Trends In Outcomes Of Patients Research Articles

Patient outcomes and cost in robotic emergency general surgery.

The use of robotic technology in general surgery continues to increase, though its utility for emergency general surgery remains under-studied. This study explores the current trends in patient outcomes and cost of robotic emergency general surgery (REGS). The Florida Agency for Healthcare Administration database (2018-2020) was queried for adult patients undergoing intra-abdominal emergency general surgery within 24h of admission and linked to CMS Cost Reports/Hospital Compare, American Hospital Association, and Rand Corporation Hospital datasets. Patients from the four most common REGS procedures were propensity matched to laparoscopic equivalents for hospital cost analysis. A telephone survey was performed with the top 10 REGS hospitals to identify key qualities for successful REGS programs. 181 hospitals (119 REGS, 62 non-REGS) performed 60,733 emergency surgeries. Six-percent were REGS. The most common REGS were cholecystectomy, appendectomy, inguinal and ventral hernia repairs. Before and after propensity matching, total cost for these four procedures were significantly higher than their laparoscopic equivalents, which was due to higher surgical cost as the non-operative costs did not differ. There were no differences in mortality, individual complications, or length of stay for most of the four procedures. REGS volume significantly increased each year. The survey found that 8/10 hospitals have robotic-trained staff available 24/7. Although REGS volume is increasing in Florida, cost remains significantly higher than laparoscopy. Given higher costs and lack of significantly improved outcomes, further study should be undertaken to better inform which specific patient populations would benefit from REGS.

Temporal trends in the utilization of advanced therapies among patients with acute pulmonary embolism: insights from a national database.

There is a paucity of data regarding the contemporary temporal trends in the adoption of advanced pulmonary embolism (PE) therapies in the United States as well as the parallel trends in outcomes of patients with acute PE. Therefore, we queried the Nationwide Readmissions Database (years 2016-2020) to report the temporal trends in utilization of advanced PE therapies. Our final analysis included 920 770 hospitalizations with acute PE. We demonstrated an increase in the proportion of patients diagnosed with high-risk PE during the study years. Overall, there was an increase in the use of advanced PE therapies, which was mainly due to the increase in the utilization of systemic thrombolytics, and catheter-directed therapies. Also, extracorporeal membrane oxygenation cannulation showed an incremental increase over the study years. The use of inferior vena cava filter has declined, while the use of surgical embolectomy did not change during the study years. The use of advanced therapies has increased among urban teaching, but not among urban non-teaching hospitals. During the study years, there was no change in unadjusted or adjusted in-hospital mortality rates among patients with acute PE, while the 90-day unplanned readmission rate has declined.

A scoping review of real-time automated clinical deterioration alerts and evidence of impacts on hospitalised patient outcomes

BackgroundHospital patients experiencing clinical deterioration are at greater risk of adverse events. Monitoring patients through early warning systems is widespread, despite limited published evidence that they improve patient outcomes. Current...

TCT-252 Temporal Trends in Patient Outcomes and Resource Utilization in a Large US Population After TAVR

TCT-252 Temporal Trends in Patient Outcomes and Resource Utilization in a Large US Population After TAVR

Drug-Coated Endovascular Intervention Is Associated With Increased Patency and Limb Salvage but No Difference in Survival

We sought to identify trends in outcomes for patients with chronic limb-threatening ischemia (CLTI) treated with endovascular intervention in a multidisciplinary limb salvage clinic, focusing on differences between drug-coated interventions (DCI) vs non-DCI.

