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.

Factors influencing hospital stay duration for patients with mild ischemic colitis: a retrospective study.

BACKGROUND: Ischemic colitis is the most prevalent ischemic injury of the gastrointestinal tract. The majority of patients with mild ischemic colitis usually achieve complete clinical recovery shortly. However, the predictors of longer hospital stay duration are unclear. This study aimed to evaluate the predictors of hospital stay duration for patients with mild ischemic colitis. METHODS: We retrospectively evaluated 100 patients with mild ischemic colitis between January 2010 and December 2020 at Xiangya Hospital (a tertiary care center). The clinical characteristics and therapeutic drugs of patients who were hospitalized for ≤ 8 days and ≥ 12 days were compared. RESULTS: Of the 100 patients included, 63 (63%) were hospitalized for ≤ 8 days and 37 (37%) were hospitalized for ≥ 12 days. Patients with cerebrovascular disease (29.7% vs. 11.1%, p = 0.019) and abdominal surgical history (29.7% vs. 7.9%, p = 0.004) were more likely to be hospitalized for ≥ 12 days than for ≤ 8 days. The D-dimer levels [0.78 (0.41-1.82) vs. 0.28 (0.16-0.73), p = 0.001] and positive fecal occult blood test results (86.5% vs. 60.3%, p = 0.006) were higher in patients who were hospitalized for ≥ 12 days than in those who were hospitalized for ≤ 8 days. Probiotic use was greater in patients hospitalized for ≤ 8 days (76.2% vs. 54.1%, p = 0.022). Multivariate analysis indicated that cerebrovascular disease (odds ratio [OR] = 4.585; 95% confidence interval [CI] 1.129-18.624; p = 0.033), abdominal surgical history (OR = 4.551; 95% CI 1.060-19.546; p = 0.042), higher D-dimer levels (OR = 1.928; 95% CI 1.024-3.632; p = 0.042), and higher positive fecal occult blood test results (OR = 7.211; 95% CI 1.929-26.953; p = 0.003) were associated with longer hospital stays. CONCLUSION: Cerebrovascular disease, abdominal surgical history, higher D-dimer levels, and higher positive fecal occult blood test results are independent and significant factors that influence longer hospital stays for patients with mild ischemic colitis. Probiotics helped reduce hospital stay in these patients.

Severe maternal morbidity: admission shift from intensive care unit to obstetric high-dependency unit.

BACKGROUND: To study temporal trends of intensive care unit (ICU) admission in obstetric population after the introduction of obstetric high-dependency unit (HDU). METHODS: This is a retrospective study of consecutive obstetric patients admitted to the ICU/HDU in a provincial referral center in China from January 2014 to December 2019. The collected information included maternal demographic characteristics, indications for ICU and HDU admission, the length of ICU stay, the total length of in-hospital stay and APACHE II score. Chi-square and ANOVA tests were used to determine statistical significance. The temporal changes were assessed with chi-square test for linear trend. RESULTS: A total of 40,412 women delivered and 447 (1.11%) women were admitted to ICU in this 6-year period. The rate of ICU admission peaked at 1.59% in 2016 and then dropped to 0.67% in 2019 with the introduction of obstetric HDU. The average APACHE II score increased significantly from 6.8 to 12.3 (P < 0.001) and the average length of ICU stay increased from 1.7 to 7.1 days (P < 0.001). The main indications for maternal ICU admissions were hypertensive disorders in pregnancy (39.8%), cardiac diseases (24.8%), and other medical disorders (21.5%); while the most common reasons for referring to HDU were hypertensive disorders of pregnancy (46.5%) and obstetric hemorrhage (43.0%). The establishment of HDU led to 20% reduction in ICU admission, which was mainly related to obstetric indications. CONCLUSIONS: The introduction of HDU helps to reduce ICU utilization in obstetric population.

Beyond the revised cardiac risk index: Validation of the hospital frailty risk score in non-cardiac surgery.

