Impact of Controlling Nutritional Status Score on Comprehensive Clinical Outcomes in Patients With Chronic Limb-Threatening Ischemia in a Local Area of Super-Aged Society.

PURPOSE: This study aimed to evaluate the relationship between nutritional status and hospital outcomes in patients with chronic limb-threatening ischemia (CLTI) in a local area of contemporary super-aged society of Japan. MATERIALS AND METHODS: We analyzed 131 consecutive patients with 179 lower limb diseases admitted to our hospital for the treatment of CLTI between April 2018 and March 2023. These 131 patients were divided into 3 groups according to hospital outcomes: home discharge (HD), out-of-home discharge (OD), and in-hospital death (ID). Patient and lesion backgrounds were compared among the 3 groups, and a multivariable regression analysis was used to analyze the interaction between malnutrition and composite hard endpoints. RESULTS: The median age was 82.8 years, and non-ambulatory patients comprised 61.8% of the study population. The HD group included more ambulatory and fewer patients with higher CONUT score or inflammation than OD or ID group. The Rutherford classification and Wound, Ischemia, and foot Infection stage were significantly more severe in the ID group than in the HD group. Endovascular treatment (EVT) was more often implemented in the HD (94.9%) and OD (81.7%) groups than in the ID group (60.0%). However, all EVT procedures in the ID group were performed until as distally as possible to achieve the target arterial path success contrary to some EVT procedures in the HD or ID group that targeted lesions only above the knee. Multivariate analysis showed that a non-ambulatory state (hazard ratio [HR]=3.65, 95% confidence interval [CI]=1.48-9.02) and a higher controlling nutritional status (CONUT) score (≥5) (HR=7.46, 95% CI=1.66-33.6) were significant predictors for composite endpoints (major amputation or ID). Patients with lower CONUT scores (≤4) showed better outcomes in all indices including overall survival, major amputation-free survival, and wound healing. CONCLUSION: Condition of the CLTI patients represented by higher CONUT score emerged as the most influential predictor of major amputation or ID. Furthermore, non-ambulatory status or condition of higher CONUT score affects the destination after discharge. Implementing multidisciplinary approaches to address patients' nutritional state and physical disability, in addition to revascularization, may enhance comprehensive prognoses in patients with CLTI. CLINICAL IMPACT: In this single-center retrospective study, we analyzed prognoses of 131 consecutive patients with 179 lower limb diseases admitted for the treatment of chronic limb-threatening ischemia (CLTI) between April 2018 and March 2023. Our main finding was that condition of the CLTI patients represented by higher controlling nutritional status (CONUT) score was the most significant predictor of either major amputation or in-hospital death. Furthermore, condition of higher CONUT score or non-ambulatory status affects the destination after discharge. This suggests that multidisciplinary approaches to address patients' nutritional state and physical disability, in addition to revascularization, may enhance the prognosis in patients with CLTI. This is the first report to evaluate nutritional status associated with comprehensive hospital outcomes in addition to previously reported hard endpoints, such as major amputation or overall survival, and will be of great help in future clinical practice.

Association of ketamine use during procedural sedation with oxygen desaturation and healthcare utilisation: a multicentre retrospective hospital registry study.

BACKGROUND: We investigated the effects of ketamine on desaturation and the risk of nursing home discharge in patients undergoing procedural sedation by anaesthetists. METHODS: We included adult patients who underwent procedures under monitored anaesthetic care between 2005 and 2021 at two academic healthcare networks in the USA. The primary outcome was intraprocedural oxygen desaturation, defined as oxygen saturation <90% for ≥2 consecutive minutes. The co-primary outcome was a nursing home discharge. RESULTS: Among 234,170 included patients undergoing procedural sedation, intraprocedural desaturation occurred in 5.6% of patients who received ketamine vs 5.2% of patients who did not receive ketamine (adjusted odds ratio [ORadj] 1.22, 95% confidence interval [CI] 1.15-1.29, P<0.001; adjusted absolute risk difference [ARDadj] 1%, 95% CI 0.7-1.3%, P<0.001). The effect was magnified by age >65 yr, smoking, or preprocedural ICU admission (P-for-interaction <0.001, ORadj 1.35, 95% CI 1.25-1.45, P<0.001; ARDadj 2%, 95% CI 1.56-2.49%, P<0.001), procedural risk factors (upper endoscopy of longer than 2 h; P-for-interaction <0.001, ORadj 2.91, 95% CI 1.85-4.58, P<0.001; ARDadj 16.2%, 95% CI 9.8-22.5%, P<0.001), and high ketamine dose (P-for-trend <0.001, ORadj 1.61, 95% CI, 1.43-1.81 for ketamine >0.5 mg kg-1). Concomitant opioid administration mitigated the risk (P-for-interaction <0.001). Ketamine was associated with higher odds of nursing home discharge (ORadj 1.11, 95% CI 1.02-1.21, P=0.012; ARDadj 0.25%, 95% CI 0.05-0.46%, P=0.014). CONCLUSIONS: Ketamine use for procedural sedation was associated with an increased risk of oxygen desaturation and discharge to a nursing home. The effect was dose-dependent and magnified in subgroups of vulnerable patients.