805 Vacuum-induced hemorrhage control versus balloon tamponade for management of postpartum hemorrhage (PPH): single center experience

Uterine balloon tamponade (UBT, eg. Bakri balloon) has been used later in the PPH cascade after failure of first-line measures such as uterotonics and uterine massage. A recent multi-center study demonstrated that a new vacuum-induced hemorrhage control (VHC) device (Jada System®, Alydia Health®) used earlier in the PPH cascade (failed first-line measures with maximum EBL 1500mL) achieved rapid control of PPH (median 3 minutes). We sought to compare VHC to UBT for PPH control at our single center. Retrospective single-center cohort study comparing VHC procedures during the PEARLE study (2019-2020) to all women treated with UBT (2015-2018, historical cohort). VHC was used per trial protocol whereas UBT was used per routine clinical practice. Given this difference, descriptive statistics are presented, statistical tests were implemented with Wilcoxon rank sum test on select variables. Individual chart review was used to ascertain baseline maternal demographics and intrapartum characteristics. Outcomes included measures of PPH management (uterotonics, surgical interventions), bleeding parameters, length of device use, and length of hospital stay. Eleven women were treated with the VHC device and 11 women received UBT treatment. While all women were treated for atony-related bleeding, the UBT group were more likely to have undergone a CD and have a higher BMI. The VHC group required fewer instances of multiple uterotonics, required no additional surgical intervention or ICU admission, and had less blood transfusions (Table). Shorter indwelling time was observed in the VHC cohort (2.2 hrs vs UBT 25 hrs) and hospital stay length was shorter with VHC (2.1 days vs UBT 5 days). These findings persisted when limited to vaginal deliveries only. Positive trends in patient outcomes can be observed with early implementation of the VHC device compared to the later clinically indicated use of UBT. Further studies should evaluate the use of devices (VHC or UBT) earlier in the PPH cascade and compare head-to-head the pragmatic use of these two individual devices for PPH treatment.

1420-P: Trends in Cardiovascular and Economic Outcomes of Patients Hospitalized for Stroke and Diabetes in the U.S.: Data from the National Inpatient Sample (2005-2014)

Background: As the prevalence of diabetes is increasing worldwide, our aim is to assess the recent cardiovascular and economic trend in outcomes of patients with stroke and diabetes in the U.S. Methods: Data from the National Inpatient Sample was analyzed between 2005 to 2014. We studied: In-hospital mortality, length of stay (LoS) and overall hospital charges in patients hospitalized for stroke, >18 years of age and known to have diabetes. Results: The prevalence of diabetes gradually increased from 28.2% to 35.5% in all patients hospitalized for stroke (p trend<0.001) between 2005 and 2014. In those patients with diabetes, mean (SD) age slightly decreased from 70 (13) years to 69 (13) years (p trend <0.001). Interestingly, hospitalization for stroke increased from 17.4 to 20.0/100 000 U.S. adults (p trend <0.001). However, in-hospital age-adjusted mortality decreased from 4.64% to 3.73% (p trend <0.001). Age-adjusted mortality of hemorrhagic strokes - which represent only a small proportion of all strokes- decreased from 28.1% to 23.1%, that of ischemic strokes decreased from 3.23% to 2.48% (p trend <0.01 for both) whereas that of TIA was almost stable and lower than 0.2%. As expected, total charges of hospital stay almost doubled as they went up from 15,970 to 31,018 USD/stay (adjusted for inflation). Nevertheless, median (IQR) LoS slightly decreased from 4 (2-6) to 3 (2-6) days (p trend <0.05). Conclusion: Our preliminary data show that the prevalence of diabetes in patients hospitalized for stroke is gradually increasing. Moreover, hospitalization for stroke is also increasing. Nevertheless, in-hospital mortality is on a descending slope, which comes at a price of an almost 2-fold increase in hospital charges from 2005 to 2014. Disclosure A. Tabbalat: None. S.R. Dargham: None. M.B. Elshazly: Stock/Shareholder; Self; Ember Medical. C. Abi Khalil: None.