Frailty is an established risk factor for adverse outcomes following non-cardiac surgery. The Hospital Frailty Risk Score (HFRS) is a recently described frailty assessment tool that harnesses administrative data and is composed of 109 International Classification of Disease variables. We aimed to examine the incremental prognostic utility of the HFRS in a generalizable surgical population. Using linked administrative databases, a retrospective cohort of patients admitted for non-cardiac surgery between October 1st, 2008 and September 30th, 2019 in Alberta, Canada was created. Our primary outcome was a composite of death, myocardial infarction or cardiac arrest at 30-days. Multivariable logistic regression was undertaken to assess the impact of HFRS on outcomes after adjusting for age, sex, components of the Charlson Comorbidity Index (CCI), Revised Cardiac Risk Index (RCRI) and peri-operative biomarkers. The final cohort consisted of 712,808 non-cardiac surgeries, of which 55·1% were female and the average age was 53·4 +/- 22·4 years. Using the HFRS, 86.3% were considered low risk, 10·7% were considered intermediate risk and 3·1% were considered high risk for frailty. Intermediate and high HFRS scores were associated with increased risk of the primary outcome with an adjusted odds ratio of 1·61 (95% CI 1·50-1.74) and 1·55 (95% CI 1·38-1·73). Intermediate and high HFRS were also associated with increased adjusted odds of prolonged hospital stay, in-hospital mortality, and 1-year mortality. The HFRS is a minimally onerous frailty assessment tool that can complement perioperative risk stratification in identifying patients at high risk of short- and long-term adverse events.

Association Between Health Literacy and Enhanced Recovery After Surgery Protocol Adherence and Postoperative Outcomes Among Patients Undergoing Colorectal Cancer Surgery: A Prospective Cohort Study.

BACKGROUND: Low health literacy (HL) adversely affects medical adherence and health outcomes in patients with chronic diseases. However, the association between HL and enhanced recovery after surgery (ERAS) adherence and postoperative outcomes has not been investigated in patients undergoing colorectal surgery. METHODS: The data of all patients from a single academic institution who underwent colorectal surgery on an ERAS pathway from January 2019 to July 2020 were prospectively collected. HL levels were assessed using the Brief Health Literacy Screen (BHLS), a proven tool that was used by surgeons after recruitment. According to the HL score, the participants were categorized into low HL (≤9 points) and high HL (10-15 points) groups. The primary outcome was ERAS adherence. Adherence was measured in 22 perioperative elements, and high adherence was defined as adherence to 17 to 22 elements. Secondary outcomes included postoperative complications, hospital length of stay (LOS), hospital charges, mortality, and readmissions. RESULTS: Of the 865 eligible patients, the high HL group consisted of 329 patients (38.0%), and the low HL group contained 536 patients (62.0%). After propensity score matching (1:1), 240 unique pairs of patients with similar characteristics were selected. Patients with high HL levels had a significantly higher rate of high adherence to ERAS standards than those with low HL levels (55% vs 25.8%; adjusted P < .001). In terms of adherence to each item, high HL levels were significantly associated with higher adherence to preoperative optimization (90.8% vs 71.7%; adjusted P < .001), postoperative gum chewing (59.2% vs 44.6%; adjusted P = .01), early feeding (59.2% vs 31.3%; adjusted P < .001), and early mobilization (56.7% vs 30.4%; adjusted P < .001). In the overall study population, adjusted logistic regression analyses also showed that high HL levels were associated with a significantly increased rate of high adherence when compared with low HL levels (adjusted odds ratio [OR], 3.57; 95% confidence interval (CI), 2.50-5.09; P < .001). In addition, low HL levels were associated with a significantly higher incidence of postoperative complications (32.1% vs 20.8%; P < .01), longer hospital LOS (9 [interquartile range {IQR}, 7-11] vs 7 [IQR, 6-9] d; P < .001), and higher hospital charges (10,489 [IQR, 8995-11942] vs 8466 [IQR, 7733-9384] dollar; P < .001) among propensity-matched patients. However, there were no differences in the mortality and readmission rates between the HL groups. CONCLUSIONS: Low HL levels were associated with lower adherence to ERAS elements among propensity-matched patients undergoing colorectal surgery.

Comparing Outcomes of Two Antiviral Therapy Combinations among COVID-19 Patients.

Several therapeutic regimens for COVID-19 have been studied, such as combination antiviral therapies. We aimed to compare outcome of two types of combination therapies atazanavir/ritonavir (ATV/r) or lopinavir/ritonavir (LPV/r) plus hydroxychloroquine among COVID-19 patients. 108 patients with moderate and severe forms of COVID-19 were divided into two groups (each group 54 patients). One group received ATV/r plus hydroxychloroquine, and the other group received hydroxychloroquine plus LPV/r. Then, both groups were evaluated and compared for clinical symptoms, recovery rates, and complications of treatment regimens. Our findings showed a significant increase in bilirubin in ATV/r-receiving group compared to LPV/r receivers. There was also a significant increase in arrhythmias in the LPV/r group compared to the ATV/r group during treatment. Other findings including length of hospital stay, outcome, and treatment complications were not statistically significant. There is no significant difference between protease inhibitor drugs including ATV/r and LPV/r in the treatment of COVID-19 regarding clinical outcomes. However, some side effects such as hyperbilirubinemia and arrhythmia were significantly different by application of atazanavir or lopinavir.