Home, but Homebound after Traumatic Brain Injury: Risk Factors and Associations with Nursing Home Entry and Death.

OBJECTIVE: To examine risk factors associated with homeboundness 1-year following traumatic brain injury (TBI) and to explore associations between homebound status and risk of future mortality and nursing home entry. DESIGN: Secondary analysis of a longitudinal prospective cohort study SETTING: TBI Model Systems (TBIMS) Centers PARTICIPANTS: Community-dwelling TBIMS participants (n=6,595) who sustained moderate-severe TBI between 2006-2016, and resided in a private residence 1-year post-injury. INTERVENTIONS: N/A MAIN OUTCOME MEASURES: Homebound status (leaving home ≤1-2 days per week), 5-year mortality, and 2- or 5-year nursing home entry. RESULTS: In our sample, 14.2% of individuals were homebound 1-year post-injury, including 2% who never left home. Older age, having less than a Bachelor's degree, Medicaid insurance, living in the Northeast or Midwest, dependence on others or special services for transportation, unemployment or retirement, and needing assistance for locomotion, bladder management, and social interactions at 1-year post-injury were associated with being homebound. After adjustment for potential confounders and an inverse probability weight for nonrandom attrition bias, being homebound was associated with a 1.69-times (95% CI: 1.35-2.11) greater risk of five-year mortality, and a non-significant but trending association with nursing home entry by 5 years post-injury (RR=1.90, 95% CI: 0.94, 3.87). Negative associations between homeboundness and mortality were consistent by age subgroup (± 65 years). CONCLUSIONS: The negative long-term health outcomes among persons with TBI who rarely leave home warrants the need to re-evaluate home discharge as unequivocally positive. The identified risk factors for homebound status, and its associated negative long-term outcomes, should be considered when preparing patients and their families for discharge from acute and post-acute rehabilitation care settings. Addressing modifiable risk factors for homeboundness, such as accessible public transportation options and home care to address mobility, could be targets for individual referrals and policy intervention.

A Novel Preoperative Risk Score to Identify Patients at High Risk for Non-Home Discharge After Elective Open Abdominal Aortic Aneurysm Repair.

BACKGROUND: Non-home discharge (NHD) to a rehabilitation or skilled nursing facility after vascular surgery is poorly described despite its impact on patients. For home-dwelling patients undergoing elective surgery, the need for postoperative NHD can have meaningful implications on quality of life, long-term outcomes, and healthcare spending. Understanding post-surgical NHD risk is essential to preoperative counseling and shared decision making. This is particularly true for the treatment of abdominal aortic aneurysms as the postoperative course can vary between open and endovascular surgery. We aimed to identify independent predictors of NHD following elective open abdominal aortic aneurysm repair (OAR), and to create a clinically useful preoperative risk score. METHODS: Elective OAR cases were queried from the SVS Vascular Quality Initiative from years 2013-2022. A risk score was created by splitting the data set into two-thirds for development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. The score was then validated, and model performance assessed. RESULTS: Overall, 8,274 patients were included and 1,502 (18.2%) required NHD. At baseline, patients who required NHD were more likely to be ≥ 80 years old (23.6% vs. 6.5%), female (35.9% vs. 23.1%), not independently ambulatory (14.6% vs. 4.3%), anemic (24.4% vs. 13.9%), have COPD (41.6% vs. 30.7%), ASA class ≥ 4 (41.0% vs. 32.5%), and a supraceliac proximal clamp (9.8% vs. 5.7%; all P<0.05). Multivariable analysis in the development group identified the following independent predictors of NHD: age ≥ 80 years, not independently ambulatory, proximal clamp location, hypogastric artery occlusion, anemia (Hb <12 g/dL), chronic obstructive pulmonary disease, female sex, hypertension, and American Society of Anesthesiologists class ≥ 4. These were then used to create a 14-point risk score. Patients were stratified into three groups based upon their risk score: low risk (0-4 points; n=4,966) with an NHD rate of 9.9%, moderate risk (5-6 points; n=2,442) with an NHD rate of 25.5%, and high risk (≥ 7 points; n=886) with an NHD rate of 44.6%. The risk score had good predictive ability with c-statistic=0.73 for model development and c-statistic=0.72 in the validation dataset. CONCLUSIONS: This novel risk score can predict NHD following elective OAR using characteristics that can be identified preoperatively. Utilization of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.