Abstract WP350: National Trends in Outcomes of Ischemic Stroke and Prognostic Influence of Stroke Center Capability in Japan

Background: Limited national-level information on temporal trends in comprehensive stroke center (CSC) capabilities and their effects on acute ischemic stroke (AIS) patients exists. Aims: To examine trends in in-hospital outcomes of AIS patients and the prognostic influence of temporal changes in CSC capabilities in Japan. Methods: This retrospective study used the J-ASPECT Diagnosis Procedure Combination database and identified 372,978 AIS patients hospitalized in 650 institutions between 2010 and 2016. Temporal trends in patient outcomes and recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy (MT) usage were examined. Facility CSC capabilities were assessed using a validated scoring system (CSC score: 1-25 points) in 2010 and 2014. The prognostic influence of temporal CSC score changes on in-hospitalmortality and poor outcomes (modified Rankin Scale: 3-6) at discharge were examined using hierarchical logistic regression models. Results: Over time, stroke severity at admission decreased, whereas median age, sex ratio, and comorbidities remained stable. During the study period, usage of rt-PA and MT in rural areas remained lower than that of urban areas, but in 2016, the differences in their use were within 1%. The median CSC score increased from 16 to 17 points. After adjusting for age, sex, comorbidities, consciousness level, and facility CSC score, proportion of in-hospitalmortality and poor outcomes at discharge decreased (from 7.6% to 5.0%, and from 48.7% to 43.1%, respectively). The preceding CSC score increase (in 2010-2014) was independently associated with reduced in-hospital mortality and poor outcomes, and increased rt-PA and MT use (odds ratio (95% confidence interval): 0.97(0.95-0.99), 0.97(0.95-1.00), 1.07(1.04-1.10), and 1.21(1.14-1.28) , respectively). Conclusions: This nationwide study revealed six-year trends in better patient outcomes and increased use of rt-PA and MT in AIS. In addition to lesser stroke severity, preceding improvement of CSC capabilities was an independent factor associated with such trends, suggesting importance of CSC capabilities as a prognostic indicator of acute stroke care.

Trends in National Use of Anterior Cervical Discectomy and Fusion from 2006 to 2016

Anterior cervical discectomy and fusion (ACDF) is the most common procedure for the treatment of degenerative cervical conditions. The objective of this study is to determine time-dependent trends in patient outcomes following ACDF for degenerative disease from 2006 to2016. We used the National Surgical Quality Improvement Program (NSQIP) database to retrospectively review all patients who underwent elective ACDF between 2006 and 2016. A descriptive statistical analysis followed by time trend analysis was performed on demographics, comorbidities, perioperative, and outcome variables. Primary outcomes were reoperation and readmission rates. Secondary outcomes were medical and surgical complications reported within 30 days of operation. A total of 36,854 patients underwent elective ACDF from the 2006 to 2016 NSQIP database. Mean age increased from 48.19 years [standard error: 1.49] in 2006 to 54.08 years [standard error: 0.12] in 2016 (P < 0.001). There was a significantly greater number of outpatient procedures from 2012 to 2016 (P < 0.001). The proportion of patients with American Society of Anesthesiologists classes 3/4 significantly increased over time (P < 0.001, P < 0.001, P= 0.005, respectively). Readmission risk, first documented in NSQIP in 2011, increased over time from 2011 to 2016 (P < 0.001). Unplanned reoperations have remained consistent at about 1.4%. Postoperative complications varied over time with no discernable patterns or trends. Since the establishment of the NSQIP database, there have been no considerable improvements in reoperation or postoperative complication rates based on available data, however, there have been increased rates of readmission. Changes in data collection and an aging patient population with greater burden of comorbidities could confound these trends.

Trends in Outcomes of Patients With Ischemic Stroke Treated Between 2002 and 2016: Insights From a Chinese Cohort.

