5% of the responders vs. 63% of the non-responders, p=0.015). Patients requiring myectomy had longer anterior leaflets (16.6±3 vs. 15.2±2mm/m2, p=0.024) and were younger (56±15 vs. 65±16 years, p<0.02). Myectomy was more common in patients with anterior leaflets ≥35mm (75%) compared to ≤35mm (33%, p<0.01). ![Figure][1] Figure 1 Conclusions: Resistance to DISO is a strong predictor of need for septal myectomy. Symptomatic patients with both resting baseline gradients >88mmHg and anterior mitral leaflets ≥33mm could reasonably be referred for myectomy without a trial of DISO. [1]: pending:yes

Survival in patients with acute kidney injury requiring dialysis after coronary artery bypass grafting

The aim was a nationwide analysis of need for dialysis and survival in all patients who had coronary artery bypass grafting (CABG) in Sweden during 2002 up to 2008. Primary isolated CABG was performed in 28 220 patients without preoperative need for dialysis. Survival was analysed in patients suffering postoperative acute kidney injury requiring dialysis. Postoperative dialysis was needed in 162 patients (0.6%). Old age, female gender, reduced glomerular filtration rate (GFR), diabetes mellitus, peripheral vascular disease, chronic obstructive pulmonary disease, prior myocardial infarction, prior stroke and reduced left ventricular function were associated with need for dialysis. Only 0.3% of the patients with GFR>60 ml/min/1.73 m2 needed postoperative dialysis compared with 9.5% if GFR was <30 ml/min/1.73 m2. Sixteen of 54 patients (27%) with GFR<30 l/min/1.73 m2 and a ≥50% increase in postoperative serum creatinine needed dialysis. There were 42 deaths (26%) within 30 days in patients who needed dialysis and 1% if dialysis was not required. Early mortality was markedly higher in patients who required dialysis than in those without dialysis after multivariable adjustment for age, sex, diabetes mellitus, left ventricular function and GFR (odds ratio 19, 95% confidence interval 13-29). The corresponding risk of late death was 2-fold higher in patients who survived for 90 days and had required dialysis compared with those who did not (hazard ratio 2.4, 95% confidence interval 1.7-3.3). Five-year survival was 43 and 89%, respectively. The risk of death increased with age. Five-year survival after dialysis was 66% in patients younger than 65 years, but 32% in those aged over 70 years. Fifty-one per cent (14 of 27) of patients 80 years of age or older who required dialysis died early compared with 3% (68 of 2426) of those who did not (P<0.001). Nine survivors who needed dialysis developed end-stage renal disease. Need for dialysis after non-emergency was an uncommon serious complication associated with high early mortality and an increased risk of late death. Old age and impaired preoperative renal function were strong predictors of need for dialysis after CABG. Postoperative dialysis after CABG was a marker of poor outcome but could, in some patients, be life-saving.

Postoperative Infection Treatment Score for the Spine (PITSS): construction and validation of a predictive model to define need for single versus multiple irrigation and debridement for spinal surgical site infection

