Pandemic of the century: COVID-19 in inflammatory rheumatic diseases of a national cohort with 3,532 patients.

Objectives: This study aimed to assess the clinical outcomes and risk factors for severe coronavirus disease 2019 (COVID-19) in patients with inflammatory rheumatic disease (IRD) of a national cohort. Patients and methods: The multicenter cross-sectional study was carried out between July 15, 2020, and February 28, 2021. Data collection was provided from a national network database system, and 3,532 IRD patients (2,359 males, 1,173 females; mean age: 48.7±13.9 years; range; 18 to 90 years) were analyzed. Demographics, clinics about rheumatic disease, comorbidities, smoking status, being infected with COVID-19, and the course of the infection were questioned by rheumatology specialists. Results: One hundred seventeen patients were infected with COVID-19, the hospitalization rate due to COVID-19 was 58.9%, and the mortality rate was 1.7%. There was no difference between the COVID-19 positive and negative groups in terms of rheumatic disease activities and receiving drugs. It was observed that patients with COVID-19 had worse compliance with isolation rules, and bacillus Calmette-Guérin (BCG) vaccination was less common. The mean age and the rate of smoking of hospitalized COVID-19 patients were higher than those without hospitalization. Conclusion: In this cohort, in which real-life data were analyzed, COVID-19 rates in IRD patients were similar to the general population for the same period. Compliance with the isolation rules and BCG vaccination attracted attention as components that reduce the risk of COVID-19 infection. The risk factors for hospitalization were older age and smoking.

Cross-sectional analysis of cardiovascular disease and risk factors in patients with spondyloarthritis: a real-life evidence from biostar nationwide registry.

The association between spondyloarthritis and cardiovascular (CV) diseases is complex with variable outcomes. This study aimed to assess the prevalence rates of CV diseases and to analyze the impact of CV risk factors on CV disease in patients with spondyloarthritis. A multi-center cross-sectional study using the BioSTAR (Biological and Targeted Synthetic Disease-Modifying Antirheumatic Drugs Registry) database was performed on patients with spondyloarthritis. Socio-demographic, laboratory, and clinical data were collected. Patients with and without major adverse cardiovascular events (MACE) were grouped as Group 1 and Group 2. The primary outcome was the overall group's prevalence rates of CV disease and CV risk factors. The secondary outcome was the difference in socio-demographic and clinical characteristics between the groups and predictive risk factors for CV disease. There were 1457 patients with a mean age of 45.7 ± 10.9 years. The prevalence rate for CV disease was 3% (n = 44). The distribution of these diseases was coronary artery disease (n = 42), congestive heart failure (n = 4), peripheral vascular disorders (n = 6), and cerebrovascular events (n = 4). Patients in Group 1 were significantly male (p = 0.014) and older than those in Group 2 (p < 0.001). There were significantly more patients with hypertension, diabetes mellitus, chronic renal failure, dyslipidemia, and malignancy in Group 1 than in Group 2 (p < 0.05). Smoking (36.7%), obesity (24.4%), and hypertension (13.8%) were the most prevalent traditional CV risk factors. Hypertension (HR = 3.147, 95% CI 1.461-6.778, p = 0.003), dyslipidemia (HR = 3.476, 95% CI 1.631-7.406, p = 0.001), and cancer history (HR = 5.852, 95% CI 1.189-28.810, p = 0.030) were the independent predictors for CV disease. A multi-center cross-sectional study using the BioSTAR (Biological and Targeted Synthetic Disease-Modifying Antirheumatic Drugs Registry) database was performed on patients with spondyloarthritis. Socio-demographic, laboratory, and clinical data were collected. Patients with and without major adverse cardiovascular events (MACE) were grouped as Group 1 and Group 2. The primary outcome was the overall group's prevalence rates of CV disease and CV risk factors. The secondary outcome was the difference in socio-demographic and clinical characteristics between the groups and predictive risk factors for CV disease. There were 1457 patients with a mean age of 45.7 ± 10.9 years. The prevalence rate for CV disease was 3% (n = 44). The distribution of these diseases was coronary artery disease (n = 42), congestive heart failure (n = 4), peripheral vascular disorders (n = 6), and cerebrovascular events (n = 4). Patients in Group 1 were significantly male (p = 0.014) and older than those in Group 2 (p < 0.001). There were significantly more patients with hypertension, diabetes mellitus, chronic renal failure, dyslipidemia, and malignancy in Group 1 than in Group 2 (p < 0.05). Smoking (36.7%), obesity (24.4%), and hypertension (13.8%) were the most prevalent traditional CV risk factors. Hypertension (HR = 3.147, 95% CI 1.461-6.778, p = 0.003), dyslipidemia (HR = 3.476, 95% CI 1.631-7.406, p = 0.001), and cancer history (HR = 5.852, 95% CI 1.189-28.810, p = 0.030) were the independent predictors for CV disease. The prevalence rate of CV disease was 3.0% in patients with spondyloarthritis. Hypertension, dyslipidemia, and cancer history were the independent CV risk factors for CV disease in patients with spondyloarthritis.