Little is known about long-term trends in outcomes of patients with ischemic stroke in China. We aimed to assess longitudinal trends in these outcomes over the past 15 years in China and explore possible factors behind the trends. Patients with ischemic stroke admitted to the Department of Neurology at West China Hospital were prospectively and consecutively enrolled in a central registry since 2002, and the present study analyzed data from those admitted to hospital within 7 days of stroke during the period 2002 to 2016. Patients were binned into three 5-year intervals for temporal analysis. Death, disability, and death/disability at 3 and 12 months after stroke were compared among the time intervals across the entire sample and in subsets stratified by age (<65 or ≥65 years). To explore the possible factors related to the trends in outcomes, interaction between the factors and time on outcomes was entered separately into the multivariable logistic regression model. Of 6462 patients with ischemic stroke in the final analysis, 3837 (59.4%) were men, and mean age was 64.2 years (SD, 13.7). Mean age at stroke onset and National Institutes of Health Stroke Scale score at admission decreased significantly during the 15-year period (P<0.001). Between 2002 to 2006 and 2012 to 2016, cumulative incidences declined significantly for death at 3 months (from 9.6% to 6.4%), disability at 3 months (from 36.8% to 28.7%), and death/disability at 3 months (from 42.9% to 33.3%), as well as for death at 12 months (from 15.9% to 10.7%), disability at 12 months (from 23.2% to 17.6%), and death/disability at 12 months (from 35.4% to 26.4%; all P<0.001). The decreases in disability and death/disability at 3 and 12 months between 2002 to 2006 and 2012 to 2016 remained significant after adjusting for confounders, and the results were similar for the entire cohort and for subgroups of patients <65 or ≥65 years. Only interactions of National Institutes of Health Stroke Scale score on admission and time period (2012-2016) were found to significantly correlate with disability and death/disability at 3 and 12 months (all P≤0.03). Our study from a large medical center in southwest China suggests that since 2002, risks of disability and death/disability at 3 and 12 months after ischemic stroke have declined. This appears to be due, at least in part, to a significant decline in National Institutes of Health Stroke Scale score on admission, which may reflect greater public awareness of stroke detection, willingness to seek medical attention, and ease of access to healthcare infrastructure. The factors behind this apparent improvement require further study.

National trends in outcomes of ischemic stroke and prognostic influence of stroke center capability in Japan, 2010-2016.

Limited national-level information on temporal trends in comprehensive stroke center capabilities and their effects on acute ischemic stroke patients exists. To examine trends in in-hospital outcomes of acute ischemic stroke patients and the prognostic influence of temporal changes in comprehensive stroke center capabilities in Japan. This retrospective study used the J-ASPECT Diagnosis Procedure Combination database and identified 372,978 acute ischemic stroke patients hospitalized in 650 institutions between 2010 and 2016. Temporal trends in patient outcomes and recombinant tissue plasminogen activator (rt-PA) and mechanical thrombectomy usage were examined. Facility comprehensive stroke center capabilities were assessed using a validated scoring system (comprehensive stroke center score: 1-25 points) in 2010 and 2014. The prognostic influence of temporal comprehensive stroke center score changes on in-hospital mortality and poor outcomes (modified Rankin Scale: 3-6) at discharge were examined using hierarchical logistic regression models. Over time, stroke severity at admission decreased, whereas median age, sex ratio, and comorbidities remained stable. The median comprehensive stroke center score increased from 16 to 17 points. After adjusting for age, sex, comorbidities, consciousness level, and facility comprehensive stroke center score, proportion of in-hospital mortality and poor outcomes at discharge decreased (from 7.6% to 5.0%, and from 48.7% to 43.1%, respectively). The preceding comprehensive stroke center score increase (in 2010-2014) was independently associated with reduced in-hospital mortality and poor outcomes, and increased rt-PA and mechanical thrombectomy use (odds ratio (95% confidence interval): 0.97 (0.95-0.99), 0.97 (0.95-0.998), 1.07 (1.04-1.10), and 1.21 (1.14-1.28), respectively). This nationwide study revealed six-year trends in better patient outcomes and increased use of rt-PA and mechanical thrombectomy in acute ischemic stroke. In addition to lesser stroke severity, preceding improvement of comprehensive stroke center capabilities was an independent factor associated with such trends, suggesting importance of comprehensive stroke center capabilities as a prognostic indicator of acute stroke care.

