Association of preoperative cognitive frailty with postoperative complications in older patients under general anesthesia: a prospective cohort study.

BACKGROUND: Cognitive frailty (CF) is characterized by the coexistence of physical frailty and cognitive impairment, and it is associated with adverse health outcomes. Older adults are particularly vulnerable to CF due to factors such as age-related brain changes and the presence of comorbidities. OBJECTIVE: To investigate the effect of preoperative CF on postoperative complications in older patients. METHODS: This prospective cohort study was conducted among 253 patients aged 60-85 years, who underwent elective orthopedic and abdominal surgery (with a postoperative hospital stay of ≥ 3 days) at the Second Affiliated Hospital of Guangzhou University of Chinese Medicine from May 2023 to November 2023. CF was assessed using the Montreal Cognitive Assessment (MoCA) for the cognitive status and the Fried criteria for five frailty scales. Participants were split into four groups: Group A (neither frailty nor cognitive impairment), Group B (frailty without cognitive impairment), Group C (cognitive impairment without frailty), and Group D (cognitive frailty). The primary outcome was postoperative complications, while secondary outcomes included mobility disability, prolonged hospital stay (PLOS), re-operation and 90-day readmission. RESULTS: The median age (interquartile range) of participants was 69 (65-73) years, of which 40.3% were male. The prevalence of CF was 17.8%. The incidence of postoperative complications was 18.2% in Group A, 50.0% in Group B, 37.4% in Group C, and 75.6% in Group D. Multivariate analysis revealed that, compared to the control group (without cognitive impairment or frailty), patients with CF had a significantly higher risk of postoperative complications (OR, 12.86; 95%CI, 4.23-39.08). "Patients with frailty without cognitive impairment" had an increased risk (OR, 6.53; 95%CI, 2.04-20.9), while "those with cognitive impairment without frailty" also showed a higher risk (OR, 3.46; 95%CI, 1.57-7.64). CONCLUSIONS: Cognitive frailty is significantly associated with an increased risk of postoperative adverse outcomes in older patients undergoing orthopedic and abdominal surgeries with general anesthesia. It indicates that clinicians should pay much attention to these older adults with CF.

Prognostic impact of CONUT score in older patients with chronic heart failure.

BACKGROUND: Malnutrition is common in older patients with chronic heart failure (HF) and often accompanies a deterioration of their condition. The Controlling Nutritional Status (CONUT) score is used as an objective indicator to evaluate nutritional status, but relevant research in this area is limited. This study aimed to report the prevalence, clinical correlates, and outcomes of malnutrition in elder patients hospitalized with chronic HF. METHODS: A retrospective analysis was conducted on 165 eligible patients admitted to the Department of Cardiology at Huadong Hospital from January 2021 to December 2022. Patients were categorized based on their CONUT score into three groups: normal nutrition status, mild risk of malnutrition, and moderate to severe risk of malnutrition. The study examined the nutritional status of this population and its relationship with clinical outcomes. RESULTS: Findings revealed that malnutrition affected 82% of the older patients, with 28% experiencing moderate to severe risk. Poor nutritional scores were significantly associated with prolonged hospital stay, increased in-hospital mortality and all-cause mortality during readmissions within one year (P < 0.05). The multivariable analysis indicated that moderate to severe malnutrition (CONUT score of 5-12) was significantly associated with a heightened risk of prolonged hospitalization (aOR: 9.17, 95%CI: 2.02-41.7). CONCLUSIONS: Malnutrition, as determined by the CONUT score, is a common issue among HF patients. Utilizing the CONUT score upon admission can effectively predict the potential for prolonged hospital stays.

CHA2DS2-VASc predicts readmission, outcomes and resource utilization in patients undergoing coronary artery bypass grafting: A 7-year National Readmission Database study.