There is very little evidence to guide treatment of patients with spinal surgical site infection (SSI) who require irrigation and debridement (I&D) in deciding need for single or multiple I&Ds or more complex wound management such as vacuum-assisted closure dressing or soft-tissue flaps. The purpose of this study was to build a predictive model that stratifies patients with spinal SSI, allowing us to determine which patients will need single versus multiple I&D. The model will be validated and will serve as evidence to support a scoring system to guide treatment. A consecutive series of 128 patients from a tertiary spine center (collected from 1999 to 2005) who required I&D for spinal SSI were studied based on data from a prospectively collected outcomes database. More than 30 variables were identified by extensive literature review as possible risk factors for SSI and tested as possible predictors of risk for multiple I&D. Logistic regression was conducted to assess each variable's predictability by a "bootstrap" statistical method. A prediction model was built in which single or multiple I&D was treated as the "response" and risk factors as "predictors." Next, a second series of 34 different patients meeting the same criteria as the first population were studied. External validation of the predictive model was performed by applying the model to the second data set, and predicted probabilities were generated for each patient. Receiver operating characteristic curves were constructed, and the area under the curve (AUC) was calculated. Twenty-four of one hundred twenty-eight patients with spinal SSI required multiple I&D. Six predictors: anatomical location, medical comorbidities, specific microbiology of the SSI, the presence of distant site infection (ie, urinary tract infection or bacteremia), the presence of instrumentation, and the bone graft type proved to be the most reliable predictors of need for multiple I&D. Internal validation of the predictive model yielded an AUC of 0.84. External validation analysis yielded AUC of 0.70 and 95% confidence interval of 0.51 to 0.89. By setting a probability cutoff of .24, the negative predictive value (NPV) for multiple I&D was 0.77 and positive predictive value (PPV) was 0.57. A probability cutoff of .53 yielded a PPV of 0.85 and NPV of 0.46. Patients with positive methicillin-resistant Staphylococcus aureus culture or those with distant site infection such as bacteremia were strong predictors of need for multiple I&D. Presence of instrumentation, location of surgery in the posterior lumbar spine, and use of nonautograft bone graft material predicted multiple I&D. Diabetes also proved to be the most significant medical comorbidity for multiple I&D. The validation of this predictive model revealed excellent PPV and good NPV with appropriately chosen probability cutoff points. This study forms the basis for an evidence-based classification system, the Postoperative Infection Treatment Score for the Spine that stratifies patients who require surgery for SSI, based on specific spine, patient, infection, and surgical factors to assess a low, indeterminate, and high risk for the need for multiple I&D.

Soft Tissue Infections and Emergency Department Disposition: Predicting the Need for Inpatient Admission

Little empiric evidence exists to guide emergency department (ED) disposition of patients presenting with soft tissue infections. This study's objective was to generate a clinical decision rule to predict the need for greater than 24-hour hospital admission for patients presenting to the ED with soft tissue infection. This was a retrospective cohort study of consecutive patients presenting to a tertiary care hospital ED with diagnosis of nonfacial soft tissue infection. Standardized chart review was used to collect 29 clinical variables. The primary outcome was >24-hour hospital admission (either general admission or ED observation unit), regardless of initial disposition. Patients initially discharged home and later admitted for more than 24 hours were included in the outcome. Data were analyzed using classification and regression tree (CART) analysis and multivariable logistic regression. A total of 846 patients presented to the ED with nonfacial soft tissue infection. After merging duplicate records, 674 patients remained, of which 81 (12%) required longer than 24-hour admission. Using CART, the strongest predictors of >24-hour admission were patient temperature at ED presentation and mechanism of infection. In the multivariable logistic regression model, initial patient temperature (odds ratio [OR] for each degree over 37 degrees C = 2.91, 95% confidence interval [CI] = 1.65 to 5.12) and history of fever (OR = 3.02, 95% CI = 1.41 to 6.43) remained the strongest predictors of hospital admission. Despite these findings, there was no combination of factors that reliably identified more than 90% of target patients. Although we were unable to generate a high-sensitivity decision rule to identify ED patients with soft tissue infection requiring >24-hour admission, the presence of a fever (either by initial ED vital signs or by history) was the strongest predictor of need for >24-hour hospital stay. These findings may help guide disposition of patients presenting to the ED with nonfacial soft tissue infections.