Surgical Outcomes in Patients With Malignant Small Bowel Obstruction: A National Cohort Study.

OBJECTIVE: The study objectives were to characterize surgical outcomes for malignant small bowel obstruction (MaSBO) as compared to other small bowel obstructions (SBO) and to develop a prediction model for postoperative mortality for MaSBO. SUMMARY BACKGROUND DATA: MaSBO is a morbid complication of advanced cancers for which the optimal management remains undefined. METHODS: Patients who underwent surgery for MaSBO or SBO were identified from the National Surgical Quality Improvement Program (2005-2017). Outcomes [30-day morbidity, unplanned readmissions, mortality, postoperative length of stay (LOS)] were compared between propensity score-matched MaSBO and SBO patients. An internally validated prediction model for mortality in MaSBO patients was developed. RESULTS: Of 46,706 patients, 1612 (3.5%) had MaSBO. Although MaSBO patients were younger than those with SBO (median 63 vs 65 years, P < 0.001), they were otherwise more clinically complex, including a higher proportion with recent weight loss (22.0% vs 4.0%, P < 0.001), severe hypoalbuminemia (18.6% vs 5.2%, P < 0.001), and cytopenias. After matching (N = 1609/group), MaSBO was associated with increased morbidity [odds ratio (OR) 1.2, P = 0.004], but not readmission (OR 1.1, P = 0.48) or LOS (incidence rate ratio 1.0, P = 0.14). The odds of mortality were significantly higher for MaSBO than SBO (OR 3.3, P < 0.001). A risk-score model predicted postoperative mortality for MaSBO with an optimism-adjusted Brier score of 0.114 and area under the curve of 0.735. Patients in the highest-risk category (11.5% of MaSBO population) had a predicted mortality rate of 39.4%. CONCLUSION: Surgery for MaSBO is associated with substantial morbidity and mortality, necessitating careful patient evaluation before operative intervention.

Percutaneous Spinal Endoscopic Combined with Thoracoscopic Surgery for Treatment of Thoracic Eden IV Dumbbell Tumors.

OBJECTIVE: Thoracic Eden IV dumbbell tumors are rare conditions characterized by neoplasms that arise from neurogenic elements, with intraforaminal and posterior mediastinal involvement. Surgical resection is commonly performed to treat thoracic Eden IV dumbbell-shaped tumors. The combined thoracic-neurosurgical approach is a routine surgical procedure according to the literature. We present our experience with resection of thoracic Eden IV dumbbell tumors with combined percutaneous spinal endoscopic and thoracoscopic procedures in a single stage. METHODS: A retrospective review of 7 patients undergoing spinal endoscopic combined with thoracoscopic surgery for thoracic Eden IV dumbbell tumors was performed in our department between 2017 and 2020. Patient demographics, clinical features, operative reports, and preoperative and postoperative images were reviewed. RESULTS: Complete resection was achieved in the 7 cases. The mean operative time was 207 minutes (range, 160-310 minutes), with mean estimated blood loss of 47 mL (range, 20-80 mL). The mean chest drain duration was 3 days (range, 2-4 days), and the mean hospital stay was 7 days (range, 5-8 days). No operative complications were observed. During the follow-up period, there were no obvious complications, tumor recurrence, or spinal instability. CONCLUSIONS: Percutaneous spinal endoscopic combined with thoracoscopic surgery for the treatment of Eden IV type thoracic dumbbell tumors is a novel, safe, and effective surgical method that can not only remove tumors inside and outside of the thoracic intervertebral foramen in a single stage but also minimize damage to the normal structure of the spine and help in early recovery.

The effect of intra-operative hypotension on acute kidney injury, postoperative mortality and length of stay following emergency hip fracture surgery.