BACKGROUND: CHA2DS2-VASc score is used to assess thromboembolic risk in patients with atrial fibrillation (AF)/atrial flutter (AFL), however its utilization to predict outcomes and readmission at following discharge in patients undergoing coronary artery bypass grafting (CABG) regardless of AF/AFL presence is understudied. We sought to assess its utility in predicting outcomes, length of hospital stay (LOS), and healthcare-associated costs (HAC) in these patients. METHOD: The National Readmission Database (NRD) was queried from 2010 to 2017 for patients with/without AF/AFL undergoing CABG using the International Classification of Diseases, Ninth and Tenth editions (ICD-9-&-10). Multiple regression analysis and multivariate analysis using Cox-Hazard analysis were used to evaluate outcomes up to 90-day readmission from discharge, LOS, and HAC against CHA2DS2-VASc score (cut-off-score:6) were abstracted from the database. RESULTS: Of the 420,458 patients that underwent CABG, 76,859 (18.3 %) were re-admitted to hospital within 90-days from discharge. Statistically significant increase in 90-day all-cause readmissions were demonstrated with increasing CHA2DS2-VASc score [No AF/AFL vs AF/AFL: score-0 (2.4 % vs1.4 %), score-6 (3.1 % vs 4.5 %, p-value<0.0001]. Similar trends were seen in re-admissions for TIA/Stroke and heart failure. The survival rate for all events were lower with incremental increase in CHA2DS2-VASc score (score-0 = 100 %; score-6 = 73 %, p-value<0.0001). Greater LOS and HAC was associated with increasing higher CHA2DS2-VASc score (standardized-beta[ß]; no AF/AFL vs AF/AFL: LOS = score-1: 0.08 vs 0.06, score-6: 0.12 vs 0.13. HAC = score-1: 0.02 vs 0.009, score-6: 0.02 vs 0.01, p-value <0.001). CONCLUSION: CHA2DS2-VASc score is an easy-to-use tool that predicts poorer outcomes, higher readmission, longer LOS, higher HAC, not just in patients with AF/AFL undergoing CABG, but also in those without AF/AFL.

Trends in the burden of hospitalised patients with cirrhosis in Switzerland: a cross-sectional study of cirrhosis-related hospitalisations between 1998 and 2020.

OBJECTIVE: Liver cirrhosis is an increasing cause of morbidity and mortality worldwide with a heavy load on healthcare systems. We analysed the trends in hospitalisations for cirrhosis in Switzerland. DESIGN: Cross-sectional study. SETTING: Large nationwide inpatient database, years between 1998 and 2020. PARTICIPANTS: Hospitalisations for cirrhosis of adult patients were selected. MAIN OUTCOMES AND MEASURES: Hospitalisations with either a primary diagnosis of cirrhosis or a cirrhosis-related primary diagnosis with a mandatory presence of cirrhosis as a secondary diagnosis were considered following the 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes. Trends in demographic and clinical characteristics, in-hospital mortality and length of stay were analysed. Causes and costs of cirrhosis-related hospitalisations were available from 2012 onwards. RESULTS: Cirrhosis-related hospitalisations increased from 1631 in 1998 to 4052 in 2020. Of the patients, 68.7% were men. Alcohol-related liver disease was the leading cause, increasing from 44.1% (95% CI, 42.4% to 45.9%) in 2012 to 47.9% (95% CI, 46.4% to 49.5%) in 2020. Assessed by exclusion of other coded causes, non-alcoholic fatty liver disease was the second cause at 42.7% (95% CI, 41.2% to 44.3%) in 2020. Hepatitis C virus-related cirrhosis decreased from 12.3% (95% CI, 11.2% to 13.5%) in 2012 to 3.2% (95% CI, 2.7% to 3.8%) in 2020. Median length of stay decreased from 11 to 8 days. Hospitalisations with an intensive care unit stay increased from 9.8% (95% CI, 8.4% to 11.4%) to 15.6% (95% CI, 14.5% to 16.8%). In-hospital mortality decreased from 12.1% (95% CI, 10.5% to 13.8%) to 9.7% (95% CI, 8.8% to 10.7%). Total costs increased from 54.4 million US$ (51.4 million €) in 2012 to 92.6 million US$ (87.5 million €) in 2020. CONCLUSIONS: Cirrhosis-related hospitalisations and related costs increased in Switzerland from 1998 to 2020 but in-hospital mortality decreased. Alcohol-related liver disease and non-alcoholic fatty liver disease were the most prevalent and preventable aetiologies of cirrhosis-related hospitalisations.

Recent temporal trends, characteristics and outcomes of patients with non-COVID-19 community-acquired pneumonia at two tertiary hospitals in Australia: an observational study.

BACKGROUND: Community-acquired pneumonia (CAP) leads to considerable morbidity and mortality globally. However, data on CAP burden in Australia, especially during the coronavirus disease 2019 (COVID-19) pandemic, are limited. AIMS: We characterised and assessed clinical outcomes of non-COVID-19 CAP hospitalisations over a 6-year period at two major hospitals in South Australia. METHODS: All non-COVID-19 CAP hospitalisations were identified using the International Statistical Classification of Diseases and Related Health Problems, Tenth revision, Australian modification (ICD-10-AM) codes, between 1 January 2018 and 31 December 2023, at two tertiary hospitals in Adelaide. Clinical outcomes included in-hospital and 30-day mortality, length of stay (LOS) in, intensive care unit (ICU) admission and 30-day readmissions. Multilevel regression models were utilised to identify predictors of clinical outcomes. RESULTS: Over the 6-year period, there were 7853 non-COVID-19 CAP hospitalisations, with a temporal increase from 100 per 100 000 population in 2018 to 208 per 100 000 population in 2023 (P < 0.001). The mean (SD) age was 75.1 (17.6) years, and 54.6% were males. The mean age declined over time (P < 0.05), while other characteristics remained stable. Streptococcus pneumoniae was the most commonly identified bacterium (21.8% of cases). In-hospital mortality occurred in 7.8% of patients, with 30-day mortality and readmission rates of 14.3% and 16.9% respectively. LOS declined significantly during the pandemic years; however, mortality remained stable over time. Frailty status, malnutrition and number of comorbidities significantly predicted 30-day mortality and LOS, in addition to pneumonia severity and ICU admission. CONCLUSIONS: There has been an increasing trend of hospitalisations for non-COVID-19 CAP during the COVID-19 pandemic, with a concomitant trend towards shorter LOS and no significant shift in other clinical outcomes.