P4590Temporal trends of the characteristics, management, and clinical outcomes of patients with acute coronary syndrome and multi-vessel disease - the ACSIS registry

Abstract Introduction Multi-vessel coronary artery disease (MVD) is common among patients with acute coronary syndrome (ACS) and is associated with worse outcomes compared with single-vessel disease. Multiple studies focused particularly on patients with ACS and MVD and their results were incorporated into guidelines' recommendations. Objectives To examine temporal trends in clinical characteristics, treatment and outcomes of patients presenting with ACS and MVD. Methods Time- dependent analysis of patients enrolled in the biennial ACS Israeli Surveys (ACSIS) between 2000 and 2016 according to three time periods: early (2004–2006; n=2,111), mid (2008–2010; n=2,049), and late (2013–2016; n=2,010). MVD was defined as &gt;50% stenosis in ≥2 separate major coronary territories at the index ACS. Clinical outcomes were 30-day MACE (death, unstable angina, myocardial infarction, stroke, stent thrombosis, urgent revascularization) and 30-days and 1-year mortality. Results Overall 6,170/15,000 patients (41.1%) had MVD (age 64.5±12.1, males 80%). Patients admitted in the later periods were older with a higher prevalence of cardiovascular risk factors and their treatment (i.e. statins, and hypoglycemic drugs) prior to admission. The rate of CABG has decreased and of MV percutaneous coronary intervention and guideline recommended medical treatment has increased with time. At 30 days, the rates of mortality, MACE and re-infarction have decreased (Figure). A trend of reduction in 1-year mortality was observed with time, yet it did not reach statistical significance (early=9.3%, mid=7.8%, late=7.7%, P=0.13). A multivariate adjusted analysis demonstrated that the mid and late periods were associated with significantly reduced risk for 30-day MACE (OR=0.65 [0.54–0.77] and 0.54 [0.45–0.65], respectively). Figure 1. Temporal trends in 30-day outcomes of patients with ACS and MVD Conclusions During the last decade, the burden of cardiovascular risk factors among ACS patients with MVD has increased, more extensive invasive and medical treatments were provided and significant improvements in 30-day outcomes were observed. Acknowledgement/Funding None

Perforated diverticulitis in the North of England: trends in patient outcomes, management approach and the influence of subspecialisation

In recent years, several management options have been used in the management of perforated diverticulitis, ranging from conservative treatment to laparotomy. General surgery has also become increasingly specialised over time. This retrospective cohort study investigated changes in patient outcomes following perforated diverticulitis, management approach and the influence of consultant subspecialisation over time. Data was collected on patients admitted with perforated diverticulitis in the North of England between 2002 and 2016. Subspecialisation was categorised as colorectal or other general subspecialties. The primary outcome of interest was overall 30-day mortality; secondary outcomes included surgical approach, stoma and anastomosis rate. A total of 3394 cases of perforated diverticulitis were analysed (colorectal, n = 1290 and other subspecialists, n = 2104) with a 30-day mortality of 11.6%. There was a significant reduction in mortality over time (2002-2006: 18.6% to 2012-2016: 6.8, P < 0.001).There was a significant reduction in open surgery (60% to 25.3%, P < 0.001) with increased conservative management (37.4% to 63.5%, P < 0.001), laparoscopic resection (0.1% to 4.9%, P < 0.001) and laparoscopic washout (0.1% to 5.7%, P < 0.001).Patients admitted under colorectal surgeons had lower mortality than other subspecialists (9.9% vs 12.4%, P = 0.027), which remained significant following multivariate adjustment (hazard ratio 1.44, P = 0.039). These patients had fewer stomas (13.9% vs. 21.0%, P = 0.001) and higher anastomosis rates (22.1% vs 15.8%, P = 0.004). This study demonstrated considerable improvements in the management of perforated diverticulitis alongside the positive impact of subspecialisation on patient outcomes.