Patient disposition after discharge following primary total hip arthroplasty: home versus skilled nursing facility-a study based on national inpatient sample database.

INTRODUCTION: In view of the shortened length of hospital stay following THA, an increasing proportion of patients have required transfer to "extended-care" (ECF) or "skilled nursing" facilities (SNF) over the past years. As a result, the expenditure related to postoperative care facility has been acknowledged as a crucial component of total economic burden associated with THA. In this context, the clinical and demographic factors leading to the need for transfer of patients to SNF following primary THA need to be clearly understood. METHODS: The NIS database was utilised to identify the patients, who underwent primary THA between 2016 and 2019. The patients were then grouped under two categories: group A-patients who required post-THA transfer to SNF; and group B-those who were discharged home. The details regarding patients' demographic profile, medical comorbidities and complication profile during the perioperative period were recorded; and compared between groups A and B. RESULTS: Based on the database, 368,431 patients underwent primary THA between 2016 and 2019; among whom, 67,498 (18.3%) were transferred to SNF (group A) following the surgery. Among the various comorbidities evaluated [on multivariate analysis (MVA)], uncomplicated DM (OR 1.45; p < 0.001), CKD (OR 1.47; p < 0.001), cirrhosis (OR 1.83; p < 0.001), Parkinson's disease (OR 3.94; p < 0.001), previous H/O dialysis (OR 2.84; p < 0.001), colostomy (OR 2.03; p < 0.001) or organ transplant (OR 1.42; p < 0.001); morbid obesity (OR 1.72; p < 0.001), cocaine abuse (OR 1.76; p < 0.001); and legal blindness (OR 2.58; p < 0.001) were associated with significantly greater need for post-THA transfer to SNF. Among the systemic complications reviewed (on MVA), pneumonia (odds ratio 3.2; p < 0.001), DVT (odds ratio 2.58; p < 0.001), higher need for blood transfusions (odds ratio 2.55; p < 0.001), ARF (odds ratio 2.32; p < 0.001), MI (odds ratio 2.2; p < 0.001), anaemia (odds ratio 1.65; p = 0.002) and PE (odds ratio 1.56; p < 0.001) significantly raised the probability of need for higher discharge destinations. In addition, prosthesis-related local complications such as prosthetic dislocation (OR 1.59; p < 0.001), fracture (OR 2.64; p < 0.001) or early peri-prosthetic infection (PPI; OR 1.71; p = 0.01) also necessitated specialised facilities of care following THA. CONCLUSION: We could observe that 0.2% of patients required transfer to SNF following primary THA. Comorbidities such as Parkinson's disease, previous H/O dialysis, legal blindness and H/O colostomy had the highest odds of necessitating patient disposition to SNF. The occurrence of one or more systemic complications including pneumonia, DVT, ARF, MI, PE, and blood loss anaemia (or need for blood transfusion) or local prosthesis-related complications (dislocation, fracture or infections) substantially increased the chances of requiring transfer to a specialised care facility.

Hospital Performance on Failure to Rescue Correlates With Likelihood of Home Discharge.

INTRODUCTION: Failure to rescue (FTR) (avoiding death after complications) has been proposed as a measure of hospital quality. Although surviving complications is important, not all rescues are created equal. Patients also place considerable values on being able to return home after surgery and resume their normal lives. From a systems standpoint, nonhome discharge to skilled nursing and other facilities is the biggest driver of Medicare costs. We wanted to determine whether hospitals' ability to keep patients alive after complications was associated with higher rates of home discharge. We hypothesized that hospitals with higher rescue rates would also be more likely to discharge patients home after surgery. METHODS: We conducted a retrospective cohort study using the nationwide inpatient sample. We included 1,358,041 patients ≥18 y old who had elective major surgery (general, vascular, orthopedic) at 3818 hospitals from 2013 to 2017. We predicted the correlation between a hospital's performance (rank) on FTR and its rank in terms of home discharge rate. RESULTS: The cohort had a median age of 66 y (interquartile range [IQR] 58-73), and 77.9% of patients were Caucasian. Most patients (63.6%) were treated at urban teaching institutions. The surgical case mix included patients having colorectal (146,993 patients; 10.8%), pulmonary (52,334; 3.9%), pancreatic (13,635; 1.0%), hepatic (14,821; 1.1%), gastric (9182; 0.7%), esophageal (4494; 0.3%), peripheral vascular bypass (29,196; 2.2%), abdominal aneurysm repair (14,327; 1.1%), coronary artery bypass (61,976; 4.6%), hip replacement (356,400; 26.2%), and knee replacement (654,857; 48.2%) operations. The overall mortality was 0.3%, the average hospital complication rate was 15.9%, the median hospital rescue rate was 99% (IQR 70%-100%), and the median hospital rate of home discharge was 80% (IQR 74%-85%).There was a small but positive correlation between hospitals' performance on the FTR metric and the likelihood of home discharge after surgery (r = 0.0453; P = 0.006). When considering hospital rates of discharge to home following a postoperative complication, there was a similar correlation between rescue rates and probability of home discharge (r = 0.0963; P < 0.001). However, on sensitivity analysis excluding orthopedic surgery, there was a stronger correlation between rescue rates and home discharge rate (r = 0.4047, P < 0.001). CONCLUSIONS: We found a small correlation between a hospital's ability to rescue patients from complication and that hospital's likelihood of discharging patients home after surgery. When excluding orthopedic operations from the analysis, this correlation strengthened. Our findings suggest that efforts to reduce mortality after complications will likely also help patients return home more frequently after complex surgery. However, more work needs to be done to identify successful programs and other patient and hospital factors that affect both rescue and home discharge.