Emergency Department Visits And Hospital Capacity In The US: Trends In The Medicare Population During The COVID-19 Pandemic.

Although emergency department (ED) and hospital overcrowding were reported during the later parts of the COVID-19 pandemic, the true extent and potential causes of this overcrowding remain unclear. Using data on the traditional fee-for-service Medicare population, we examined patterns in ED and hospital use during the period 2019-22. We evaluated trends in ED visits, rates of admission from the ED, and thirty-day mortality, as well as measures suggestive of hospital capacity, including hospital Medicare census, length-of-stay, and discharge destination. We found that ED visits remained below baseline throughout the study period, with the standardized number of visits at the end of the study period being approximately 25 percent lower than baseline. Longer length-of-stay persisted through 2022, whereas hospital census was considerably above baseline until stabilizing just above baseline in 2022. Rates of discharge to postacute facilities initially declined and then leveled off at 2 percent below baseline in 2022. These results suggest that widespread reports of overcrowding were not driven by a resurgence in ED visits. Nonetheless, length-of-stay remains higher, presumably related to increased acuity and reduced available bed capacity in the postacute care system.

Rehabilitation after surgery for hip fracture - the impact of prompt, frequent and mobilisation-focused physiotherapy on discharge outcomes: an observational cohort study.

PURPOSE: To determine the relationship between three postoperative physiotherapy activities (time to first postoperative walk, activity on the day after surgery, and physiotherapy frequency), and the outcomes of hospital length of stay (LOS) and discharge destination after hip fracture. METHODS: A cohort study was conducted on 437 hip fracture surgery patients aged ≥ 50 years across 36 participating hospitals from the Australian and New Zealand Hip Fracture Registry Acute Rehabilitation Sprint Audit during June 2022. Study outcomes included hospital LOS and discharge destination. Generalised linear and logistic regressions were used respectively, adjusted for potential confounders. RESULTS: Of 437 patients, 62% were female, 56% were aged ≥ 85 years, 23% were previously living in a residential aged care facility, 48% usually walked with a gait aid, and 38% were cognitively impaired prior to their injury. The median acute and total LOS were 8 (IQR 5-13) and 20 (IQR 8-38) days. Approximately 71% (n = 179/251) of patients originally living in private residence returned home and 29% (n = 72/251) were discharged to a residential aged care facility. Previously mobile patients had a higher total LOS if they walked day 2-3 (10.3 days; 95% CI 3.2, 17.4) or transferred with a mechanical lifter or did not get out of bed day 1 (7.6 days; 95% CI 0.6, 14.6) compared to those who walked day 1 postoperatively. Previously mobile patients from private residence had a reduced odds of return to private residence if they walked day 2-3 (OR 0.38; 95% CI 0.17, 0.87), day 4 + (OR 0.38; 95% CI 0.15, 0.96), or if they only sat, stood or stepped on the spot day 1 (OR 0.29; 95% CI 0.13, 0.62) when compared to those who walked day 1 postoperatively. Among patients from private residence, each additional physiotherapy session per day was associated with a -2.2 (95% CI -3.3, -1.0) day shorter acute LOS, and an increased log odds of return to private residence (OR 1.76; 95% CI 1.02, 3.02). CONCLUSION: Hip fracture patients who walked earlier, were more active day 1 postoperatively, and/or received a higher number of physiotherapy sessions were more likely to return home after a shorter LOS.

Impact of the COVID-19 pandemic on management and outcomes of patients with acute heart failure.