Comparison of preoperative magnetic resonance imaging with postoperative pathology results in rectal cancer patients undergoing neoadjuvant therapy.

BACKGROUND: Locally advanced rectal cancer often requires neoadjuvant treatment (NAT) before surgical intervention. This study aimed to assess the concordance between preoperative magnetic resonance imaging (MRI) findings and postoperative pathology results after NAT in rectal cancer patients. METHOD: A retrospective analysis of 52 patients who underwent NAT and subsequent surgery at Ankara Bilkent City Hospital between May 2019 and May 2023 was conducted. Demographics, preoperative MRIs, time intervals between NAT, MRI, and surgery, and postoperative pathology were assessed. RESULTS: The median age of the cohort was 59 years, with a male predominance (76.9%). Tumour T stage (κ = 0.157), lymph node stage (κ = 0.138), and circumferential resection margin (κ = 0.138) concordance showed poor agreement between post-neoadjuvant treatment (PNT) MRI and pathology. PNT MRI demonstrated a limited correlation with postoperative pathology. CONCLUSIONS: While preoperative MRI is commonly used for restaging after NAT in rectal cancer, our study highlights its limited concordance with postoperative pathology. The sensitivity and specificity metrics, although reported in the literature, should be interpreted alongside concordance assessments for a comprehensive evaluation.

Real-life data on the comorbidities in spondyloarthritis from our multicenter nationwide registry: BioStar.

Objectives: Considering that the comorbid situations during the management of Spondyloarthritis (SpA) have been underlined in several recommendations, the main objective of this study was to evaluate the comorbid conditions of Turkish patients with SpA. Patients and methods: This cross-sectional observational study was conducted with 1,242 SpA patients (844 males, 398 females; mean age: 43.9±11.0 years; range, 19 to 81 years) diagnosed according to the modified New York criteria for ankylosing spondylitis or the Assessment of SpondyloArthritis International Society (ASAS) criteria. The patient data were collected from the Biologic and targeted Synthetic antirheumatic drugs Registry (BioStar) between February 1, 2019, and December 29, 2020. Clinical and demographic data, including, age, sex, disease duration, body mass index (BMI), pain, patient's global assessment, physician's global assessment, Bath Ankylosing Spondylitis Disease Activity Index, Ankylosing Spondylitis Disease Activity Score, Bath Ankylosing Spondylitis Functional Index, Bath Ankylosing Spondylitis Metrology Index, and Maastricht Enthesitis Score, were recorded. Comorbid conditions were recorded by filling out a questionnaire according to the clinical history or medical records. Charlson Comorbidity Index and Rheumatic Disease Comorbidity Index scores were calculated from the gathered comorbidity information. Results: Nine hundred thirteen patients had radiographic axial SpA, 153 had nonradiographic axial SpA, and 176 had peripheral SpA. The most common comorbidities were hypertension (HT) (n=167, 13.4%), diabetes mellitus (DM) (n=83, 6.7%), thyroid disorders (n=64, 5.6%), and depression (n=61, 4.9%). The comorbidities and the calculated comorbidity indices were significantly higher in females, in those with a BMI >25 kg/m2 , and those over 60 years of age. No relationship was found between smoking and alcohol use and comorbidities. A significantly higher prevalence of HT and DM in peripheral SpA patients and a lower prevalence of thyroid disorders in radiographic axial SpA patients were observed. Conclusion: The most commonly reported comorbidities were HT, DM, thyroid disorders, and depression in SpA patients according to the BioStar database. The frequency of comorbidities and composite comorbidity scores were higher among females, older (>60 years) patients, and overweight (BMI >25 kg/m2 ) patients.

Investigation of the clinical efficacy of thiol-disulfide homeostasis, delta neutrophil index, and ischemia-modified albumin in cases of incarcerated and strangulated hernia.

