Decreased preoperative functional status is associated with increased mortality following coronary artery bypass graft surgery

Determinants of Early Mobilization in Postcardiac Surgery Patients

Coronary Heart Disease is the number 1 cause of death in the world, one of which is surgical intervention. Surgery can cause immobilization which has a risk of complications, reduces comfort, wellbeing and affects the patient's quality of life. Early mobilization of postcardiac surgery patients is influenced by various factors. The purpose of this study was to identify factors that influence the early mobilization of postcardiac surgery patients. Cross-sectional study design with a sample size of 86 postcardiac surgery patients. The instruments used were observation sheets, Visual Analoque Scale, State-Trait Anxiety Inventory compiled by Spilberger, observation sheets referring to the Malaysia Society of Intensive Care and Thompson. The multivariate analysis used in this study used Structural Equation Modeling. There is a significant effect between anxiety and early mobilization p value 0.041 with a regression coefficient of 0.308. There is a significant effect between energy levels and early mobilization p value 0.044 with a regression coefficient of 0.191. There is a significant indirect effect of exercise therapy intervention on early mobilization mediated by anxiety with a p value of 0.048 and a regression coefficient of 0.230. Other exogenous variables have no significant effect on early mobilization variables, pain and anxiety. Management of pain, anxiety, giving exercise therapy and fulfilling energy levels need to be done to increase early mobilization of patients after cardiac surgery.

Risk stratification with explainable machine learning for 30-day procedure-related mortality and 30-day unplanned readmission in patients with peripheral arterial disease

Predicting 30-day procedure-related mortality risk and 30-day unplanned readmission in patients undergoing lower extremity endovascular interventions for peripheral artery disease (PAD) may assist in improving patient outcomes. Risk prediction of 30-day mortality can help clinicians identify treatment plans to reduce the risk of death, and prediction of 30-day unplanned readmission may improve outcomes by identifying patients who may benefit from readmission prevention strategies. The goal of this study is to develop machine learning models to stratify risk of 30-day procedure-related mortality and 30-day unplanned readmission in patients undergoing lower extremity infra-inguinal endovascular interventions. We used a cohort of 14,444 cases from the American College of Surgeons National Surgical Quality Improvement Program database. For each outcome, we developed and evaluated multiple machine learning models, including Support Vector Machines, Multilayer Perceptrons, and Gradient Boosting Machines, and selected a random forest as the best-performing model for both outcomes. Our 30-day procedure-related mortality model achieved an AUC of 0.75 (95% CI: 0.71-0.79) and our 30-day unplanned readmission model achieved an AUC of 0.68 (95% CI: 0.67-0.71). Stratification of the test set by race (white and non-white), sex (male and female), and age (≥65 years and <65 years) and subsequent evaluation of demographic parity by AUC shows that both models perform equally well across race, sex, and age groups. We interpret the model globally and locally using Gini impurity and SHapley Additive exPlanations (SHAP). Using the top five predictors for death and mortality, we demonstrate differences in survival for subgroups stratified by these predictors, which underscores the utility of our model.

A decline in functional status while awaiting liver transplantation is predictive of increased post-transplantation mortality

BACKGROUND

Functional status (FS) is dynamic and changes over time. We examined how changes in FS while awaiting liver transplantation influence post-transplant outcomes.

METHODS

Data on adult liver transplants performed in the United States during the MELD era were obtained through September 2020. Patient and graft survival were compared between groups with no change or improved FS, and those with worsening FS.

RESULTS

Of the 90,210 transplant recipients included in the analysis, 39,193 (43%) had worsening FS, which was associated with longer waiting-list time (187 vs. 329 days, p < 0.001) and worse patient survival after liver transplant (1858 vs. 1727 days, p < 0.001). A consistent and dose-dependent relationship was observed for each 10-point decrease in Karnofsky Performance Score and post-transplant survival. Multivariable regression analysis confirmed that a decline in FS was associated with worse patient survival (HR 1.15, p < 0.001). Similar findings were observed for graft survival.

CONCLUSION

A decline in FS on the waiting-list is associated with significantly greater post-liver transplant mortality in recipients. These results should be taken into consideration when allocating organs and determining transplant candidacy. Strategies to optimize FS prior to transplantation should be prioritized as even subtle decreases in FS are associated with inferior post-transplantation outcomes.

Development of a clinical prediction rule for patients with cervical spinal cord injury who have difficulty in obtaining independent living

BACKGROUND CONTEXT

A simple and easy to use clinical prediction rule (CPR) to detect patients with a cervical spinal cord injury (SCI) who would have difficulty in obtaining independent living status is vital for providing the optimal rehabilitation and education in both care recipients and caregivers. A machine learning approach was recently applied to the field of rehabilitation and has the possibility to develop an accurate and useful CPR.

PURPOSE

The aim of this study was to develop and assess a CPR using a decision tree algorithm for predicting which patients with a cervical SCI would have difficulty in obtaining an independent living.

STUDY DESIGN

The present study was a cohort study.

