Charlson comorbidity index as a predictor of short-term outcomes after pulmonary resection

Bloodless Total Hip Arthroplasty in Jehovah's Witness Patients: Contemporary Strategies and Outcomes

BACKGROUND

Reported blood transfusion rates in total hip arthroplasty (THA) range between 3 and 22%. Jehovah's Witnesses (JW) do not accept blood transfusions and make conscience decisions to accept blood derivatives. This study reports on strategies and outcomes for bloodless THA.

METHODS

All JW patients undergoing primary THA at our institution between 2011 and 2022 were included in this study (94 of 110 THA). The indications for THA were osteoarthritis (92%), femoral neck fracture (6%), rheumatoid arthritis (1%), and failed open reduction and internal fixation (1%). Strategies used to optimize outcomes included erythropoietin, tranexamic acid, cell savers, intrailiac artery tourniquets, and minimizing phlebotomy.

RESULTS

The mean estimated blood loss was 201.2 ± 122.2 mL. Preoperative hemoglobin (Hgb) levels were 13.4 ± 1.4 g/dL, which decreased to 11.0 ± 1.3 g/dL on postoperative day 1 (POD1, P < 0.001), 10.3 ± 1.5 g/dL on POD2 (P = 0.001), and 9.8 ± 1.1 g/dL on POD3 (P = 0.171). The use of tranexamic acid significantly decreased Hgb drop on POD1 (P = 0.04). Subgroup analysis showed that preoperatively anemic patients (closed circuit, Hgb < 12 g/dL) had significantly less Hgb drop postoperatively (P = 0.003). No patients met the recommended transfusion threshold (Hgb < 7 g/dL). There were two 90-day readmissions due to falls. There was zero 90-day mortality.

CONCLUSIONS

A THA can be safely performed on JW patients. Preoperatively anemic patients had a decreased Hgb drop postoperatively. JW patients make a conscious decision to accept blood derivatives, which may be present in medications including erythropoietin. We recommend maintaining an Hgb above 11 g/dL prior to surgery, as a Hgb drop of 3.1 g/dL can be expected. These findings highlight the efficacy of a multimodal approach to optimizing bloodless primary THAs.

Patients' frailty and co-morbidities do not affect short-term mortality following emergency colorectal cancer surgery

AIM

To investigate the effects of frailty and co-morbidities on short and medium-term outcome following emergency colorectal cancer surgery.

METHODS

Data of patients who underwent emergency colorectal cancer operations between January 2013 and December 2016 were reviewed retrospectively. Collected data included demographic and operative variables, clinical frailty scale (CFS), Charlson comorbidity index (CCI) and cause of death with minimum 3 years follow-up.

RESULTS

Three-hundred and six patients (median age 72, range 18-100 years) underwent emergency colorectal cancer surgery; Some 74 (24.2%) patients had metastatic cancer at the time of emergency surgery, 77 (25.2%) were frail (CFS ≥4), while 118 (38.6%) were comorbid (CCI of ≥8). Thirty-day mortality was 4.2% (13 patients) and a further 12 patients died within 90 days (8.2%). By 1 year 73 (23.9%) patients had died, and by 3 years 151 (49.3%) patients died. Frailty did not impact 30-day mortality (6.5% vs 3.5%, p = 0.26) but frail patients (CFS ≥4) had a higher mortality rate at 90 days (16.9% vs 5.2%, p < 0.05), 1 year (37.7% vs 19.2%, p < 0.05) and 3 years (61.0% vs 45.4%, p < 0.05). Similarly, higher comorbidity (CCI ≥8) did not impact 30-day mortality (5.9% vs 3.2%, p = 0.25), but they had a higher mortality rate at 90 days (14.4% vs 4.3%, p < 0.05), 1 year (40.7% vs 13.3%, p < 0.05), and 3 years (76.3% vs 32.4%, p < 0.05).

CONCLUSION

Thirty-day mortality after emergency colorectal cancer surgery in frail and comorbid patients are similar to that of the general population.

Total intravenous anesthesia decreases hospital stay but not incidence of postoperative pulmonary complications after lung resection surgery: a propensity score matching study

BACKGROUND

There is no consensus regarding the superiority of volatile or total intravenous anesthesia (TIVA) in reducing the incidence of postoperative pulmonary complications (PPCs) after lung resection surgery (LRS). Thus, the aim of this study was to investigate the different anesthetic regimens and the incidence of PPCs in patients who underwent LRS. We hypothesized that TIVA is associated with a lower incidence of PPCs than volatile anesthesia.