BACKGROUND: The treatment of patients presenting with the diagnosis of incarcerated and/or strangulated inguinal hernia is mostly surgery. If strangulation and necrosis are present, the need for laparotomy arises, which may increase the risk of morbidity. Currently, it is not possible to clearly determine whether there is bowel ischemia and necrosis before surgery. In this study, we aimed to investigate the clinical efficacy of the thiol-disulfide homeostasis, delta neutrophil index (DNI), and ischemia-modified albumin (IMA) parameters in incarcerated and strangulated hernia cases. METHODS: Patients that presented to the general surgery outpatient clinic due to inguinal hernia or to the emergency department of the hospital with a preliminary diagnosis of incarcerated and/or strangulated hernia in April 2021-November 2021 were included in the study. The patients were divided into the following four groups: patients that underwent elective repair for inguinal hernia (Group 1), those who were followed up without surgery due to incarcerated hernia (Group 2), those who underwent hernia repair without bowel resection due to incarceration (Group 3), and those who underwent bowel resection due to strangulation (Group 4). Group 1 was defined as the control group, while Groups 2, 3, and Group 4 were evaluated as the incarcerated/strangulated hernia group. The demographic data of the patients, length of hospital stay, body mass index, comorbidities, medical history and physical examina-tion findings, radiological examinations, treatments applied, white blood cell (WBC) count, lactate, and DNI, thiol-disulfide and IMA parameters were evaluated. RESULTS: The WBC count, disulfide/native thiol, disulfide/total thiol, and IMA values were significantly higher in the incarcerated/strangulated hernia group than in the control group, while the native thiol and total thiol values were higher in the latter than in the former (P<0.05). There was no statistically significant difference between the groups in terms of lactate (P>0.05), but the mean WBC count was higher in Group 4 compared to Group 1, and the mean DNI was significantly higher among the patients who underwent bowel resection and anastomosis than in those that were followed up and discharged (P<0.05). CONCLUSION: We consider that the preoperative evaluation of the thiol-disulfide homeostasis, IMA, and DNI parameters in incarcerated/strangulated hernia cases can be an effective and easily applicable method in predicting difficulties that may be encountered intraoperatively and the surgical procedure to be applied to the patient.

A new, simple marker for predicting complicated appendicitis in patients with normal white blood cell count indicator; LUC.

BACKGROUND: The aim of this study was to investigate the ability of a new marker that could be easily obtained to differentiate between complicated and uncomplicated appendicitis in a patients with a white blood cell (WBC) count within the normal range. METHODS: The patients who underwent surgery with histopathologically proven acute appendicitis (AA) between January 2021 and October 2022 were evaluated retrospectively. Patients were classified into two groups as uncomplicated and complicated appendicitis, based on the surgical and histopathological findings. Groups were compared in terms of laboratory parameters at the time of hospital admission. RESULTS: During the study period, 2589 patients underwent an appendectomy, among these 612 patients who had a WBC count within the normal range at the time of admission were analyzed. Uncomplicated appendicitis was detected in 79.6% of the patients and complicated appendicitis in 20.4%. Neutrophil%, neutrophil-to-lymphocyte ratio, C-reactive protein, and total bilirubin levels were significantly higher, whereas lymphocyte%, lymphocyte count, lymphocyte-to-monocyte ratio, sodium levels, and large unstained cells (LUC)% were significantly lower in patients with complicated appendicitis. Multiple logistic regression analysis revealed that lower LUC% (Odds Ratio [OR]: 0.45; 95% Confidence Intervals [CI]: 1.08-2.09; P=0.01) and higher total bilirubin levels (OR: 1.50; 95% CI: 1.08-2.09; P=0.01) were independent risk factors for complicated appendicitis. CONCLUSION: In patients with a diagnosis of AA with a normal WBC value, LUC% obtained from the complete blood count can be used as a new parameter predicting the diagnosis of complicated appendicitis.

Xanthogranulomatous Cholecystitis and Gallbladder Cancer: Two Diseases with Difficult Differential Diagnoses.