Nationwide improvement in outcomes of emergency admission for ulcerative colitis in England, 2005‐2013

SummaryBackgroundThe UK IBD Audit Programme reported improved inpatient care processes for ulcerative colitis (UC) between 2005 and 2013. There are no independent data describing national or institutional trends in patient outcomes over this period.AimTo assess the association between the outcome of emergency admission for UC and year of treatment.MethodsRetrospective analysis of hospital administrative data, focused on all emergency admissions to English public hospitals with a discharge diagnosis of UC. We extracted case mix factors (age, sex, co‐morbidity, emergency bed days in last year, deprivation status), outcomes of index admission (death and first surgery), 30‐day emergency readmissions (all‐cause, and selected causes) and outcome of readmission.ResultsThere were 765 deaths and 3837 unplanned first operations in 44 882 emergency admissions, with 5311 emergency readmissions (with a further 171 deaths and 517 first operations). Case mix adjusted odds of death for any given year were 9% lower (OR 0.91, 95% CI: 0.89‐0.94), and that for emergency surgery 3% lower (OR 0.97, 95% CI: 0.95‐0.98) than the preceding year. Results were robust to sensitivity analysis (admissions lasting ≥4 days). There was no reduction in odds for all‐cause readmission, but rates for venous thromboembolism declined significantly. Analysis of institutional‐level metrics across 136 providers showed a stepwise reduction in outliers for mortality and unplanned surgery.ConclusionsRisk of death and unplanned surgery for UC patients admitted as emergencies declined consistently, as did unexplained variation between hospitals. Risk of readmission was unchanged (over 1 in 10). Multiple factors are likely to explain these nationwide trends.

Impact of a national enhanced recovery after surgery programme on patient outcomes of primary total knee replacement: an interrupted time series analysis from “The National Joint Registry of England, Wales, Northern Ireland and the Isle of Man”

We aimed to test whether a national Enhanced Recovery After Surgery (ERAS) Programme in total knee replacement (TKR) had an impact on patient outcomes. Natural-experiment (April 2008-December 2016). Interrupted time-series regression assessed impact on trends before-during-after ERAS implementation. Primary operations from the UK National Joint Registry (NJR) were linked with Hospital Episode Statistics (HES) data which contains inpatient episodes undertaken in National Health Service (NHS) trusts in England, and Patient Reported Outcome Measures (PROMs). Patients undergoing primary planned TKR aged ≥18 years. ERAS implementation (April 2009-March 2011). Regression coefficients of monthly means of Length of stay (LOS), bed day costs, change in Oxford knee scores (OKS) 6-months after surgery, complications (at 6 months), and rates of revision surgeries (at 5 years). 486,579 primary TKRs were identified. Overall LOS and bed-day costs decreased from 5.8 days to 3.7 and from £7607 to £5276, from April 2008 to December 2016. Oxford knee score (OKS) change improved from 15.1 points in April 2008 to 17.1 points in December 2016. Complications decreased from 4.1 % in April 2008 to 1.7 % in March 2016. 5-year revision rates remained stable at 4.8 per 1000 implants years in April 2008 and December 2011. After ERAS, declining trends in LOS and bed costs slowed down; OKS improved, complications remained stable, and revisions slightly increased. Different secular trends in outcomes for patients having TKR have been observed over the last decade. Although patient outcomes are better than a decade ago ERAS did not improve them at national level.

Trends in patient outcome over the past two decades following allogeneic stem cell transplantation for acute myeloid leukaemia: an ALWP/EBMT analysis.

Outcomes for patients with acute myeloid leukaemia (AML) undergoing allogeneic stem cell transplantation (allo-SCT) have significantly improved in recent years. To assess the incremental improvement of transplanted AML patients in the last two decades. Patients included in this analysis were adult AML patients who underwent allo-SCT from an HLA-matched sibling donor (MSD) or HLA-matched unrelated donor (MUD) in first remission. Patient outcomes were assessed between three cohorts according to the year of transplant (1993-2002, 2003-2007 and 2008-2012). The analysis comprised a total of 20187 patients of whom 4763 were transplanted between 1993 and 2002, 5835 in 2003 and 2007, and 9589 in 2008 and 2012. In multivariate analysis, leukaemia-free survival (LFS) rates were significantly improved in more recently transplanted patients compared to patients transplanted in 1993-2002 [Hazard ratio (HR)=0.84, confidence interval (CI) 95%, 0.77-0.92; P=0.003], a benefit which also extended to improved overall survival (OS; HR=0.8, CI 95%, 0.73-0.89; P<0.0001), and decreased nonrelapse mortality (NRM) rates (HR=0.65, CI 95%, 0.56-0.75; P<0.0001). Subset analysis revealed that in MSD, the rates of LFS, NRM and OS significantly improved in patients in the more recent cohort with similar results also seen in MUD. Finally, the incidence of acute graft-versus-host disease (GVHD) was significantly reduced leading to improved GVHD-free/relapse-free survival (GRFS) rates in more recently transplanted patients. Outcome of allo-SCT for AML patients has markedly improved in the last two decades owing to decreased nonrelapse mortality and improved rates of leukaemia-free survival resulting in significantly longer survival.