METHODS

This was a retrospective cohort study of patients who underwent LRS at Taipei Veterans General Hospital between January 2016 and December 2020. The patients' charts were reviewed and data on patient characteristics, perioperative features, and postoperative outcomes were extracted and analyzed. The patients were categorized into TIVA or volatile anesthesia groups and their clinical data were compared. Propensity score matching was performed to reduce potential selection bias. The primary outcome was the incidence of PPCs, whereas the secondary outcomes were the incidences of other postoperative events, such as length of hospital stay (LOS) and postoperative nausea and vomiting (PONV).

RESULTS

A total of 392 patients each were included in the TIVA and volatile anesthesia groups. There was no statistically significant difference in the incidence of PPCs between the volatile anesthesia and TIVA groups. The TIVA group had a shorter LOS (p < 0.001) and a lower incidence of PONV than the volatile anesthesia group (4.6% in the TIVA group vs. 8.2% in the volatile anesthesia group; p = 0.041). However, there were no significant differences in reintubation, 30-day readmission, and re-operation rates between the two groups.

CONCLUSIONS

There was no significant difference between the incidence of PPCs in patients who underwent LRS under TIVA and that in patients who underwent LRS under volatile anesthesia. However, TIVA had shorter LOS and lower incidence of PONV which may be a better choice for maintenance of anesthesia in patients undergoing LRS.

Surgical Cost Awareness Program Study: Impact of a Novel, Real-Time, Cost Awareness Intervention on Operating Room Expenses in Thoracoscopic Lobectomy

BACKGROUND

For surgical patients, operating room expenses are significant drivers of overall hospitalization costs. Surgical teams often lack awareness of the costs associated with disposable surgical supplies, which may lead to unnecessary expenditures. The aim of this study is to evaluate whether a Surgical Cost Awareness Program would reduce operating room costs.

STUDY DESIGN

A prototype software displays the types and costs of disposable instruments used in real-time during surgery and generates insight-driven operative cost reports, which are automatically sent to the surgeons. A prospective pre-post controlled trial of thoracoscopic lobectomy procedures performed by 7 surgeons at a single academic center was conducted. Control and intervention groups consisted of consecutive cases from February 2nd through June 23, 2021, and from June 28th through December 22, 2021, respectively. The primary outcome was mean per case surgical disposables cost.

RESULTS

Three hundred twenty-two lobectomies were evaluated throughout the study period (control: n = 164; intervention: n = 158). Baseline characteristics were comparable between groups. Mean disposables cost per case was $3,320.73 ± $814.83 in the control group compared with $2,567.64 ± $594.59 in the intervention group, representing a mean cost reduction of $753.08 (95% CI, $622.29 to $883.87; p < 0.001). All surgeons experienced a reduction in disposable costs after the intervention. Intraoperative and postoperative outcomes did not differ between the cohorts.

CONCLUSIONS

Providing real-time educational feedback to surgical teams significantly reduced costs associated with disposable surgical equipment without compromising perioperative outcomes for lobectomy. Integrating the novel AssistIQ software across other procedural settings may generate further data insights with the potential for significant cost savings on a larger scale.

Predictors of 30-Day Pulmonary Complications after Video-Assisted Thoracoscopic Surgery Lobectomy

BACKGROUND

 Pulmonary complications are the most common adverse event after lung resection, yet few large-scale studies have examined pertinent risk factors after video-assisted thoracoscopic surgery (VATS) lobectomy. Veterans, older and less healthy compared with nonveterans, represent a cohort that requires further investigation. Our objective is to determine predictors of pulmonary complications after VATS lobectomy in veterans.

METHODS

 A retrospective review was conducted on patients who underwent VATS lobectomy from 2008 to 2018 using the Veterans Affairs Surgical Quality Improvement Program database. Patients were divided into two cohorts based on development of a pulmonary complication within 30 days. Patient characteristics were compared via multivariable analysis to determine clinical predictors associated with pulmonary complication and reported as adjusted odds ratios (aORs) with 95% confidence intervals. Patients with preoperative pneumonia, ventilator dependence, and emergent cases were excluded.

RESULTS

 In 4,216 VATS lobectomy cases, 480 (11.3%) cases had ≥1 pulmonary complication. Preoperative factors independently associated with pulmonary complication included chronic obstructive pulmonary disease (COPD) (aOR = 1.37 [1.12-1.69]; p = 0.003), hyponatremia (aOR = 1.50 [1.06-2.11]; p = 0.021), and dyspnea (aOR = 1.33 [1.06-1.66]; p = 0.013). Unhealthy alcohol consumption was associated with pulmonary complication via univariable analysis (17.1 vs. 13.0%; p = 0.016). Cases with pulmonary complication were associated with increased mortality (12.1 vs. 0.8%; p < 0.001) and longer length of stay (12.0 vs. 6.8 days; p < 0.001).

