Significance of preoperative total lymphocyte count as a prognostic criterion in adult cardiac surgery

Effects of Preoperative Nutritional Status and Lymphocyte Count on the Development of Early-term Atrial Fibrillation After Coronary Artery Bypass Grafting: A Retrospective Study

INTRODUCTION

Although there are publications in the literature stating that parameters related to the nutritional status of patients are associated with the clinical outcomes of those with coronary artery disease, it is also stated that there is insufficient data on the relationship between nutritional indices and long-term outcomes and major adverse cardiovascular events in patients undergoing isolated coronary artery bypass grafting.

METHODS

This retrospective study was conducted with patients who underwent isolated elective on-pump coronary artery bypass grafting in our hospital. Patients who underwent emergency coronary artery bypass grafting or those with known atrial fibrillation in the preoperative period were excluded. Patients were analyzed and compared in two groups according to the development of postoperative atrial fibrillation.

RESULTS

The data of 93 coronary artery bypass grafting patients (71 [76%] males) with a mean age of 62.86 ± 9.53 years included in the study were evaluated. Both groups had similar preoperative ejection fraction value, hemoglobin level, age, number of distal bypasses, and postoperative mortality rates. Although the mean cardiopulmonary bypass and aortic cross-clamping times were higher in Group 1, they were not statistically significant. In our study, the mean prognostic nutrition index value was 51.76 ± 3002.

CONCLUSION

According to our study results, there was no statistically significant difference between prognostic nutrition index values and the development of atrial fibrillation after coronary artery bypass grafting, which is similar to some publications in the literature. We think that it would be beneficial to conduct randomized studies involving more patients on this subject.

Development of interpretable machine learning models for prediction of acute kidney injury after noncardiac surgery: a retrospective cohort study

BACKGROUND

Early identification of patients at high-risk of postoperative acute kidney injury (AKI) can facilitate the development of preventive approaches. This study aimed to develop prediction models for postoperative AKI in noncardiac surgery using machine learning algorithms. The authors also evaluated the predictive performance of models that included only preoperative variables or only important predictors.

MATERIALS AND METHODS

Adult patients undergoing noncardiac surgery were retrospectively included in the study (76 457 patients in the discovery cohort and 11 910 patients in the validation cohort). AKI was determined using the KDIGO criteria. The prediction model was developed using 87 variables (56 preoperative variables and 31 intraoperative variables). A variety of machine learning algorithms were employed to develop the model, including logistic regression, random forest, extreme gradient boosting, and gradient boosting decision trees. The performance of different models was compared using the area under the receiver operating characteristic curve (AUROC). Shapley Additive Explanations (SHAP) analysis was employed for model interpretation.

RESULTS

The patients in the discovery cohort had a median age of 52 years (IQR: 42-61 years), and 1179 patients (1.5%) developed AKI after surgery. The gradient boosting decision trees algorithm showed the best predictive performance using all available variables, or only preoperative variables. The AUROCs were 0.849 (95% CI: 0.835-0.863) and 0.828 (95% CI: 0.813-0.843), respectively. The SHAP analysis showed that age, surgical duration, preoperative serum creatinine, and gamma-glutamyltransferase, as well as American Society of Anesthesiologists physical status III were the most important five features. When gradually reducing the features, the AUROCs decreased from 0.852 (including the top 40 features) to 0.839 (including the top 10 features). In the validation cohort, the authors observed a similar pattern regarding the models' predictive performance.

CONCLUSIONS

The machine learning models the authors developed had satisfactory predictive performance for identifying high-risk postoperative AKI patients. Furthermore, the authors found that model performance was only slightly affected when only preoperative variables or only the most important predictive features were included.

Prognostic significance of preoperative nutritional status for postoperative acute kidney injury in older patients undergoing major abdominal surgery: a retrospective cohort study

BACKGROUND

The association between malnutrition and postoperative acute kidney injury (AKI) has not been well studied. In this study, the authors examined the association between preoperative nutritional status and postoperative AKI in older patients who underwent major abdominal surgery, as well as the predictive value of malnutrition for AKI.

MATERIALS AND METHODS

The authors retrospectively included patients aged 65 or older who underwent major elective abdominal surgery. The nutritional status of the patient was evaluated using three objective nutritional indices, such as the geriatric nutritional risk index (GNRI), the prognostic nutritional index (PNI), and the controlling nutritional status (CONUT). AKI was determined using the KDIGO criteria. The authors performed logistic regression analysis to investigate the association between preoperative nutritional status and postoperative AKI, as well as the predictive value of nutritional scores for postoperative AKI.