Trends in Outcomes of Patients With Metastatic Cancer Undergoing Intubation and Mechanical Ventilation: Results of the National Hospital Discharge Survey.

Background: There has been an overall decline in intensive care unit mortality over the past 2 decades, including in patients undergoing intubation and mechanical ventilation (MV). Whether this decline extends to patients with metastatic cancer remains unknown. We analyzed the outcomes of patients with metastatic cancer undergoing intubation/MV using the National Hospital Discharge Survey (NHDS) database from 2001 to 2010. Methods: Diagnosis and procedure codes were used to identify patients with metastatic cancer who underwent intubation/MV. Demographics, diagnoses, length of stay (LOS), and discharge information were abstracted. Multivariate linear and logistic regression models with weighted analysis were conducted to study trends in outcomes. Results: During the 10-year study period, 200,350 patients with metastatic cancer and who underwent intubation/MV were identified; the mean age was 65.3 years and 46.2% were men. There was an increase in the total number of patients with metastatic cancer who underwent intubation/MV during the study period, from 36,881 in 2001-2002 to 51,003 in 2009-2010 (P<.001). The overall inpatient mortality rate was 57.3%, discharge to a care facility (DTCF) rate was 40.9% among patients alive at discharge, and mean LOS was 11.1 days. No significant trends were seen in rates of mortality, DTCF, or LOS from 2001 to 2010. Conclusions: In this national database, there was an increase in the number of patients with metastatic cancer who underwent intubation/MV. These patients had high rates of inpatient mortality and DTCF, which did not improve during the study period. Therefore, novel solutions are required to improve outcomes for these patients.

Variation in Hospital Use and Outcomes Associated With Pulmonary Artery Catheterization in Heart Failure in the United States.

There has been an increase in the use of pulmonary artery (PA) catheters in heart failure (HF) in the United States in recent years. However, patterns of hospital use and trends in patient outcomes are not known. In the National Inpatient Sample 2001 to 2012, using International Classification of Diseases-Ninth Revision codes, we identified 11 888 525 adult (≥18 years) HF hospitalizations nationally, of which an estimated 75 209 (SE 0.6%) received a PA catheter. In 2001, the number of hospitals with ≥1 PA catheterization was 1753, decreasing to 1183 in 2011. The mean PA catheter use per hospital trended from 4.9 per year in 2001 (limits 1-133) to 3.8 per year in 2007 (limits 1-46), but increased to 5.5 per year in 2011 (limits 1-70). During 2001 to 2006, PA catheterization declined across hospitals; however, in 2007 to 2012, there was a disproportionate increase at hospitals with large bedsize, teaching programs, and advanced HF capabilities. The overall in-hospital mortality with PA catheter use was higher than without PA catheter use (13.1% versus 3.4%; P<0.0001); however, in propensity-matched analysis, differences in mortality between these groups have attenuated over time-risk-adjusted odds ratio for mortality for PA catheterization, 1.66 (95% confidence interval, 1.60-1.74) in 2001 to 2003 down to 1.04 (95% confidence interval, 0.97-1.12) in 2010 to 2012. There is substantial hospital-level variability in PA catheterization in HF along with increasing volume at fewer hospitals over-represented by large, academic hospitals with advanced HF capabilities. This is accompanied by a decline in excess mortality associated with PA catheterization.