CONCLUSION

 This analysis revealed several preoperative factors associated with development of pulmonary complications. It is imperative to optimize pulmonary-specific comorbidities such as COPD or dyspnea prior to VATS lobectomy. However, unhealthy alcohol consumption and hyponatremia were linked with development of pulmonary complication in our analysis and should be addressed prior to VATS lobectomy. Future studies should explore long-term consequences of pulmonary complications.

The Impact of the Age, Dyspnoea, and Airflow Obstruction (ADO) Index on the Medical Burden of Chronic Obstructive Pulmonary Disease (COPD)

There are currently no good indicators that can be used to predict the medical expenses of chronic obstructive pulmonary disease (COPD). This was a retrospective study that focused on the correlation between the age, dyspnoea, and airflow obstruction (ADO) index and the Charlson comorbidity index (CCI) on the medical burden in COPD patients, specifically, those of patients with complete ADO index and CCI data in our hospital from January 2015 to December 2016. Of the 396 patients with COPD who met the inclusion criteria, 382 (96.5%) were male, with an average age of 71.3 ± 8.4 years. Healthcare resource utilisation was positively correlated with the ADO index. A significant association was found between the ADO index and CCI of COPD patients (p < 0.001). In-hospitalization expenses were positively correlated with the CCI (p < 0.001). Under the same CCI, the higher the ADO score, the higher the hospitalisation expenses. The ADO quartiles were positively correlated with the number of hospitalisations (p < 0.001), hospitalisation days (p < 0.001), hospitalisation expenses (p = 0.03), and total medical expenses (p = 0.037). Findings from this study show that the ADO index can predict the medical burden of COPD.

Evaluation of the Potential Risk of Mortality from SARS-CoV-2 Infection in Hospitalized Patients According to the Charlson Comorbidity Index

Background: The pandemic of COVID-19 has represented a major threat to global public health in the last century and therefore to identify predictors of mortality among COVID-19 hospitalized patients is widely justified. The aim of this study was to evaluate the possible usefulness of Charlson Comorbidity Index (CCI) as mortality predictor in patients hospitalized because COVID-19. Methods: This study was carried out in Zacatecas, Mexico, and it included 705 hospitalized patients with suspected of SARS-CoV-2 infection. Clinical data were collected, and the CCI score was calculated online using the calculator from the Sociedad Andaluza de Medicina Intensiva y Unidades Coronarias; the result was evaluated as mortality predictor among the patients with COVID-19. Results: 377 patients were positive for SARS-COV-2. Obesity increased the risk of intubation among the study population (odds ratio (OR) = 2.59; 95 CI: 1.36–4.92; p = 0.003). The CCI values were higher in patients who died because of COVID-19 complications than those observed in patients who survived (p < 0.001). Considering a CCI cutoff > 31.69, the area under the ROC curve was 0.75, with a sensitivity and a specificity of 63.6% and 87.7%, respectively. Having a CCI value > 31.69 increased the odds of death by 12.5 times among the study population (95% CI: 7.3–21.4; p < 0.001). Conclusions: The CCI is a suitable tool for the prediction of mortality in patients hospitalized for COVID-19. The presence of comorbidities in hospitalized patients with COVID-19 reflected as CCI > 31.69 increased the risk of death among the study population, so it is important to take precautionary measures in patients due to their condition and their increased vulnerability to SARS-CoV-2 infection.

Comparison of Major Clinical Outcomes between Accredited and Nonaccredited Hospitals for Inpatient Care of Acute Myocardial Infarction

Hospital accreditation programs are used worldwide to improve the quality of care and improve patient safety. It is of great help in improving the structure of hospitals, but there are mixed research results on improving the clinical outcome of patients. The purpose of this study was to compare the levels of core clinical outcome indicators after receiving inpatient services from accredited and nonaccredited hospitals in patients with acute myocardial infarction (AMI). For all patients with AMI admitted to general hospitals in Korea from 2010 to 2017, their 30-day mortality and readmissions and length of stay were compared according to accreditation status. In addition, through a multivariate model that controls various patients’ and hospitals’ factors, the differences in those indicators were analyzed more accurately. The 30-day mortality of patients admitted to accredited hospitals was statistically significantly lower than that of patients admitted to nonaccredited hospitals. However, for 30-day readmission and length of stay, accreditation did not appear to yield more desirable results. This study shows that when evaluating the clinical impact of hospital accreditation programs, not only the mortality but also various clinical indicators need to be included, and a more comprehensive review is needed.