RESULTS

A total of 2775 patients were included in the study, of which 707 (25.5%), 291 (10.5%), and 517 (18.6%) had moderate to severe malnutrition according to GNRI, PNI, and CONUT calculations. After surgery, 144 (5.2%) patients developed AKI, 86.1% at stage 1, 11.1% at stage 2, and 2.8% at stage 3 as determined by KDIGO criteria. After adjustment for traditional risk factors, worse nutritional scores were associated with a higher AKI risk. In addition to traditional risk factors, these nutritional indices improved the predictive ability of AKI prediction models, as demonstrated by significant improvements in integrated discrimination and net reclassification.

CONCLUSIONS

Poor preoperative nutritional status, as assessed by GNRI, PNI, and CONUT scores, was associated with an increased risk of postoperative AKI. Incorporating these scores into AKI prediction models improved their performance. These findings emphasize the need for screening surgical patients for malnutrition risk. Further research is needed to determine whether preoperative malnutrition assessment and intervention can reduce postoperative AKI incidence.

Potential mechanisms of multimodal prehabilitation effects on surgical complications: a narrative review

Continuous advances in prehabilitation research over the past several decades have clarified its role in improving preoperative risk factors, yet the evidence demonstrating reduced surgical complications remains uncertain. Describing the potential mechanisms underlying prehabilitation and surgical complications represents an important opportunity to establish biological plausibility, develop targeted therapies, generate hypotheses for future research, and contribute to the rationale for implementation into the standard of care. In this narrative review, we discuss and synthesize the current evidence base for the biological plausibility of multimodal prehabilitation to reduce surgical complications. The goal of this review is to improve prehabilitation interventions and measurement by outlining biologically plausible mechanisms of benefit and generating hypotheses for future research. This is accomplished by synthesizing the available evidence for the mechanistic benefit of exercise, nutrition, and psychological interventions for reducing the incidence and severity of surgical complications reported by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). This review was conducted and reported in accordance with a quality assessment scale for narrative reviews. Findings indicate that prehabilitation has biological plausibility to reduce all complications outlined by NSQIP. Mechanisms for prehabilitation to reduce surgical complications include anti-inflammation, enhanced innate immunity, and attenuation of sympathovagal imbalance. Mechanisms vary depending on the intervention protocol and baseline characteristics of the sample. This review highlights the need for more research in this space while proposing potential mechanisms to be included in future investigations.

Association of Preoperative Prognostic Nutritional Index with Risk of Postoperative Acute Kidney Injury: A Meta-Analysis of Observational Studies

This meta-analysis aimed to assess the clinical association of the preoperative prognostic nutritional index (pre-PNI) with the risk of postoperative acute kidney injury. Four databases (e.g., Medline) were searched from inception to December 2022 to investigate the association between pre-PNI (i.e., low vs. high) and PO-PNI as well as the correlation between pre-PNI and other postoperative prognostic indices. Overall, 13 observational studies, including 9185 patients, were eligible for analysis. A low PNI was related to increased risks of PO-AKI [odd ratio (OR) = 1.65, p = 0.001, 3811 patients], postoperative infection (OR = 2.1, p < 0.00001, 2291 patients), and mortality (OR = 1.93, p < 0.0001, 2159 patients). Albeit statistically nonsignificant, a trend was noted, linking a low PNI to higher risks of postoperative bleeding (OR = 2.5, p = 0.12, 1157 patients) and stroke (OR = 1.62, p = 0.07, 2036 patients). Pooled results revealed a prolonged intensive care unit (ICU) stay in patients with low PNIs compared to those with high PNIs (MD: 0.98 days, p = 0.02, 2209 patients) without a difference in hospital stay between the two groups (MD: 1.58 days, p = 0.35, 2249 patients). This meta-analysis demonstrated an inverse correlation between PNI and the risks of PO-AKI, postoperative infection, and mortality, as well as the length of ICU stay, which warrants further investigations for verification.

