The obesity paradox: Underweight patients are at the greatest risk of mortality after cholecystectomy.

BACKGROUND: Elevated body mass index is a risk factor for gallstone disease and cholecystectomy, but outcomes for low body mass index patients remain uncharacterized. We examined the association of body mass index with morbidity, mortality, and resource use after cholecystectomy. METHODS: The 2005 to 2016 American College of Surgeons National Surgical Quality Improvement Program was retrospectively analyzed for adult patients undergoing laparoscopic and open cholecystectomy. Patients were stratified into 5 groups: body mass index <18.5 (underweight), body mass index 18.5 to 24.9 (normal weight), body mass index 25 to 29.9 (overweight), body mass index 30 to 34.9 (class I obesity), body mass index 35 to 39.9 (class II obesity), and body mass index ≥40 (class III obesity). Multivariable regressions identified independent associations of covariates with 30-day mortality, complications, and resource use. RESULTS: Of 327,473 cholecystectomy patients, 1.0% were underweight, 19.5% normal weight, 30.3% overweight, 24.0% class I obesity, 13.5% class II obesity, and 11.7% class III obesity. After multivariable analysis, underweight patients had a higher risk of mortality (adjusted odds ratio = 1.53; P = .029) and postoperative bleeding (adjusted odds ratio = 1.45; P = .011) relative to normal weight patients. Conversely, class III obesity patients had lower mortality (adjusted odds ratio = 0.66; P = .005) but increased operative time (ß = 10.2 minutes; P < .001), wound infection (adjusted odds ratio = 1.38; P < .001), and wound dehiscence (adjusted odds ratio = 2.20; P < .001). Hospital duration of stay and readmission rates were highest for underweight patients. CONCLUSION: Underweight patients experience increased risk of mortality and readmission, while class III obesity patients have higher rates of wound infection and dehiscence as well as prolonged operative time. These findings may guide choice of intervention.

Readmissions after ovarian cancer cytoreduction surgery: The first 30 days and beyond.

BACKGROUND AND OBJECTIVES: Postoperative readmissions are often used to assess quality of surgical care. This study compared 30-day vs 31- to 90-day readmission following surgery for ovarian, fallopian tube, or primary peritoneal cancer. METHODS: This retrospective study of the 2010-2015 Nationwide Readmissions Database characterized 90-day readmissions following cytoreductive surgery for these cancers. Each patient's first postoperative hospitalization was included. Univariate analysis compared patient demographics and reasons for readmission. Multivariable regression identified independent predictors of readmission. RESULTS: Of an estimated 76 652 patients, 10 264 (13.4%) were readmitted within 30 days, and 6942 (9.1%) between 31 and 90 days. The 30-day readmissions were more frequently associated with postoperative infection, while 31- to 90-day readmissions were more frequently associated with renal or hematologic diagnoses. Predictors of any 90-day readmission included index hospitalization longer than 7 days (adjusted odds ratio (AOR) 1.61 [1.48-1.75], P < .001), extended surgical procedure (AOR 1.41 [1.30-1.53], P < .001), pulmonary circulation disorder (AOR = 1.34 [1.13-1.60], P = .001), and diabetes mellitus (AOR = 1.12 [1.02-1.24], P = .020). CONCLUSIONS: Readmission rates remain high during the 31- to 90-day postoperative period in ovarian cancer patients, although these readmissions are less frequently related to postoperative complications. Prospective study is merited to optimize surveillance beyond the initial 30 days after ovarian cancer surgery.

Incidence, Predictors, and Impact of Clostridium difficile Infection on Cardiac Surgery Outcomes.