AIMS: Guidelines recommend non-invasive positive pressure ventilation (NPPV) for patients with acute decompensated heart failure (ADHF) with an inadequate response to initial oxygen therapy. During Japan's coronavirus disease 2019 pandemic, NPPV use in emergency departments (EDs) was limited due to aerosol-spreading concerns. This study compared the respiratory management and clinical outcomes of patients with ADHF in EDs before and during the pandemic. METHODS AND RESULTS: This retrospective cohort study was conducted at a single centre in Japan using hospital data from September to November 2019 (before the pandemic) and September to November 2020 (during the pandemic). Patients diagnosed with ADHF were included. Patients not responding to standard oxygen therapy were intubated or started on NPPV therapy. The primary outcome measure was discharge after death. The secondary outcomes were length of hospital stay and medical expenses. The study included 37 patients before the pandemic and 36 during the pandemic. No significant differences were found in vital signs or laboratory data between the groups. NPPV utilization decreased significantly from 26 (70.3%) to 7 (19.4%) (P < 0.01). Two patients required intubation during both periods, with no significant differences (P = 0.98). No significant intergroup disparities were observed in discharge after death (1/36 [2.7%] vs. 1/37 [2.7%]; P = 0.19), length of hospital stay (17.5 vs. 19.0 days; P = 0.65), and medical expenses (57 590 vs. 57 600 yen; P = 0.65). CONCLUSIONS: Despite a large decrease in NPPV use before and during the pandemic, there were no significant differences in discharge after death, hospital stay, or medical expenses.

Morbidity and trends in length of hospitalisation of very and extremely preterm infants born between 2008 and 2021 in the Netherlands: a cohort study.

OBJECTIVES: This study investigated changes in the length of stay (LoS) at a level III/IV neonatal intensive care unit (NICU) and level II neonatology departments until discharge home for very preterm infants and identified factors influencing these trends. DESIGN: Retrospective cohort study based on data recorded in the Netherlands Perinatal Registry between 2008 and 2021. SETTING: A single level III/IV NICU and multiple level II neonatology departments in the Netherlands. PARTICIPANTS: NICU-admitted infants (n=2646) with a gestational age (GA) <32 weeks. MAIN OUTCOME MEASURES: LoS at the NICU and overall LoS until discharge home. RESULTS: The results showed an increase of 5.1 days (95% CI 2.2 to 8, p<0.001) in overall LoS in period 3 after accounting for confounding variables. This increase was primarily driven by extended LoS at level II hospitals, while LoS at the NICU remained stable. The study also indicated a strong association between severe complications of preterm birth and LoS. Treatment of infants with a lower GA and more (severe) complications (such as severe retinopathy of prematurity) during the more recent periods may have increased LoS. CONCLUSION: The findings of this study highlight the increasing overall LoS for very preterm infants. LoS of very preterm infants is presumably influenced by the occurrence of complications of preterm birth, which are more frequent in infants at a lower gestational age.

Chronic obstructive pulmonary disease affects outcome in surgical patients with perioperative organ injury: a retrospective cohort study in Germany.

BACKGROUND: The impact of chronic obstructive pulmonary disease (COPD) on outcome in perioperative organ injury (POI) has not yet been investigated sufficiently. METHODS: This retrospective cohort study analysed data of surgical patients with POI, namely delirium, stroke, acute myocardial infarction, acute respiratory distress syndrome, acute liver injury (ALI), or acute kidney injury (AKI), in Germany between 2015 and 2019. We compared in-hospital mortality, hospital length of stay (HLOS) and perioperative ventilation time (VT) in patients with and without COPD. RESULTS: We analysed the data of 1,642,377 surgical cases with POI of which 10.8% suffered from COPD. In-hospital mortality was higher (20.6% vs. 15.8%, p < 0.001) and HLOS (21 days (IQR, 12-34) vs. 16 days (IQR, 10-28), p < 0.001) and VT (199 h (IQR, 43-547) vs. 125 h (IQR, 32-379), p < 0.001) were longer in COPD patients. Within the POI examined, AKI was the most common POI (57.8%), whereas ALI was associated with the highest mortality (54.2%). Regression analysis revealed that COPD was associated with a slightly higher risk of in-hospital mortality (OR, 1.19; 95% CI:1.18-1.21) in patients with any POI. CONCLUSIONS: COPD in patients with POI is associated with higher mortality, longer HLOS and longer VT. Especially patients suffering from ALI are susceptible to the detrimental effects of COPD on adverse outcome.

Racial Disparities in Alcoholic Hepatitis Hospitalizations in the United States: Trends, Outcomes, and Future Projections.

