Validation of a combined comorbidity index

Long-term impact of molecular epidemiology shifts of methicillin-resistant Staphylococcus aureus on severity and mortality of bloodstream infection

A 2019 nationwide study in Japan revealed the predominant methicillin-resistant Staphylococcus aureus (MRSA) types in bloodstream infections (BSIs) to be sequence type (ST)8-carrying SCCmec type IV (ST8-MRSA-IV) and clonal complex 1-carrying SCCmec type IV (CC1-MRSA-IV). However, detailed patient characteristics and how these MRSA types evolve over time remain largely unknown. In this long-term single-center study, MRSA strains isolated from blood cultures at Nagasaki University Hospital from 2012 to 2019 were sequenced and analyzed. Additionally, we compared the SCCmec types and patient characteristics identified in this study with previous data from our hospital spanning 2003-2007 and 2008-2011. Over this 16-year period, SCCmec type II decreased significantly from 79.2% to 15.5%, while type IV increased from 18.2% to 65.5%. This shift in SCCmec types was associated with notable changes in severity and outcomes; the sequential organ failure assessment (SOFA) score decreased from 5.8 to 3.1; in-hospital mortality declined from 39.8% to 15.5%. In contrast, no significant changes in patient demographics, such as age, sex, or underlying diseases, were observed. Between 2012 and 2019, the major combinations of SCCmec type and sequence type were ST8-MRSA-IV, ST8-MRSA-I, CC1-MRSA-IV, and ST5-MRSA-II. Additionally, ST8-MRSA-IV was divided into CA-MRSA/J, t5071-ST8-MRSA-IV, and USA300-like clone based on the results of molecular analysis. These major combinations showed similar drug resistance patterns, molecular characteristics, and phylogenetic features to those identified in nationwide surveillance. This study highlights the evolving nature of MRSA types in bloodstream infections, correlating with improved patient outcomes over time.

Insights into very elderly multiple myeloma treatment from Kansai Myeloma Forum

BACKGROUND

With the aging population, there is a growing need for treating multiple myeloma (MM) in elderly patients; however, real-world studies of them are quite limited.

METHODS

We retrospectively analyzed 519 patients diagnosed between 1997 and 2020 in the Kansai Myeloma Forum database to evaluate the efficacy and safety of novel agents available for 80 years and older patients with MM. Patients were divided into groups according to the treatment year: up to 2010 (Group 1), 2011-2015 (Group 2), and 2016-2020 (Group 3).

RESULTS

The median age and number of treatment lines were 83 years (range, 80-96) and 2, respectively. The median time to next treatment (TTNT) was 7.8 months. The TTNT for Group 3 was significantly shorter (3.8 months) than in other groups (p < 0.001). Median progression free survival and overall survival (OS) were 24.4 and 43.7 months, respectively, and did not differ significantly between 3 groups based on pairwise comparisons. In Group 3, the 1-year cumulative incidence of adverse events (AEs), progression or death, and planned treatment leading to treatment discontinuation was 37.7%, 29.4%, and 15.6%, respectively. In addition, the median time until discontinuation due to AEs has been shortened in recent years.

CONCLUSION

Our findings suggest that AEs threaten the continued treatment of very elderly patients receiving novel agents, with careful management needed to extend the TTNT.

Workload-capacity imbalances and their impact on self-management complexity in patients with multimorbidity: a multicenter cross-sectional study

INTRODUCTION

Multimorbidity is increasing globally, emphasizing the need for effective self-management strategies. The Cumulative Complexity Model (CuCoM) offers a unique perspective on understanding self-management based on workload and capacity. This study aims to validate the CuCoM in multimorbid patients and identify tailored predictors of self-management.

METHODS

This multicenter cross-sectional survey recruited 1920 multimorbid patients in five primary health centres and four hospitals in China. The questionnaire assessed workload (drug intake, doctor visits and follow-up, disruption in life, and health problems), capacity (social, environmental, financial, physical, and psychological), and self-management. Data were analyzed using latent profile analysis, chi-square, multivariate linear regression, and network analysis.

RESULTS

d Patients were classified into four profiles: low workload-low capacity (10.2%), high workload-low capacity (7.5%), low workload-high capacity (64.6%), and high workload-high capacity (17.7%). Patients with low workload and high capacity exhibited better self-management (β = 0.271, p < 0.001), while those with high workload and low capacity exhibited poorer self-management (β=-0.187, p < 0.001). Social capacity was the strongest predictor for all profiles. Environmental capacity ranked second for 'high workload-high capacity' (R² = 3.26) and 'low workload-low capacity' (R² = 5.32) profiles. Financial capacity followed for the 'low workload-high capacity' profile (R² = 5.40), while psychological capacity was key in the 'high workload-low capacity' profile (R² = 6.40). In the network analysis, socioeconomic factors exhibited the central nodes (p < 0.05).

CONCLUSIONS

Personalized interventions designed to increase capacity and reduce workload are essential for improving self-management in multimorbid patients. Upstream policies promoting health equity are also crucial for better self-management outcomes.

Residential mobility, neighborhood environment, and diabetes complications among socioeconomically disadvantaged patients in the United States

Residential mobility can affect health through changes in available resources, social support, or continuity of healthcare. This study sought to understand whether residential mobility and/or change in neighborhood environment among patients with diabetes were associated with diabetes-related complications. This retrospective study used electronic health record data from 19,853 adults aged 18-64 with a diabetes diagnosis seen in 110 safety-net clinics across the United States. Generalized estimating equations logistic regression models estimated whether moving (pre/post) and change in neighborhood environment (improving, worsening, similar) were associated with diagnoses of chronic diabetes-related complications. Post-move versus pre-move was associated with significantly higher probability of diabetes-related chronic complications (predicted probability: 13.16 vs 6.00, respectively), but no association was found by change in neighborhood environment. Those who moved had lower probability of chronic complications than those who did not move which could have been driven by pre-move circumstances among patients who moved. Residential mobility plays an important role in understanding diabetes-related complications while changes in neighborhood environment may be less important among low-income patients served by safety-net clinics. Moving may not be directly responsible for the development of diabetes-related chronic complications, but it may be an indicator for other factors of instability.

Evaluation and comparison of machine learning algorithms for predicting discharge against medical advice in injured inpatients

BACKGROUND

Whether the application of machine learning algorithms offers an advantage over logistic regression in forecasting discharge against medical advice occurrences needs to be evaluated.

METHODS

This retrospective study included all inpatient records from January 1, 2018, to December 31, 2023. The foundational data set (2018-2021) was divided into a training set (80%) and a test set (20%) for model construction and internal validation. The temporal validation data set (2022-2023) was used to assess the model's prospective performance. Feature selection was performed using the BorutaShap method. Techniques including random oversampling, random undersampling, synthetic minority oversampling technique, and edited nearest neighbors were applied to address data imbalance. Model performance was evaluated using metrics including the area under the receiver operating characteristic curve, accuracy, specificity, sensitivity, F1 score, and geometric mean. The Shapley Additive Explanations analysis provided interpretation for the best machine learning model.

RESULTS

A total of 48,394 inpatient records for injured patients met the study criteria, of which 44,119 were discharged following medical advice and 4,275 chose discharge against medical advice, resulting in a ratio of 10.32:1. Among injury inpatients, 8.8% opted for discharge against medical advice. Based on the results of feature selection and multicollinearity analysis, 16 variables were ultimately selected for the construction and evaluation of the discharge against medical advice model. The light gradient boosting machine + edited nearest neighbors model showed the best generalization, with areas under the curves of 0.820 for internal validation and 0.837 for temporal validation. The Shapley Additive Explanations method was used to interpret the model, indicating that the grade of surgery is the most important variable.

CONCLUSIONS

The study is the first to use machine learning models to predict discharge against medical advice in injured inpatients, demonstrating its feasibility. In the future, health care institutions can learn from these models to optimize patient management and reduce discharge against medical advice incidents.

ACCREDIT: Validation of clinical score for progression of COVID-19 while hospitalized

COVID-19 is no longer a global health emergency, but it remains challenging to predict its prognosis.

Objective

To develop and validate an instrument to predict COVID-19 progression for critically ill hospitalized patients in a Brazilian population.

Methodology

Observational study with retrospective follow-up. Participants were consecutively enrolled for treatment in non-critical units between January 1, 2021, to February 28, 2022. They were included if they were adults, with a positive RT-PCR result, history of exposure, or clinical or radiological image findings compatible with COVID-19. The outcome was characterized as either transfer to critical care or death. Predictors such as demographic, clinical, comorbidities, laboratory, and imaging data were collected at hospitalization. A logistic model with lasso or elastic net regularization, a random forest classification model, and a random forest regression model were developed and validated to estimate the risk of disease progression.

Results

Out of 301 individuals, the outcome was 41.8 %. The majority of the patients in the study lacked a COVID-19 vaccination. Diabetes mellitus and systemic arterial hypertension were the most common comorbidities. After model development and cross-validation, the Random Forest regression was considered the best approach, and the following eight predictors were retained: D-dimer, Urea, Charlson comorbidity index, pulse oximetry, respiratory frequency, Lactic Dehydrogenase, RDW, and Radiologic RALE score. The model's bias-corrected intercept and slope were - 0.0004 and 1.079 respectively, the average prediction error was 0.028. The ROC AUC curve was 0.795, and the variance explained was 0.289.

Conclusion

The prognostic model was considered good enough to be recommended for clinical use in patients during hospitalization (https://pedrobrasil.shinyapps.io/INDWELL/). The clinical benefit and the performance in different scenarios are yet to be known.

Indirect effect of the COVID-19 pandemic on cardiovascular diseases incidence, mortality, and healthcare use among patients with hypertension but without SARS-CoV-2 infection in Hong Kong: an interrupted time series analysis

This study investigated the effects of the COVID-19 pandemic on cardiovascular disease (CVD) incidence among hypertensive patients without SARS-CoV-2 infection by changes in CVD incidence, all-cause mortality, blood pressure (BP) control, and healthcare utilization rates among this population from Hong Kong. Individuals diagnosed with hypertension from January 2010 to January 2020 were followed up until death, SARS-CoV infection, or April 2022. Interrupted time series analyses on 1,318,907 patients with hypertension, comparing outcomes across four periods: pre-pandemic (January 2012-January 2020), early pandemic (February 2020-February 2021), interwave (March-December 2021), and Omicron outbreak (January-April 2022). A significant increase in out-of-hospital mortality was found when the early pandemic started. Overall all-cause mortality increased progressively during the interwave period. CVD incidence decreased immediately in the early pandemic period, followed by a progressive increase, and surpassed the pre-pandemic level at the beginning of the interwave period. The proportion of patients with office-measured BP ≤ 140/90 mmHg remained below pre-pandemic levels across the pandemic periods. Healthcare utilization declined immediately in February 2020, while most utilization rebounded to the pre-pandemic level after March 2021 and declined again during the Omicron outbreak. Healthcare disruptions during the early pandemic likely delayed CVD diagnosis and treatment, driving an immediate rise in out-of-hospital mortality. When healthcare services gradually recovered in the interwave period, CVD incidence rebounded and both in and out-of-hospital all-cause mortality increased with a lag, possibly related to delayed treatment.