Depression Is Associated With Non-Home Discharge After Coronary Artery Bypass Graft.

INTRODUCTION: Depression is disproportionately high in patients with coronary artery disease and has been associated with adverse outcomes following coronary artery bypass graft (CABG). One quality metric, non-home discharge (NHD), can have substantial implications for patients and health care resource utilization. Depression increases the risk of NHD after many operations, but it has not been studied after CABG. We hypothesized that a history of depression would be associated with an increased risk of NHD following CABG. METHODS: CABG cases were identified from the 2018 National Inpatient Sample using ICD-10 codes. Depression, demographic data, comorbidities, length of stay (LOS), rate of NHD were analyzed using appropriate statistical tests where a P-value < 0.05 was defined as statistically significant. Adjusted multivariable logistic regression models were used to assess independent association between depression and NHD as well as LOS while controlling for confounders. RESULTS: There were 31,309 patients, of which 2743 (8.8%) had depression. Depressed patients were younger, females, in a lower income quartile, and more medically complex. They also demonstrated more frequent NHD and prolonged LOS. After adjusted multivariable analysis, depressed patients had a 70% increased odds of NHD (adjusted odds ratio: 1.70 [1.52-1.89] P < 0.001) and a 24% increased odds of prolonged LOS (AOR: 1.24 [1.12-1.38] P < 0.001). CONCLUSIONS: From a national sample, depressed patients were associated with more frequent NHD following CABG. To our knowledge, this is the first study to demonstrate this, and it highlights the need for improved preoperative identification in order to improve risk stratification and timely allocation of discharge services.

Which factors influence the decision to perform Hartmann's reversal in various causative disease situations? A retrospective cohort study between 2006 and 2021.

AIM: Our aim was to investigate the predictive factors for Hartmann's reversal and to describe the differences in the rates and timings of Hartmann's reversal for various causative diseases. METHOD: In this multicentre retrospective cohort study patients who underwent Hartmann's procedure (HP) between 2006 and 2018 were enrolled. To describe the demographic patterns of Hartmann's reversal through to 2021, we analysed the cumulative incidence rate of Hartmann's reversal over time based on the Kaplan-Meier failure estimate. Multivariable Cox proportional hazard analysis was performed with cluster-adjusted robust standard errors to calculate hazard ratios (HRs) for the assessment of variables associated with colostomy reversal. RESULTS: Of 250 patients who underwent the index HP and survived to discharge, 112 (45%) underwent subsequent Hartmann's reversal (36% for malignant and 51% for benign disease). The causative diseases with the highest probability of colostomy reversal were trauma (85%) and diverticular disease (73%). Conversely, colostomy reversal was performed in only 16% for colonic volvulus and 17% for bowel ischaemia. Home discharge after index HP (HR 5.22, 95% CI 3.31-8.23) and a higher body mass index (HR 1.03, 95% CI 1.01-1.04) were associated with a higher probability of Hartmann's reversal, whereas older age, malignant disease and a history of cardiovascular and psychoneurological diseases were independently associated with a lower probability of colostomy reversal. CONCLUSION: The probability and timing of Hartmann's reversal varied considerably with the surgical indications for colostomy creation. Our results could help surgeons counsel patients and their families regarding stoma closure surgery to set realistic expectations.

The effects of sugammadex vs. neostigmine on postoperative respiratory complications and advanced healthcare utilisation: a multicentre retrospective cohort study.