INTRODUCTION: Alcoholic hepatitis (AH) is a serious complication of alcohol consumption with high morbidity and mortality, particularly in the United States where alcohol-related liver diseases rank as one of the leading causes of preventable death. Our study aims to analyze the morbidity and mortality of AH across racial groups and project hospitalization trends up to 2028, thereby informing public health initiatives. METHODS: We conducted a cross-sectional study utilizing data from the Nationwide Inpatient Sample (NIS) spanning 2012 to 2021. The study population comprised hospitalizations identified using specific ICD-9-CM and ICD-10-CM codes for AH. We assessed hospitalizations, in-hospital mortality rates, length of stay (LOS), and morbidities related to alcoholic hepatitis adjusting for sociodemographic factors and hospital characteristics. Statistical analyses were performed using Stata and R software, employing logistic and linear regression analyses, and SARIMA models for forecasting. RESULTS: Our results indicated a predominantly White cohort (68%), with a notable increase in AH hospitalizations among Hispanics (129.1% from 2012 to 2021). Racial disparities were observed in inpatient mortality, liver transplant accessibility, and the occurrence of in-hospital complications. The study forecasts a continued rise in hospitalizations across all racial groups, with Hispanics experiencing the sharpest increase. CONCLUSION: Our study reveals a disproportionate rise in the AH burden among Hispanics with projections indicating a persistent upward trend through 2028. These findings highlight the need for targeted public health strategies and improved healthcare access to mitigate the increasing AH burden and address disparities in care and outcomes.

Trends in Adolescent Comorbid Cannabis Use Disorder and Postoperative Complications.

BACKGROUND: Increasing legalization and widespread misinformation about the dangers of cannabis use have contributed to the rising prevalence of cannabis use disorder (CUD) among adolescents. Our objective was to determine the prevalence of CUD in adolescent surgical patients and evaluate its association with postoperative complications. METHODS: We performed a retrospective, 1:1 propensity-matched cohort study of adolescents (aged 10-17 years) with and without CUD who underwent inpatient operations at US hospitals participating in the Pediatric Health Information System from 2009 to 2022. The primary outcome was the trend in prevalence of CUD. Secondary outcomes included postoperative complications. Using a Bonferroni correction, we considered a P value < .008 to be significant. RESULTS: Of 558 721 adolescents undergoing inpatient surgery from 2009 to 2022, 2604 (0.5%) were diagnosed with CUD (2483 were propensity matched). The prevalence of CUD increased from 0.4% in 2009 to 0.6% in 2022 (P < .001). The adjusted odds of respiratory complications, ICU admission, mechanical ventilation, and extended hospital stay were significantly higher in adolescents with CUD (respiratory complications: odds ratio [OR], 1.52; 95% confidence interval [CI], 1.16-2.00; P = .002; ICU admission: OR, 1.78; 95% CI, 1.61-1.98; P < .001; mechanical ventilation: OR, 2.41; 95% CI, 2.10-2.77; P < .001; extended hospital stay: OR, 1.96; 95% CI, 1.74-2.20; P < .001). The propensity score-adjusted odds of postoperative mortality or stroke for adolescents with CUD were not significantly increased (mortality: OR, 1.40; 95% CI, 0.87-2.25; P = .168; stroke: OR, 2.46; 95% CI, 1.13-5.36; P = .024). CONCLUSIONS: CUD is increasing among adolescents scheduled for surgery. Given its association with postoperative complications, it is crucial to screen adolescents for cannabis use to allow timely counseling and perioperative risk mitigation.

Short­ and long­term outcomes after laparoscopic and open pancreatoduodenectomy for elderly patients: a propensity score­matched study.

BACKGROUND: The feasibility and safety of laparoscopic pancreatoduodenectomy (LPD) in elderly patients is still controversial. This study aimed to compare the clinical outcomes of LPD and open pancreatoduodenectomy (OPD) in elderly patients. METHODS: Clinical and follow-up data of elderly patients (≥ 65 years) who underwent LPD or OPD between 2015 and 2022 were retrospectively analyzed. A 1:1 propensity score-matching (PSM) analysis was performed to minimize differences between groups. Univariate and multivariate logistic regression analysis were used to select independent prognostic factors for 90-day mortality. RESULTS: Of the 410 elderly patients, 236 underwent LPD and 174 OPD. After PSM, the LPD group had a less estimated blood loss (EBL) (100 vs. 200 mL, P < 0.001), lower rates of intraoperative transfusion (10.4% vs. 19.0%, P = 0.029), more lymph node harvest (11.0 vs. 10.0, P = 0.014) and shorter postoperative length of stay (LOS) (13.0 vs. 16.0 days, P = 0.013). There were no significant differences in serious complications, reoperation, 90-day readmission and mortality rates (all P > 0.05). Multivariate logistic regression analysis showed that post-pancreatectomy hemorrhage (PPH) was an independent risk factor for 90-day mortality. Elderly patients with pancreatic ductal adenocarcinoma (PDAC) who underwent LPD or OPD had similar overall survival (OS) (22.5 vs.20.4 months, P = 0.672) after PSM. CONCLUSIONS: It is safe and feasible for elderly patients to undergo LPD with less EBL and a shorter postoperative LOS. There was no statistically significant difference in long-term survival outcomes between elderly PDAC patients who underwent LPD or OPD.