BACKGROUND: Clostridium difficile infection (CDI) has been associated with morbidity and mortality after cardiac operations. The present study examined incidence, predictors, and impact of CDI on inpatient mortality and resource utilization. METHODS: An analysis of adult patients undergoing elective coronary artery bypass grafting or valvular operations from 2005 to 2016 was performed using the National Inpatient Sample. Trends in CDI were assessed using a modified Cochran-Armitage analysis. Multivariable multilevel regressions were used to identify predictors of CDI, and propensity-matched pairs were generated using Mahalanobis 1-to-1 matching to compare mortality, length of stay, and costs of CDI patients with the non-CDI cohort. RESULTS: The overall rate of CDI for an estimated 2,026,267 patients who underwent elective major cardiac surgery was 0.5% with no change in incidence (P for trend = .99). Predictors of CDI included advanced age (≥65 y; adjusted odds ratio [AOR], 1.88; 95% confidence interval [CI], 1.58-2.24), female gender (AOR, 1.29; 95% CI, 1.15-1.44), heart failure (AOR, 1.57; 95% CI, 1.40-1.76), and combined coronary artery bypass grafting/valve operations (AOR, 1.60; 95% CI, 1.24-2.08). Neither region nor bed size was associated with CDI. In contrast CDI mortality was lower at teaching hospitals compared with rural hospitals. Among matched pairs CDI was independently associated with higher mortality, length of stay, and Gross Domestic Product-adjusted costs. CONCLUSIONS: CDI occurs in less than 1% of all elective, major cardiac operations. Patient predictors included advanced age, female gender, and several chronic comorbidities. Teaching institutions had the highest odds of CDI but lowest odds of case fatality. Further investigation of factors contributing to CDI is warranted to disseminate institutional best practices.

Height mismatch: An overlooked component of adult heart transplant outcomes.

Heart transplantation guidelines recommend against matching donors with significant weight but not height discrepancies. This study analyzed the impact of donor-recipient height mismatch on mortality among heart transplant recipients. We retrospectively analyzed all adult patients in the United Network for Organ Sharing (UNOS) registry undergoing heart transplantation from 1990 to September 2016. Moderate and severe height mismatch were classified as >10% and >15% difference in donor height from recipient height, respectively. The primary outcome was 1-year mortality. Adjusted Cox hazards regression was performed, and Kaplan-Meier estimates illustrated 10-year survival. Of 44 877 transplants, 4822 (10.7%) were moderately height mismatched. Height-mismatched recipients were more frequently female (41.6% vs 21.8%, P < .001), sex mismatched (53.8% vs 24.9%, P < .001), and weight mismatched (4.9% vs 1.9%, P < .001). After adjustment, recipients of moderately (HR = 1.15 [1.02-1.30]) and severely (HR = 1.38 [1.10-1.74]) taller donor hearts were at increased risk of mortality at 1 year relative to height-matched recipients. Furthermore, of 1042 (21.6%) severe mismatches, recipients with taller (HR = 1.39 [1.11-1.74]) but not shorter (HR = 0.79 [0.44-1.43]) donors faced increased 10-year mortality. The effect was pronounced among re-transplant candidates (HR = 1.96 [1.07-3.59]). In conclusion, matching with moderately or severely taller donors is an independent predictor of mortality among primary and re-transplant candidates.

Revisiting the International Normalized Ratio Threshold for Bleeding Risk and Mortality in Primary Total Hip Arthroplasty: A National Surgical Quality Improvement Program Analysis of 17,567 Patients.

BACKGROUND: Efforts to identify preoperative risk factors for primary total hip arthroplasty have amplified with its increasing incidence. The international normalized ratio (INR) is 1 measure that may influence postoperative outcomes. This study of a national database assessed whether there exists an association between preoperative INR and postoperative bleeding and mortality among patients who underwent primary total hip arthroplasty. METHODS: We retrospectively analyzed 17,567 adult patients who underwent primary total hip arthroplasty in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) between 2005 and 2016. Patients were stratified by preoperative INR into 4 groups: INR <1.0, 1.0 to <1.25, 1.25 to <1.5, and ≥1.5. Bleeding necessitating transfusion was the primary outcome, and secondary outcomes included mortality, infection, and readmission. Multivariable logistic regressions controlled for baseline differences. RESULTS: Among the patients who underwent total hip arthroplasty, 20.5% had INR <1.0, 73.6% had INR 1.0 to <1.25, 4.2% had INR 1.25 to <1.5, and 1.8% had INR ≥1.5. Mortality increased incrementally from 0.3% for INR <1.0 to 4.9% for INR ≥1.5 (p < 0.001), and bleeding risk increased from 13.2% for INR <1.0 to 29.3% for INR ≥1.5 (p < 0.001). After adjustment, bleeding risk was increased for INR 1.25 to <1.5 (odds ratio [OR], 1.55 [95% confidence interval (CI), 1.26 to 1.92]) and INR ≥1.5 (OR, 1.55 [95% CI, 1.15 to 2.08]) compared with INR <1.0. The only group associated with increased mortality was INR ≥1.5 (OR, 2.69 [95% CI, 1.07 to 6.76]). The length of stay significantly increased with increasing INR, from 3.6 to 6.3 days (p < 0.001). CONCLUSIONS: This study found a significant, independent effect between increased preoperative INR and increased bleeding and mortality. Bleeding risk becomes evident at INR ≥1.25, and those patients with INR ≥1.5 are at significantly increased risk of mortality. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous cholecystostomy for grade III acute cholecystitis is associated with worse outcomes.

