Factors associated with poorer outcomes for posterior lumbar decompression and or/or discectomy: an exploratory analysis of administrative data.

PURPOSE: This study aimed to identify factors associated with poorer patient outcomes for lumbar decompression and/or discectomy (PLDD). METHODS: We extracted data from the Hospital Episodes Statistics database for the 5 years from 1st April 2014 to 31st March 2019. Patients undergoing an elective one- or two-level PLDD aged ≥ 17 years and without evidence of revision surgery during the index stay were included. The primary patient outcome measure was readmission within 90 days post-discharge. RESULTS: Data for 93,813 PLDDs across 111 hospital trusts were analysed. For the primary outcome, greater age [< 40 years vs 70-79 years odds ratio (OR) 1.28 (95% confidence interval (CI) 1.14 to 1.42), < 40 years vs ≥ 80 years OR 2.01 (95% CI 1.76-2.30)], female sex [OR 1.09 (95% CI 1.02-1.16)], surgery over two spinal levels [OR 1.16 (95% CI 1.06-1.26)] and the comorbidities chronic pulmonary disease, connective tissue disease, liver disease, diabetes, hemi/paraplegia, renal disease and cancer were all associated with emergency readmission within 90 days. Other outcomes studied had a similar pattern of associations. CONCLUSIONS: A high-throughput PLDD pathway will not be suitable for all patients. Extra care should be taken for patients aged ≥ 70 years, females, patients undergoing surgery over two spinal levels and those with specific comorbidities or generalised frailty.

Data quality and autism: Issues and potential impacts.

INTRODUCTION: Large healthcare datasets can provide insight that has the potential to improve outcomes for patients. However, it is important to understand the strengths and limitations of such datasets so that the insights they provide are accurate and useful. The aim of this study was to identify data inconsistencies within the Hospital Episodes Statistics (HES) dataset for autistic patients and assess potential biases introduced through these inconsistencies and their impact on patient outcomes. The study can only identify inconsistencies in recording of autism diagnosis and not whether the inclusion or exclusion of the autism diagnosis is the error. METHODS: Data were extracted from the HES database for the period 1st April 2013 to 31st March 2021 for patients with a diagnosis of autism. First spells in hospital during the study period were identified for each patient and these were linked to any subsequent spell in hospital for the same patient. Data inconsistencies were recorded where autism was not recorded as a diagnosis in a subsequent spell. Features associated with data inconsistencies were identified using a random forest classifiers and regression modelling. RESULTS: Data were available for 172,324 unique patients who had been recorded as having an autism diagnosis on first admission. In total, 43.7 % of subsequent spells were found to have inconsistencies. The features most strongly associated with inconsistencies included greater age, greater deprivation, longer time since the first spell, change in provider, shorter length of stay, being female and a change in the main specialty description. The random forest algorithm had an area under the receiver operating characteristic curve of 0.864 (95 % CI [0.862 - 0.866]) in predicting a data inconsistency. For patients who died in hospital, inconsistencies in their final spell were significantly associated with being 80 years and over, being female, greater deprivation and use of a palliative care code in the death spell. CONCLUSIONS: Data inconsistencies in the HES database were relatively common in autistic patients and were associated a number of patient and hospital admission characteristics. Such inconsistencies have the potential to distort our understanding of service use in key demographic groups.

Frailty, Comorbidity, and Associations With In-Hospital Mortality in Older COVID-19 Patients: Exploratory Study of Administrative Data.