Clinical Outcomes of Laparoscopic vs Robotic-Assisted Cholecystectomy in Acute Care Surgery

Importance

The use of robotic-assisted cholecystectomy in acute care surgery is increasing, but its safety and efficacy compared with laparoscopic cholecystectomy remain unclear.

Objective

To compare clinical outcomes and bile duct injury rates between robotic-assisted cholecystectomy and laparoscopic cholecystectomy in acute care surgery.

Design, Setting, and Participants

This was a retrospective cohort study using patient data from a commercial claims and encounter database from 2016 to 2021. Included in the study were adult patients undergoing robotic-assisted cholecystectomy or laparoscopic cholecystectomy in acute care surgery. Data were analyzed from January to October 2024.

Exposures

Robotic-assisted or laparoscopic cholecystectomy in acute care surgery.

Main Outcomes and Measures

The primary outcome was bile duct injury.

Results

A total of 844 428 patients (mean [SD] age, 45.6 [12.5] years; 547 665 female [64.9%]) were included in this analysis. After propensity score matching, robotic-assisted cholecystectomy (n = 35 037) and laparoscopic cholecystectomy (n = 35 037) had similar bile duct injury rates (0.37% [128 of 35 037] vs 0.39% [138 of 35 037]; odds ratio [OR], 0.93; 95% CI, 0.73-1.18; P = .54). Robotic-assisted cholecystectomy had higher major postoperative complications (8.37% [2934 of 35 037] vs 5.50% [1926 of 35 037]; OR, 1.57; 95% CI, 1.48-1.67; P < .001), more postoperative drain use (0.63% [219 of 35 037] vs 0.48% [132 of 35 037]; OR, 1.66; 95% CI, 1.34-2.07; P < .001), and longer median (IQR) hospital length of stay (3 [2-4] days vs 2 [1-4] days; P < .001).

Conclusions and Relevance

In this large, propensity-matched cohort analysis of acute care surgery cholecystectomy, robotic-assisted and laparoscopic cholecystectomy had similar bile duct injury rates, but robotic-assisted cholecystectomy was associated with higher postoperative complications, longer hospital stays, and increased drain use. Further research is needed to optimize the use of robotic-assisted cholecystectomy for acute gallbladder disease. These findings suggest that, under current practice conditions, robotic-assisted cholecystectomy may not offer clear benefits compared with the standard, established laparoscopic cholecystectomy approach.

Association of health literacy with illness perception of Chinese community patients with chronic disease

BACKGROUND

This study aimed to examine the association between health literacy and illness perception among Chinese patients with chronic disease in the community through a national cross-sectional study.

METHODS

This cross-sectional study was conducted in China from June 20, 2022, to August 31, 2022, and used a multistage sampling approach to select patients with chronic diseases. The study included 5,525 participants from 15 provinces, drawn from the Psychology and Behavior Investigation of Chinese Residents in 2022. We constructed univariate analysis, smooth curve fitting, threshold saturation effect analysis, and forest plot of subgroup analysis to evaluate the association between health literacy and illness perception.

RESULTS

The analysis revealed an inverted J-shaped association between health literacy and illness perception (P < 0.001). Moreover, the identified inflection point was 22.22. When the health literacy score was below 22.22, illness perception exhibited a positive association with health literacy (β = 0.12, 95%CI = 0.03, 0.21, P = 0.009). When the health literacy score was higher than 22.22, illness perception decreased with the increasing health literacy (β=-0.23, 95%CI=-0.27, -0.19, P < 0.001). The significant association between health literacy and illness perception did not differ significantly across subgroups, except for the Hukou subgroup.

CONCLUSIONS

This study determined a threshold of health literacy that was associated with the illness perception of Chinese chronic disease patients. Additionally, an inverted J-shaped association between health literacy and illness perception was observed, suggesting that targeted health literacy intervention measures should be tailored to specific chronic disease groups rather than a uniform approach.

CLINICAL TRIAL NUMBER

Not applicable.

Intraperitoneal Intraoperative Chemotherapy in Advanced Ovarian Cancer: Rethinking the Future Beyond Complete Macroscopic Resection

BACKGROUND

The rationale for intraperitoneal chemotherapy after complete macroscopic cytoreduction (CC-0) is well-established for peritoneal surface malignancies. This study aimed to analyze prognostic factors for disease-free survival (DFS) of patients with high-grade serous ovarian cancer (HGSOC) undergoing interval CC-0 cytoreductive surgery (iCRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

This retrospective multicenter study included 293 HGSOC patients treated between January 2010 and May 2023. All the patients received neoadjuvant platinum-based chemotherapy followed by CC-0 iCRS and HIPEC with cisplatin or paclitaxel. Prognostic factors for DFS were analyzed using Kaplan-Meier curves, log-rank tests, and Cox proportional hazards regression.

RESULTS

The median DFS was 23 months, with 3- and 5-year survival rates of 39 % and 29 %, respectively. The patients with a peritoneal carcinomatosis index (PCI) of 15 or lower had significantly better DFS than those with a PCI greater than 15 (24 vs 15 months; p < 0.05). Paclitaxel-based HIPEC was associated with superior DFS compared with cisplatin (25 vs 16 months; p < 0.05). Multivariate analysis showed a PCI greater than 15 related to a lower DFS (hazard ratio [HR], 1.539; p = 0.048) and paclitaxel-based HIPEC as a factor associated with better DFS (HR, 0.663; p = 0.016). The patients treated with HIPEC-paclitaxel and with a PCI of 15 or lower demonstrated the best outcomes (median DFS, 33 months).

CONCLUSION

In HGSOC, the PCI is the most significant determinant of DFS after CC-0 iCRS and HIPEC. Paclitaxel-based HIPEC showed better outcomes than cisplatin, particularly for patients with a PCI of 15 or lower. Further prospective studies are needed to confirm the role of paclitaxel and to evaluate BRCA mutation and homologous recombination deficiency status in treatment efficacy.

Usefulness of Geriatric Parameters in Preoperative Evaluation of Patients Undergoing Minimally Invasive Surgery for Endometrial Cancer: A Retrospective Cohort Study

INTRODUCTION

Patients operated for endometrial cancer (EMCA) are typically elderly with multiple comorbidities, potentially impacting surgical outcomes and survival. This study evaluated the prognostic value of frailty and frailty-related scores in predicting perioperative morbidity and survival in EMCA patients undergoing minimally invasive surgery.

METHODS

This retrospective cohort study included 289 patients from the Sentinel Database treated for EMCA at Bern University Hospital (2012-2020). Patients underwent minimally invasive hysterectomy with sentinel lymph node dissection (39%) or additional radical lymphadenectomy (61%). Frailty was assessed using the Age-Adjusted Charlson Comorbidity Index (ACCI), modified Frailty Index (mFI), 5-item mFI (mFI-5), American Society of Anesthesiologists (ASA) scores, and independent parameters. Primary outcomes included perioperative complications, hospital stay, recurrence-free survival (RFS), and overall survival (OS).

RESULTS

Median age was 65 years (range 26-94) and median follow-up was 41 months (0-105). ACCI > 4 (23.2%) was the strongest predictor of postoperative complications (p = 0.025), prolonged hospitalization (p = 0.03), and reduced OS (hazard ratio [HR] 2.57, 95% confidence interval [CI] 1.18-5.60; p = 0.018). Multivariable analysis confirmed ACCI > 4 (HR 2.24, 95% CI 1.02-4.90; p = 0.044), European Society for Medical Oncology (ESMO) risk group (HR 1.61, 95% CI 1.24-2.07; p < 0.001), hemoglobin (HR 1.03, 95% CI 1.00-1.05; p = 0.033), and congestive heart failure (HR 6.29, 95% CI 1.35-29.27; p =0.019) were significant predictors of OS. Radical lymphadenectomy (p < 0.001), ACCI > 4 (p = 0.025), and age > 70 years (p = 0.034) increased complication risks.

CONCLUSIONS

ACCI > 4 is a practical tool for preoperative risk assessment and predicting surgical tolerance and survival, and is therefore applicable for guiding surgical decisions and personalized care in patients with EMCA.

Examining the impact of 28-week multicomponent and strength exercises on brain health, salivary stress, and mental well-being in frail older women: A controlled trial analysis

BACKGROUND

In recent years, the efficacy of various physical exercise programs in enhancing functional fitness among frail older adults has gained recognition. However, limited research has concurrently explored the long-term effects of exercise on brain health, stress biomarkers, and mental well-being. This study aimed to investigate the impact of two distinct chair-based exercise programs on salivary stress hormones and psychological well-being in frail older women over a 28-week period.

METHODS

A total of 140 individuals participated in the enrollment phase, with 84 eligible participants randomly assigned to three groups. Following the intervention, data from 60 participants were analyzed across the multicomponent exercise (MCE, n = 23), elastic band muscle-strength exercise (ESE, n=19), and non-exercise control (CG n=18) groups. Salivary biomarkers of alpha-amylase (α-AMY) Cortisol (COR), alpha-amylase/cortisol ratio, psychological indicators and physical frailty (PF) and functional fitness were assessed pre- and post-intervention.

RESULTS

Salivary COR levels exhibited a significant time × group interaction, with a moderate increase in MCE, a small decrease in ESE, and a substantial increase in CGne. Salivary α-AMY levels varied significantly over time and by group, with a small decrease in both exercise groups and a moderate increase in CGne. The α-AMY /COR ratio also displayed a significant interaction effect. Additionally, significant improvements were observed in PF compound scores, general self-efficacy, attitudes toward aging, and reductions in perceived stress and depressive symptoms (p < 0.05).

CONCLUSIONS

Notably, the MCE program demonstrated greater benefits than ESE. The observed associations between changes in α-AMY levels, mental well-being, and functional fitness indicators contribute novel evidence on the psychophysiological adaptations to long-term exercise. Importantly, reductions in PF scores correlated with improvements in self-efficacy, attitudes toward aging, and handgrip strength, reinforcing the link between functional fitness, stress regulation, and psychological well-being. These findings emphasize the need for tailored exercise interventions to enhance both physiological resilience and mental health in frail older populations.

Post-Discharge Outcomes of Elderly Patients Hospitalized for Inflammatory Bowel Disease Flare Complicated by Clostridioides difficile Infection

OBJECTIVES

Elderly hospitalized patients with inflammatory bowel disease (IBD) flare and concurrent Clostridioides difficile infection (CDI) are considered at high risk of IBD-related complications. We aimed to evaluate the short-,intermediate-, and long-term post-discharge complications among these patients.

METHODS

A retrospective multicenter cohort study assessing outcomes of elderly individuals (≥60 years) hospitalized for an IBD flare who were tested for CDI (either positive or negative) and discharged. The primary outcome was the 3-month post-discharge IBD-related complication rates defined as steroid dependency, re-admissions (emergency department or hospitalization), IBD-related surgery, or mortality. We assessed post-discharge IBD-related complications within 6 month and mortality at 12 month among secondary outcomes. Risk factors for complication were assessed by multivariable logistic regression.