Leukocyte cell population data in patients with cardiac surgery and cardiopulmonary bypass: A potential readily available tool to monitor immunity

Purpose

Cardiac surgery with cardiopulmonary bypass triggers sterile inflammation that is responsible for post-operative morbidity. Automated flow cytometry devices used for leucocyte count provide cell population data (CPD) regarding fluorescence intensity, size and granularity of leukocytes that have never been studied in the context of sterile inflammation. Our objective was to explore leukocyte cell population data in patients undergoing cardiac surgery with cardiopulmonary bypass in order to determine whether CPD could be used to monitor immune cell activation.

Methods

This is an ancillary study of a cohort of patients undergoing cardiac surgery with cardiopulmonary bypass. Cell population data (CPD) extracted from a routine automated flow cytometer were analyzed (Fluorescence targeted to nucleic acids). The time points of interest were: pre-operative, postoperative and 5 days after surgery. The variations in those parameters were studied. Data were then compared between patients according to the occurrence of a composite criteria (supra-ventricular arrythmia, stroke, acute renal failure, and/or death).

Results

Data from 1453 patients were analyzed. The neutrophil count, fluorescence granularity (NE-SCC), intensity (NE-SFL) and size (NE-FSC) increased with surgery. Heterogeneity of neutrophils decreased in terms of fluorescence granularity (NE-WX) and size (NE-WZ) but increased in terms of intensity (NE-WY). The lymphocyte count decreased with surgery. While fluorescence granularity (LY-X) and size increased (LY-Z), Lymphocyte intensity decreased (LY-Y). Lymphocytes were less heterogeneous in terms of their granularity, size and intensity after surgery (LY-WX, LY-WY, LY-WZ). Patients who developed the composite complication criteria had a higher pre-operative neutrophil count (5.08 [3.89;6.95] vs 4.76 [3.60;6.13], p = 0.02; AUC = 0.56 [0.51;0.60]), and more heterogeneous neutrophils in terms of fluorescence granularity (NE-WX, AUC = 0.57 [0.52;0.62]) and intensity (NE-WY, AUC 0.61 [0.56;0.65]). Those patients also had lower pre-operative lymphocyte count (1.49 [1.10;1.14] vs 1.81 [1.39;2.39], p<0.01, AUC = 0.61 [0.57;0.66]) and fluorescence granularity (LY-X, AUC = 0.57 [0.53;0.62]). NE-WX, NE-WY and LY-X were associated with post-operative complications after adjustment on the EuroSCORE 2 (adjusted odd ratio of 1.01 [1.00;1.02]; 1.01 [1.00;1.01] and 1.08 [1.02;1.15] respectively).

Conclusion

Cardiac surgery with cardiopulmonary bypass was associated with substantial alterations of CPD probably reflecting leukocytes activation in sterile inflammation. Pre-operative NE-WX, NE-WY and LY-X biomarkers levels were associated with post-operative complications, independently of the EuroSCORE 2. Such routine, unexploited and low cost parameters might represent useful tools likely to monitor immune function and predict outcomes for patients undergoing cardiac surgery. Our findings requires validation on a larger external cohort.

Correlation Between the Prognosis of Sudden Total Deafness and the Peripheral Blood Inflammation Markers

Objective

To analyze the correlation between prognosis of sudden total deafness (STD) and peripheral blood inflammation markers including white blood cell count (WBC), monocytes, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), fibrinogen (FIB).

Methods

125 patients with STD who were hospitalized in our department from 2014 to 2019 were enrolled. The general physical conditions, clinical manifestations, pure tone audiometry, imaging examination, and peripheral blood inflammation markers were collected, and all patients were divided into effective and ineffective two groups according to the degree of hearing recovery at the time of discharge. Then binary logistic regression was used to analyze the correlation between multiple factors and prognosis, meanwhile the receiver operating characteristic (ROC) curve was used to evaluate the predictive value of the above prognostic factors.

Results

Compared with the ineffective group, patients in the effective group were younger and have higher PLR level and lower FIB levels. Age and PLR are independent prognostic factors. Taking age ≤ 56 years old, PLR >142.6 as the standard to predict the prognosis of patients with STD has the largest AUC with the potential effective rate reaching 78.1%.

Conclusions

Age and PLR are independent prognostic factors for patients with STD. The younger the age and the higher the PLR, the better the prognosis. Clinically, the prognosis of patients with STD can be evaluated by the patient's age and PLR level, which is of great significance to predict the prognosis of patients with STD.