Contemporary trends of leadless pacemaker implantation in the United States.

INTRODUCTION: Leadless pacemakers (LPM) have established themselves as the important therapeutic modality in management of selected patients with symptomatic bradycardia. To determine real-world utilization and in-hospital outcomes of LPM implantation since its approval by the Food and Drug Administration in 2016. METHODS: For this retrospective cohort study, data were extracted from the National Inpatient Sample database from the years 2016-2020. The outcomes analyzed in our study included implantation trends of LPM over study years, mortality, major complications (defined as pericardial effusion requiring intervention, any vascular complication, or acute kidney injury), length of stay, and cost of hospitalization. Implantation trends of LPM were assessed using linear regression. Using years 2016-2017 as a reference, adjusted outcomes of mortality, major complications, prolonged length of stay (defined as >6 days), and increased hospitalization cost (defined as median cost >34 098$) were analyzed for subsequent years using a multivariable logistic regression model. RESULTS: There was a gradual increased trend of LPM implantation over our study years (3230 devices in years 2016-2017 to 11 815 devices in year 2020, p for trend <.01). The adjusted mortality improved significantly after LPM implantation in subsequent years compared to the reference years 2016-2017 (aOR for the year 2018: 0.61, 95% CI: 0.51-0.73; aOR for the year 2019: 0.49, 95% CI: 0.41-0.59; and aOR for the year 2020: 0.52, 95% CI: 0.44-0.62). No differences in adjusted rates of major complications were demonstrated over the subsequent years. The adjusted cost of hospitalization was higher for the years 2019 (aOR: 1.33, 95% CI: 1.22-1.46) and 2020 (aOR: 1.69, 95% CI: 1.55-1.84). CONCLUSION: The contemporary US practice has shown significantly increased implantation rates of LPM since its approval with reduced rates of inpatient mortality.

Unplanned transfer to acute care during inpatient geriatric rehabilitation: incidence, risk factors, and associated short-term outcomes.

BACKGROUND: Information is scarce on unplanned transfers from geriatric rehabilitation back to acute care despite their potential impact on patients' functional recovery. This study aimed 1) to determine the incidence rate and causes of unplanned transfers; 2) to compare the characteristics and outcomes of patients with and without unplanned transfer. METHODS: Consecutive stays (n = 2375) in a tertiary geriatric rehabilitation unit were included. Unplanned transfers to acute care and their causes were analyzed from discharge summaries. Data on patients' socio-demographics, health, functional, and mental status; length of stay; discharge destination; and death, were extracted from the hospital database. Bi- and multi-variable analyses investigated the association between patients' characteristics and unplanned transfers. RESULTS: One in six (16.7%) rehabilitation stays was interrupted by a transfer, most often secondary to infections (19.3%), cardiac (16.8%), abdominal (12.7%), trauma (12.2%), and neurological problems (9.4%). Older patients (AdjORage≥85: 0.70; 95%CI: 0. 53-0.94, P = .016), and those admitted for gait disorders (AdjOR: 0.73; 95%CI: 0.53-0.99, P = .046) had lower odds of transfer to acute care. In contrast, men (AdjOR: 1.71; 95%CI: 1.29-2.26, P < .001), patients with more severe disease (AdjORCIRS: 1.05; 95%CI: 1.02-1.07, P < .001), functional impairment before (AdjOR: 1.69; 95%CI: 1.05-2.70, P = .029) and at rehabilitation admission (AdjOR: 2.07; 95%CI: 1.56- 2.76, P < .001) had higher odds of transfer. Transferred patients were significantly more likely to die than those without transfer (AdjOR 13.78; 95%CI: 6.46-29.42, P < .001) during their stay, but those surviving had similar functional performance and rate of home discharge at the end of the stay. CONCLUSION: A significant minority of patients experienced an unplanned transfer that potentially interfered with their rehabilitation and was associated with poorer outcomes. Men, patients with more severe disease and functional impairment appear at increased risk. Further studies should investigate whether interventions targeting these patients may prevent unplanned transfers and modify associated adverse outcomes.

Emerging trends in nationwide mortality, limb loss, and resource utilization for critical limb ischemia in young adults.