BACKGROUND: The aim of the present study was to evaluate the mortality, morbidity, and readmissions associated with management of grade 3 cholecystitis in the elderly, vulnerable population. METHODS: This was a retrospective cohort study of non-elective admissions for acute cholecystitis from 2010 to 2015 using the nationwide readmissions database for adults ≥ 65 years with evidence of end-organ dysfunction (grade 3) who underwent percutaneous cholecystostomy (PC), laparoscopic (LC) or open cholecystectomy (OC). Index and readmission outcomes were analyzed using logistic regression and inverse probability treatment weight analysis. RESULTS: Of the estimated 358,624 patients, 14.9% underwent PC, 15.7% OC, and 69.4% LC. PC had significantly higher odds of mortality (AOR 5.8, 95%CI 5.1-6.6), composite morbidity (AOR 3.8, 95%CI 3.5-4.1), early (AOR 1.9, 95%CI 1.7-2.0) and intermediate (AOR 2.2, 95%CI 2.0-2.5) readmission compared to LC and OC. CONCLUSIONS: Patients undergoing cholecystostomy had higher mortality, complications, and readmission rates warranting revaluation of criteria for cholecystostomy at initial presentation.

Predicting morbidity and mortality in laparoscopic cholecystectomy: Preoperative serum albumin still matters.

BACKGROUND: This study examined the association of preoperative serum albumin with outcomes for laparoscopic cholecystectomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program was retrospectively analyzed from 2005 to 2016 for adult patients undergoing laparoscopic cholecystectomy. Patients were stratified into four groups: <3.0 g/dL (Severe Malnutrition), 3.0-<3.5 (Moderate Malnutrition), 3.5-<4.0 (Mild Malnutrition), and ≥4.0 g/dL (Normal Nutrition). The primary outcome of 30-day mortality was evaluated with multivariable regression. RESULTS: Of 131,855 patients, 14.0% had Severe, 22.8% Moderate, and 29.7% Mild Malnutrition, with 33.5% classified as Normal Nutrition. Adjusted multivariable regressions demonstrated that relative to Normal Nutrition, mortality risk was increased for Severe (OR = 3.09 [95% Confidence Interval: 2.09-4.56]) and Moderate (OR = 1.83 [1.24-2.72]) Malnutrition. Severe (OR = 2.45 [1.67-3.61]) and Moderate (OR = 1.52 [1.04-2.24]) Malnutrition were also associated with increased risk of postoperative septic shock. CONCLUSIONS: Even in less invasive laparoscopic cholecystectomy, reduced preoperative serum albumin is strongly associated with increased morbidity and mortality.

Donor history of malignancy: A limited risk for heart transplant recipients.

Organ donor contraindications are frequently reassessed for impact on recipient outcomes in attempt to meet demand for transplantation. This study retrospectively analyzed the United Network for Organ Sharing (UNOS) registry for adult heart transplants from 1987 to September 2016 to characterize the impact of donor malignancy history in heart transplantation. Kaplan-Meier estimates illustrated 10-year survival. Propensity score matching was utilized for 1:1 matching of donors with and without history of malignancy, and Cox proportional hazards and logistic regressions were used to analyze the matched population. Of 38 781 heart transplants, 622 (1.6%) had a donor history of malignancy. Cox regressions demonstrated that donor malignancy predicted increased 10-year mortality (HR = 1.16 [1.01-1.33]), but this difference did not persist when conditioned upon 1 year post-transplant survival (log-rank = 0.643). Cox regressions of the propensity score-matched population (455 pairs) found no association between donor malignancy and 10-year mortality (HR = 1.02 [0.84-1.24]). Older age and higher rates of hypertension were observed in donors with a history of malignancy whose recipients died within the first year post-transplant. Therefore, increased recipient mortality is likely due to donor characteristics beyond malignancy, creating the potential for expanded donor selection.