Association of Preoperative Prognostic Nutritional Index and Postoperative Acute Kidney Injury in Patients Who Underwent Hepatectomy for Hepatocellular Carcinoma

Various biological indicators are reportedly associated with postoperative acute kidney injury (AKI) in the surgical treatment of hepatocellular carcinoma (HCC). However, only a few studies have evaluated the association between the preoperative prognostic nutritional index (PNI) and postoperative AKI. This study evaluated the association of the preoperative PNI and postoperative AKI in HCC patients. We retrospectively analyzed 817 patients who underwent open hepatectomy between December 2007 and December 2015. Multivariate regression analysis was performed to evaluate the association between the PNI and postoperative AKI. Additionally, we evaluated the association between the PNI and outcomes such as postoperative renal replacement therapy (RRT) and mortality. Cox regression analysis was performed to assess the risk factors for one-year and five-year mortality. In the multivariate analysis, high preoperative PNI was significantly associated with a lower incidence of postoperative AKI (odds ratio (OR): 0.92, 95% confidence interval (CI): 0.85 to 0.99, p = 0.021). Additionally, diabetes mellitus and the use of synthetic colloids were significantly associated with postoperative AKI. PNI was associated with postoperative RRT (OR: 0.76, 95% CI: 0.60 to 0.98, p = 0.032) even after adjusting for other potential confounding variables. In the Cox regression analysis, high PNI was significantly associated with low one-year mortality (Hazard ratio (HR): 0.87, 95% CI: 0.81 to 0.94, p < 0.001), and five-year mortality (HR: 0.93, 95% CI: 0.90–0.97, p < 0.001). High preoperative PNI was significantly associated with a lower incidence of postoperative AKI and low mortality. These results suggest that the preoperative PNI might be a predictor of postoperative AKI and surgical prognosis in HCC patients undergoing open hepatectomy.

Prognostic Value of Preoperative Absolute Lymphocyte Count in Children With Tetralogy of Fallot

Background

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Absolute lymphocyte count (ALC) is a low‐cost and easy‐to‐obtain inflammatory indicator; however, its association with the prognosis of patients with TOF remains unknown. This study aimed to determine the prognostic value of preoperative ALC in children with TOF.

Methods and Results

This retrospective study included 707 patients aged <6 years who underwent corrective operations for TOF between January 2016 and December 2018 in Fuwai Hospital, China. The end points were mortality, extracorporeal membrane oxygenation placement, postoperative hospital stay >30 days, and severe postoperative complications; patients were grouped on the basis of prognosis: poor prognosis (n=76) and good prognosis (n=631). Univariable and multivariable logistic regression analyses were performed to identify the independent risk factors for poor prognosis, on which a risk scoring system was based. The receiver operating characteristic curve was used to assess model performance. Using another model without ALC, the effect of the addition of ALC was assessed. Results suggested that ALC was an independent factor with a cutoff point of 4.36×10⁹/L. The addition of ALC improved the area under the curve from 0.771 to 0.781 (P<0.001). To avoid reverse causality and further control for confounding factors, the patients were further divided on the basis of ALC level, and a propensity score matching was performed; 117 paired patients were identified for further analysis. Low ALC levels had an odds ratio of 3.500 (95% CI, 1.413–8.672).

Conclusions

Low preoperative ALC represents an independent predictor of poor prognosis in children with TOF.

Association of Preoperative Prognostic Nutritional Index and Postoperative Acute Kidney Injury in Patients with Colorectal Cancer Surgery