The association between intra-operative hypotension and postoperative acute kidney injury, mortality and length of stay has not been comprehensively evaluated in a large single-centre hip fracture population. We analysed electronic anaesthesia records of 1063 patients undergoing unilateral hip fracture surgery, collected from 2015 to 2018. Acute kidney injury, 3-, 30- and 365-day mortality and length of stay were evaluated to assess the relationship between intra-operative hypotension absolute values (≤ 55, 60, 65, 70 and 75 mmHg) and duration of hypotension. The rate of acute kidney injury was 23.7%, mortality at 3-, 30- and 365 days was 3.7%, 8.0% and 25.3%, respectively, and median (IQR [range]) length of stay 8 (6-12 [0-99]) days. Median (IQR [range]) time ≤ MAP 55, 60, 65, 70 and 75 mmHg was 0 (0-0.5[0-72.1]); 0 (0-4.4 [0-104.9]); 2.2 (0-8.7 [0-144.2]); 6.6 (2.2-19.7 [0-198.8]); 17.5 (6.6-37.1 [0-216.3]) minutes, and percentage of surgery time below these thresholds was 1%, 2.5%, 7.9%, 12% and 21% respectively. There were some univariate associations between hypotension and mortality; however, these were no longer evident in multivariable analysis. Multivariable analysis found no association between hypotension and acute kidney injury. Acute kidney injury was associated with male sex, antihypertensive medications and cardiac/renal comorbidities. Three-day mortality was associated with delay to surgery ? 48 hours, whilst 30-day and 365-day mortality was associated with delay to surgery ≥ 48 hours, impaired cognition and cardiac/renal comorbidities. While the rate of acute kidney injury was similar to other studies, use of vasopressors and fluids to reduce the time spent at hypotensive levels failed to reduce this complication. Intra-operative hypotension at the levels observed in this cohort may not be an important determinant of acute kidney injury, postoperative mortality and length of stay.

Elective versus nonelective brain tumor resections: a 5-year propensity score matching cost comparison analysis.

OBJECTIVE: Elective surgical cases generally have lower costs, higher profit margins, and better outcomes than nonelective cases. Investigating the differences in cost and profit between elective and nonelective cases would help hospitals in planning strategies to withstand financial losses due to potential pandemics. The authors sought to evaluate the exact cost and profit margin differences between elective and nonelective supratentorial tumor resections at a single institution. METHODS: The authors collected economic analysis data in all patients who underwent supratentorial tumor resection at their institution between January 2014 and December 2018. The patients were grouped into elective and nonelective cases. Propensity score matching was used to adjust for heterogeneity of baseline characteristics between the two groups. RESULTS: There were 143 elective cases and 232 nonelective cases over the 5 years. Patients in the majority of elective cases had private insurance and in the majority of nonelective cases the patients had Medicare/Medicaid (p < 0.01). The total charges were significantly lower for elective cases ($168,800.12) compared to nonelective cases ($254,839.30, p < 0.01). The profit margins were almost 6 times higher for elective than for nonelective cases ($13,025.28 vs $2,128.01, p = 0.04). After propensity score matching, there was still a significant difference between total charges and total cost. CONCLUSIONS: Elective supratentorial tumor resections were associated with significantly lower costs with shorter lengths of stay while also being roughly 6 times more profitable than nonelective cases. These findings may help future planning for hospital strategies to survive financial losses during future pandemics that require widespread cancellation of elective cases.

Randomized Controlled Trial Comparing the Short-term Outcomes of Enhanced Recovery After Surgery and Conventional Care in Laparoscopic Distal Gastrectomy (GISSG1901).

OBJECTIVE: This study aimed to compare the effects of ERAS and conventional programs on short-term outcomes after LDG. SUMMARY OF BACKGROUND DATA: Currently, the ERAS program is broadly applied in surgical areas. Although several benefits of LDG with the ERAS program have been covered, high-level evidence is still limited, specifically in advanced gastric cancer. METHODS: The present study was designed as a randomized, multicenter, unblinded trial. The enrollment criteria included histologically confirmed cT2-4aN0-3M0 gastric adenocarcinoma. Postoperative complications, mortality, readmission, medical costs, recovery, and laboratory outcomes were compared between the ERAS and conventional groups. RESULTS: Between April 2019 and May 2020, 400 consecutive patients who met the enrollment criteria were enrolled. They were randomly allocated to either the ERAS group (n = 200) or the conventional group (n = 200). After excluding patients who did not undergo surgery or gastrectomy, 370 patients were analyzed. The patient demographic characteristics were not different between the 2 groups. The conventional group had a significantly longer allowed day of discharge and postoperative hospital stay (6.96 vs 5.83 days, P < 0.001; 8.85 vs 7.27 days, P < 0.001); a longer time to first flatus, liquid intake and ambulation (3.37 vs 2.52 days, P < 0.001; 3.09 vs 1.13 days, P < 0.001; 2.85 vs 1.38 days, P < 0.001, respectively); and higher medical costs (6826 vs 6328 $, P = 0.027) than the ERAS group. Additionally, patients in the ERAS group were more likely to initiate adjuvant chemotherapy earlier (29 vs 32 days, P = 0.035). There was no significant difference in postoperative complications or in the mortality or readmission rates. Regarding laboratory outcomes, the procalcitonin and C-reactive protein levels on postoperative day 3 were significantly lower and the hemoglobin levels on postoperative day 5 were significantly higher in the ERAS group than in the conventional group. CONCLUSION: The ERAS program provides a faster recovery, a shorter postoperative hospitalization length, and lower medical costs after LDG without increasing complication and readmission rates. Moreover, enhanced recovery in the ERAS group enables early initiation of adjuvant chemotherapy.