BACKGROUND: Xanthogranulomatous cholecystitis (XGC) etiology has not yet been precisely determined; it is often confused with gallbladder cancer (GBC) in the differential diagnosis. METHODS: This study retrospectively evaluated patients who underwent surgery with the pre-diagnosis of cholelithiasis, cholecystitis, or gallbladder carcinoma at a tertiary center, and were confirmed to have XGC or GBC according to the histological examinations. RESULTS: In the GBC group, there was a higher number of female patients, patients with magnetic resonance imaging (MRI) and computed tomography (CT) imaging, those that directly underwent open surgery, and those requiring catheters and developed complications; while in the XGC group, there was a higher number of patients with ultrasonography (USG) imaging and those requiring conversion from laparoscopic to open surgery (P < .05). The rate of patients with a preoperative diagnosis of cholelithiasis was higher in the XGC group than in the GBC group, and cases with intrahepatic bile duct (IHBD) dilatation were higher in the GBC group than in the XGC group, and the GBC group also had a higher rate of cases with a malignant diagnosis in the preoperative examination compared to the XGC group (P < .05). CONCLUSION: When a suspicious malignant mass is detected in the localization of the gallbladder, XGC must be considered in the differential diagnosis. Although it is not a malignant pathology, early diagnosis and treatment are particularly important due to the associated complications and the possibility of coexistence with GBC.

Assessment of the relationship between endocan and obstructive sleep apnea severity.

INTRODUCTION: Obstructive sleep apnea (OSA) and endothelial dysfunction are associated with cardiovascular risk factors and the development of atherosclerosis. Endocan is a marker of endothelial dysfunction, while obstructive sleep apnea is one of the causes of endothelial dysfunction. In this study, we investigated the relationship between endocan and obstructive sleep apnea severity. MATERIAL AND METHODS: A total of 179 patients with snoring complaints were included. All patients underwent polysomnography, and based on the results, the participations were allocated to the control group (n = 39) or to the obstructive sleep apnea group (n = 140). The OSA group was classified as having mild (apnea-hypopnea index (AHI) = 5-15; n = 43), moderate (AHI = 15-30; n = 42), or severe OSA (AHI > 30; n = 55). All participations had their endocan levels measured. RESULTS: Endocan levels in OSA patients were significantly higher than in the control group (11.8 (3.13-200) vs 3.13 (3.13-23) ng/ml, p < 0.001). Also, endocan levels were significantly higher in the severe OSA group than moderate and mild obstructive OSA (13.2 (3.13-200), 12.6 (3.13-200) and 8.44 (3.13-50.5) ng/ml, p = 0.015, respectively). Multiple logistic regression analysis showed that smoking, age and endocan levels were independent predictors of OSA severity (p = 0.024, p = 0.037, p = 0.004, respectively). CONCLUSIONS: Endocan seems to be a potential risk stratification marker in this patient population.

Textbook Outcomes Among Medicare Patients Undergoing Hepatopancreatic Surgery.

OBJECTIVE: To define and test "Textbook Outcome" (TO)-a composite measure for healthcare quality-among Medicare patients undergoing hepatopancreatic resections. Hospital variation in TO and Medicare payments were analyzed. BACKGROUND: Composite measures of quality may be superior to individual measures for the analysis of hospital performance. METHODS: The Medicare Provider Analysis and Review (MEDPAR) Inpatient Files were reviewed to identify Medicare patients who underwent pancreatic and liver procedures between 2013 and 2015. TO was defined as: no postoperative surgical complications, no prolonged length of hospital stay, no readmission ≤ 90 days after discharge, and no postoperative mortality ≤ 90 days after surgery. Medicare payments were compared among patients who achieved TO versus patients who did not. Multivariable logistic regression was used to investigate patient factors associated with TO. A nomogram to predict probability of TO was developed and validated. RESULTS: TO was achieved in 44% (n = 5919) of 13,467 patients undergoing hepatopancreatic surgery. Adjusted TO rates at the hospital level varied from 11.1% to 69.6% for pancreatic procedures and from 16.6% to 78.7% for liver procedures. Prolonged length of hospital stay represented the major obstacle to achieve TO. Average Medicare payments were substantially higher among patients who did not have a TO. Factors associated with TO on multivariable analysis were age, sex, Charlson comorbidity score, previous hospital admissions, procedure type, and surgical approach (all P > 0.05). CONCLUSIONS: Less than one-half of Medicare patients achieved a TO following hepatopancreatic procedures with a wide variation in the rates of TO among hospitals. There was a discrepancy in Medicare payments for patients who achieved a TO versus patients who did not. TO could be useful for the public reporting of patient level hospital performance and hospital variation.

Patient preferences on the use of technology in cancer surveillance after curative surgery: A cross-sectional analysis.