The prognostic nutritional index (PNI) has been reported to be associated with postoperative complications and prognosis in cancer surgery. However, few studies have evaluated the association between preoperative PNI and postoperative acute kidney injury (AKI) in colorectal cancer patients. This study evaluated association of preoperative PNI and postoperative AKI in patients who underwent colorectal cancer surgery. This study retrospectively analyzed 3543 patients who underwent colorectal cancer surgery between June 2008 and February 2012. The patients were classified into four groups by the quartile of PNI: Q1 (≤43.79), Q2 (43.79–47.79), Q3 (47.79–51.62), and Q4 (≥51.62). Multivariate regression analysis was performed to assess the risk factors for AKI and 1-year mortality. AKI was defined according to Kidney Disease Improving Global Outcomes classification (KDIGO) criteria. Additionally, we assessed surgical outcomes such as hospital stay, ICU admission, and postoperative complications. The incidence of postoperative AKI tended to increase in the Q1 group (13.4%, 9.2%, 9.4%, 8.8%). In the multivariate analysis, high preoperative PNI was significantly associated with low risk of postoperative AKI (adjusted odds ratio [OR]: 0.96, 95% confidence interval [CI]: 0.93–0.99, p = 0.003) and low 1-year mortality (OR: 0.92, 95% CI: 0.86–0.98, p = 0.011). Male sex, body mass index, diabetes mellitus, and hypertension were risk factors for AKI. The Q1 (≤43.79) group had poor surgical outcomes, such as postoperative AKI (OR: 1.52, 95% CI: 1.18–1.95, p = 0.001), higher rates of ICU admission (OR: 3.13, 95% CI: 1.82–5.39, p < 0.001) and higher overall mortality (OR: 3.81, 95% CI: 1.86–7.79, p < 0.001). In conclusion, low preoperative PNI levels, especially in the Q1 (≤43.79), were significantly associated with postoperative AKI and surgical outcomes, such as hospital stay, postoperative ICU admission, and mortality.

LYMPHOCYTE COUNT AND PLATELET VOLUME PREDICTS POSTOPERATIVE COMPLICATIONS IN ESOPHAGECTOMY FOR CANCER: A COHORT STUDY

BACKGROUND

Biomarkers from routine complete blood count are known predictive factors of long-term outcomes in cancer patients. The value of these biomarkers in the setting of trimodal therapy for esophageal cancer in predicting early postoperative outcomes is not studied.

OBJECTIVE

The present study evaluated the value of cellular blood components changes during neoadjuvant chemoradiotherapy followed by curative intent esophagectomy for cancer in predicting postoperative mortality and morbidity.

METHODS

A cohort of 149 consecutive patients that underwent chemoradiotherapy using platinum- and taxane-based regimens followed by esophagectomy was analyzed. Cellular components of blood collected before neoadjuvant therapy (period A) and before surgery (period B) were assessed for postoperative mortality and complications. Univariate and multivariate Cox regression models were applied to evaluate the independent prognostic significance of blood count variables.

RESULTS

Postoperative morbidity was present in 46% of the patients. On multiple regression analysis platelet volume (B) (OR: 1.53; 95% CI: 1.2-2.33) was an independent predictor of general complications. Severe postoperative surgical complications were present in 17% of the patients. On multiple regression analysis, lymphocyte decrease between B-A periods (OR: 0.992; 95% CI: 0.990-0.997) was related to higher risk for severe complications. Cervical anastomotic leakage was present in 25.6% of the patients. On univariate analysis eosinophil count in A and B periods was related to cervical anastomotic leakage. For this outcome, multivariate joint model could not identify independent risk variables of cellular components of blood. The 30-day mortality rate was 7.4%. On univariate analysis, platelet count in period B was associated to higher risk for mortality. The multivariate joint model could not accurately predict mortality due to the few number of patients in the mortality group.

CONCLUSION

This is the first study to assess the relationship between peripheral blood count variables changes during neoadjuvant chemoradiotherapy using a platinum- and taxane-based regimen followed by curative intent esophagectomy for cancer in predicting postoperative complications. The platelet volume prior to surgery is related to postoperative complications and the lymphocyte count change prior to surgery predicts severe postoperative complications in the setting of trimodal therapy for esophageal cancer.

The predictive value of the prognostic nutritional index for postoperative acute kidney injury in patients undergoing on-pump coronary bypass surgery

BACKGROUND

We aimed to investigate the predictive value of the prognostic nutritional index (PNI) regarding the development of acute kidney injury (AKI) after elective coronary artery bypass grafting (CABG).

METHODS

A total of 336 consecutive patients with normal serum creatinine levels undergoing CABG were enrolled in this retrospective study. AKI was defined as meeting Acute Kidney Injury Network (AKIN) criteria based on the occurrence of creatinine changes within the first 48 h after CABG surgery. The patients were grouped according to whether they developed AKI or not into an AKI (-) and an AKI (+) group.