Reversing neuromuscular blockade with sugammadex can eliminate residual paralysis, which has been associated with postoperative respiratory complications. There are equivocal data on whether sugammadex reduces these when compared with neostigmine. We investigated the association of the choice of reversal drug with postoperative respiratory complications and advanced healthcare utilisation. We included adult patients who underwent surgery and received general anaesthesia with sugammadex or neostigmine reversal at two academic healthcare networks between January 2016 and June 2021. The primary outcome was postoperative respiratory complications, defined as post-extubation oxygen saturation < 90%, respiratory failure requiring non-invasive ventilation, or tracheal re-intubation within 7 days. Our main secondary outcome was advanced healthcare utilisation, a composite outcome including: 7-day unplanned intensive care unit admission; 30-day hospital readmission; or non-home discharge. In total, 5746 (6.9%) of 83,250 included patients experienced postoperative respiratory complications. This was not associated with the reversal drug (adjusted OR (95%CI) 1.01 (0.94-1.08); p = 0.76). After excluding patients admitted from skilled nursing facilities, 8372 (10.5%) patients required advanced healthcare utilisation, which was not associated with the choice of reversal (adjusted OR (95%CI) 0.95 (0.89-1.01); p = 0.11). Equivalence testing supported an equivalent effect size of sugammadex and neostigmine on both outcomes, and neostigmine was non-inferior to sugammadex with regard to postoperative respiratory complications or advanced healthcare utilisation. Finally, there was no association between the reversal drug and major adverse cardiovascular events (adjusted OR 1.07 (0.94-1.21); p = 0.32). Compared with neostigmine, reversal of neuromuscular blockade with sugammadex was not associated with a reduction in postoperative respiratory complications or post-procedural advanced healthcare utilisation.

The Relationship Between Preoperative Frailty Risk as Assessed by the Hospital Frailty Risk Score and the Outcome at Discharge in Coronary Artery Bypass Grafting (CABG) Patients: A Retrospective Observational Study Using the Diagnosis Procedure Combination Database.

The relationship between the Hospital Frailty Risk Score (HFRS)-based frailty risk and outcomes after coronary artery bypass grafting (CABG) is yet unclear. The objective of this study was to investigate the relationship between preoperative frailty risk as assessed by the HFRS and postoperative outcomes in patients undergoing CABG. This observational study used the diagnosis procedure combination (DPC) system in Japan (2014-2017). In total, 35,015 adults aged ≥ 65 years and diagnosed with angina pectoris and acute myocardial infarction who had undergone CABG were enrolled. We investigated the association between the HFRS-based frailty risk and the home discharge rate, as well as the prevalence of complications. Multilevel logistic regression analysis revealed that having an HFRS ≥ 5 was a determinant of lower home discharge rate (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.49-0.74, P <0.01), aspiration pneumonia (OR 2.25, 95%CI 1.27-3.96, P <0.01) and disuse syndrome (OR 1.90, 95%CI 1.23-2.94, P <0.01). Preoperative stratification of frailty risk using HFRS may help in predicting postoperative progress and in planning postoperative rehabilitation.

Grip strength as a predictor for home discharge in convalescent rehabilitation patients.

[Purpose] We examined the impact of the assessment items for sarcopenia on discharge destination in convalescent rehabilitation patients. [Participants and Methods] In this study, 174 patients (males; 77, mean age; 72.4 years, females; 97, mean age; 80.1 years) who were admitted and discharged from the convalescent rehabilitation wards of the International University of Health and Welfare, Shioya Hospital, were included. The participants' height, weight, grip strength, and lower calf circumference were measured. Additionally, the number of motor functional independence measure (mFIM) at discharge, length of stay in the wards, and average number of rehabilitation sessions per day were calculated as the convalescent rehabilitation wards index. [Results] Age, weight, grip strength, lower calf circumference, mFIM at discharge, length of stay in the wards, and average number of rehabilitation sessions per day had significant differences between the return-to-home and non-home groups. Binomial logistic regression analysis revealed significant differences in grip strength and mFIM at discharge. [Conclusion] This study adjusted the sarcopenia criteria for sex and age and showed that grip strength significantly affected the outcome destination. Grip strength was shown to be a predictor of home discharge in convalescent rehabilitation patients.

Relationship between the fasting status during hospitalisation, the length of hospital stay and the outcome.