BACKGROUND: Advances in communication technology have enabled new methods of delivering test results to cancer survivors. We sought to determine patient preferences regarding the use of newer technology in delivering test results during cancer surveillance. METHODS: A single institutional, cross-sectional analysis of the preferences of adult cancer survivors regarding the means (secure digital communication versus phone call or office visit) to receive surveillance test results was undertaken. RESULTS: Among 257 respondents, the average age was 59.1 years (SD 13.5) and 61.8% were female. Common malignancies included melanoma/sarcoma (29.5%), thyroid (25.7%), breast (22.8%), and gastrointestinal (22.0%) cancer. Although patients expressed a relative preference to receive normal surveillance results via MyChart or secure e-mail, the majority preferred abnormal imaging (87.2%) or blood results (85.9%) to be communicated by in-office appointments or phone calls irrespective of age or cancer type. Patients with a college degree or higher were more likely to prefer electronic means of communication of abnormal blood results compared with a telephone call or in-person visit (odds ratio 2.18, 95% confidence interval: 1.01-4.73, P < .05). In contrast, patients >65 years were more likely to express a preference for telephone or in-person communication of normal imaging results (odds ratio: 2.03, 95% CI: 1.16-3.56, P < .05) versus patients ≤65 years. Preference also varied according to malignancy type. CONCLUSION: Although many cancer patients preferred to receive "normal" surveillance results electronically, the majority preferred receiving abnormal results via direct conversation with their provider. Shifting routine communication of normal surveillance results to technology-based applications may improve patient satisfaction and decrease health care system costs.

Complications after liver surgery: a benchmark analysis.

BACKGROUND: The best achievable short-term outcomes after liver surgery have not been identified. Several factors may influence the post-operative course of patients undergoing hepatectomy increasing the risk of post-operative complications. We sought to identify risk-adjusted benchmark values [BMV] for liver surgery. METHODS: The National Surgery Quality Improvement Program (NSQIP) database was used to develop Bayesian models to estimate risk-adjusted BMVs for overall and liver related (post-hepatectomy liver failure [PHLF], biliary leakage [BL]) complications. A separate international multi-institutional database was used to validate the risk-adjusted BMVs. RESULTS: Among the 11,243 patients included in the NSQIP database, the incidence of complications, PHLF, and BL was 36%, 5%, and 8%, respectively. The risk-adjusted BMVs for complication (range, 16-72%), PHLF (range, 1%-20%), and BL (range, 4%-22%) demonstrated a high variability based on patients characteristics. When tested using an international database including nine institutes, the risk-adjusted BMVs for complications ranged from 26% (Institute-4) to 43% (Institute-1), BMVs for PHLF between 3% (Institute-3) and 12% (Institute-5), while BMVs for BL ranged between 5% (Institute-4) and 9% (Institute-7). CONCLUSIONS: Multiple factors influence the risk of complications following hepatectomy. Risk-adjusted BMVs are likely much more applicable and appropriate in assessing "acceptable" benchmark outcomes following liver surgery.

Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy-Stratification of Patient Risk.

BACKGROUND: Postoperative pancreatic fistula (POPF) remains a major cause of morbidity following pancreaticoduodenectomy (PD). We sought to develop and validate a risk score system that utilized preoperative computed tomography (CT) measurements, laboratory values, and intraoperative pancreatic texture to estimate risk of developing POPF after PD. METHODS: Patients who underwent PD between 2014 and 2017 were identified. Pre- and intraoperative risk factors associated with POPF were identified. Three separate risk models were developed and assessed using multivariable analyses and receiver operating curves. RESULTS: Among the 150 patients who underwent a PD, mean age was 64 years and the majority of the patients were male (59.3%, n = 89). Overall, the incidence of BL/POPF following PD was 22%. On multivariable analysis, factors associated with POPF included preoperative total serum protein < 6 g/dL (OR 3.35, 95% CI 1.04-10.34, p = 0.04), radiologic pancreatic duct diameter (OR 0.72, 95% CI 0.53-0.97, p = 0.03), intraoperative pancreatic gland texture estimated by surgeon (OR 0.17, 95% CI 0.05-0.62, p = 0.006), as well as intraoperative pancreatic duct diameter measured by surgeon (OR 0.77, 95% CI 0.61-0.98, p = 0.030). Each risk factor was assigned a weighted score (CT pancreatic duct diameter < 5 mm: 8 points; soft pancreatic gland texture: 5 points; total serum protein < 6 g/dL: 3 points; CT visceral abdominal fat ≥ 230 cm2: 2 points). Patients scoring 4-5 were at low risk of POPF, while patients with a score of 6-18 had a high risk for POPF. The Harrell's c-index for the scoring system was 0.71 (standard error [SD] 0.094) for the training set and 0.67 (SD 0.034) for the test set (with n = 1000 bootstrapping resamples). CONCLUSION: A simple risk score for POPF that utilized preoperative radiologic and clinical variables combined with specific intra-operative factors was able to stratify patients relative to POPF risk with good discriminatory ability.