RESULTS

AKI developed in 88 (26.2%) of all patients. The PNI was independently predictive of AKI (OR: 0.829, 95% CI: 0.783-0.877, p <  0.001). Moreover, C-reactive protein (CRP), a history of diabetes mellitus, and positive inotropric usage were independent risk factors for AKI in the multivariate logistic regression analysis. The area under the curve (AUC) of the multivariable model, including positive inotrope support, a history of diabetes mellitus, and CRP, was 0.693 (95% CI: 0.626-0.760, p <  0.001) in predicting AKIN. When the PNI was added to the multivariable model, the AUC was 0.819 (95% CI, 0.762-0.865, z = 3.777, difference p = 0.0002). Also, the addition of the PNI to the multivariable model was associated with a significant net reclassification improvement estimated at 88.2% (p <  0.001) and an integrated discrimination improvement of 0.22 (p <  0.001).

CONCLUSIONS

Our study demonstrated that decreasing the PNI could be associated with the development of AKI after coronary artery bypass surgery.

Risk factors for development of early infectious and noninfectious complications in systemic lupus erythematosus patients undergoing major surgery

Background We aimed to identify risk factors for early complications in systemic lupus erythematosus (SLE) patients undergoing major surgery. Methods We conducted a retrospective comparative cohort study including patients with SLE undergoing major surgery, and non-SLE patients matched 1:1. Main outcomes were development of infectious and noninfectious complications, and 30-day postoperative mortality. Results A total of 382 patients (191 SLE and 191 non-SLE) were included. Postoperative complications occurred in 82 (43%) SLE patients and 58 (30%) without SLE, ( p = 0.01). Variables associated with infectious complications in SLE patients: prednisone use (OR 1.81, 95% CI 1.13-2.90), anemia (OR 2.43, 95% CI 1.45-4.08), hypoalbuminemia (OR 2.58, 95% CI 1.55-4.30) and lymphopenia (OR 2.43, 95% CI 1.52-3.89), p < 0.05. Variables associated with noninfectious complications: anemia (OR, 1.93, 95% CI 1.03-3.64) and hypoalbuminemia (OR 2.11, 95% CI 1.16-3.86), p < 0.05. Variables associated with any complication: SLEDAI-2K (OR 1.1, 95% CI 1.01-1.20), nephritis (OR 10.08, 95% CI 1.21-83.63), aspirin use (OR 2.68, 95% CI 1.19-6.02, p = 0.01), low C3 (OR 2.00, 95% CI 1.06-3.80), anemia (OR 2.68, 95% CI 1.39-5.18), hypoalbuminemia (OR 3.49, 95% CI 1.83-6.66) and lymphopenia (OR 2.36, 95% CI 1.30-4.26), p < 0.05. More patients with SLE died (6% vs 1%, p = 0.02). Conclusions SLE patients present higher frequency of postoperative complications and mortality compared with non-SLE patients. Hypoalbuminemia, anemia, lymphopenia and aspirin use are independent risk factors.

Cardiac surgery in systemic lupus erythematosus patients: Clinical characteristics and outcomes

OBJECTIVES

To study the clinical characteristics and outcomes in systemic lupus erythematosus (SLE) patients who underwent cardiac surgery.

METHODS

Retrospective analysis of 30 SLE patients who underwent cardiac surgery at a single center. Demographics, comorbidities, clinical and serologic characteristics, cardiovascular risk scores and treatment were recorded. Type of surgery, postoperative complications, mortality and histology were analyzed.

RESULTS

Disease duration at surgery was 2 years. Valve replacement was the procedure most frequently performed (53%), followed by pericardial window (37%). At least one postoperative complication developed in 63% (mainly infections). An aortic cross-clamp time≥76minutes was associated with at least one postoperative complication (OR 6.4, 95% CI 1.1-35.4, p=.03). Early death occurred in 5 patients (17%) and late in 3 (10%); main causes were sepsis and heart failure. Disease activity was associated with pericardial window (OR 12.6, 95% CI 1.9-79, p=.007); lymphopenia≤1.200 (OR 10.1, 95% CI 1.05-97, p=.04); age≤30 years (OR 7.7, 95% CI 1.2-46.3, p=.02); and New York Heart Association class III (OR 7.0, 95% CI 1.1-42, p=.03). Postoperative infection was associated with length of hospital stay≥2 weeks (OR 54.9, 95% CI 5.0-602.1, p=.001); intensive care unit stay≥10 days (OR 20, 95% CI 1.6-171.7, p=.01); duration of mechanical ventilation≥5 days (OR 16.9, 95% CI 1.5-171.7, p=.01); and pulmonary artery systolic pressure≥50mmHg (OR 7.8, 95% CI 1.4-41.2, p=.01).