Travelling to a High-Volume Center Confers Improved Survival in Stage I Non-small Cell Lung Cancer.

BACKGROUND: The association of hospital volume with outcomes has been assessed previously for patients with non-small cell lung cancer (NSCLC), but there are limited data on the cumulative effect of travel burden and hospital volume on treatment decisions and survival outcomes. We used the National Cancer Database to evaluate this relationship in early-stage NSCLC. METHODS: Outcomes of interest were compared between 2 propensity-matched groups with stage I NSCLC: patients in the bottom quartile of distance travelled who underwent surgery at low-volume centers (Local) and those in the top quartile of distance travelled who received surgery at high-volume centers (Distant). Outcomes included type of resection (anatomic or nonanatomic), time to resection (< or ≥8 weeks), number of lymph nodes examined (< or ≥10 nodes) and R0 resection. RESULTS: We identified 3325 Local patients who travelled 2.3 miles (interquartile range [IQR]: 1.4-3.3 miles) to centers that treated 10.5 (IQR: 6.5-16.5) stage I NSCLCs/year and 3361 Distant patients who travelled 40.0 miles (IQR: 29.1-63.4 miles) to centers treating 56.9 (IQR: 40.1-84.7) stage I NSCLCs/year. Local patients were less likely to receive surgery <8 weeks post-diagnosis, have ≥10 lymph nodes examined during surgery, and undergo an R0 resection (all P < .01). Distant patients had shorter hospital stays and superior median survival, both P < .01. CONCLUSIONS: Patients travelling longer distances to high-volume centers receive better and more timely surgical care, leading to shorter hospital stays and improved survival outcomes. Regionalization of lung cancer care by improving travel support to larger treatment facilities may help improve early-stage NSCLC outcomes.

National Trends in Length of Stay for Microvascular Breast Reconstruction: An Evaluation of 10,465 Cases Using the American College of Surgeons National Surgical Quality Improvement Program Database.

BACKGROUND: Decreasing length of stay benefits patients and hospital systems alike. This should be accomplished safely without negatively impacting patient outcomes. The authors hypothesize that in the United States, the average length of stay for patients undergoing microsurgical breast reconstruction has decreased since 2012 without a concurrent increase in complication and readmission rates. METHODS: The authors identified female patients who underwent microvascular breast reconstruction (CPT 19364) from the 2012 to 2018 National Surgical Quality Improvement Program database. Trends in complication and readmission rates and length of stay were examined over 7 years. Multivariable logistic regression models and Mann-Kendall trend tests were used to evaluate associations between length of stay and complication and readmission rates. RESULTS: A total of 10,465 cases were identified. The number of autologous microvascular breast reconstruction procedures performed increased annually between 2012 and 2018. Length of stay decreased significantly from 2012 to 2018 (from 4.47 days to 3.90 days) (p < 0.01). Minor and major complication rates remained constant, although major complications showed a decreasing trend (from 27 percent to 21 percent) (p = 0.07). Thirty-day readmission, surgical-site infection, and wound dehiscence rates remained consistent over the study period, whereas rates of blood transfusion or bleeding decreased (p = 0.02). CONCLUSIONS: Using a national sample from 2012 to 2018, the authors observed a significant decrease in length of stay for patients undergoing microvascular breast reconstruction without a concurrent increase in complication and readmission rates. Current efforts to reduce length of stay have been successful without increasing complication or readmission rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Birth Hospital Length of Stay and Rehospitalization During COVID-19.