RESULTS

In a cohort of 654 patients hospitalized for IBD {age 68.9 (interquartile range [IQR]): 63.9-75.2 years, 60.9% ulcerative colitis (UC)}, 23.4% were CDI-positive. Post-discharge complication rates at 3 and 6 months, and 12 months mortality, did not differ significantly between CDI-positive and CDI-negative patients (32% vs 33.1%, p = 0.8; 40.5% vs 42.5%, p = 0.66; and 4.6% vs 8%, p = 0.153, respectively). The Charlson comorbidity index was the only significant risk factor for complications within 3 months (aOR 1.1), whereas mesalamine (5-aminosalicylic acid [5-ASA]) use was protective (aOR 0.6). An UC diagnosis was the sole risk factor for complication at 6 months (aOR 1.5). Clostridioides difficile infection did not significantly impact outcomes or interact with IBD type.

CONCLUSIONS

In elderly IBD patients hospitalized for IBD flare and subsequently discharged, a concurrent CDI infection was not associated with post-discharge IBD-related complications or mortality up to 1 year.

Hypoparathyroidism After Total Thyroidectomy: A Population-Based Analysis of California Databases

INTRODUCTION

Postthyroidectomy hypoparathyroidism is common and usually managed as an outpatient. A better understanding of patients at risk for an emergency department (ED) visit can improve health-care utilization and patient care.

METHODS

The California Cancer Registry and Health Care Access and Information Databases were linked to identify patients who underwent a thyroidectomy for thyroid cancer 2005-2018 and had an ED visit for hypoparathyroidism within 2 y of surgery. Cumulative incidence and multivariable Cox proportional hazards models were used to identify factors associated with an ED visit.

RESULTS

Among 41,502 thyroidectomy patients, 588 (1.42%) presented to the ED for hypoparathyroidism, with a median time between thyroidectomy and first ED visit of 4 ds. Two-year cumulative incidence was highest for women (1.56%), Hispanic patients (2.04%), younger adults aged 18-40 y (1.97%), higher Charlson comorbidity index score (2.43%), lowest neighborhood socioeconomic status quintile (1.97%), patients with >4 lymph nodes removed (2.04%), and patients not seen at an American College of Surgeons Committee on Cancer site (1.60%). Multivariable analysis revealed several factors associated with an increased risk of hypoparathyroidism, including female gender (hazard ratio [HR] 1.67, 95% confidence interval [CI] = 1.32-2.10), Hispanic ethnicity (HR 1.41, 95% CI = 1.16-1.71), a higher Charlson comorbidity index score (≥2 = HR 1.91 [95% CI = 1.46-2.51]), and patients with >4 lymph nodesremoved (HR 1.70 [95% CI = 1.43-2.01]).

CONCLUSIONS

ED visits for postthyroidectomy hypoparathyroidism are uncommon, but usually occurs shortly after surgery. Most risk factors identified are not modifiable, but they help identify high-risk patients who could benefit from targeted postoperative care (programs) to reduce unplanned ED visits.

It's Never Too Early, It's Never Too Late: The Potential of Health Behaviors for Cardiovascular Health in Nonagenarians. Data From the Mugello Study

BACKGROUND

The Life's Essential 8 (LE8) is a composite metric including 4 health behaviors (diet, physical activity, nicotine exposure, and sleep) and 4 health factors (body mass index, nonhigh-density lipoprotein cholesterol, blood glucose, and blood pressure). This study aimed to describe the cardiovascular health (CVH) metrics promoted by LE8 in nonagenarians and to investigate their relationship with mortality at 5 and 10 years.

METHODS

This study was conducted within the framework of the Mugello Study, a longitudinal survey on nonagenarians living in the Mugello area (Tuscany, Italy). One-hundred and fifty-seven subjects (42 males and 115 females, median age 92 years) were administered a series of validated questionnaires and underwent instrumental examinations and blood withdrawal. CVH metrics were calculated according to LE8 guidelines. Physical activity and sleep duration were quantitatively estimated using a monitor device.

RESULTS

In the male group, after 5 and 10 years of follow-up, a higher Health Behavior score was associated with a lower risk of all-cause mortality (HR: 0.963, p = .005 and HR: 0.972, p = .020; after 5 and 10 years). Differently, in the female group, no significant association was observed between the LE8 total score and subscores and different risk of mortality after 5 and 10 years from the interview.

CONCLUSIONS

These findings highlight the importance of potentially modifiable behaviors in improving survival. They support resource investments to address the needs of individuals in this stage of life and encourage them to be empowered and actively engage in health-promoting behaviors.

Sex and age-related implications for preventive measures of intensive care admitted traumatic brain injury patients in Switzerland: an observational study

PURPOSE

Epidemiological studies of traumatic brain injury (TBI) in Switzerland have, to date, poorly investigated sex-related differences in causality and predisposing factors. This study examines differences in sex and age related TBI epidemiology in a high-volume trauma centre intensive care unit (ICU) cohort, aiming to identify potential targets for prevention.

METHODS

This retrospective, single centre study includes all consecutive TBI patients admitted to the ICU in a 4-year study period. Patient demographics, comorbidities, co-medication, trauma setting and associated risk behaviour were compared between sexes and age groups (over/under 65 years).

RESULTS

592 patients (73.3% male, 26.7% female) were included. The leading cause of TBI was falls (52.4%), followed by road traffic accidents (RTA) (35.8%). Overall, men were more likely to suffer from a road traffic accident, while women were more likely to suffer a low energy fall. No differences in injury severity and comorbidities between sexes were observed. Young patients most likely suffered from a RTA while older patients from a low energy fall irrespective of sex. Both sexes portrayed risk associated behaviors with higher rates of alcohol intoxication in males, while females were less likely to wear a helmet in two-wheeled RTAs.

CONCLUSIONS

We conclude that sex- and age-related epidemiologic differences in TBI exist. Our results suggest that sex and age-specific prevention measures might be advisable for optimal mitigation of TBI and its sequelae.

The quality of life and related factors in older adults with possible sarcopenia and sarcopenia in rural areas of Xinjiang, China: a cross sectional study

BACKGROUND

Studies have shown that sarcopenia prevalence in the Chinese population aged over 60 years was 14%. The quality of life of older adults with sarcopenia has drawn increasing attention. Sarcopenia-related quality of life has not been well studied. We explored the quality of life of patients with sarcopenia and the related influencing factors in Xinjiang.

METHODS

This study was conducted from July-September 2023 in the northern and southern regions of Xinjiang, China. Possible sarcopenia and sarcopenia were diagnosed according to the AWGS 2019. The Sarqol® questionnaire was used to evaluate quality of life. A linear regression model with a stepwise method was used to identify quality-of-life-associated factors for possible sarcopenia and sarcopenia.

RESULTS

A total of 987 older adults were enrolled,18.5% had possible sarcopenia, and 15.1% had sarcopenia. Quality of life scores: possible sarcopenia 26.46-92.55 (56.31 ± 14.69), sarcopenia 30.74-90.93 (56.91 ± 13.45).The indicators for which the difference analysis were meaningful, in the group with possible sarcopenia are gender, inhabiting information, ACCI score, hearing loss, social support level and self-rated risk of falling. In the sarcopenia group are gender, ACCI score, hearing loss, vision loss, self-rated health status, number of remaining teeth, self-rated risk for falling, and dysphagia status. The risk factors for quality of life in patients with possible sarcopenia were gender and hearing loss, whereas self-rated of general health, self-rated of poor health, self-rated of very poor health and falls were risk factors in the sarcopenia group.

CONCLUSION

This study focused on quality of life and factors in older adults with possible sarcopenia or sarcopenia. The research results showed that in order to prevent the decline in the quality of life of older adults with sarcopenia, it is very important to regularly examine the oral health status of the older adults, prevent the occurrence of chronic diseases.Multimodal interventions address common sensory impairments.Carry out aging-friendly renovation of the home environment and conduct balance training to prevent the occurrence of falls among the older adults.

Preoperative Factors Associated With Worse PROMIS Pain Interference 2 Years After Hand and Wrist Surgery

BACKGROUND

The purpose of this study was to identify preoperative factors associated with worse postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) scores 2 years after hand and wrist surgery. We hypothesized that older age, more comorbidities, increased substance use, and lower socioeconomic status would correlate with worse 2-year PROMIS PI scores.

METHODS

This study was a retrospective review of prospectively acquired data on 253 patients. Surveys were administered within 1 week of surgery and 2 years postoperatively. Bivariate and multivariable analyses were conducted to identify significant predictors of worse 2-year PROMIS PI scores and change in PROMIS PI scores.

RESULTS

Older age, higher body mass index, more comorbidities, lower preoperative expectations, more prior surgeries, unemployment, smoking, higher American Society of Anesthesiologists (ASA) score, and multiple other socio-demographic factors were correlated with worse 2-year PROMIS PI scores (P ≤ .018). Similar factors were also correlated with less improvement in 2-year PROMIS PI scores (P ≤ .048). Worse scores on all preoperative patient-reported outcome measures correlated with worse 2-year PROMIS PI scores (P ≤ .007). Multivariable analysis identified smoking history, less frequent alcohol consumption, worse preoperative PROMIS social satisfaction and Numeric Pain Scale whole body scores, and higher ASA scores as independent predictors of worse 2-year PROMIS PI. The same factors in addition to better baseline PROMIS PI were predictive of less improvement in 2-year PROMIS PI.

CONCLUSION

Numerous preoperative factors were predictive of worse postoperative 2-year PROMIS PI and less improvement in 2-year PROMIS PI for patients undergoing hand and wrist surgery.

Associations between participation in a diabetes pay-for-performance program and health outcomes and healthcare utilization among people with comorbid schizophrenia and type 2 diabetes in Taiwan

OBJECTIVE

Few population-based studies with large sample sizes have examined the long-term effects of integrated diabetes care in patients with schizophrenia. This study aimed to examine the association between participation in the nationwide diabetes Pay-for-Performance (DM-P4P) program and both health outcomes and healthcare utilization in individuals with schizophrenia comorbid with type 2 diabetes in Taiwan.

STUDY SETTING AND DESIGN

This was a longitudinal, real-world, nested case-control follow-up study from 2015 to 2021 in Taiwan.

DATA SOURCE AND ANALYTICAL SAMPLE

Multiple national population-based databases were used, including Taiwanese population-based longitudinal National Health Insurance (NHI) claims database, registry for NHI enrollment, catastrophic illness registry, board-certificated specialist registry, and registry for health care facilities. A total of 6172 schizophrenia patients with type 2 diabetes and matched controls were compared on a set of process outcome, health utilization, and direct medical cost measures between DM-P4P and non-P4P patients, with a follow-up period of at least three years. Generalized linear regression models were used to investigate the factors influencing participation in the DM-P4P program and to compare health outcomes.

PRINCIPLE FINDINGS

Schizophrenia patients with more severe diabetes complications and chronic comorbid conditions, or those who had previously participated in a schizophrenia P4P program, were more likely to participate in the program. Those who participated in the DM-P4P program were more likely to receive regular diabetes check-ups, and to have had more DM-related outpatient visits but fewer emergency room visits, hospitalizations, and related expenditures, as well as lower all-cause mortality, than non-DM-P4P patients.