The effects of long-term fasting on the prognosis and hospital economy of hospitalised patient have not been established. To clarify the effects of long-term fasting on the prognosis and hospital economy of hospitalised patients, we conducted a prospective observational study on the length of hospital stay of patients hospitalised at thrity-one private university hospitals in Japan. We conducted a prospective observational study on the effects of fasting period length on the length of hospital stay and outcome of patients hospitalised for 3 months in those hospitals. Of the 14 172 cases of hospitalised patients during the target period on the reference day, 770 cases (median 71 years old) were eligible to fast for the study. The length of hospital stay for fasting patients was 33 (4-387) days, which was about 2·4 times longer than the average length of hospital stay for all patients. A comparative study showed the length of hospital stay was significantly longer in the long-term-fasting (fasting period > 10 d; n 386) group than in the medium-term-fasting (< 10 d; n 384) group (median 21 v. 50; P < 0·0001). Although the discharge to home rate was significantly higher in the medium-term-fasting group (71·4 % v. 36·5 %; P < 0·0001), the mortality rate was significantly higher in the long-term fasting group (10·8 % v. 25·8 %; P < 0·0001). It was verified that the longer the fasting period during hospitalisation, the longer the length of hospital stay and lower home discharge rate, thus indicating that patient quality of life and hospital economy may be seriously dameged.

Outcomes of Prolonged ICU Stay for Patients Undergoing Cardiac Surgery in Australia and New Zealand.

OBJECTIVE: To determine the effect of intensive care unit (ICU) length of stay (LOS) on hospital mortality and non-home discharge for patients undergoing cardiac surgery over a 16-year period in Australia and New Zealand. DESIGN: A retrospective, multicenter cohort study covering the period January 1, 2004 to December 31, 2019. SETTING: One hundred one hospitals in Australia and New Zealand that submitted data to the Australia New Zealand Intensive Care Society Adult Patient Database. PARTICIPANTS: Adult patients (aged >18) who underwent coronary artery bypass grafting, valve surgery, or combined valve + coronary artery surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors analyzed 252,948 cardiac surgical patients from 101 hospitals, with a median age of 68.3 years (IQR 60-75.5), of whom 74.2% (187,632 of 252,948) were male patients. A U-shaped relationship was observed between ICU LOS and hospital mortality, with significantly elevated mortality at short (<20 hours) and long (>5 days) ICU LOS, which persisted after adjustment for illness severity and across clinically important subgroups (odds ratio for mortality with ICU LOS >5 days = 3.21, 95% CI 2.88-3.58, p < 0.001). CONCLUSIONS: Prolonged duration of ICU LOS after cardiac surgery is associated with increased hospital mortality in a U-shaped relationship. An ICU LOS >5 days should be considered a meaningful definition for prolonged ICU stay after cardiac surgery.

Predictors of hospital discharge and mortality in patients with diabetes and COVID-19: updated results from the nationwide CORONADO study.

AIMS/HYPOTHESIS: This is an update of the results from the previous report of the CORONADO (Coronavirus SARS-CoV-2 and Diabetes Outcomes) study, which aims to describe the outcomes and prognostic factors in patients with diabetes hospitalised for coronavirus disease-2019 (COVID-19). METHODS: The CORONADO initiative is a French nationwide multicentre study of patients with diabetes hospitalised for COVID-19 with a 28-day follow-up. The patients were screened after hospital admission from 10 March to 10 April 2020. We mainly focused on hospital discharge and death within 28 days. RESULTS: We included 2796 participants: 63.7% men, mean age 69.7 ± 13.2 years, median BMI (25th-75th percentile) 28.4 (25.0-32.4) kg/m2. Microvascular and macrovascular diabetic complications were found in 44.2% and 38.6% of participants, respectively. Within 28 days, 1404 (50.2%; 95% CI 48.3%, 52.1%) were discharged from hospital with a median duration of hospital stay of 9 (5-14) days, while 577 participants died (20.6%; 95% CI 19.2%, 22.2%). In multivariable models, younger age, routine metformin therapy and longer symptom duration on admission were positively associated with discharge. History of microvascular complications, anticoagulant routine therapy, dyspnoea on admission, and higher aspartate aminotransferase, white cell count and C-reactive protein levels were associated with a reduced chance of discharge. Factors associated with death within 28 days mirrored those associated with discharge, and also included routine treatment by insulin and statin as deleterious factors. CONCLUSIONS/INTERPRETATION: In patients with diabetes hospitalised for COVID-19, we established prognostic factors for hospital discharge and death that could help clinicians in this pandemic period. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT04324736.

Operative Duration and Short-Term Postoperative Complications after Unicompartmental Knee Arthroplasty.