Procedure-Specific Volume and Nurse-to-Patient Ratio: Implications for Failure to Rescue Patients Following Liver Surgery.

BACKGROUND: The effect of various hospital characteristics on failure to rescue (FTR) after liver surgery has not been well examined. We sought to examine the relationship between hospital characteristics and FTR after liver surgery. METHODS: The 2013-2015 Medicare-Provider Analysis and Review (MEDPAR) database was used to identify Medicare beneficiaries who underwent liver surgery. The effect of various hospital characteristics on FTR was compared among the highest mortality hospitals (HMH) and the lowest mortality hospitals (LMH). RESULTS: Among 4902 patients undergoing hepatectomy, patients treated at HMH had a higher risk of FTR (OR 3.08, 95% CI 2.03-4.66). Hospital factors such as total number of beds (OR 0.80, 95% 0.56-1.15), operating rooms (OR 0.81, 95% 0.57-1.14), and overall hospital surgical volume (OR 0.88, 95% 0.61-1.25) were not associated with FTR (all p > 0.05). In contrast, hospitals with a greater nurse-to-patient ratio had a markedly lower risk of FTR following a complication (OR 0.70, 95% CI 0.54-0.91; p = 0.007) (Table 3). As volume of liver operations and nurse-to-patient ratio decreased the risk of FTR increased (p > 0.001). After risk-adjusting for patient characteristics, both the effect of surgical volume (adjusted OR 0.66, 95% CI 0.46-0.94; p = 0.022) and nurse-to-patient ratio (adjusted OR 0.68, 95% CI 0.51-0.90; p = 0.008) remained strongly associated with FTR. CONCLUSION: FTR rates varied considerably among hospital performing hepatectomy. Higher procedure-specific hepatectomy volume, as well as a higher nurse-to-patient ratio, accounted for a reduction in the FTR rates. These data highlight the importance of not only procedure volume, but also adequate nurse staffing in reducing FTR and improving mortality following complex procedures such as hepatectomy.

Perioperative use of blood products is associated with risk of morbidity and mortality after surgery.

BACKGROUND: Administration of blood products may be associated with increased morbidity and perioperative mortality in surgical patients. METHODS: Patients aged 18 + who underwent gastrointestinal surgery at the Ohio State University Wexner Medical Center 9/10/2015-5/9/2018 were identified. Multivariable logistic regression models were used to evaluate impact of blood product use on survival and complications, as well as to identify factors associated with receipt of transfusions. RESULTS: Among 10,756 patients, 35,517 units of blood products were transfused. Preoperative nadir hemoglobin was associated with receipt of blood product transfusion (OR 0.55, 95% CI 0.53, 0.68). After adjusting for patient and procedural characteristics, patients undergoing transfusion of blood products had an increased risk of perioperative mortality (OR 7.80, 95% CI 6.02, 10.10). CONCLUSIONS: The use of blood products was associated with increased risk of complication and death. Patient blood management programs should be implemented to provide rational criteria and guidance for the transfusion of blood products.

Variation in the cost-of-rescue among medicare patients with complications following hepatopancreatic surgery.

BACKGROUND: The relationship of expenditures related to rescuing patients from complications and hospital quality has not been well characterized. We sought to examine the relationship between payments for treating post-operative complications after liver and pancreas surgery and hospital quality. METHODS: A retrospective cohort study of patients who underwent hepatopancreatic surgery was performed using claims data from 2013 to 2015 in the Medicare Provider Analysis and Review (MEDPAR) database. Medicare payments for index hospitalization and readmissions, as well as perioperative clinical outcomes were analyzed. Hospitals were stratified using average payments for patients who were rescued from complications (cost-of-rescue). RESULTS: A total of 13,873 patients and 737 hospitals were included in the analyses. Patient characteristics were similar across hospitals. Risk-adjusted rates of overall complications were higher at the highest cost-of-rescue hospitals (relative risk [RR], 1.35, 95% confidence interval [CI] 1.16-1.58), as well as rates of serious complications (RR, 1.78, 95% CI 1.51-2.09), 30-day readmission (RR 1.21 95% CI 1.06-1.39), 90-day mortality (RR, 1.29, 95% CI 1.01-1.64), and rates of failure-to-rescue (RR, 1.50, 95% CI 1.14-1.97). CONCLUSION: Highest cost-of-rescue hospitals demonstrated worse quality metrics, including higher rates of serious complications, failure-to-rescue, 30-day readmission, and 90-day mortality.