CONCLUSIONS

The nationwide DM-P4P program positively affected health outcomes and healthcare utilization among people with schizophrenia comorbid with type 2 diabetes. Policymakers should consider establishing incentive mechanisms to encourage integrated care for schizophrenia patients with diabetes.

Stereotactic body radiation therapy (SBRT) of centrally located medically inoperable early-stage non-small cell lung cancer (T1-T3N0M0) - A subgroup analysis of the expanded HILUS study

INTRODUCTION

Centrally located early-stage non-small cell lung cancer (ES NSCLC) with tumors close to the bronchi is potentially curable with stereotactic body radiation therapy (SBRT). To evaluate the clinical benefit of the treatment, both the risk of high-grade toxicity as well as the treatment efficacy need to be assessed.

MATERIAL AND METHODS

From the expanded HILUS cohorts, 72 patients with T1-T3N0M0 NSCLC were included in the current analysis. All patients had been treated with SBRT in 8 fractions to 56 Gy for a tumor located within 2 cm from the tracheobronchial tree. Primary endpoint was progression free survival (PFS) and secondary endpoints included pattern of failure, local control (LC), lung cancer-specific survival (LCSS), overall survival (OS) and toxicity. The Kaplan-Meier method and Cox regression analysis were used.

RESULTS

The median age of the cohort was 73 years and all patients suffered from comorbidities prior to SBRT. T2-T3 tumors were seen in 65 % of the patients. Seventeen patients relapsed after SBRT and distant recurrence was the most common form of relapse. Three-year PFS was 31 % (95 % CI 22-44) and largely explained by the short overall survival (38 % (95 % CI 22-44) at 3 years). Three-year rates of LC and LCSS were 97 % (95 % CI 92-100) and 76 % (95 % CI 65-89), respectively. Twelve patients (17 %) suffered from grade 5 toxicity, of which 9 were bronchopulmonary bleedings.

CONCLUSION

The severe toxic profile limits the clinical benefit using SBRT with the investigated approach for patients with centrally located ES NSCLC.

Etiology and therapy of pharyngeal perforations

OBJECTIVE

The primary aim of this study is to evaluate the impact of diagnostic procedures and treatment interventions performed at our medical institution on the final outcomes and survival rates of patients with iatrogenic and traumatic pharyngeal perforation (PP).

MATERIALS AND METHODS

We reviewed the medical records of 36 patients with iatrogenic and trauma-induced PP who were treated at the Quaternary Medical Center of Otorhinolaryngology between 2010 and 2020. Comorbidities were classified according to the Age-adjusted Charlson Comorbidity Index (ACCI) scoring system, and postoperative complications were classified according to the Clavien and Dindo scoring system.

RESULTS

Of the 36 patients, 15 (41.7%) were male and 21 (58.3%) were female. The median age was 73 years, and PP was typically diagnosed within one day. Notably, the perforation site was identified in the hypopharynx in 29 (80.5%) patients. The median ACCI score was 4, with the most frequent ACCI score observed being 5. During the treatment course, 17 patients (47.2%) experienced complications, with 9 of these patients experiencing grade IV complications according to the Clavien and Dindo classification.

CONCLUSION

Our study showed that patients with hypopharyngeal perforations have an almost 42-fold higher risk of mortality during hospitalization compared to those with epipharyngeal or oropharyngeal perforations, though results are limited by the small sample size and the variable dates. Additionally, neurosurgery of the cervical spine, transesophageal echocardiography, and diverticular surgery emerged as procedures carrying the highest risk for pharyngeal perforations. Within our patient cohort, 4 patients (11.11%, all female) died during the treatment course.

Frailty index predicts adverse short- and long-term outcomes in older adults with rib fractures

BACKGROUND

Older adults with rib fractures pose an increasing clinical and financial burden on healthcare. Identifying and addressing the increased risk of adverse outcomes has been a key objective in geriatric co-management of surgical patients. The Comprehensive Geriatric Assessment-based Frailty Index (FI-CGA) is a useful predictor of complications and mortality in older adults, but its value in rib fracture management remains unclear. This study investigates the association between FI-CGA and short- and long-term outcomes of older adults with rib fractures.

METHODS

Rib fracture patients ≥65 years, with a FI-CGA score available, were retrospectively identified from a single level-I trauma center between 2018 and 2022. FI-CGA scores were categorized as pre-frail (<0.20), mild frailty (0.20-0.29), moderate frailty (0.30-0.39), and severe frailty (≥0.40). Outcome measures included mortality up to two years, length of stay (LOS), complications, and 30-day readmission.

RESULTS

288 patients were included for analysis (57 pre-frail; 66 mildly frail; 61 moderately frail; 104 severely frail). Compared to the pre-frail group, only severely frail patients were at higher risk of 90-day (OR 5.71 [CI 1.29 - 52.67]) and 1-year mortality (OR 6.66 [CI 2.18 - 27.37]), while 2-year mortality was higher in mild (OR 3.77 [CI 1.30 - 12.57]), moderate (OR 4.28 [CI 1.46 - 14.51]) and severe (OR 6.42 [CI 2.43 - 20.11]) frailty groups. Hospital (p=0.183) and ICU LOS (p=0.131) was similar across groups. Severely frail patients were at risk of pneumonia (OR 3.50 [CI 0.95 - 19.48]) and delirium (OR 4.16 [CI 1.33 - 17.40]), while other complications were similar between groups (p=0.679). Adjusted proportional hazard ratios for mortality were significantly higher for moderate frailty (HR 1.99 [CI 1.02 - 3.89]) and severe frailty (HR 2.66 [CI 1.10 - 3.73]). FI-CGA was also a significant predictor if used per 0.01 point (HR 1.03 [CI 1.01 - 1.04)]) and per 0.1 point (HR 1.29 [CI 1.12 - 1.47]).

CONCLUSION

FI-CGA can identify vulnerable rib fracture patients at risk of in-hospital complications, and short- and long-term mortality. Continuous FI-CGA scores provide a granular and individualized risk assessment. In severely frail patients with rib fractures, FI-CGA may assist in aligning treatment with individual patients' needs and goals of care.

Preservation of the lateral femoral circumflex artery in total hip arthroplasty using the bikini-type direct anterior approach : effect on muscle status and clinical outcomes

Aims

The direct anterior approach (DAA) is increasing in popularity as a minimally invasive technique for total hip arthroplasty (THA). DAA-THA involves ligation of the ascending branch of the lateral femoral circumflex artery (a-LFCA), considered to contribute to the blood supply of the tensor fasciae latae (TFL) muscle. To determine the morbidity of these surgical steps, periarticular muscle status and clinical outcomes were assessed after bikini-type DAA-THA with a-LFCA preservation versus ligation.

Methods

We evaluated the surgical records of 140 patients undergoing DAA-THA with continuous attempt of a-LFCA preservation from May to October 2021. A total of 92 patients were eligible and 46 consented to study participation (n = 20 preservation, n = 26 ligation). Preoperative and six-week clinical and radiological data were retrospectively extracted from patient files, and patient-reported outcome measures (PROMs) from the institutional registry. Clinical and MRI examinations were performed two years postoperatively to analyze volume and fatty infiltration of the TFL, gluteus medius, and gluteus minimus relative to the contralateral hip. A total of 13 patients underwent contralateral THA and were excluded from the analysis of muscle status.

Results

Coxa valga morphology and less muscular habitus were more frequent in a-LFCA preservation. After a-LFCA preservation, less anterolateral soft-tissue swelling was described at six weeks (p < 0.001) and TFL local pain at two years (p = 0.034) postoperatively. PROMs did not differ between groups. Mean TFL volume side-difference was not significantly different after a-LFCA preservation (p = 0.276), but it was significantly different after ligation (11.6% smaller (SD 15.5); p = 0.022). TFL fatty infiltration side-difference was larger after a-LFCA ligation (p = 0.010). Muscle status of the gluteus medius and minimus did not differ between sides and groups.

Conclusion

a-LFCA preservation had a minor effect on TFL muscle status. Since preservation was primarily feasible in hips with simpler morphology, it remains uncertain whether differences were due to preserved vascularity or reduced TFL injury. Hence, a-LFCA preservation does not appear essential. However, until further evidence becomes available, attempting a-LFCA preservation may be advisable.

Re-do laparoscopic common bile duct exploration for recurrent common bile duct stones: a single-center retrospective cohort study

Purpose

Common bile duct (CBD) stone recurrence after laparoscopic CBD exploration (LCBDE) is relatively common. No studies have been conducted evaluating the safety and feasibility of re-do LCBDE in the treatment of recurrent CBD stones.

Methods

This single-center retrospective study reviewed 340 consecutive patients who underwent LCBDE for CBD stones between January 2004 and December 2020. Patients with pancreatobiliary malignancies and those who underwent other surgical procedures were excluded.

Results

Of the 340 included patients, 45 experienced a recurrence after a mean follow-up period of 24.2 months. Of them, 18 underwent re-do LCBDE, 20 underwent endoscopic intervention, 2 underwent radiologic intervention, and 5 underwent observation. Re-do LCBDE and initial LCBDE showed similar surgical outcomes in terms of operative time (113.1 minutes vs. 107.5 minutes, P = 0.515), estimated blood loss (42.5 mL vs. 49.1 mL, P = 0.661), open conversion rate (2.9% vs. 0%, P = 0.461), postoperative complication (15.3% vs. 22.2%, P = 0.430), and postoperative hospital stay (6.5 days vs. 6.4 days, P = 0.921). Comparing re-do LCBDE and nonsurgical treatment (endoscopic or radiologic), no statistically significant differences were noted in posttreatment complication (22.2% vs. 13.6%, P = 0.477), hospital stay (6.4 days vs.7.3 days, P = 0.607), and recurrence (50.0% vs. 36.4%, P = 0.385). The clearance rate was higher in the re-do LCBDE group than in the nonsurgical group (100% vs. 81.8%, P = 0.057).

Conclusion

Compared to initial LCBDE and endoscopic or radiological treatments, re-do LCBDE for recurrent CBD stones is a treatment option worth considering in selected patients.

Epidemiology and palliative care of in-patient cerebral metastases cases in Germany

INTRODUCTION

Cerebral metastases (CM) are the most common intracranial neoplasms, significantly impacting patient quality-of-life. Despite advancements in diagnostics and therapeutics, the burden remains high. This study evaluates inpatient management, palliative care use, and mortality outcomes for CM patients in German hospitals in 2022.

METHODS

A cross-sectional analysis was conducted on 71,787 inpatient cases involving adult CM and leptomeningeal malignancies patients in German hospitals in 2022. Data submitted by hospitals according to §21 of the Hospital Remuneration Act were analyzed, focusing on demographic data, primary tumor types, treatment methods, participation in palliative care, and discharge outcomes.