BACKGROUND: Prolonged operative duration is an independent risk factor for postoperative complications in many orthopedic procedures ranging from shoulder arthroscopy to total hip and knee arthroplasties. It has not been well studied in unicompartmental knee arthroplasty (UKA). The purpose of this study is to assess the effect of operative duration on complications after UKA. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program registry, we identified all primary unilateral UKAs from 2005 to 18. Patients were divided into three cohorts based on the operative duration: < 90 minutes, between 90 and 120 minutes, and >120 minutes. Baseline patient and operative demographics (age, gender, etc.) and thirty-day complications were compared using bivariate analysis. Multivariate analysis was used to assess the independent effect of operative duration on postoperative outcomes after adjusting for differences in baseline characteristics. RESULTS: We identified 11,806 patients who underwent primary UKA from 2005 to 18. There was no difference in the "any complication" rate between cohorts. However, operative duration >120 minutes was associated with a significantly higher likelihood of reoperation (odds ratio [OR] 2.02, 95% confidence interval [CI]: 1.15-3.57, P = .015), non-home discharge (OR: 2.14, CI: 1.65-2.77, P < .001), surgical site infection (OR: 1.76, CI: 1.03-3.01, P = .038), and blood transfusions (OR: 3.23, CI: 1.44-7.22, P = .004) when compared with operative duration <90 minutes. There was no difference in mortality rates. CONCLUSION: Increased operative duration greater than 2 hours in primary UKA is associated with an increased risk of non-home discharge, surgical site infection, reoperation, and blood transfusion.

Decision Tree Algorithm Identifies Stroke Patients Likely Discharge Home After Rehabilitation Using Functional and Environmental Predictors.

BACKGROUND AND PURPOSE: The importance of environmental factors for stroke patients to achieve home discharge was not scientifically proven. There are limited studies on the application of the decision tree algorithm with various functional and environmental variables to identify stroke patients with a high possibility of home discharge. The present study aimed to identify the factors, including functional and environmental factors, affecting home discharge after stroke inpatient rehabilitation using the machine learning method. METHOD: This was a cohort study on data from the maintained database of all patients with stroke who were admitted to the convalescence rehabilitation ward of our facility. In total, 1125 stroke patients were investigated. We developed three classification and regression tree (CART) models to identify the possibility of home discharge after inpatient rehabilitation. RESULTS: Among three models, CART model incorporating basic information, functional factor, and environmental factor variables achieved the highest accuracy for identification of home discharge. This model identified FIM dressing of the upper body (score of ≤2 or >2) as the first single discriminator for home discharge. Performing house renovation was associated with a high possibility of home discharge even in patients with stroke who had a poor FIM score in the ability to dress the upper body (≤2) at admission into the convalescence rehabilitation ward. Interestingly, many patients who performed house renovation have achieved home discharge regardless of the degree of lower limb paralysis. CONCLUSION: We identified the influential factors for realizing home discharge using the decision tree algorithm, including environmental factors, in patients with convalescent stroke.

Machine Learning Algorithm Identifies the Importance of Environmental Factors for Hospital Discharge to Home of Stroke Patients using Wheelchair after Discharge.

BACKGROUND AND PURPOSE: Physical environmental factors are generally likely to become barriers for discharge to home of wheelchair users, compared with non-wheelchair users. However, the importance of environmental factors has not been investigated adequately. Application of machine learning technology might efficiently identify the most influential factors, although it is not easy to interpret and integrate various information including individual and environmental factors in clinical stroke rehabilitation. This study aimed to identify the influential factors affecting home discharge in the stroke patients who use a wheelchair after discharge by using machine learning technology. METHODS: This study used the rehabilitation database of our facility, which includes all stroke patients admitted into the convalescence rehabilitation ward. The chi-squared automatic interaction detection (CHAID) algorithm was used to develop a model to classify wheelchair-using stroke patients discharged to home or not-to-home. RESULTS: Among the variables, including basic information, motor functional factor, activities of daily living ability factor, and environmental factors, the CHAID model identified house renovation and the existence of sloping roads around the house as the first and second discriminators for home discharge. CONCLUSIONS: Our present results could scientifically clarify that the clinician need to focus on the physical environmental factors for achieving home discharge in the patients who use a wheelchair after discharge.

Comparison of Supervised Machine Learning Algorithms for Classifying of Home Discharge Possibility in Convalescent Stroke Patients: A Secondary Analysis.