OBJECTIVES: To determine if birth hospitalization length of stay (LOS) and infant rehospitalization changed during the coronavirus disease 2019 (COVID-19) era among healthy, term infants. METHODS: Retrospective cohort study using Epic's Cosmos data from 35 health systems of term infants discharged ≤5 days of birth. Short birth hospitalization LOS (vaginal birth <2 midnights; cesarean birth <3 midnights) and, secondarily, infant rehospitalization ≤7 days after birth hospitalization discharge were compared between the COVID-19 (March 1 to August 31, 2020) and prepandemic eras (March 1 to August 31, 2017, 2018, 2019). Mixed-effects models were used to estimate adjusted odds ratios (aORs) comparing the eras. RESULTS: Among 202 385 infants (57 110 from the COVID-19 era), short birth hospitalization LOS increased from 28.5% to 43.0% for all births (vaginal: 25.6% to 39.3%, cesarean: 40.1% to 61.0%) during the pandemic and persisted after multivariable adjustment (all: aOR 2.30, 95% confidence interval [CI] 2.25-2.36; vaginal: aOR 2.12, 95% CI 2.06-2.18; cesarean: aOR 3.01, 95% CI 2.87-3.15). Despite shorter LOS, infant rehospitalizations decreased slightly during the pandemic (1.2% to 1.1%); results were similar in adjusted analysis (all: aOR 0.83, 95% CI 0.76-0.92; vaginal: aOR 0.82, 95% CI 0.74-0.91; cesarean: aOR 0.87, 95% CI 0.69-1.10). There was no change in the proportion of rehospitalization diagnoses between eras. CONCLUSIONS: Short infant LOS was 51% more common in the COVID-19 era, yet infant rehospitalization within a week did not increase. This natural experiment suggests shorter birth hospitalization LOS among family- and clinician-selected, healthy term infants may be safe with respect to infant rehospitalization, although examination of additional outcomes is needed.

Usability of the Level of the S100B Protein, the Gosling Pulsatility Index, and the Jugular Venous Oxygen Saturation for the Prediction of Mortality and Morbidity in Patients with Severe Traumatic Brain Injury.

The high frequency of traumatic brain injury imposes severe economic stress on health and insurance services. The objective of this study was to analyze the association between the serum S100B protein, the Gosling pulsatility index (PI), and the level of oxygen saturation at the tip of the internal jugular vein (SjVO2%) in patients diagnosed with severe TBI. The severity of TBI was assessed by a GCS score ≤ 8 stratified by Glasgow outcome scale (GOS) measured on the day of discharge from the hospital. Two groups were included: GOS < 4 (unfavorable group (UG)) and GOS ≥ 4 (favorable group (UG)). S100B levels were higher in the UG than in the FG. PI levels in the UG were also substantially higher than in the FG. There were similar levels of SjVO2 in the two groups. This study confirmed that serum S100B levels were higher in patients with unfavorable outcomes than in those with favorable outcomes. Moreover, a clear demarcation in PI between unfavorable and FGs was observed. This report shows that mortality and morbidity rates in patients with traumatic brain injury can be assessed within the first 4 days of hospitalization using the S100B protein, PI values, and SjVO2.

Health system costs and days in hospital for colorectal cancer patients in New South Wales, Australia.

INTRODUCTION: Colorectal cancer (CRC) care costs the Australian healthcare system more than any other cancer. We estimated costs and days in hospital for CRC cases, stratified by site (colon/rectal cancer) and disease stage, to inform detailed analyses of CRC-related healthcare. METHODS: Incident CRC patients were identified using the Australian 45 and Up Study cohort linked with cancer registry records. We analysed linked hospital admission records, emergency department records, and reimbursement records for government-subsidised medical services and prescription medicines. Cases' health system costs (2020 Australian dollars) and hospital days were compared with those for cancer-free controls (matched by age, sex, geography, smoking) to estimate excess resources by phase of care, analysed by sociodemographic, health, and disease characteristics. RESULTS: 1200 colon and 546 rectal cancer cases were diagnosed 2006-2013, and followed up to June 2016. Eighty-nine percent of cases had surgery, chemotherapy or radiotherapy, and excess costs were predominantly for hospitalisations. Initial phase (12 months post-diagnosis) mean excess health system costs were $50,434 for colon and $60,877 for rectal cancer cases, with means of 16 and 18.5 excess hospital days, respectively. The annual continuing mean excess costs were $6,779 (colon) and $8,336 (rectal), with a mean of 2 excess hospital days each. Resources utilised (costs and days) in these phases increased with more advanced disease, comorbidities, and younger age. Mean excess costs in the year before death were $74,952 (colon) and $67,733 (rectal), with means of 34 and 30 excess hospital days, respectively-resources utilised were similar across all characteristics, apart from lower costs for cases aged ≥75 at diagnosis. CONCLUSIONS: Health system costs and hospital utilisation for CRC care are greater for people with more advanced disease. These findings provide a benchmark, and will help inform future cost-effectiveness analyses of potential approaches to CRC screening and treatment.