BACKGROUND: Older adults have worse outcomes following hospitalization with COVID-19, but within this group there is substantial variation. Although frailty and comorbidity are key determinants of mortality, it is less clear which specific manifestations of frailty and comorbidity are associated with the worst outcomes. OBJECTIVE: We aimed to identify the key comorbidities and domains of frailty that were associated with in-hospital mortality in older patients with COVID-19 using models developed for machine learning algorithms. METHODS: This was a retrospective study that used the Hospital Episode Statistics administrative data set from March 1, 2020, to February 28, 2021, for hospitalized patients in England aged 65 years or older. The data set was split into separate training (70%), test (15%), and validation (15%) data sets during model development. Global frailty was assessed using the Hospital Frailty Risk Score (HFRS) and specific domains of frailty were identified using the Global Frailty Scale (GFS). Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Additional features employed in the random forest algorithms included age, sex, deprivation, ethnicity, discharge month and year, geographical region, hospital trust, disease severity, and International Statistical Classification of Disease, 10th Edition codes recorded during the admission. Features were selected, preprocessed, and input into a series of random forest classification algorithms developed to identify factors strongly associated with in-hospital mortality. Two models were developed; the first model included the demographic, hospital-related, and disease-related items described above, as well as individual GFS domains and CCI items. The second model was similar to the first but replaced the GFS domains and CCI items with the HFRS as a global measure of frailty. Model performance was assessed using the area under the receiver operating characteristic (AUROC) curve and measures of model accuracy. RESULTS: In total, 215,831 patients were included. The model using the individual GFS domains and CCI items had an AUROC curve for in-hospital mortality of 90% and a predictive accuracy of 83%. The model using the HFRS had similar performance (AUROC curve 90%, predictive accuracy 82%). The most important frailty items in the GFS were dementia/delirium, falls/fractures, and pressure ulcers/weight loss. The most important comorbidity items in the CCI were cancer, heart failure, and renal disease. CONCLUSIONS: The physical manifestations of frailty and comorbidity, particularly a history of cognitive impairment and falls, may be useful in identification of patients who need additional support during hospitalization with COVID-19.

Data consistency in the English Hospital Episodes Statistics database.

BACKGROUND: To gain maximum insight from large administrative healthcare datasets it is important to understand their data quality. Although a gold standard against which to assess criterion validity rarely exists for such datasets, internal consistency can be evaluated. We aimed to identify inconsistencies in the recording of mandatory International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10) codes within the Hospital Episodes Statistics dataset in England. METHODS: Three exemplar medical conditions where recording is mandatory once diagnosed were chosen: autism, type II diabetes mellitus and Parkinson's disease dementia. We identified the first occurrence of the condition ICD-10 code for a patient during the period April 2013 to March 2021 and in subsequent hospital spells. We designed and trained random forest classifiers to identify variables strongly associated with recording inconsistencies. RESULTS: For autism, diabetes and Parkinson's disease dementia respectively, 43.7%, 8.6% and 31.2% of subsequent spells had inconsistencies. Coding inconsistencies were highly correlated with non-coding of an underlying condition, a change in hospital trust and greater time between the spell with the first coded diagnosis and the subsequent spell. For patients with diabetes or Parkinson's disease dementia, the code recording for spells without an overnight stay were found to have a higher rate of inconsistencies. CONCLUSIONS: Data inconsistencies are relatively common for the three conditions considered. Where these mandatory diagnoses are not recorded in administrative datasets, and where clinical decisions are made based on such data, there is potential for this to impact patient care.

Early postoperative epidermal growth factor receptor inhibition: safety and effectiveness in inhibiting microscopic residual of oral squamous cell carcinoma in vivo.

BACKGROUND: The local-regional failure of advanced oral squamous cell carcinoma (OSCC) after surgery results from the regrowth of residual tumor cells that may be stimulated by epidermal growth factor receptor (EGFR) ligands during the wound healing process. METHODS: The level of EGFR ligands in human drain fluids (DFs) from OSCC resection and remote flap donor site were determined. A mouse model of microscopic residual OSCC was established and treated with cetuximab to measure tumor growth, survival, and cervical lymph node metastases. A mouse model of wound healing was also established to assess the effect of an EGFR antibody on the wound healing process. RESULTS: EGFR ligands are found in sites from OSCC resection. EGFR targeted therapy can delay tumor regrowth in a microscopic residual disease model of OSCC without significant effects on local wound healing. CONCLUSION: These results provide a strong rationale for clinical evaluation of this approach to treat patients with local-regionally advanced OSCC.

Trans-complementation of an NS2 defect in a late step in hepatitis C virus (HCV) particle assembly and maturation.