International Normalized Ratio (INR) Is Comparable to MELD in Predicting Mortality after Cholecystectomy.

Guidelines suggest targeting a preoperative international normalized ratio (INR) < 1.5. We examined and compared the predictive value of INR relative to the Model for End-Stage Liver Disease (MELD). We reviewed the American College of Surgeons NSQIP from 2005 to 2016 for adult patients undergoing open or laparoscopic cholecystectomy. Patients with a preoperative INR were stratified into groups: ≤1, >1 to ≤1.5, >1.5 to ≤2, and >2. Thirty day postoperative mortality was the primary outcome. Multivariable logistic regressions controlled for baseline differences. Of 58,177 cholecystectomy patients, 15.2 per cent had INR ≤ 1, 80.4 per cent had INR > 1 to ≤1.5, 3.7 per cent had INR > 1.5 to ≤2, and 0.7 per cent had INR > 2. Patients with INR > 2 were older and more likely to have diabetes and hypertension (P < 0.001). Multivariable regression demonstrated a stepwise increase in mortality for INR > 1 to ≤1.5 (odds ratio (OR) = 1.50 [1.10-2.05]), INR > 1.5 to ≤2 (OR = 2.96 [1.97-4.45]), and INR > 2 (OR = 3.21 [1.64-6.31]) relative to INR ≤ 1. C-statistic for INR (0.910) and MELD (0.906) models indicated a similar value in predicting mortality. INR groups also faced an incremental, increased risk of bleeding. Although unable to track preoperative correction of INR, this analysis identifies that INR remains an excellent predictor of postoperative mortality and bleeding after both open and laparoscopic cholecystectomies and is comparable to MELD.

Understanding lung transplant listing practices: Survival in lung transplant candidates who improve clinically to delisting.

BACKGROUND: Occasionally, lung transplant candidates improve to the point where they are removed from the transplant list. We sought to determine the characteristics and outcomes of lung transplant candidates who improved to delisting both before and after implementation of the lung allocation score. METHODS: Using the United Network for Organ Sharing database, we reviewed all adult patients listed for lung transplant between 1987 and 2012. The last permanent status change was classified into transplanted, improved to delisting (improved), or deteriorated to delisting (deteriorated). Survival time was calculated using the linked date of death from the Social Security Administration. Survival analysis was performed via the Kaplan-Meier method, and adjusted multivariable logistic regressions identified characteristics predicting improvement to delisting. RESULTS: Of 13,688 candidates, 12,188 (89.0%) were transplanted, 454 (3.3%) improved, and 1,046 (7.6%) deteriorated. The 5-year mortality was greater in improved (hazard ratio = 1.21 [1.07-1.38], P = .002) and deteriorated (hazard ratio = 3.36 [3.11-3.64], P < .001) candidates relative to those transplanted; however, 1-year survival was greater in improved versus transplanted candidates (75.9% vs 67.2%, log rank P < .001). Older, female patients listed for primary pulmonary hypertension and retransplantation were more likely to improve to delisting. The proportion of improved patients varied by hospital quartile volume (P < .001) and the United Network for Organ Sharing geographic region (P < .001). The number of patients improving to delisting decreased after implementation of the lung allocation score. CONCLUSION: Lung transplant candidates improving to delisting faced less short-term but greater long-term mortality relative to transplanted candidates. Given that the improved population decreased dramatically after implementation of the lung allocation score, redefining patient listing criteria appears to have improved patient appropriateness for transplant.

Impact of Donor Diabetes on Outcomes of Lung Transplantation in the United States.