RESULTS

Among the 71,787 cases, 53.4% were patients aged 65 years or older. Malignant lung tumors were present in 61.6% of cases, followed by breast malignancies (12%) and malignant melanoma and diffuse diffuse large B-cell lymphoma (each 6.4%). Specialized inpatient palliative care (SIPC) was provided in 14.8% (10,636 cases), with 85.2% not receiving such care. Hospital mortality was 13.1% (9413 cases), with 42.2% of these involving patients who received SIPC. Discharge outcomes included discharge home (72.7%), transfers to other hospitals (7.1%), rehabilitation facilities (0.4%), nursing facilities (2%), and hospices (2.4%).

CONCLUSION

Despite treatment advances, high mortality rates for CM patients persist, underscoring the need for palliative care integration and comprehensive training to enhance patient outcomes. Health care planning is a growing topic, our study establishes a benchmark for CM care in German hospitals, revealing a significant number of patients not receiving SIPC. This research can inform future healthcare strategies in neuro-oncology.

Sex-specific associations of vitamin D and bone biomarkers with bone density and physical function during recovery from hip fracture: the Baltimore Hip Studies

Less is known about recovery from hip fracture in men. We found differences in 25-hydroxyvitamin D and bone biomarkers between men and women during the year after hip fracture, underscoring the importance of vitamin D assessment in older men and pharmaceutical treatment to reduce bone resorption after hip fracture.

PURPOSE

Less is known about recovery from hip fracture in men compared to women. We examined differences between men and women in 25-hydroxyvitamin D (25OHD) and bone turnover markers, and associations with bone mineral density (BMD) and physical function, during the year after a hip fracture.

METHODS

Community-dwelling, ambulatory adults aged 65 years and over (157 men and 154 women) enrolled in the Baltimore Hip Studies 7th cohort were included. We analyzed 25OHD, C-terminal telopeptide (β-CTX-I), procollagen type I N-terminal propeptide (PINP), PTH, and femoral neck BMD at baseline, 2, 6, and 12 months after hip fracture, and short physical performance battery (SPPB) at 2, 6, and 12 months.

RESULTS

During admission for hip fracture, median 25OHD levels were 15.2 ng/mL (IQR 10.0) in men compared with 23.9 ng/mL (IQR 13.4) in women and remained lower in men at 2, 6, and 12 months (all p < 0.001). β-CTX-I was higher in men on admission, and at 2 and 6 months (all p < 0.05), and PINP was higher in men at 6 months (p = 0.04), with no significant differences between men and women in PTH. Higher 25OHD and PINP concentrations in women only and lower β-CTX-I and PTH concentrations in both sexes were associated with greater BMD. Higher 25OHD concentrations were associated with higher SPPB scores in both sexes.

CONCLUSIONS

These findings underscore the importance of vitamin D assessment in older men and missed opportunities in both sexes for vitamin D supplementation and pharmaceutical treatment to reduce bone resorption after hip fracture.

Geriatric-led transitional care for older adults discharged from the emergency department: impact on hospital readmissions and disability. Protocol for the controlled prospective quasi-experimental study LASUITE

BACKGROUND

Even when older people are discharged directly home after an emergency department (ED) visit, the risk of deterioration of health status and loss of independence persists. We hypothesize that among older adults discharged from the ED, hospital-community transition care provided by geriatric mobile teams (GMTs) may reduce the early readmission rate and level of disability. Such approaches have rarely been evaluated and cannot be generalized yet. Providing evidence of the positive impact of these strategies may influence public health policies.

METHODS

We will conduct a national, multicentre, prospective, controlled, quasi-experimental study. All participating centres have an ED and a GMT, some of which provide transitional care. Participants recruited from hospitals where GMT provide transitional care form the "intervention group", whereas participants recruited from hospitals where GMT provide standard in-hospital management are the "control group". Inclusion criteria are age ≥ 75 years, returning to personal home after the ED visit (exclusion of nursing home residents) and having a significant risk for early readmission and/or loss of independence after discharge according to a Triage Risk Screening Tool score ≥ 2. The primary objective of this study is to compare hospital ED readmission rates within 30 days. Among secondary objectives, disability scores at 3 and 6 months will be compared between groups. We estimated that 1322 participants, i.e., 661 per group, is required for the main analysis.

DISCUSSION

By conducting this study, we aim to provide more evidence of the effectiveness of transitional care on reducing ED readmissions for older adults, and particularly highlight determinants and effects of hospital-community GMT-led interventions. These strategies can be cost-effective while preserving independence and quality of life. We expect that the results will provide a basis to generalize effective strategies to address the challenges of demographic ageing for healthcare systems.

TRIAL REGISTRATION

The study protocol was registered on ClinicalTrial.org (ID NCT05814328 Date 20230414).

[Special considerations in geriatric anesthesiology : Aspects of perioperative management in older adults]

Older people need a specialized preoperative risk assessment to reliably identify those highly vulnerable risk patients who are in danger of a poor postoperative outcome. In this way these vulnerable risk patients can be separated from those who have successfully and healthily aged and therefore still show a high resilience even in old age. Careful planning of the perioperative management with integration of all disciplines and professions involved can ensure a safe perioperative treatment even for high-risk patients. The corresponding possibilities are presented in this article. The perioperative geriatric anesthesiological treatment pathway must be individually adapted and conceived to specifically address the risks of those patients who are particularly in danger of functional decline and complications.

Association between the fat mass/fat-free mass ratio and muscle strength, static balance and exercise capacity in older adults: a cross-sectional study

BACKGROUND

the FM/FFM ratio has been proposed as a new body composition variable. However, the association between FM/FFM ratio and physical function in older adults remains limited. Therefore, the aim of this study was to analyze the association between FM/FFM ratio and muscle strength, static balance, and exercise capacity in older adults.

METHODS

this was a cross-sectional study involving 392 older adults from Londrina, Brazil. Subjects underwent body composition analysis by bioelectrical impedance, and assessments for aerobic capacity, muscle strength and static balance including the 6-minutes walking test, handgrip strength and one-legged stance test. Statistical analysis was conducted using correlation tests and lineal regression models adjusted for age and gender. The statistical significance considered was p < 0.05.

RESULTS

a total of 392 older adults participated (mean age = 69.77 years; women: 74.7 %). The FM/FFM ratio was significantly associated with muscle strength (β = -22.779, 95 % CI: -26.741 to -18.818; p < 0.001), static balance (β = -14.335, 95 % CI: -19.980 to -8.690; p < 0.001), and exercise capacity (β =-98.937, 95 % CI: -152.286 to -45.588, p < 0.001). After adjusting for age and gender, FM/FFM ratio was an important predictor of muscle strength (β = -4.687, 95 % CI: -8.646 to -0.728; p = 0.020) and static balance (β = -18.361, 95 % CI: -24.943 to -11.778; p < 0.001).

CONCLUSIONS

the FM/FFM ratio is an important clinical measure of body composition that is significantly associated with key indicators of physical performance, including muscle strength, static balance, and exercise capacity in older adults.

The relationship between bariatric surgery and risk of hip or knee replacement in severe osteoarthritis is obesity class-specific

BACKGROUND

In patients with osteoarthritis, bariatric surgery is associated with diminished joint pain and improved functionality.

OBJECTIVES

To evaluate the relationship between the risk of total joint replacement (TJR) and the fact of having undergone bariatric surgery (yes or no) in people living with obesity.

SETTINGS

Data from the French National Hospitals Database.

METHODS

This case-control study was conducted to identify hospitalizations for TJR. The main exposure of interest was having undergone (or not) a bariatric surgery procedure between January 2017 and December 2021. After a 6-month run-in phase, data on hospitalizations for the first TJR (i.e., hip or knee) from July 2017 to December 2023 were classified by obesity class and surgical type.

RESULTS

One hundred sixty thousand seven hundred seventy-three patients who had undergone bariatric surgery (mean age: 40.8 years, 79.5% females) and 160,773 matched controls were identified. The most frequent surgical technique was sleeve gastrectomy (72.2%), followed by gastric bypass (27.8%). The average follow-up was 4.7 years. An increase in the overall risk of TJR, with a hazard ratio (HR) of 1.09 (95% confidence interval [CI], 1.03-1.15), was observed. Depending on obesity class, patients with body mass index (BMI) < 40 kg/m2 had a lower risk of TJR (HR: 5.85; 95% CI: .78-.93), whereas a higher risk was observed in patients with BMI ≥40 kg/m2 (HR: 5 1.25; 95% CI: 1.16-1.34).

CONCLUSIONS

In France, hospitalizations for TJR following bariatric surgery were associated with an increase of 25% in patients with BMI ≥ 40 kg/m2, whereas it was associated with a decrease of 15% in patients with BMI < 40 kg/m2.

BSG/ACPGBI guidance on the management of colorectal polyps in patients with limited life expectancy

BACKGROUND

Determining optimal management of colorectal polyps in patients with limited life expectancy of under 10 years can be difficult, due to challenges balancing an uncertain natural history of polyp progression to symptomatic malignancy versus the increased risk and consequences of polypectomy complications.

AIM

This British Society of Gastroenterology and Association of Coloproctologists of Great Britain and Ireland guidance aims to help clinicians and patients consider these risks to aid decision-making for polypectomy versus a conservative approach.

METHODS

A guidance development group comprising 28 members was established, including gastroenterologists, colorectal surgeons, elderly care physicians, anaesthetists, epidemiologists, nurse endoscopists, a general practitioner and patient representatives. Estimates on life expectancy stratified by age and comorbidity, polyp dwell time for differing polyp sizes, cancer sojourn time and polypectomy complication rates for comorbid/elderly patients both on and off antithrombotic medication were collated from various literature searches. A model was created to compare the risk of symptomatic malignancy in a patient's lifetime against the risk of significant complications.

RESULTS

Following a modified Delphi consensus process and after three rounds of voting, 33 recommendations were made within 10 domains (principles, diagnostic investigation, life expectancy, polyp and cancer natural history, polypectomy risks, management recommendations, follow-up, decision-making practicalities, training and education, future research). A table was created, summarising whether polypectomy or conservative management might be the favoured option for 40 clinical scenarios of patients with differing life expectancy, polyp sizes and use of antithrombotic medication.

CONCLUSIONS

This guidance provides a framework to facilitate more objective and informed decision-making, from which an individualised plan can be developed between the patient and their clinician.

Wrist rotation metrics as digital biomarkers for detecting physio-cognitive decline syndrome in older adults

INTRODUCTION

Physio-cognitive decline syndrome (PCDS) is a reversible condition affecting physical and cognitive health in older adults. Early detection is essential to facilitate timely interventions. This study aimed to evaluate wrist rotation metrics as potential biomarkers for PCDS and explore their applicability in digital health tools.

METHODS

This pilot study recruited 50 community-dwelling individuals aged 50 years or older from Yi-Lan County, Taiwan, including 19 with PCDS and 31 robust participants. Wrist rotation movements were assessed using a custom device, and statistical analyses, including logistic regression and receiver operating characteristic (ROC) curve analysis, were performed to evaluate the diagnostic accuracy of the metrics.

RESULTS

Two rotation metrics, Rotate (60°-30°) and the ratio Rotate (30°-90°)/Rotate (60°-90°), were significantly associated with PCDS. The ratio metric demonstrated high sensitivity, making it suitable for initial screening, while Rotate (60°-30°) exhibited high specificity, supporting its use as a confirmatory test. These complementary roles highlight the potential of these metrics in tiered diagnostic frameworks.