Index versus Non-index Readmission After Hepato-Pancreato-Biliary Surgery: Where Do Patients Go to Be Readmitted?

INTRODUCTION: The Center for Medicare and Medicaid Services (CMS) has identified readmission as an important quality metric. With an increased emphasis on regionalization of complex hepato-pancreato-biliary (HPB) surgery to high-volume centers, care of readmitted HPB patients may be fragmented if readmission occurs at a non-index hospital. We sought to define the proportion of HPB readmissions, as well as evaluate outcomes, that occur at an index versus non-index hospitals and to identify factors associated with non-index hospital readmission. METHODS: The National Readmissions Database (NRD) was used to identify patients who underwent major HPB surgery between 2010 and 2015. Factors associated with readmission at 30 and 90 days at index versus non-index hospitals were analyzed. Differences in mortality and complications were analyzed among patients readmitted to index versus non-index hospitals. RESULTS: A total of 49,080 patients underwent HPB surgery (liver n = 27,081, 55%; pancreas n = 14,787, 30%; biliary n = 7212, 15%). Overall, 6643 (14%) and 11,709 (24%) patients were readmitted within 30 and 90 days, respectively. Among all first readmissions, 18 and 21% were to a non-index hospital within the first 30 and 90 days, respectively. On multivariable analysis, factors associated with readmission to a non-index hospital included age (OR 1.19, 95% CI 1.05, 1.34), pancreatic cancer (OR 1.40, 95% CI 1.14, 1.34) and ≥ 3 comorbidities (OR 1.34, 95% CI 1.10, 1.63), while procedures on the pancreas (OR 0.69, 95% CI 0.61, 0.80), private insurance (OR 0.77, 95% CI 0.68, 0.87), initial admission at a large hospital (OR 0.77, 95% CI 0.65, 0.91), and initial admission length of stay > 7 days (OR 0.77, 95% CI 0.69, 0.86) were associated with decreased odds of a non-index hospital readmission (all p < 0.05). Patients readmitted to a non-index hospital had higher inpatient mortality (3.7 vs. 2.7%, p = 0.010). CONCLUSIONS: Roughly 1 in 5 patients were readmitted to a non-index hospital where the initial HPB operation had not taken place. Readmission to a non-index hospital was associated with higher overall in-hospital mortality. The impact of regionalization of HPB care relative to site of subsequent readmission may have important implications for patients.

Serum levels of tumor necrosis factor-like weak inducer of apoptosis (TWEAK) in predicting the severity of acute pancreatitis.

INTRODUCTION: Acute pancreatitis (AP) is a severe disease associated with significant morbidity and mortality. The overall outcome has improved, but specific treatment(s) remains elusive. The challenge is the early identification and treatment of patients who will develop severe acute pancreatitis. Therefore, the aim of the present study is to investigate plasma levels of tumor necrosis factor-like weak inducer of apoptosis (TWEAK) in the initial phase of predicted severe acute pancreatitis. METHODS: Between June 2014 and January 2016, 64 patients with acute pancreatitis and 36 healthy individuals were included to study. Four blood samples, for serum TWEAK measurement, were taken from each individual in each group. The first measurement was taken from the admission blood sample. The subsequent three samples were taken at 12, 24, and 48 h after the hospital admission. RESULTS: Serum TWEAK levels were significantly higher in patients with acute pancreatitis when compared with healthy controls. TWEAK plasma concentrations in severe pancreatitis patients were significantly higher than in mild pancreatitis patients. CONCLUSION: Serum TWEAK levels increase progressively with the severity of acute pancreatitis and TWEAK might be a novel early marker of severity in acute pancreatitis.

Time to Readmission and Mortality Among Patients Undergoing Liver and Pancreatic Surgery.