Systematic review and meta-analysis of objective and subjective quality of life among pediatric, adolescent, and young adult bone tumor survivors.

Pediatric, adolescent, and young adult survivors of bone sarcomas are at risk for poor quality of life (QOL). We conducted a systematic review and meta-analysis to summarize the literature describing QOL in this population and differences in QOL based on local control procedures. Included studies described ≥5 patients <25 years old who had completed local control treatment for bone sarcoma, defined QOL as a main outcome, and measured it with a validated instrument. Data extraction and quality assessments were conducted with standardized tools. Meta-analyses compared QOL based on surgical procedure (limb-sparing vs. amputation) and were stratified by assessment type (objective physical function, clinician-assessed disability, patient-reported disability, and patient-reported QOL). Effect sizes were reported as the standard mean difference when multiple instruments were used within a comparison and weighted mean difference otherwise. All were weighted by inverse variance and modeled with random effects. Twenty-two of 452 unique manuscripts were included in qualitative syntheses, eight of which were included in meta-analyses. Manuscripts were heterogeneous with respect to included patient populations (age, tumor type, time since treatment) and QOL instruments. Prospective studies suggested that QOL improves over time, and that female sex and older age at diagnosis are associated with poor QOL. Meta-analyses showed no differences in outcomes between patients who underwent limb-sparing versus amputation for local control. QOL studies among children and AYAs with bone sarcoma are remarkably diverse, making it difficult to detect trends in patient outcomes. Future research should focus on standardized QOL instruments and interpretations.

A Study of Various Angioaccess in Haemodialysis Patients

Contemporary societies are in the midst of an epidemic of chronic non communicable diseases including that of chronic disease (CKD). India is no exception to this rule. Hemodialysis is still the main treatment given for patients of Chronic Kidney Disease, although renal transplantation is slowly changing the trends with better immunosuppression and better surgical techniques with wider acceptance of the masses. The provision of effective and timely hemodialysis requires a stable and reliable vascular access. Thus, vascular access is not only the obvious 'Achilles heel' of hemodialysis (HD) but it is also the quiet undercurrent of trends in patient outcomes. Data on the comparisons between various angioaccess are very limited in literature. So we undertook a study to compare the various angioaccess used for hemodialysis in patients of CKD. Key Word: CKD- Chronic Kidney Disease, HD- Hemodialysis 3 This global prevalence, however, may be grossly underestimated for a number of reasons. Patients with CKD are at high risk for cardiovascular disease (CVD) and cerebrovascular disease (CBVD), and they are more likely to die of CVD than to develop end-stage renal failure. Moreover, patients with CVD often develop CKD during the course of their disease, which may go unrecognized. Therefore, an unknown proportion of people whose death and disability attributed to CVD have disease as well. 4 Moreover, most epidemiological data (prevalence, incidence, patient demography, morbidity, and mortality) on CKD are derived from renal registries. However, most registries record data of patients who are at late stage of disease. Much less is known about the prevalence of the earlier stages of the CKD. Indeed, it has been acknowledged that the majority of the individuals at early stages of CKD have gone undiagnosed and under treated. 4 The number of end stage of renal disease patients that need dialysis or renal transplantation increased in the world. The overall magnitude and pattern of chronic disease (CKD) in India has been studied sporadically. The CKD Registry of India is a new initiative that has been started to document CKD and its course in our country. Modern haemodialysis therapy started on 17 March 1943, when Willem Kolff, a young doctor in the small hospital of Kampen (The Netherlands), treated a 29-year-old housemaid suffering from malignant hypertension and contracted kidneys. Kolff had constructed a rotating drum kidney with the support of Mr Berk, the director of the local enamel factory. First, Kolff used only venipuncture needles to obtain blood from the femoral artery and to reinfuse it by puncturing a vein. Later, he performed surgical cut-down of the radial artery which caused severe bleeding during heparinization.