OBJECTIVES: Classifying the possibility of home discharge is important during stroke rehabilitation to support decision-making. There have been several studies on supervised machine learning algorithms, but only a few have compared the performance of different algorithms based on the same dataset for the classification of home discharge possibility. Therefore, we aimed to evaluate five supervised machine learning algorithms for the classification of home discharge possibility in stroke patients. MATERIALS AND METHODS: This was a secondary analysis based on the data of 481 stroke patients from the database of our institution. Five models developed by supervised machine learning algorithms, including decision tree (DT), linear discriminant analysis (LDA), k-nearest neighbors (k-NN), support vector machine (SVM), and random forest (RF) were compared by constructing a classification system based on the same dataset. Several parameters including classification accuracy, area under the curve (AUC), and F1 score (a weighted average of precision and recall) were used for model evaluation. RESULTS: The k-NN model had the best classification accuracy (84.0%) with a moderate AUC (0.88) and F1 score (87.8). The SVM model also showed high classification accuracy (82.6%) along with the highest AUC (0.91), sensitivity (94.4), negative predictive value (87.5), and negative likelihood ratio (0.088). The DT, LDA, and RF models had high classification accuracies (≥ 79.9%) with moderate AUCs (≥ 0.84) and F1 scores (≥ 83.8). CONCLUSIONS: Regarding model performance, the k-NN and SVM seemed the best candidate algorithms for classifying the possibility of home discharge in stroke patients.

Factors influencing the length of stay in the palliative care unit in patients discharged home: results from a tertiary hospital in Turkey

Background/aim: Increased length of stay (LOS) in the palliative care unit (PCU) is a serious burden to the patients and the health care system. The predictors of longer LOS in a PCU have not been reported so far from Turkey. Our aim in this study was to evaluate the factors associated with the LOS in the PCU of a tertiary hospital. Materials and methods: This cross-sectional analysis of a retrospective cohort evaluated adult patients' medical records admitted to the PCU between 2017 and 2019. The main inclusion criteria were 4 or more days of palliative unit stay and being discharged home during the study period. Data on demographics, chronic diseases, mobilization disability, route of feeding, tracheostomy, sleep disturbances, pressure ulcers, and antidepressant use were collected. Potential factors associated with prolonged LOS tertiles were examined by ordinal regression analysis. Results: A total of 287 discharges from the PCU to home were analyzed. Mean (SD) age was 70.5 (15.8) years, and there was a male predominance (55.7%). The majority of patients had malnutrition, mobility limitation, hypertension, malignant disease, and sleep disturbances. Median LOS was 15 days (4­79). Mean age, hypertension, infections, mobilization limitation, tube feeding, permanent tracheostomy, and pressure ulcers increased from the short stay tertile (4­12 days) to the medium stay tertile (13­20 days) and long stay tertile (>21 days) of LOS. Mobilization limitation [p = 0.013, OR: 2.34 (95% CI: 1.19­4.60)], tube feeding [p = 0.001, OR: 2.63 (95% CI: 1.49­4.66)], permanent tracheostomy [p = 0.007, OR: 4.10 (95% CI: 1.48­11.36)], and hypertension diagnosis [p = 0.023, OR: 1.80, (95% CI: 1.09­2.98)] on admission were associated with being in the medium stay or long stay tertiles of LOS compared to the lowest tertile. Conclusion: A longer length of PCU stay is associated with mobilization limitation, tube feeding, permanent tracheostomy, and hypertension. We found no evidence that age, infections or pressure ulcers on admission were associated with extra LOS in the PCU in patients discharged home.

Shorter Interval between Onset and Admission to Convalescent Rehabilitation Wards Is Associated with Improved Outcomes in Ischemic Stroke Patients.

As Japan's population ages, there is a growing interest in regional health care coordination. Our study aimed to evaluate whether the interval between onset and admission to convalescent rehabilitation wards (onset-admission) was associated with outcomes in ischemic stroke patients. We conducted a retrospective cohort study in a single rehabilitation hospital. Ischemic stroke patients consecutively admitted to the wards were eligible to enroll. Outcomes included Functional Independence Measure (FIM)-motor gain, the Food Intake Level Scale (FILS) and a discharge rate to home. FIM assesses functional independence, including motor (FIM-motor) and cognitive domains, and is a measure of activities of daily living (ADLs). The FIM-motor gain indicates the difference between the FIM-motor scores at admission and discharge. FILS is a 10-point observer-rated scale to measure swallowing. After enrollment, 481 patients (mean age 74.4 years; 45.7% women) were included. The median [interquartile range] onset-admission interval was 13 [10-20] days and the median National Institute of Health Stroke Scale score, a measure of stroke severity, was 8 [3-13]. In multivariate analysis, the onset-admission interval was independently associated with FIM-motor gain (ß = -0.107, p = 0.024), FILS score at discharge (ß = -0.159, p = 0.041), and the rate of discharge to home (odds ratio: 0.946, p = 0.032). In conclusion, a shorter interval between stroke onset and admission to convalescent rehabilitation wards contributes to improved outcomes, including ADLs, dysphagia, and a discharge rate to home, in ischemic stroke patients, regardless of stroke severity.