CONCLUSIONS

Wrist rotation metrics show promise as scalable and non-invasive tools for detecting PCDS. These findings support their integration into digital platforms, such as smartphone applications, for early screening and intervention. Further studies are needed to validate these findings in larger, diverse populations and to assess their utility in monitoring disease progression and guiding interventions to improve physical and cognitive health.

Performance of a Modified Version of the Charlson Comorbidity Index in Predicting Multiple Sclerosis Disability Accrual

BACKGROUND

The natural history of multiple sclerosis (MS) is highly heterogeneous and almost unpredictable since several factors may affect the disease course including comorbidities. The aims of this study were to predict the risk of disability worsening and disease progression at the first patient's visit by using a modified version of the Charlson Comorbidity Index (mCCI).

METHODS

the mCCI was obtained by incorporating the grade of pyramidal functional system scores extracted by the Expanded Disability Status Scale (EDSS) into the original CCI version. The risk of reaching EDSS 4, EDSS 6, and secondary MS progression (SPMS) associated to mCCI classes was calculated by carrying out multivariable Cox-regression models and it was reported as hazard ratios (HRs) and 95% confidence intervals (95% CIs). The accuracy of mCCI for the recognition of individuals who reached the study milestones was estimated by building the receiving operator curves and the optimal cut-off values were estimated.

RESULTS

A total of n = 622 individuals were enrolled (72.7% women; median age 30.8 years [24-40]). Compared with patients with a mCCI equal to zero, the HRs for those with a mCCI comprised between 1 and 2 at the first visit were 1.53 (1.1-2.1), 2.17 (1.48-2.96), and 1.57 (1.16-2.1) for the reaching of EDSS 4, EDSS 6, and SPMS, respectively. Moreover, individuals with a mCCI equal or higher than 3 were at even higher risk of reaching EDSS 6 (HR = 2.34 [1.44-3.8]) and SPMS conversion (HR = 2.38 [1.29-4.01]). The mCCI cut-off value of 3 reached a sensitivity and specificity of 88.1% and 77.8%, respectively, for the recognition of EDSS 4, while the mCCI cut-off of 4 reached a sensitivity of 83.1% and a specificity of 80.7% for the recognition of EDSS 6 and a sensitivity and a specificity of 76.8% and 87.5%, respectively, for the recognition of SPMS conversion.

CONCLUSION

mCCI appeared a simple and fast tool for the prediction of MS prognosis since the first patient's visit and its best cut-off values showed higher sensitivity and specificity for the recognition of patients who undergo disability worsening and SPMS conversion.

Impact of Living Arrangements on Delirium in Older ED Patients

Background: The purpose of this study is to assess how the socio-family demographic status of patients is related to the onset of delirium in a large cohort of older adults aged ≥65 years evaluated in the emergency department (ED) using a comprehensive geriatric assessment (CGA). Methods: This is a cross-sectional, observational, retrospective study conducted in the ED of a teaching hospital. We enrolled 2770 geriatric patients admitted to the ED from January 2019 to December 2023 and evaluated them using CGA. Clinical variables assessed in the ED were evaluated for associations with delirium onset and in-hospital mortality. Results: Delirium was statistically related to frailty statuses as measured via the Clinical Frailty Scale (CFS) (OR 1.47 [1.39-1.56]; p < 0.001). The occurrence of delirium was also associated with living arrangements: "living with other relatives" condition (OR 1.43 [1.12-1.83]; p = 0.004) and residence in a nursing home (OR 1.72 [1.30-2.31]; p < 0.001). In addition, compared to patients in emergency conditions (NEWS > 5), it emerges that patients with better clinical stability have a lower risk of developing delirium (NEWS 3-5 OR 0.604 [0.48-0.75]; p < 0.001-NEWS < 3 OR 0.42 [0.34-0.53]; p < 0.001). In-hospital mortality was associated with age, male sex, frailty status, clinical instability, and the onset of delirium in the ED. Conclusions: Delirium is a multifactorial and acute syndrome representing a negative prognostic factor of in-hospital mortality, especially in elderly patients. Independent of the clinical condition, the patient's living arrangement could be of relevance to the onset of delirium in the ED. Early comprehensive geriatric assessments in the ED could allow the early detection of all predisposing risk factors, resulting in the timely implementation of supportive strategies to prevent the onset of delirium in EDs.

Skeletal Muscle Density as a Predictor of Prognosis and Physical Reserve in Patients with Cancer of Unknown Primary

Introduction: The Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) is widely used to assess patient status but relies on subjective judgment and may not fully reflect their physical reserve. While studies have shown that skeletal muscle quality and quantity are associated with patient prognosis, their role in cancers of unknown primary (CUP) remains unclear. Therefore, this study aimed to investigate whether computed tomography (CT)-based skeletal muscle indicators reflect physical reserve and their prognostic value in patients with CUP. Methods: This study enrolled 184 patients with CUP, comprising both inpatients and outpatients, who were diagnosed at Seoul St. Mary's Hospital between 1 January 2008, and 30 June 2024. Overall survival (OS) was evaluated using the Kaplan-Meier method and analyzed using the log-rank test. Univariate and multivariate analyses were performed using Cox proportional hazard models. Statistical significance was defined as p < 0.05. Correlation analyses were conducted to evaluate the relationships between skeletal muscle density (SMD), skeletal muscle index (SMI), and other prognostic factors. Results: SMD was positively correlated with SMI and negatively correlated with age, neutrophil-to-lymphocyte ratio, Charlson Comorbidity Index (CCI), and ECOG-PS. Jonckheere's trend test revealed that SMD decreased significantly as CCI and ECOG-PS increased (p < 0.001), indicating that a higher comorbidity burden and poorer performance status were associated with lower SMD. Both ECOG-PS and SMD were identified as prognostic factors in the univariate analysis of survival; however, only SMD demonstrated statistical significance regarding prognostic value in the multivariate analysis (p = 0.004) Conclusions: SMD, as a measure of muscle quality, demonstrates superior prognostic value compared to the subjective ECOG-PS and may serve as a reliable objective tool for assessing physical reserve in patients with CUP.

Feasibility and Effects of Implementing Multimodal Prehabilitation Before Cytoreductive Surgery in Patients with Ovarian Cancer: The Gynofit Multicenter Study

Background: Cytoreductive surgery (CRS), in combination with chemotherapy, is the main treatment for advanced-stage ovarian cancer. In vulnerable patients, this extensive surgery has a high complication risk and may lead to clinical decline. There is emerging evidence that prehabilitation could be valuable in optimizing the patient's condition prior to cytoreductive surgery, as is shown in colorectal surgery. However, there is limited evidence in gynecologic oncology. The objective of this study is to evaluate the feasibility and effects of implementing multimodal prehabilitation before cytoreductive surgery in patients with ovarian cancer. Methods: In two Dutch hospitals, 46 patients with ovarian cancer were included during the study period, of whom 32 participated in a multimodal prehabilitation program before CRS. The programs included at least physiotherapy, dietary advice and intoxication cessation. The timing, extent and content of the programs differed. Feasibility was assessed by eligibility and participation rates and adherence to the physiotherapy program. Effectiveness was measured by differences in functional capacity, postoperative outcomes and tolerance to adjuvant chemotherapy. Results: Eligibility rates in both hospitals were 83% and 89%, and participation rates were 68% and 72%. Adherence to the physiotherapy program was moderate and only satisfactory in 55% and 63% of the patients. All fitness endpoint measurements improved compared to the baseline. No significant differences in postoperative outcomes were found between prehabilitation and control patients. Prehabilitation patients appeared to have better tolerance to adjuvant chemotherapy, with fewer dose reductions (21% vs. 73%, p = 0.017) and dose deferrals (39% vs. 46%, not significant) compared to the control group. Conclusions: The implementation of multimodal prehabilitation before CRS is feasible and effective in patients with ovarian cancer with respectable eligibility and participation rates, along with improved functional capacity, even during neoadjuvant chemotherapy.

The relationship between shrunken pore syndrome and all-cause mortality in people with type 2 diabetes and normal renal function: the Fremantle Diabetes Study Phase II

AIMS/HYPOTHESIS

Estimated GFRs utilising creatinine- (eGFRcreat) or cystatin C-based (eGFRcyst) equations can generate discrepant results that are associated with clinical outcomes. A low eGFRcyst/eGFRcreat ratio (<0.60), reflecting a pathological glomerular state termed shrunken pore syndrome (SPS), has been associated with excess mortality in some clinical situations including diabetes. The aim of the present study was to explore this association in a longitudinal observational study of type 2 diabetes with special reference to participants with normal renal function.

METHODS

Of 1481 Fremantle Diabetes Study Phase II participants with type 2 diabetes, aged ≥17 years, 1466 had eGFRcreat and eGFRcyst assessed as part of the baseline assessment and were followed for 10 years or until death, whichever came first. Cox regression modelling was used to determine independent associates of death excluding eGFR; eGFRcyst/eGFRcreat ratio was then added to this model separately as a categorical or continuous variable. These analyses were also conducted in a subgroup (n=754) of participants with normal renal function (eGFRcreat ≥60 ml/min per 1.73 m2 and urinary albumin/creatinine ratio <3 mg/mmol) at baseline.

RESULTS

At entry, the participants had a mean age of 65.9 years, 51.8% were male, the median diabetes duration was 9.0 years and 10.4% had eGFRcyst/eGFRcreat ratio <0.60 (the definition of SPS). There were 384 deaths (26.2%) during follow-up. The eGFRcyst/eGFRcreat ratio was independently, significantly and negatively associated with death (adjusted HR [95% CI] 0.91 [0.85, 0.97] for an increase of 0.1, p=0.004). Of eGFRcyst/eGFRcreat ratio categories, only <0.60 added significantly to the most parsimonious Cox model of time to death (HR [95% CI] 1.56 [1.07, 2.29], p=0.021). In those with normal renal function, 123 (16.3%) died during follow-up. An eGFRcyst/eGFRcreat ratio <0.60, observed in 57 (7.6%), was also independently associated with mortality (HR [95% CI] 2.55 [1.34, 4.84], p=0.004).

CONCLUSIONS/INTERPRETATION

A low eGFRcyst/eGFRcreat ratio is independently associated with mortality in type 2 diabetes, including in people without conventional markers of diabetic kidney disease. The presence of SPS may add clinical value to the risk assessment of people with type 2 diabetes regardless of renal status.

Non-liver comorbidity in patients with hepatocellular carcinoma and curative treatments - a Swedish national registry study

OBJECTIVES

Treatment decisions for hepatocellular carcinoma (HCC) involve considering tumour stage, liver function and performance status, including comorbidities, although rarely analysed specifically. This study examines the patterns and prognostic impact of comorbidities in HCC patients.

METHODS

We included patients diagnosed with HCC before undergoing transplantation, resection or ablation, registered in the Swedish Registry for Cancers in the Liver and Bile ducts (SweLiv) 2008-2016. Data were cross-linked with the Swedish National Patient Registry (NPR) to capture International Classification of Diseases (ICD) codes reflecting comorbidities within 10 years before the HCC treatment decision. The Charlson Comorbidity Index (CCI), excluding the liver disease category (CCI-P), was used to estimate accumulated comorbidity.