BACKGROUND: Diabetes mellitus is among several factors considered when assessing the suitability of donated organs for transplantation. Lungs from diabetic donors (LDD) are not contraindicated for use as allografts, despite established evidence of diabetes-mediated parenchymal damage. The present study used a national database to assess the impact of donor diabetes on the longevity of lung transplant recipients. METHODS: This retrospective study of the United Network for Organ Sharing database analyzed all adult lung transplant recipients from June 2005 through September 2016. Donor and recipient demographics including the presence of diabetes were used to create a multivariable model. The primary outcome was 5-y mortality, with hazard ratios (HRs) assessed using multivariable Cox regression analysis. Survival curves were calculated using the Kaplan-Meier method. RESULTS: Of the 17,839 lung transplant recipients analyzed, 1203 (6.7%) received LDD. Recipients of LDD were more likely to be female (44.1% versus 40.2%, P < 0.01) and have mismatched race (47.5% versus 42.2%, P < 0.01). Diabetic donors were more likely to have hypertension (74.6% versus 19.0%, P < 0.01). Multivariable analysis revealed LDD to be an independent predictor of mortality at 5 y (HR 1.16 [1.04-1.29], P < 0.01). However, among the subgroup of diabetic recipients, transplantation of LDD showed no independent association with 5-y mortality (HR 0.81 [0.63-1.06], P = 0.12). CONCLUSIONS: Recipients of LDD had a lower 5-y post lung transplantation survival compared with recipients of lungs from nondiabetic donors. LDD allografts did not influence the survival of diabetic recipients.

Readmissions Following Isolated Coronary Artery Bypass Graft Surgery in the United States (from the Nationwide Readmissions Database 2010 to 2014).

Readmission following cardiac surgery is associated with poor outcomes and increased healthcare expenditure. However, a nationwide understanding of the incidence, cost, causes, and predictors of 30-day readmission following coronary artery bypass grafting is limited. The Nationwide Readmissions Database was used to identify all adult patients who underwent isolated coronary artery bypass grafting (CABG) with no other concomitant surgery between 2010 and 2014. The primary outcome was all-cause readmission within 30 days of discharge after surgery. Risk-adjusted multivariable analyses were used to develop a model of readmission risk. Of 855,836 patients, 95,504 (11.2%) had an emergent 30-day readmission following CABG. The most common causes of readmission were related to respiratory complications (17.1%), infection (13.5%), and heart failure (11.9%). Readmission cost an average of $13,392 per patient, accounting for an estimated annual cost of over $250 million. Independent predictors of 30-day readmission encompassed female gender (odds ratio [OR] 1.27; 95% confidence interval [CI] 1.24 to 1.31), emergent index admission (OR 1.29; 95% CI 1.25 to 1.33), and preoperative co-morbidities, including atrial fibrillation (OR 1.24; 95% CI 1.21 to 1.28), liver disease (OR 1.29; 95% CI 1.17 to 1.41), renal failure (OR 1.38; 95% CI 1.34 to 1.43), among others. CABG performed at a high CABG volume hospital was protective of readmission (OR 0.95; 95% CI 0.91 to 0.99). In conclusion, we characterized using a national sample the incidence, causes, costs, and predictors of 30-day readmission following CABG. Targeting modifiable risk factors for readmission should be a priority to reduce rates of readmission and decrease healthcare expenditure.

Hemiarthroplasty or Total Hip Arthroplasty: Is There a Racial Bias in Treatment Selection for Femoral Neck Fractures?

INTRODUCTION: Hip fractures in the elderly individuals are associated with significant morbidity and mortality, and outcomes are directly related to prompt surgical intervention with either total hip arthroplasty (THA) or hemiarthroplasty. Minority hip fracture patients have increased delays to surgical intervention and poorer functional outcomes. This study explored racial biases in the surgical treatment decision between THA and hemiarthroplasty for displaced femoral neck fractures as well as racial disparities in postoperative complications, readmission rates, and 30-day mortality. METHODS: We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2006 to 2014. Patients were identified using diagnosis code for transcervical femoral neck fractures and Current Procedural Terminology codes for THA or hemiarthroplasty. A multivariable regression analysis was conducted including race, demographic information, and medical comorbidities. RESULTS: Of 11 408 patients, race was recorded in 8538 individuals. Most patients were white (88.3%), followed by Hispanic (4.7%), African American (4.1%), and Asian/Native Hawaiian/Pacific Islander/American Indian/Alaska Native (2.9%). No differences were observed in the likelihood of receiving a THA versus hemiarthroplasty among racial groups. Only younger age and steroid use were independent risk factors for receiving a THA. Race was significantly associated with postoperative mortality (P = .014) and major postoperative complications for the Asian cohort (P = .013). DISCUSSION: The NSQIP data do not support a racial bias in the selection of patients for THA versus hemiarthroplasty. However, this study found racial disparities in postoperative mortality and complications. The reasons underlying the differences in postoperative outcomes are uncertain but may be the result of specific challenges to accessing care. CONCLUSION: There was no racial bias in the treatment of femoral neck fractures. However, there were racial disparities in postoperative mortality and complication rates. Further research is warranted to elucidate the true causes of these observed disparities.