Recent studies using cell culture infection systems that recapitulate the entire life cycle of hepatitis C virus (HCV) indicate that several nonstructural viral proteins, including NS2, NS3, and NS5A, are involved in the process of viral assembly and release. Other recent work suggests that Ser-168 of NS2 is a target of CK2 kinase-mediated phosphorylation, and that this controls the stability of the genotype 1a NS2 protein. Here, we show that Ser-168 is a critical determinant in the production of infectious virus particles. Substitution of Ser-168 with Ala (or Gly) ablated production of infectious virus by cells transfected with a chimeric viral RNA (HJ3-5) containing core-NS2 sequences from the genotype 1a H77 virus within the background of genotype 2a JFH1 virus. An S168A substitution also impaired production of virus by cells transfected with JFH1 RNA. This mutation did not alter polyprotein processing or genome replication. This defect in virus production could be rescued by expression of wt NS2 in trans from an alphavirus replicon. The trans-complementing activities of NS2 from genotypes 1a and 2a demonstrated strong preferences for rescue of the homologous genotype. Importantly, the S168A mutation did not alter the association of core or NS5A proteins with host cell lipid droplets, nor prevent the assembly of core into particles with sedimentation and buoyant density properties similar to infectious virus, indicating that NS2 acts subsequent to the involvement of core, NS5A, and NS3 in particle assembly. Second-site mutations in NS2 as well as in NS5A can rescue the defect in virus production imposed by the S168G mutation. In aggregate, these results indicate that NS2 functions in trans, in a late-post assembly maturation step, perhaps in concert with NS5A, to confer infectivity to the HCV particle.

NS3 helicase domains involved in infectious intracellular hepatitis C virus particle assembly.

A mutation within subdomain 1 of the hepatitis C virus (HCV) NS3 helicase (NS3-Q221L) (M. Yi, Y. Ma, J. Yates, and S. M. Lemon, J. Virol. 81:629-638, 2007) rescues a defect in production of infectious virus by an intergenotypic chimeric RNA (HJ3). Although NS3-Gln-221 is highly conserved across HCV genotypes, the Leu-221 substitution had no effect on RNA replication or NS3-associated enzymatic activities. However, while transfection of unmodified HJ3 RNA failed to produce either extracellular or intracellular infectious virus, transfection of HJ3 RNA containing the Q221L substitution (HJ3/QL) resulted in rapid accumulation of intracellular infectious particles with release into extracellular fluids. In the absence of the Q221L mutation, both NS5A and NS3 were recruited to core protein on the surface of lipid droplets, but there was no assembly of core into high-density, rapidly sedimenting particles. Further analysis demonstrated that a Q221N mutation minimally rescued virus production and led to a second-site I399V mutation in subdomain 2 of the helicase. Similarly, I399V alone allowed only low-level virus production and led to selection of an I286V mutation in subdomain 1 of the helicase which fully restored virus production, confirming the involvement of both major helicase subdomains in the assembly process. Thus, multiple mutations in the helicase rescue a defect in an early-intermediate step in virus assembly that follows the recruitment of NS5A to lipid droplets and precedes the formation of dense intracellular viral particles. These data reveal a previously unsuspected role for the NS3 helicase in early virion morphogenesis and provide a new perspective on HCV assembly.

Compensatory mutations in E1, p7, NS2, and NS3 enhance yields of cell culture-infectious intergenotypic chimeric hepatitis C virus.

There is little understanding of mechanisms underlying the assembly and release of infectious hepatitis C virus (HCV) from cultured cells. Cells transfected with synthetic genomic RNA from a unique genotype 2a virus (JFH1) produce high titers of virus, while virus yields are much lower with a prototype genotype 1a RNA containing multiple cell culture-adaptive mutations (H77S). To characterize the basis for this difference in infectious particle production, we constructed chimeric genomes encoding the structural proteins of H77S within the background of JFH1. RNAs encoding polyproteins fused at the NS2/NS3 junction ("H-NS2/NS3-J") and at a site of natural, intergenotypic recombination within NS2 ["H-(NS2)-J"] produced infectious virus. In contrast, no virus was produced by a chimera fused at the p7-NS2 junction. Chimera H-NS2/NS3-J virus (vH-NS2/NS3-J) recovered from transfected cultures contained compensatory mutations in E1 and NS3 that were essential for the production of infectious virus, while yields of infectious vH-(NS2)-J were enhanced by mutations within p7 and NS2. These compensatory mutations were chimera specific and did not enhance viral RNA replication or polyprotein processing; thus, they likely compensate for incompatibilities between proteins of different genotypes at sites of interactions essential for virus assembly and/or release. Mutations in p7 and NS2 acted additively and increased the specific infectivity of vH-(NS2)-J particles, while having less impact on the numbers of particles released. We conclude that interactions between NS2 and E1 and p7 as well as between NS2 and NS3 are essential for virus assembly and/or release and that each of these viral proteins plays an important role in this process.