RESULTS

We identified 980 HCC patients with transplantation (225), resection (425) or ablation (330). The comorbidity burden, assessed using the CCI-P, was highest in ablation patients and lowest in the transplanted group (p < 0.001). The CCI-P category distribution varied across treatment groups. After adjusting for age and tumour burden, several CCI-P categories were associated with 5-year mortality, including heart failure, cerebrovascular disease, pulmonary disease, ulcers, and renal disease. ICD diagnoses not included in the CCI, such as trauma, infection, psychiatric disease, anaemia, and obesity, were also linked to 5-year mortality.

CONCLUSIONS

Comorbidity burden and patterns differed between HCC treatment groups, with CCI-P significantly associated with mortality. Preoperative attention to cardiovascular disease is important, but other comorbid conditions may require vigilance. Given the higher prevalence of comorbidities in ablation and resection patients, efforts to optimize comorbidity in these groups may be warranted.

Association between time to geriatric ward admission and change in functional status in older adults after an emergency department visit: a prospective cohort study

The impact of total time from emergency department (ED) admission to geriatric ward admission in older patients remains unknown. The objective of the study was to assess the association between time to geriatric ward admission on 6-month mortality and functional decline in older adults. A prospective, single-center cohort study was conducted including patients 75 years or older admitted to an acute-care geriatric unit following an ED visit in 2023 with a 6-month follow-up. Functional decline was defined as a decrease of at least 1 point in the Activities of Daily Living (ADL) scale between admission and 6 months. The primary end point was a composite of 6-month mortality and functional decline. Association between quartiles of time to geriatric ward admission and the primary end point was analyzed using multivariable logistic regression. Among the 360 included patients (median age 86, median time to geriatric ward admission 32.2 h), 198 (55%) experienced the composite outcome (31% death and 24% functional decline): 42%, 47%, 60%, and 71% in the first to last quartile, respectively. Compared to the first quartile, there was an independent association between time to geriatric ward admission and the primary outcome with an adjusted odds ratios of 1.4 (95% CI 0.8-2.7), 2.3 (95% CI 1.2-4.3), and 3.4 (95% CI 1.8-6.6) for the second, third, and fourth quartiles, respectively. Prolonged time to geriatric ward admission following ED consultation is associated with a higher risk of 6-month mortality and functional decline in older adults.Trial registration 2023-A02753-42 (CPP Sud-Est V approval).

Early surgical fixation of proximal femur fractures under active direct oral anticoagulation (DOAC) therapy does not increase the postoperative blood loss. Results from a prospective cohort study with a matched-pair analysis

INTRODUCTION

This study aims to investigate whether early surgery in patients under active DOAC (direct oral anticoagulation) therapy with trochanteric, proximal femur fractures leads to higher postoperative blood loss.

MATERIAL AND METHODS

A prospective cohort study on DOAC patients with trochanteric, proximal femur fractures undergoing early surgery (≤ 24 h) was conducted. Propensity score matching with a retrospective control group of DOAC patients with trochanteric, proximal femur fractures undergoing delayed surgery (> 24 h) was performed for comparison. Key outcome measurements included peri- and postoperative blood loss, transfusion rates, time to surgery and hospital length of stay (LOS).

RESULTS

No differences in the median blood loss in patients undergoing early surgery vs. delayed surgery on postoperative day 1 (1078.35 ml (IQR 745.86) vs. 1120.79 ml (IQR 928.50); p = 0.824) or postoperative day 3 (1592.39 ml (IQR 1304.91) vs. 1339.73 ml (IQR 735.57); p = 0.165) was seen. No differences in the rate of blood transfusion (72.5% vs. 68.1%; p = 0.576) or the number of transfused red blood cells (RBCs) (2 units (IQR 2) vs. 2 units (IQR 3); p = 0.567) were detected. A significantly longer median time to surgery, and a significantly longer LOS was seen in the delayed surgery group (p < 0.001). No difference in the rates of perioperative complications was detected between both groups.

CONCLUSION

Early surgery of trochanteric, proximal femur fractures within 24 h under active DOAC therapy does not increase postoperative blood loss or the need for postoperative blood transfusions but leads to a significantly shorter length of stay.

LEVEL OF EVIDENCE

IIb.

Effects of exergaming and yoga on exercise capacity and physical and mental health in heart failure patients: a randomized sub-study

AIMS

This study aimed to explore effects of exergaming and medical yoga on exercise capacity, fatigue, shortness of breath, health-related quality of life, depression, and anxiety in patients with heart failure.

METHODS AND RESULTS

A randomized sub-study with a 3-month intervention and outcomes measures at baseline, 3, 6, and 12 months. Participants were recruited from heart failure clinics in Sweden. Treatment effects in change of outcomes were tested in an analysis of mixed-effects models with repeated measures. Change in outcomes was the dependent variable. The independent fixed-effect parameters were treatment group, time, and the interaction between treatment group and time.In total, 104 patients (37% women, mean age 71 ± 12, 48% in New York Heart Association Class II and 42% in III) were randomized to exergaming (n = 35), medical yoga (n = 33), or an active control group (n = 36). No statistically significant differences were found between these three groups on any of the outcome measures. Exergaming significantly improved exercise capacity, fatigue, shortness of breath, and physical health-related quality of life and medical yoga improved symptoms of fatigue and emotional health-related quality of life. The control group did not change on the exercise capacity, symptoms, health-related quality of life, or depressive or anxiety symptoms. The well-being score in patients in the control group significantly decreased at 3 months.

CONCLUSION

Both exergaming and medical yoga demonstrated positive impacts on outcomes when compared with a control group. Exergaming, characterized by its elevated physical intensity, exerted effects primarily on physical health, while medical yoga, as a mind-body intervention, exhibited influences on emotional well-being.

REGISTRATION

ClinicalTrial.gov: NCT01785121.

Increasing Rates of Bowel Resection Surgery for Stricturing Crohn's Disease in the Biologic Era

BACKGROUND

The era of biologics is associated with declining rates of surgery for Crohn's disease (CD), but the impact on surgery for stricturing CD is unknown. Our study aimed to assess nationwide trends in bowel resection surgery for obstruction in CD since the introduction of infliximab for CD in 1998.

METHODS

Using the Nationwide Inpatient Sample, we performed a nationwide analysis, identifying patients hospitalized for CD who underwent bowel resection for an indication of obstruction between 1998 and 2020 (era of biologics). Longitudinal trends in all CD-related resections and resection for obstruction were evaluated. Multivariable logistic regression identified patient and hospital characteristics associated with bowel resection surgery for obstruction.

RESULTS

Hospitalizations for all CD-related resections decreased from 12.0% of all hospitalizations in 1998 to 6.9% in 2020, while hospitalizations for CD-related resection for obstructive indication increased from 1.3% to 2.0%. The proportion of resections for obstructive indication amongst all CD-related bowel resections increased from 10.8% in 1998 to 29.1% in 2020. In the multivariable models stratified by elective admission, the increasing year was associated with risk of resection for obstructive indication regardless of urgency (nonelective model: odds ratio, 1.01; 95% CI, 1.00-1.02; elective model: odds ratio, 1.06; 95% CI, 1.04-1.08).

CONCLUSIONS

In the era of biologics, our findings demonstrate a decreasing annual rate of CD-related bowel resections but an increase in resection for obstructive indication. Our findings highlight the effect of medical therapy on surgical rates overall but suggest limited impact of current medical therapy on need of resection for stricturing disease.

Efficacy and Validity of Percutaneous Transhepatic Gallbladder Drainage as a Bridge to Surgery for Octogenarian and Older Patients With Acute Cholecystitis: A Single-Center Retrospective Observational Study in Japan

BackgroundJapan currently has a super-aged society, with a rapid increase in elderly patients in need of medical care. Determining treatment strategies for acute cholecystitis (AC) in very elderly patients with various comorbidities is often difficult. Although percutaneous cholecystostomy (PC) is a less-invasive treatment option, its impact on subsequent surgery remains debatable. This study investigated the validity of PC as a bridge to surgery in very elderly patients with AC.MethodsOf 215 patients who underwent cholecystectomy for AC at our hospital, we retrospectively investigated 83 patients aged ≥80 years-53 and 30 who underwent upfront surgery (US) and PC before surgery, respectively-to assess the treatment strategies and clinical course.ResultsThe PC group had a significantly worse systemic status at diagnosis than the US group, including age, severity grading, comorbidities, performance status, systemic inflammatory status, and blood coagulation abnormalities, which improved after PC. The elective surgery rate was significantly higher in the PC group than in the US group. Despite the high number of severe cases in the PC group, surgical quality indicators, including the conversion rate to open surgery, operative time, blood loss, and critical view of safety achievement rate, tended to be better in the PC group, without severe perioperative complications.DiscussionPC followed by cholecystectomy improves preoperative conditions, including systemic inflammation status and blood coagulation abnormalities, in very elderly patients, allowing safe elective surgical treatment while securing the quality of surgery and clinical outcomes.

Quality of life and cost-utility analysis in patients with femoral neck fracture: a propensity score matching study comparing monopolar hemiarthroplasty and total hip arthroplasty

INTRODUCTION

Femoral neck fracture impacts patients' quality of life. Patients treated with a total hip arthroplasty (THA) versus a hemiarthroplasty (HA) may have higher quality of life scores after the intervention. This work aims to analyze and compare quality of life among patients with femoral neck fracture treated with THA versus monopolar HA and to perform a cost-utility analysis (CUA) on the procedures.

MATERIALS AND METHODS

A prospective, comparative study was conducted on 424 patients with femoral neck fractures, 268 treated with monopolar HA and 156 with THA. To ensure comparability between the groups, Propensity Score Matching (PSM) was performed based on variables such as age and the Charlson Comorbidity Index. The index accounted for comorbidities including cardiovascular disease, diabetes, chronic pulmonary disease, renal disease, and malignancy. After PSM, 156 matched pairs were analyzed. Follow-up data, including quality of life (QoL) assessed via the EQ-5D scale, were collected at 1 year.

RESULTS

Twelve months after the procedure, patients treated with THA had significantly higher EuroQol-5D (EQ-5D) index values than those treated with monopolar HA (0.83 vs. 0.68; p = 0.001), with a large effect size (Cohen's d = 0.92), however, both procedures presented similar results on the EQ-5D visual analog scale (VAS) (86.59 vs. 87.11; p = 0.255). THA led to a gain of 0.15 quality-adjusted life years (QALY) compared to monopolar HA (0.83 QALY vs. 0.68 QALY) and demonstrated greater cost-effectiveness, particularly in patients younger than 80 years and those with fewer comorbidities.

CONCLUSIONS

Patients with femoral neck fracture treated with THA may have higher quality of life levels than those treated with monopolar HA. Likewise, the greatest gain in QALY with THA versus monopolar HA was observed in patients younger than 80 years of age and those who had less comorbidity.