PATIENT SAMPLE

In the present study, the data was obtained from the nationwide Japan Rehabilitation Database (JRD). The data on the SCIs was collected from 10 hospitals and the data was collected from the registries obtained between 2005 and 2015. The severity of SCI can vary, and patient prognosis differs depending on the damage site. In this study, the patients with cervical SCI were included.

OUTCOME MEASURES

In this study, the degree of the independent living at discharge was investigated. The degree of the independent living was classified and listed as below: independent in social, independent at home, need care at home, independent at facility, need care at facility. In this study, the independent in social and independent at home were defined as "independent," and the other situations were defined as "non-independent."

METHODS

We performed a classification and regression tree (CART) analysis to develop the CPR to predict whether the cervical SCI patients obtain an independent living at discharge. The area under the curve, the classification accuracy, sensitivity, specificity, and positive predictive value were used for model evaluation.

RESULTS

A total of 4181 patients with SCI were registered in the JRD and the CART analysis was performed for 1282 patients with the cervical SCI. The Functional Independence Measure (FIM) total score and the American Spinal Injury Association impairment scale were identified as the first and second discriminators for predicting the degree of the independence, respectively. Subsequently, the CART model identified FIM eating, the residual function level, and the FIM bed to chair transfer as next discriminators. Each parameter for evaluating the CART model were the area under the curve 0.813, the classification accuracy 78.6%, the sensitivity 80.7%, the specificity 75.1%, and the positive predictive value 84.5%.

CONCLUSIONS

In this study, we developed a clinically useful CPR with moderate accuracy to predict whether the cervical SCI patients obtain independent living at the discharge.

Anaesthesia for the elderly: a narrative review

As octogenarians in the operation room are no longer an exemption but the norm, perioperative management needs to be adopted to meet the special requirements of this group of patients. Anaesthesia does not need to be re-invented to fit the elderly. However, as elderly patients are among those most affected by adverse postoperative outcomes, the same diligence that is as a matter of course exercised in anaesthesiologic care of the youngest patients needs to be exercised for the eldest as well. Aging is associated with characteristic physiologic changes and an overall reduction in compensation width. However, the individual relevance of these changes varies distinctly. A comprehensive preoperative assessment is therefore essential to identify those at high risk. Maintaining functionality and preventing cognitive decline are central elements of perioperative care for frail elders, often only requiring unspectacular, but effective adjustments to established routine care processes. This review focuses on current recommendations in the perioperative anaesthesiologic management of elderly patients with a view towards assisting clinical anaesthesiologists in implementing respective structures in their setting and adjusting care pathways to meet the needs of this vulnerable but growing group of patients and improve their postoperative outcome.

Emergent pancreatectomy for neoplastic disease: outcomes analysis of 534 ACS-NSQIP patients

BACKGROUND

While emergent pancreatic resection for trauma has been previously described, no large contemporary investigations into the frequency, indications, and outcomes of emergent pancreatectomy (EP) secondary to complications of neoplastic disease exist. Modern perioperative outcomes data are currently unknown.

METHODS

ACS-NSQIP was reviewed for all non-traumatic pancreatic resections (DP - distal pancreatectomy, PD - pancreaticoduodenectomy, or TP- total pancreatectomy) in patients with pancreatico-biliary or duodenal-ampullary neoplasms from 2005 to 2013. Patients treated for complications of pancreatitis were specifically excluded. Emergent operation was defined as NSQIP criteria for emergent case and one of the following: ASA Class 5, preoperative ventilator dependency, preoperative SIRS, sepsis, or septic shock, or requirement of > 4 units RBCs in 72 h prior to resection. Chi-square tests, Fisher's exact tests were performed to compare postoperative outcomes between emergent and elective cases as well as between pancreatectomy types.

RESULTS

Of 21,452 patients who underwent pancreatectomy for neoplastic indications, we identified 534 (2.5%) patients who underwent emergent resection. Preoperative systemic sepsis (66.3%) and bleeding (17.9%) were most common indications for emergent operation. PD was performed in 409 (77%) patients, DP in 115 (21%), and TP in 10 (2%) patients. Overall major morbidity was significantly higher (46.1% vs. 25.6%, p < 0.001) for emergent vs. elective operations. Emergent operations resulted in increased transfusion rates (47.6% vs. 23.4%, p < 0.001), return to OR (14.0% vs. 5.6%, p < 0.001), organ-space infection (14.6 vs. 10.5, p = 0.002), unplanned intubation (9.% vs. 4.1%, p < 0.001), pneumonia (9.6% vs. 4.2%, p < 0.001), length of stay (14 days vs. 8 days, p < 0.001), and discharge to skilled facility (31.1% vs. 13.9%). These differences persisted when stratified by pancreatic resection type. The 30-day operative mortality was higher in the emergent group (9.4%vs. 2.7%, p < 0.001) and highest for emergent TP (20%).

CONCLUSION

Emergent pancreatic resection is markedly uncommon in the setting of neoplastic disease. Although these operations result in increased morbidity and mortality compared to elective resections, they can be life-saving in specific circumstances. The results of this large series of modern era national data may assist surgeons as well as patients and their families in making critical decisions in select cases of acutely complicated neoplastic disease.