Pretransplant malignancy among lung transplant recipients in the modern era.

BACKGROUND: Malignancy is a relative contraindication in transplant candidates, given the increased neoplastic risk accompanying posttransplant immunosuppression. However, the number of patients receiving a lung transplant despite pretransplant malignancy is rising, and their outcomes remain unclear. Our purpose was to examine the outcomes of lung transplant recipients with pretransplant malignancy in the modern era. METHODS: We evaluated the United Network for Organ Sharing registry for adult lung transplants that were completed between June 2005 and September 2016. Transplant recipients were stratified by pretransplant malignancy, with subgroup analysis by sex and active malignancy. The primary outcome was 5-year survival and the secondary outcome was cause of death. Kaplan-Meier estimates illustrated 5-year survival and multivariable Cox proportional hazards regressions controlled for demographics and comorbidities. RESULTS: Of 18,032 transplant patients, 1,321 transplant recipients (7.3%) possessed a pretransplant malignancy. Patients with pretransplant malignancy faced significantly greater mortality within 5 years (36.0% vs 32.8%, P = .017), an effect greatest in men with pretransplant malignancy (39.2% vs 33.7%, P = .002). Patients with pretransplant malignancy also faced greater risk of death from posttransplant malignancy (15.6% vs 9.4%, P < .001), particularly for those with active malignancy at transplant (34.8% vs 9.8%, P < .001). Pretransplant malignancy remained a significant predictor of 5-year mortality in adjusted Cox regressions (hazard ratio: 1.16 [1.05-1.27], P = .003). CONCLUSION: Patients with pretransplant malignancy, and particularly men with pretransplant malignancy and those with active malignancy at transplant, are at an increased risk of 5-year mortality and posttransplant death from malignancy. Balancing individual risk of posttransplant malignancy with immunosuppressive care is necessary to optimize outcomes for pretransplant malignancy patients.

Association of Autoimmune Connective Tissue Disease and Outcomes in Patients Undergoing Transcatheter Aortic Valve Implantation.

Patients with autoimmune connective tissue disease (CTD) are at higher risk for developing aortic valve pathology, but the safety and value of transcatheter aortic valve implantation (TAVI) in this population has not been investigated. This study evaluated mortality, complication, and readmission rates along with length of stay and total costs after TAVI in patients with CTD. We retrospectively reviewed 47,216 patients who underwent TAVI from the National Readmissions Database between January 2011 and September 2015. Patients with systemic lupus erythematosus, scleroderma, rheumatoid arthritis, and other autoimmune CTD comprised the cohort. The primary outcome was mortality at index hospitalization. The 2,557 CTD patients (5.4%) had a higher Elixhauser co-morbidity index (7.1 vs 6.1, p <0.001) than non-CTD patients. CTD and non-CTD patients had similar mortality (2.8 vs 4.1%, p = 0.052), 30-day readmission (19.3 vs 17.0%, p = 0.077), length of stay (8.2 vs 8.3 days, p = 0.615), and total adjusted costs ($57,202 vs $58,309, p = 0.196), respectively. However, CTD patients were more frequently readmitted for postoperative infection (9.4 vs 5.6%, p = 0.042) and septicemia (8.2 vs 4.5%, p = 0.019). After multivariable adjustment, CTD patients faced lower mortality at index hospitalization (odds ratio [OR] 0.56 [0.38 to 0.82], p = 0.003) but were more frequently readmitted for septicemia (OR = 1.95 [1.10 to 3.45], p = 0.023) and postoperative infection (OR = 3.10 [1.01 to 9.52], p = 0.048) relative to non-CTD patients. In conclusion, CTD is not a risk factor for in-hospital mortality but is an independent risk factor for infectious complications post-TAVI.