Association between objective physical activity and frailty transition in community-dwelling prefrail Japanese older adults

BACKGROUND

Frailty transition is common, and increased physical activity can prevent it. An objective assessment of physical activity could eliminate bias and provide more precise information on the association between frailty transitions and physical activity.

OBJECTIVES

This study aimed to examine the association between objective physical activity and frailty transition in community-dwelling prefrail Japanese older adults.

DESIGN

This is a retrospective cohort study based on the National Institute for Longevity Science-Longitudinal Study of Aging data.

PARTICIPANTS

A total of 387 community-dwelling older adults with prefrailty were enrolled (mean age 72.0 years).

MEASUREMENTS

Frailty was assessed using modified components of the Cardiovascular Health Study criteria, and frailty statuses were reassessed two years later. The frailty transitions were categorized into three groups: deterioration, persistence, and reversal. Participants wore a uniaxial accelerometer to assess the physical activities. Differences in baseline characteristics according to frailty transitions were assessed. To compare the baseline objective physical activities based on frailty transition, a general linear model and a logistic regression model were used.

RESULTS

Among the 387 participants, 40 (10.3%) deteriorated to frailty, 97 (25.0%) reversed to robust, and the majority (n = 250, 64.6%) remained prefrail after a 2-year follow-up. Using the general linear model, after adjusting for other factors, total energy expenditure (TEE) in the reversal group was significantly higher than that in the deterioration and persistence groups. No differences in TEE were observed between the persistence and deterioration groups. No significant differences existed in the numbers of daily steps, exercise energy expenditure (EEE) and physical activity with different intensity among these three groups. The logistic model also showed a significant association between TEE and the reversal of frailty.

CONCLUSION

Frailty transitions were common in the Japanese prefrail population. This study showed that a higher TEE was positively associated with frailty reversal in prefrail older adults. Promoting proactive programs for older adults to increase physical activity could help them stay healthy and prevent frailty deterioration.

Oncologic outcomes for invasive squamous cell carcinoma with a clinically resolved biopsy site managed by watchful waiting: A retrospective cohort study

BACKGROUND

Treatment of cutaneous squamous cell carcinoma (cSCC) largely involves surgical excision. Few studies have examined oncologic outcomes of tumors managed by watchful waiting (WW) when the lesion appears resolved after the biopsy site has healed.

OBJECTIVE

To describe oncologic outcomes for patients diagnosed with cSCC that was determined clinically resolved at follow-up and subsequently managed by WW.

METHODS

This retrospective cohort included pathology proven cases of cSCC occurring from January 1st, 2013 to April 31st, 2023. Each required documented clinical resolution more than 4 weeks after biopsy, management by WW, and at least 12 months of follow-up.

RESULTS

Of 148 tumors managed by WW, there were 2 cases of local recurrence, and no cases of nodal metastasis, distant metastasis, or disease specific death. Log-rank test found significant risk of recurrence in immunocompromised participants (Hazard ratio = 12.87, P = .0193) and those with rheumatologic disease (Hazard ratio = 16.18, P = .0075).

LIMITATIONS

Retrospective, single-center design.

CONCLUSION

The recurrence rate in this cohort compares favorably to reported recurrence rates for surgically managed cSCC. In select cases, WW may be a reasonable management option for low-risk lesions that appear clinically resolved after healing of the biopsy site.

The Impact of Neuroanesthesia Fellowship Training and Anesthesiologist-Surgeon Dyad Volume on Patient Outcomes in Adult Spine Surgery: A Population-Based Study

INTRODUCTION

Extensive research has explored the impact of surgeons' characteristics on patient outcomes; however, the influence of anesthesiologists remains understudied. We performed a population-based retrospective cohort study to investigate the impact of anesthesiologists' characteristics on in-hospital morbidity after spine surgery.

METHODS

Adult patients who underwent spine surgery at the London Health Science Centre, Ontario, Canada between January 1, 2010 and June 30, 2023 were included in this study. Data was extracted from the local administrative database. Five anesthesiologists' characteristics (neuroanesthesia fellowship and residency training backgrounds, surgeon familiarity, annual case volume, and sex) were examined as primary exposures. The primary outcome was composite in-hospital morbidity, encompassing 141 complications. Multivariable logistic regression was performed to assess the association between anesthesiologists' characteristics and postoperative morbidity with adjustment of patients' sex, Charlson Comorbidities Index, surgical complexity, and surgeon characteristics.

RESULTS

A total of 7692 spine surgeries were included in the analysis. Being a neuroanesthesia fellowship-trained anesthesiologist and high anesthesiologist-surgeon annual dyad volume were associated with reduction in in-hospital comorbidity; adjusted odds ratio (95% CI) of 0.58 (0.49-0.69; P <0.001) and 0.93 (0.91-0.95; P <0.001), respectively. Conversely, anesthesiologist annual case volume, characteristics of residency training and anesthesiologist sex showed only nuanced associations with outcomes.

CONCLUSIONS

Neuroanesthesia fellowship training and high surgeon-anesthesiologist dyad familiarity was associated with a reduction in in-hospital morbidity following spine surgery. These findings underscore the superiority of structured fellowship education over case exposure experience alone, advocate for dedicated neuroanesthesia teams with high surgeon-anesthesiologist dyad volume and recognize neuroanesthesia as a crucial subspecialty in spine surgery.

Carbapenem-Resistant, Virulence Plasmid-Harboring Klebsiella pneumoniae, United States

Carbapenem-resistant and virulence plasmid-harboring Klebsiella pneumoniae (pVir-CRKP) has emerged and spread globally, yet clinical investigations from the United States remain limited. We conducted a genomic analysis of 884 unique carbapenem-resistant K. pneumoniae isolates from a multicenter US cohort and identified 6 pVir-CRKP isolates, including 2 sequence type (ST) 23, 2 ST893, and 2 ST11 isolates. Patients infected with pVir-CRKP experienced high Pitt bacteremia scores and a 33% 30-day mortality rate. The pVir-CRKP isolates exhibited significant sequence variation in virulence genes and plasmids, along with differences in mucoviscosity, capsule production, survival in normal human serum, resistance to killing by human polymorphonuclear neutrophils, and in vivo pathogenicity. Phylogenetic analyses showed that most pVir-CRKP isolates were genetically similar to strains reported from other global regions. The emergence of pVir-CRKP with higher virulence potential and carbapenem resistance in the United States than the predominant carbapenem-resistant K. pneumoniae clone underscores the need for active global surveillance.

The Modified Fragility Index and Perioperative Albumin as Predictors of Complications in Complex Abdominal Wall Reconstruction

BACKGROUND AND SIGNIFICANCE

Complex abdominal wall reconstruction (CAWR) is performed to restore the structure and function of the abdominal wall. These procedures carry the risk of complications such as delayed wound healing, skin necrosis, infection, recurrence, or even death. The 5-factor modified fragility index (5-mFI) has gained popularity as a concise method of evaluating preoperative risk across various surgical specialties. Additionally, perioperative hypoalbuminemia has been previously associated with delayed wound healing after surgery. The purpose of this study was to assess the utility of the 5-mFI in combination with perioperative albumin levels for assessing risk in complex abdominal wall reconstruction.

METHODS

This was a retrospective, single-institution chart review study of all patients who underwent CAWR by the senior author (A.L.) from 2002 to 2023. Demographics, comorbidities, details of surgery, perioperative albumin levels, ASA scores, and complications were collected for each patient. Five-factor modified fragility indices were calculated for each patient. Statistical analysis consisted of χ 2 and Fisher exact tests for categorical variables, t tests for continuous variables, and multivariate analysis.

RESULTS

Our analysis included 437 patients. The average age of our patients was 54.3 years, the average BMI was 32.1 kg/m 2 , and the average length of follow-up with the plastic surgery service was 264 days. A total of 118 (27.0%) developed complications, with the most common complications being delayed wound healing (89 patients, 20.4%) and infection (78 patients, 17.8%). Other complications included skin necrosis, fistula formation, hematoma, seroma, infection, and death. Sixty patients (13.7%) experienced recurrence of their hernias within the follow-up period. An mFI of 2 or greater was significantly associated with delayed wound healing (LR, 11.42; P = 0.0436) as well as skin necrosis (LR, 4.826; P = 0.028). The presence of an mFI of 2 or greater and perioperative hypoalbuminemia was significantly associated with development of major complications (LR, 3.221; P = 0.0457), delayed wound healing (LR, 5.999; P = 0.0143), skin necrosis (LR, 9.19; P = 0.0024), and mortality (LR, 5.287; P = 0.0215). On multivariate analysis, the presence of an mFI of 2 or greater when combined with perioperative hypoalbuminemia was found to be independently associated with mortality (LR, 1524.5; P < 0.0001).

CONCLUSIONS

We found the 5-factor mFI to be significantly associated with delayed wound healing and skin necrosis in our patient population. When an mFI of 2 or greater was present along with perioperative hypoalbuminemia, patients were significantly more likely to experience complications, issues with wound healing, and mortality. Surgeons should take these findings into account when counseling patients preoperatively.

Quality Management Outweighs Pandemic: Retrospective Analysis Shows Improved Quality of Care for Staphylococcus aureus Bacteremia Despite SARS-CoV-2

BACKGROUND

Staphylococcus aureus bacteremia (SAB) is of great clinical relevance, as it is the most common type of bacteremia. Several studies show that the quality of care and thus the outcome can be positively influenced by the involvement of infectious disease specialists and structured programs like Antimicrobial Stewardship (AMS). In 2020, the SARS-CoV-2 pandemic occurred, which dominated the healthcare system and global events during this time. At the same time, a standard operational procedure (SOP) for SAB quality management (SABQM) was introduced in a German maximum-care hospital with 500 beds. Additionally, voluntary AMS team consultations were introduced in June 2021. This work addresses whether the introduction of SABQM has led to an improvement in the quality of care for SAB, despite the possible negative influences of the pandemic.

METHODS

Retrospective statistical analyses were conducted on all 145 cases coded as SAB at this hospital during the "pre-pandemic" period (2017 to 2019, 75 cases) and the pandemic period (2020 to 2022, 70 cases). Population parameters and quality management parameters were extracted from the clinical patient documentation. In a first analysis, the SARS-CoV-2 status served as a discriminatory parameter to determine its influence on the quality of care within the "pandemic period". In a second analysis, the period served as a discriminatory parameter to determine its influence on the quality of care. In a third analysis, the use of AMS team consultation served as a discriminatory parameter to determine its influence on the quality of care in a subgroup of 42 cases from June 2021 to 2022.

RESULTS

The SARS-CoV-2 status had no influence on the population parameters or the quality management parameters. Between both analyzed periods, there was an improvement in the quality management parameters, with statistically significant higher rates of follow-up blood cultures, transthoracic echocardiography and adequate antibiotic therapy. AMS team consultation led to a relevant, but not statistically significant improvement in the quality management indicators.

CONCLUSIONS

An SOP for SABQM leads to an improvement in the quality of care, even under the possible negative influences of a pandemic. AMS team consultations further strengthen this positive influence, even if this is not statistically significant due to the small number of cases in the subgroup analyzed.