Altered mental status predicts length of stay but not death in a community-based cohort of hospitalized COVID-19 patients.

INTRODUCTION: Altered Mental Status (AMS) is a common neurological complication in patients hospitalized with the diagnosis of COVID-19 (Umapathi et al., 2020; Liotta et al., 2020). Studies show that AMS is associated with death and prolonged hospital stay. In addition to respiratory insufficiency, COVID-19 causes multi-organ failure and multiple metabolic derangements, which can cause AMS, and the multi-system involvement could account for the prolonged hospital stay and increased mortality. In this study, we built on our previous publication (Chachkhiani et al., 2020) using a new, larger cohort to investigate whether we could reproduce our previous findings while addressing some of the prior study's limitations. Most notably, we sought to determine whether AMS still predicted prolonged hospital stay and increased mortality after controlling for systemic complications such as sepsis, liver failure, kidney failure, and electrolyte abnormalities. OBJECTIVES: The primary purpose was to document the frequency of AMS in patients with COVID-19 at the time of presentation to the emergency room. Secondary aims were to determine: 1) if AMS at presentation was associated with worse outcomes as measured by prolonged hospitalization and death; and 2) if AMS remained a predictor of worse outcome after adjusting for concomitant organ failure and metabolic derangements. RESULTS: Out of 367 patients, 95 (26%) had AMS as a main or one of the presenting symptoms. Our sample has a higher representation of African Americans (53%) than the US average and a high frequency of comorbidities, such as obesity (average BMI 29.1), hypertension (53%), and diabetes (30%). Similar to our previous report, AMS was the most frequent neurological chief complaint. At their admission, out of 95 patients with AMS, 83 (88%) had organ failure or one of the systemic problems that could have caused AMS. However, a similar proportion (86%) of patients without AMS had one or more of these same problems. Age, race, and ethnicity were the main demographic predictors. African Americans had shorter hospital stay [HR1.3(1.0,1.7),p = 0.02] than Caucasians. Hispanics also had shorter hospital stay than non-Hispanics [HR1.6(1.2,2.1), p = 0.001]. Hypoxia, liver failure, hypernatremia, and kidney failure were also predictors of prolonged hospital stay. In the multivariate model, hypoxia, liver failure, and acute kidney injury were the remaining predictors of longer hospital stay, as well as people with AMS at baseline [HR0.7(0.6,0.9), p < 0.02] after adjusting for the demographic characteristics and clinical predictors. AMS at baseline predicted death, but not after adjusting for demographics and clinical variables in the multivariate model. Hypoxia and hyperglycemia at baseline were the strongest predictors of death. CONCLUSION: Altered mental status is an independent predictor of prolonged hospital stay, but not death. Further studies are needed to evaluate the causes of AMS in patients with COVID-19.

Full-Thickness Laparoendoscopic Excision for Management of Complex Colon Polyps.

BACKGROUND: Benign colon polyps are increasingly being detected because of improved colonoscopic screening and early detection of masses on the adenoma-to-carcinoma pathway. Full-thickness laparoendoscopic excision is a colon-preserving technique for endoscopically unresectable polyps consisting of endoscopically guided nonanatomic wedge colectomy. OBJECTIVE: This study aimed to evaluate the safety and success of full-thickness laparoendoscopic excision compared to segmental colectomy for complex polyps not amenable to endoscopic resection. DESIGN: This is a retrospective case-control study. SETTINGS: This study was conducted at a tertiary academic center. PATIENTS: A prospectively maintained institutional database identified 22 patients with benign complex polyps managed with full-thickness laparoendoscopic excision from 2015 to 2020. These patients were compared with 22 propensity score-matched controls from the same database that underwent laparoscopic segmental colectomy. MAIN OUTCOME MEASURES: Primary outcome was inpatient length of stay. Secondary outcomes included operative details and postoperative morbidities. RESULTS: Full-thickness laparoendoscopic excision was successful in all patients. Patients had a median age of 64 years (41-85), and 82% were men. Final pathology revealed complete excision of benign lesions in 20 of 22 patients and adenocarcinoma in 2 of 22. For the adenocarcinomas, 1 patient underwent subsequent elective colectomy without complications, and 1 patient declined surgery. Propensity score matching was successful for age, sex, BMI, ASA score, colon location, and prior abdominal surgery. Compared with controls, cases had significantly shorter operative time (89.5 minutes (46-290) vs 122 minutes (85-200), p = 0.009), length of stay (1 day (0-17) vs 3 days (1-8), p < 0.001), and reduced blood loss (5 mL (2-15) vs 25 mL (10-150), p < 0.001). Thirty-day morbidity (9.1% vs 27.3%, p = 0.240) was not significantly different. An unplanned 30-day reoperation was performed in 1 patient for suspected small-bowel obstruction. There was 1 mortality due to decompensated cirrhosis in the treatment group. LIMITATIONS: This study was limited by its single-institution retrospective design. CONCLUSIONS: Full-thickness laparoendoscopic excision is safe and successful compared with corresponding segmental colectomy for complex polyps. Favorable postoperative outcomes, including decreased operative time, length of stay, and blood loss, make it a useful approach for managing complex polyps throughout the colon.