Revisiting the International Normalized Ratio (INR) Threshold for Complications in Primary Total Knee Arthroplasty: An Analysis of 21,239 Cases.

BACKGROUND: Consensus guidelines recommend use of the international normalized ratio (INR) to predict the risk of perioperative bleeding in orthopaedic surgery. However, current recommendations for targeting an INR of <1.5 are based on studies across all surgical disciplines. This study examined the impact of the INR on perioperative bleeding, mortality, postoperative infections, length of hospital stay (LOS), and readmissions following primary total knee arthroplasty (TKA). METHODS: We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for adult patients who underwent primary TKA from 2010 to 2016. Patients for whom an INR had been recorded within 1 day before the surgery were stratified and analyzed for perioperative bleeding, mortality within 30 days, deep wound and superficial infections, LOS, and readmissions. Multivariable regressions were utilized to adjust for differences in demographics and comorbidities among INR groups. RESULTS: Of 21,239 patients, 57.2% had an INR of ≤1.0; 38.1% had an INR of >1.0 to 1.25, 3.9% had an INR of >1.25 to 1.5, and 0.8% had an INR of >1.5. After adjustment, a progressively increased bleeding risk was found with an INR of >1.0 to 1.25 (odds ratio [OR] = 1.19, 95% confidence interval [CI] = 1.07 to 1.31, p = 0.001), an INR of >1.25 to 1.5 (OR = 1.29, 95% CI = 1.02 to 1.63, p = 0.033), and an INR of >1.5 (OR = 2.02, 95% CI = 1.29 to 3.14, p = 0.002) relative to an INR of ≤1.0. Patients with an INR of >1.5 were at increased risk for infection (OR = 5.34, 95% CI = 2.45 to 11.68, p < 0.001), but only patients with an INR of >1.25 to 1.5 were at increased risk for mortality (OR = 3.37, 95% CI = 1.31 to 8.63, p = 0.011) relative to those with an INR of ≤1.0. Overall and TKA-related readmission rates and LOS were significantly increased for patients with an INR of >1.25 to 1.5 or an INR of >1.5. CONCLUSIONS: An INR of >1.25 to 1.5 was associated with increased bleeding, infection, and mortality rates following TKA, and an INR of >1.5 was associated with increased bleeding and infection rates. Current INR target recommendations in consensus guidelines should be reconsidered. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinical Outcomes of Infective Endocarditis in Injection Drug Users.

BACKGROUND: Rising rates of hospitalization for infective endocarditis (IE) have been increasingly tied to rising injection drug use (IDU) associated with the opioid epidemic. OBJECTIVES: This study analyzed recent trends in IDU-IE hospitalization and characterized outcomes and readmissions for IDU-IE patients. METHODS: The authors evaluated the National Readmissions Database (NRD) for IE cases between January 2010 and September 2015. Patients were stratified by IDU status and surgical versus medical management. Primary outcome was 30-day readmission and cause, with secondary outcomes including mortality, length of stay (LOS), adjusted costs, and 180-day readmission. The Kruskal-Wallis and chi-square tests were used to analyze baseline differences by IDU status. Multivariable regressions were used to analyze mortality, readmissions, LOS, and adjusted costs. RESULTS: The survey-weighted sample contained 96,344 (77.8%) non-IDU-IE and 27,432 (22.2%) IDU-IE cases. IDU-IE increased from 15.3% to 29.1% of IE cases between 2010 and 2015 (p < 0.001). At index hospitalization, IDU-IE was associated with reduced mortality (6.8% vs. 9.6%; p < 0.001) but not 30-day readmission (23.8% vs. 22.9%; p = 0.077) relative to non-IDU-IE. Medically managed IDU-IE patients had higher LOS (ß = 1.36 days; 95% confidence interval [CI]: 0.71 to 2.01), reduced costs (ß = -$4,427; 95% CI: -$7,093 to -$1,761), and increased readmission for endocarditis (18.1% vs. 5.6%; p < 0.001), septicemia (14.0% vs. 7.3%; p < 0.001), and drug abuse (4.3% vs. 0.7%; p < 0.001) compared with medically managed non-IDU-IE. Surgically managed IDU-IE patients had increased LOS (ß = 4.26 days; 95% CI: 2.73 to 5.80) and readmission for septicemia (15.6% vs. 5.2%; p < 0.001) and drug abuse (7.3% vs. 0.9%; p < 0.001) compared with non-IDU-IE. CONCLUSIONS: The incidence of IDU-IE continues to rise nationally. Given the increased readmission for endocarditis, septicemia, and drug abuse, IDU-IE presents a serious challenge to current management of IE.