BACKGROUND/OBJECTIVES: Recent trends indicate a rise in the incidence of critical limb ischemia (CLI) among younger adults. This study examines trends in CLI hospitalization and outcomes among young adults with peripheral arterial disease (PAD) in the United States. METHODS: Adult hospitalizations (18-40 years) for PAD/CLI were analyzed from the 2016-2020 nationwide inpatient sample database using ICD-10 codes. Rates were reported per 1000 PAD or 100,000 cardiovascular disease admissions. Outcomes included trends in mortality, major amputations, revascularization, length of hospital stay (LOS), and hospital costs (THC). We used the Jonckheere-Terpstra tests for trend analysis and adjusted costs to the 2020 dollar using the consumer price index. RESULTS: Approximately 63,045 PAD and 20,455 CLI admissions were analyzed. The mean age of the CLI cohort was 32.7 ± 3 years. The majority (12,907; 63.1 %) were female and white (11,843; 57.9 %). Annual CLI rates showed an uptrend with 3265 hospitalizations (227 per 1000 PAD hospitalizations, 22.7 %) in 2016 to 4474 (252 per 1000 PAD hospitalizations, 25.2 %) in 2020 (Ptrend<0.001), along with an increase in PAD admissions from 14,405 (188 per 100,000, 0.19 %) in 2016 to 17,745 (232 per 100,000, 0.23 %%) in 2020 (Ptrend<0.0001). Annual in-hospital mortality increased from 570 (2.8 %) in 2016 to 803 (3.9 %) in 2020 (Ptrend = 0.001) while amputations increased from 1084 (33.2 %) in 2016 to 1995 (44.6 %) in 2020 (Ptrend<0.001). Mean LOS increased from 5.1 (SD 2.7) days in 2016 to 6.5 (SD 0.9) days in 2020 (Ptrend = 0.002). The mean THC for CLI increased from $50,873 to $69,262 in 2020 (Ptrend<0.001). The endovascular revascularization rates decreased from 11.5 % (525 cases) in 2016 to 10.7 % (635 cases) in 2020 (Ptrend = 0.025). Surgical revascularization rates also increased from 4.9 % (225 cases) in 2016 to 10.4 % (600 cases) in 2020 (Ptrend = 0.041). CONCLUSION: Hospitalization and outcomes for CLI worsened among young adults during the study period. There is an urgent need to enhance surveillance for risk factors of PAD in this age group.

Temporal Trends, Outcomes, and Predictors of Next-Day Discharge and Readmission Following Uncomplicated Evolut Transcatheter Aortic Valve Replacement: A Propensity Score-Matched Analysis.

BACKGROUND: Next-day discharge (NDD) outcomes following uncomplicated self-expanding transcatheter aortic valve replacement have not been studied. Here, we compare readmission rates and clinical outcomes in NDD versus non-NDD transcatheter aortic valve replacement with Evolut. METHODS AND RESULTS: Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry patients (n=29 597) undergoing elective transcatheter aortic valve replacement with self-expanding supra-annular valves (Evolut R, PRO, and PRO+) from July 2019 to June 2021 were stratified by postprocedure length of stay: ≤1 day (NDD) versus >1 day (non-NDD). Propensity score matching was used to compare risk adjusted 30-day readmission rates and 1-year outcomes in NDD versus non-NDD, and multivariable regression to determine predictors of NDD and readmission. Between the first and last calendar quarter, the rate of NDD increased from 45.4% to 62.1% and median length of stay decreased from 2 days to 1. Propensity score matching produced relatively well-matched NDD and non-NDD cohorts (n=10 549 each). After matching, NDD was associated with lower 30-day readmission rates (6.3% versus 8.4%; P<0.001) and 1-year adverse outcomes (death, 7.0% versus 9.3%; life threatening/major bleeding, 1.6% versus 3.4%; new permanent pacemaker implantation/implantable cardioverter-defibrillator, 3.6 versus 11.0%; [all P<0.001]). Predictors of NDD included non-Hispanic ethnicity, preexisting permanent pacemaker implantation/implantable cardioverter-defibrillator, and previous surgical aortic valve replacement. CONCLUSIONS: Most patients undergoing uncomplicated self-expanding Evolut transcatheter aortic valve replacement are discharged the next day. This study found that NDD can be predicted from baseline patient characteristics and was associated with favorable 30-day and 1-year outcomes, including low rates of permanent pacemaker implantation and readmission.

Incidence and Predictors of Readmissions to Non-Index Hospitals After Transcatheter Aortic Valve Implantation in the Contemporary Era in New South Wales, Australia.