CONCLUSIONS

Cardiac surgery in SLE confers high morbidity and mortality. SLE-specific preoperative risk scores should be designed to identify prognostic factors.

Impact of Platelet-to-Lymphocyte Ratio on Clinical Outcomes in Patients With ST-Segment Elevation Myocardial Infarction

We investigated the association between platelet-to-lymphocyte ratio (PLR) and clinical outcomes (including all-cause mortality, recurrent myocardial infarction, heart failure, serious cardiac arrhythmias and ischemic stroke) in patients with ST-segment elevation myocardial infarction (STEMI). Based on PLR quartiles, 5886 patients with STEMI were categorized into 4 groups: <98.8 (n = 1470), 98.8 to 125.9 (n = 1474), 126.0 to 163.3 (n = 1478), >163.3 (n = 1464), respectively. We used Cox proportional hazards models to examine the relation between PLR and clinical outcomes. Mean duration of follow-up was 81.6 months, and 948 patients (16.1%) died during follow-up. The lowest mortality occurred in the lowest PLR quartile group ( P = 0.006), with an adjusted hazard ratio of 1.18 (95% confidence interval [CI], 1.04-1.55), 1.31 (95% CI, 1.18-1.64), and 1.59 (95% CI, 1.33-1.94) in patients with PLR of 98.8 to 125.9, 126.0 to 163.3, >163.3, respectively. Higher levels of PLR were also associated with recurrent myocardial infarction ( P_trend = .023), heart failure ( P_trend = .018), and ischemic stroke ( P_trend = .043). In conclusion, a higher PLR was associated with recurrent myocardial infarction, heart failure, ischemic stroke, and all-cause mortality in patients with STEMI.

The Neutrophil to Lymphocyte Ratio on Admission and Short-Term Outcomes in Orthogeriatric Patients

AIM

To investigate the association of the neutrophil to lymphocyte ratio (NLR) at admission with presence of fracture, comorbid conditions, and its prognostic value for short-term outcomes in orthogeriatric patients.

METHODS

On 415 consecutive patients (mean age 78.8 ±8.7[SD] years, 281 women, 255 with a non-vertebral bone fracture, including 167 with a hip fracture, HF) admitted to the Department of Orthopaedic Surgery at the Canberra hospital (2010 - 2011) data on clinical and laboratory characteristics were collected prospectively. The validation dataset included 294 consecutive patients (mean age 82.1 ± 8.0 years, 72.1% women) with HF.

RESULTS

Multivariate regression revealed four variables, presence of HF, hypoalbuminaemia (<33g/L), anaemia (<120g/L) and hyperparathyroidism (PTH>6.8 pmol/L), as independent determinants of admission NLR≥5.1. There was a dose-graded relationship between presence of fracture, especially HF, postoperative complications and levels of NLR categorized as tertiles. Compared to patients with NLR<5.1(first tertile), patients with NLR 5.1-8.5 (second tertile) had a 1.8-, 3.1-, 2.6-, and 2.5-fold higher risk for presence of any fracture, HF, developing postoperative myocardial injury (troponin I rise) and a high inflammatory response/infection (CRP>100mg/L after the 3rd postoperative day), respectively, while in subjects with NLR>8.5 (third tertile) these risks were 2.6-, 4.9-, 5.9- and 4.5-times higher, respectively; subjects with NLR>8.5 had a 9.7 times higher chance of dying in the hospital compared to patients with NLR 5.1-8.5; the NLR retained its significance on multivariate analyses. The NLR ≥5.1 predicted postoperative myocardial injury with an area under the curve (AUC) of 0.626, CRP>100mg/L with AUC of 0.631 and the NLR >8.5 predicted in-hospital mortality with an AUC of 0.793, showing moderately high sensitivity (86.7%, 80% and 90%, respectively) and negative predictive value (92.9%, 71.2%, 99.6%, respectively), but low specificity. Admission NLR was superior to other, except hypoalbuminaemia, prognostic markers; combined use of both NLR≥5.1 and albumin<33g/L only moderately increased the accuracy of prediction. The validation study confirmed the prognostic value of the admission NLR.

CONCLUSIONS

In orthogeriatric patients, high NLR on admission is an independent indicator of fracture presence, a significant risk factor and moderate predictor of postoperative myocardial injury, high inflammatory response/infection and in-hospital death.