BACKGROUND: The impact of time to readmission (TTR) on post-discharge mortality has not been well examined. We sought to define the impact of TTR on postoperative mortality after liver or pancreas surgery. METHODS: A retrospective cohort analysis of liver and pancreas surgical patients was conducted using 2013-2015 Medicare Provider Analysis and Review database. Patients were subdivided into TTR groups: 1-5 days, 6-15, 15-30, 31-60, 61-90, and no readmission. The association of index complication, readmission causes, TTR, and mortality was assessed. RESULTS: Among 18,177 patients, a total of 4485 (24.7%) patients were readmitted within 90 days of discharge. Major causes for readmission differed across TTR groups. Patients readmitted within 1-15 days were more likely to be readmitted for postoperative infection compared with patients who had a late readmission (1-5 days: 63.1% vs. 6-15 days: 65.0% vs. 61-90 days: 39.3%; P < 0.001). In contrast, causes of late readmissions were more likely related to gastrointestinal complications (1-5 days: 28.9% vs. 61-90 days: 39.7%; P < 0.001). Compared with no readmission, 180-day mortality was highest among patients readmitted within 16-30 days (aOR 3.60; 95% CI 2.94-4.41). Among patients with index complications, patients who were readmitted within 1-5 days had a higher risk-adjusted 180-day mortality than late readmission (1-5 days: 37.3% vs. 61-90 days: 27.1%) (P < 0.001). CONCLUSIONS: Among patients who were readmitted, the incidence of mortality increased with TTR up to 60 days after discharge yet decreased thereafter. The relation of TTR and mortality was particularly pronounced among those patients who had an index complication. Future efforts should consider TTR when identifying specific approaches to decrease readmission.

Management of Psoriatic Arthritis: Turkish League Against Rheumatism (TLAR) Expert Opinions.

OBJECTIVES: This study aims to establish the first national treatment recommendations by the Turkish League Against Rheumatism (TLAR) for psoriatic arthritis (PsA) based on the current evidence. PATIENTS AND METHODS: A systematic literature review was performed regarding the management of PsA. The TLAR expert committee consisted of 13 rheumatologists and 12 physical medicine and rehabilitation specialists experienced in the treatment and care of patients with PsA from 22 centers. The TLAR recommendations were built on those of European League Against Rheumatism (EULAR) 2015. Levels of evidence and agreement were determined. RESULTS: Recommendations included five overarching principles and 13 recommendations covering therapies for PsA, particularly focusing on musculoskeletal involvement. Level of agreement was greater than eight for each item. CONCLUSION: This is the first paper that summarizes the recommendations of TLAR as regards the treatment of PsA. We believe that this paper provides Turkish physicians dealing with PsA patients a practical guide in their routine clinical practice.

Preoperative prognostic nutritional index predicts survival of patients with intrahepatic cholangiocarcinoma after curative resection.

BACKGROUND: Intrahepatic cholangiocarcinoma (ICC) is an aggressive malignancy. We sought to examine the association between preoperative prognostic nutritional index (PNI) and long-term overall survival among patients with ICC who underwent curative-intent resection. METHODS: Patients who underwent hepatectomy for ICC between 1990 and 2015 were identified using an international multi-institutional database. Clinic-pathological characteristics and long-term outcomes of patients with PNI ≥ 40 and <40 were compared using univariable and multivariable analyses. RESULTS: Among 637 patients, 53 patients had PNI < 40 (8.3%) and 584 patients had PNI ≥ 40 (91.7%). While there was no difference between PNI groups with regard to tumor size (P = .87), patients with PNI < 40 were more likely to have multifocal disease (PNI < 40, n = 16, 30.2% vs PNI ≥ 40, n = 65, 11.1%; P < 0.001), poorly differentiated or undifferentiated ICC (PNI < 40, n = 13, 25.5% vs PNI ≥ 40, n = 75, 13.1%; P = 0.020) and T2/T3/T4 disease vs patients with PNI ≥ 40 (PNI < 40, n = 38, 71.7% vs PNI ≥ 40, n = 265, 45.4%; P < 0.001). Patients with PNI ≥ 40 had better OS vs patients with PNI < 40 (5-year OS: PNI ≥ 40: 47.5%, 95% CI, 42.2 to 52.6% vs PNI < 40: 24.6%, 95% CI, 12.1 to 39.6%; P < 0.001). On multivariable analysis, PNI < 40 remained associated with increase risk of death (HR, 1.71; 95% CI, 1.15 to 2.53; P = 0.008). CONCLUSION: A low preoperative PNI was associated with a more aggressive ICC phenotype. After controlling for these factors, PNI remained independently associated with a markedly worse prognosis.