BACKGROUND: In Australia, transcatheter aortic valve implantation (TAVI) is only performed in a limited number of specialised metropolitan centres, many of which are private hospitals, making it likely that TAVI patients who require readmission will present to another (non-index) hospital. It is important to understand the impact of non-index readmission on patient outcomes and healthcare resource utilisation. METHOD: We analysed linked hospital and death records for residents of New South Wales, Australia, aged ≥18 years, who had an emergency readmission within 90 days following a TAVI procedure in 2013-2022. Mixed-effect, multi-level logistic regression models were used to evaluate predictors of non-index readmission, and associations between non-index readmission and readmission length of stay, 90-day mortality, and 1-year mortality. RESULTS: Of 4,198 patients (mean age, 82.7 years; 40.6% female) discharged alive following TAVI, 933 (22.2%) were readmitted within 90 days of discharge. Over three-quarters (76.0%) of those readmitted returned to a non-index hospital, with no significant difference in readmission principal diagnosis between index hospital and non-index hospital readmissions. Among readmitted patients, independent predictors of non-index readmission included: residence in regional or remote areas, lower socio-economic status, having a pre-procedure transfer, and a private index hospital. Readmission length of stay (median, 4 days), 90-day mortality (adjusted odds ratio [OR] 1.04, 95% confidence interval [CI] 0.56-1.96) and 1-year mortality (adjusted OR 1.01, 95% CI 0.64-1.58) were similar between index and non-index readmissions. CONCLUSIONS: Non-index readmission following TAVI was highly prevalent but not associated with increased mortality or healthcare utilisation. Our results are reassuring for TAVI patients in regional and remote areas with limited access to return to index TAVI hospitals.

Trends in Plasma Exchange Use in Optic Neuritis Hospitalizations in the United States.

PURPOSE: To report use trends of plasma exchange (PLEX) as well as sociodemographic and medical comorbidities associated with PLEX in the United States. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Adult patients (≥ 18 years) admitted for inpatient hospitalization with a primary diagnosis of optic neuritis (ON). METHODS: Data from the National Inpatient Sample database was compiled to assess PLEX use rates between 2000 and 2020. The cohorts of patients receiving PLEX versus not receiving PLEX were analyzed between quarter 4 of 2015 through 2020 (International Classification of Diseases, Tenth Revision [ICD-10], only) for patient sociodemographic variables, medical diagnoses, insurance types, hospital characteristics, cause of disease, time to therapy, length of stay (LOS), and total charges incurred. MAIN OUTCOME MEASURES: Incidence of ON, incidence of PLEX, demographics, diagnoses associated with PLEX therapy, total charges, and LOS. RESULTS: From 2000 through 2020, 11 209 patients hospitalized with a primary diagnosis of ON were identified, with a significant majority managed at urban teaching hospitals. Use of PLEX increased steadily over 2 decades from 0.63% to 5.46%. Use was greatest in the western United States and least in the eastern United States. In the subset of ICD-10 cases, 3215 patients were identified. The median time to therapy of PLEX was 1 day after admission, and PLEX use was highest in patients with neuromyelitis optica spectrum disorder (NMOSD) (21.21%) and lowest in multiple sclerosis-associated ON (3.80%). Use of PLEX was associated with significantly longer LOS and higher total charges incurred. Medical comorbidities associated with PLEX included adverse reaction to glucocorticoids (adjusted odds ratio [aOR], 31.50), hemiplegia (aOR, 28.48), neuralgia (aOR, 4.81), optic atrophy (aOR, 3.74), paralytic strabismus (aOR, 2.36), and psoriasis (aOR, 1.76). CONCLUSIONS: Over the last 2 decades in the United States, PLEX therapy for ON has increased, with the highest use in the western United States and for patients with the diagnosis NMOSD ON. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Early supported discharge for older adults admitted to hospital after orthopaedic surgery: a systematic review and meta-analysis.

BACKGROUND: Early supported discharge (ESD) aims to link acute and community care, allowing hospital inpatients to return home, continuing to receive the necessary input from healthcare professionals that they would otherwise receive in hospital. Existing literature demonstrates the concept having a reduced length of stay in stroke inpatients and medical older adults. This systematic review aims to explore the totality of evidence for the use of ESD in older adults hospitalised with orthopaedic complaints. METHODS: A literature search of Cochrane Central Register of Controlled Trials in the Cochrane Library (CENTRAL), EMBASE, CINAHL and MEDLINE in EBSCO was carried out on January 10th, 2024. Randomised controlled trials or quasi-randomised controlled trials were the study designs included. For quality assessment, The Cochrane Risk of Bias Tool 2.0 was used and GRADE was applied to evaluate the certainty of evidence. Acute hospital length of stay was the primary outcome. Secondary outcomes included the numbers of fallers and function. A pooled meta-analysis was conducted using RevMan software 5.4.1. RESULTS: Seven studies with a population of older adults post orthopaedic surgery met inclusion criteria, with five studies included in the meta-analysis. Study quality was predominantly of a high risk of bias. Statistically significant effects favouring ESD interventions were only seen in terms of length of stay (FEM, MD = -5.57, 95% CI -7.07 to -4.08, I2 = 0%). No statistically significant effects favouring ESD interventions were established in secondary outcomes. CONCLUSION: In the older adult population with orthopaedic complaints, ESD can have a statistically significant impact in reducing hospital length of stay. This review identifies an insufficient existing evidence base to establish the key benefits of ESD for this population group. There is a need for further higher quality research in the area, with standardised interventions and outcome measures used.