Modeling the need for hip and knee replacement surgery. Part 1. A two‐stage cross‐cohort approach

To explore inequalities in the need for hip/knee replacement surgery using a 2-stage cross-cohort approach. In the first stage, a small-area population-based survey, the Somerset and Avon Survey of Health, was used to provide a high-quality measure of need for hip/knee replacement using the New Zealand (NZ) score. Receiver operating characteristic curve analyses were used to validate a simplified NZ score, excluding information from clinical examination. In the second stage, a nationally representative population-based survey, the English Longitudinal Study of Ageing, was used to explore inequalities in need for hip/knee replacement using the simplified NZ score. Multilevel Poisson regression modeling was used to estimate rates of need for surgery. Exposures considered were age, sex, social class, ethnicity, obesity, Index of Multiple Deprivation 2004 deprivation quintiles, rurality, and ethnic mix of area. Rates of need for hip/knee replacement increase with age and are lower in men than in women (rate ratio [RR] 0.7, 95% confidence interval [95% CI] 0.6-0.9 for hips; RR 0.8, 95% CI 0.7-1.0 for knees). Those of lowest social class have greater need. Need was greatest for people living in more deprived areas. Individual ethnic group did not predict the need for surgery. For hip replacement, there was no rurality effect; for knee replacement, those in town and fringe areas had greater need. Obesity was a strong predictor of need for surgery (RR 2.3, 95% CI 1.9-2.8 for hips; RR 2.4, 95% CI 2.0-2.8 for knees). This study provides evidence of greater variations of inequalities in need for hip/knee replacement than previous studies. Further research should explore geographic variation and produce small-area estimates of need to inform local health planning. It is important to complement data on need with willingness to undergo surgery.

Minimal eating observation form: reliability and validity.

Eating difficulties are common for patients in hospitals (82% have one or more). Eating difficulties predict undernourishment, need for assistance when eating, length of hospital stay and level of care after hospital stay. Eating difficulties have through factor analysis (FA) been found to belong to three dimensions (ingestion, deglutition and energy). The present study investigates inter-observer reliability. Other questions at issue are if the findings from the previous FA can be confirmed, if adjustments need to be done and if the Minimal Eating Form (MEOF) can serve as an assessment model for identification of eating difficulties. Previously found associations between eating difficulties and outcomes as well as measures taken to improve oral intake were also investigated. Inter-observer study and cross-sectional observational study. Hospitals and special accommodations (SAs). Inter-observer study: Observers made standardized assessments of eating, independently and at the same time, on a sample of 50 patients with stroke. Survey study: 2600 (88%) out of 2945 persons agreed to participate in a survey of eating and nutrition. All SAs within six municipalities and six hospitals were involved. Nursing students, clinical tutors and staff performed the assessments, supported by the researchers. The average agreement between observers of eating difficulties was 89% (Kappa coefficient 0.70). In the survey study, the mean age of persons (n=1726) living in SAs was 85 years (SD 8) and 69% were women, while the corresponding figures for patients (n=874) in hospitals were 69 years (SD 18) and 53% women. Low Body Mass Index (BMI) was found in 27%, unintentional weight loss in 23% and need of eating assistance in 38% of the persons. Protein- and energy- (PE-) enriched food was given to 4%, adapted consistency of food to 23% and food supplements to 16% of the persons. The new FA confirmed the previous one and minor adjustments of the model were made. Having ingestion difficulties was the strongest predictor of need for eating assistance (OR 14.5). Deglutition difficulties strongly predicted serving of adapted consistency of food (OR 7.3). Poor energy levels and reduced appetite predicted weight loss (OR 6.0), BMI below limits (OR 2.5), supplements (OR 5.3) and PE-enriched food (OR 3.4). The MEOF has satisfying validity and reliability. The earlier model of eating difficulties was confirmed (MEOF-I), and the model was slightly adjusted to a new model, MEOF-II. Providing eating assistance seems effective in preventing malnutrition (weight loss and BMI below limits), and is mainly provided to persons with ingestion difficulties. Difficulties with energy intake and appetite are not associated with eating assistance; indicating that those persons might need support of some other kind. This support can include providing PE-enriched food and supplements, but seems however insufficiently or inadequately delivered, as low energy and appetite problems are also associated with both weight loss and low BMI. Findings from other studies are confirmed.