Recipient working status is independently associated with outcomes in heart and lung transplantation.

Employment status may capture elements of patients' physical strength, mental resilience, and socioeconomic status to better prognosticate transplant outcomes. This study characterized the effect of working status on thoracic transplant outcomes by evaluating the United Network for Organ Sharing registry for adult lung or heart transplants from 2005 to 2016. Kaplan-Meier estimates illustrated 5-year and 10-year survival by working status at transplant, while multivariable Cox proportional hazards regressions controlled for baseline differences, including functional and socioeconomic status. Of 17 778 lung transplant recipients, 1700 (9.6%) worked at transplant and experienced significantly lower 5-year mortality than nonworking recipients (38.6% vs 45.5%, P < 0.001). Of 21 394 heart transplant recipients, 1289 (6.0%) were employed and experienced significantly lower 10-year mortality than nonworking recipients (34.1% vs 40.2%, P < 0.001). Adjusted Cox regressions demonstrated that employment significantly reduced mortality independent of functional status for both lung (HR: 0.86 [0.78-0.95], P = 0.003) and heart (HR: 0.84 [0.72-0.97], P = 0.023) recipients. After accounting for insurance status, the effect of working status persisted only in lung transplantation (HR: 0.89 [0.81-0.98], P = 0.023). Since heart and lung transplant candidates employed at transplant face lower long-term mortality, working status must encompass a broad set of physical, psychological, and socioeconomic variables that may prognosticate post-transplant outcomes.

Preoperative Serum Albumin Levels Predict Treatment Cost in Total Hip and Knee Arthroplasty.

BACKGROUND: Hypoalbuminemia (serum albumin < 3.5 g/dL) is associated with increased morbidity and mortality in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, costs associated with hypoalbuminemia remain unknown. This study investigated the effect of serum albumin on direct treatment costs, length of stay (LOS), and readmissions for primary and revision THA and TKA patients. METHODS: All adult patients at a single institution undergoing primary or revision THA or TKA between January 2014 and December 2016 were retrospectively reviewed. Patients were stratified by preoperative serum albumin level. The primary outcome was total direct costs at index hospitalization. Secondary outcomes included LOS and readmission within 30 days. Multivariable regressions were utilized to adjust for demographics and comorbidities. RESULTS: Of 3,785 patients, 114 (3.0%) had hypoalbuminemia. After adjustment, hypoalbuminemia was associated with a 16.2% increase in costs (ß = 0.162; 95% confidence interval [CI], 0.112 to 0.213; p < 0.001), representing an average cost increase of $3,383 (95% CI, $2,281 to $4,485) relative to costs for serum albumin > 4.5 g/dL. The increased total costs were significantly higher in revision ($4,322, p = 0.034) than in primary ($3,446, p < 0.001) procedures. In adjusted regression, each 1.0 g/dL increase in serum albumin yielded a 6.6% reduction in costs (ß = -0.066; 95% CI, -0.090 to -0.042]; p < 0.001), for average savings of $1,282 (95% CI, $759 to $1,806) per unit albumin. Adjusted regressions demonstrated that a 1-point increase in serum albumin reduced readmissions by 53% (odds ratio, 0.47; 95% CI, 0.31-0.73; p = 0.001) and LOS by 0.6 days (ß = -0.60; 95% CI, -0.76 to -0.44; p < 0.001). CONCLUSIONS: Hypoalbuminemia is associated with increased total direct costs, LOS, and readmissions following primary and revision THA and TKA. Future efforts to predict and address total costs should take into consideration the patient's preoperative serum albumin levels.