Prospective Study on the Postoperative Use of Levosimendan After Conventional Heart Valve Replacement.

BACKGROUND The aim of this study was to explore the effect of levosimendan in patients after heart valve replacement and its influence on postoperative recovery. MATERIAL AND METHODS This prospective study included 185 patients with valvular diseases undergoing conventional valve replacement. Patients were divided into 2 groups using a random number table before surgery. Patients in the levosimendan group were administrated levosimendan intravenous infusion immediately after entering the Intensive Care Unit (ICU). The left ventricular ejection fraction (LVEF), cardiac output, and heart failure-related index, such as B-type natriuretic peptide (BNP) level, were recorded at 1, 3, and 7 days after surgery. The dosage and administration time of dopamine and epinephrine, mechanical ventilation time, ICU length of stay, and postoperative adverse events were recorded. RESULTS Cardiac output and LVEF of patients in the levosimendan group were significantly higher than those in the control group at different time points (P<0.05), and BNP level was lower than that of the control group (P<0.0001). Dosage and administration time of dopamine and epinephrine in the levosimendan group were lower than those of the control group (P<0.0001, P<0.0001, respectively). ICU length of stay and total incidence of postoperative adverse events were lower than those of the control group (P<0.0001, P=0.002, respectively). CONCLUSIONS Levosimendan administration immediately after heart valve replacement effectively improved the heart function of patients, reduced administration of vasoactive drugs, shortened length of ICU stay, reduced incidence of postoperative adverse events, and promoted recovery of patients after surgery.

Acute Colonic Pseudo-Obstruction (Ogilvie Syndrome) After Primary Spinal Fusion: An Analysis of Outcomes and Risk Factors from 2005 to 2014.

BACKGROUND: Ogilvie syndrome (OS) is a rare but serious condition seen in the postoperative period. This was an epidemiologic study using data from the National Inpatient Sample from 2005 to 2014 to look at incidence, risk factors, and outcomes associated with OS after primary spine fusion. METHODS: International Classification of Diseases, Ninth Revision codes were used to identify patients who underwent spine fusion surgery. Patients were separated into 2 cohorts based on the diagnosis of OS. Outcome measures and risk factors for cohorts were analyzed using multivariate logistic regression and compared. RESULTS: Over the 10-year study period, 3,884,395 patients underwent primary spine fusion surgery. Among these, 0.04% developed OS during the index hospitalization. The greatest incidence seen in primary fusion involved the thoracic spine (0.15%). OS was more common after spine fusion for spine deformity (P < 0.001). Patients with OS were more likely to be men (P < 0.001), older (P < 0.0001), and have more comorbidities (P < 0.0001). Patients with OS were more likely to require postoperative blood transfusions (odds ratio [OR], 3.39; 95% confidence interval [CI], 2.51-4.59; P < 0.001) and sustain any complication (OR, 4.20; 95% CI, 3.17-5.57; P < 0.001). Patients with OS had a longer length of stay (15.7 vs. 3.9 days; P < 0.001) and increased average hospitalization cost ($63,037.03 vs. $26,792.19; P < 0.001). The development of OS was associated with fluid electrolyte disorder (OR, 4.06; 95% CI, 2.99-5.51; P < 0.001). CONCLUSIONS: OS is a rare but serious complication of primary spine fusion surgery. Identifying the specific risk factors, symptoms, and potential complications related to OS is critical to aid in decreasing the significant morbidity associated with its development.