Differential roles of comorbidity burden and functional status in elderly and non-elderly patients with infections in general wards

Association of Preoperative Functional Status With Short-Term Major Adverse Outcomes After Cardiac Surgery

Introduction Cardiac surgery plays a crucial role in treating a wide range of cardiovascular conditions, offering life-saving interventions for patients with diseases such as coronary artery disease, heart valve disorders, and heart failure. However, these procedures are not without significant risks, including complications such as stroke, acute kidney injury, respiratory failure, and infections. It is important to not only recognize the potential complications associated with these procedures but also identify high-risk patients early in the treatment process. With the aging population and the increasing burden of comorbidities, a growing number of patients are likely to present with suboptimal functional status prior to cardiac surgery. By incorporating functional status into preoperative evaluations, healthcare providers can improve patient selection, enhance perioperative care, and improve outcomes in this high-risk patient population. Therefore, this study aims to investigate whether preoperative dependent functional status is associated with an increased risk of postoperative major adverse outcomes in patients undergoing cardiac surgery. Methods We performed a retrospective cohort analysis on adult cardiac surgery patients based on the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) 2011-2021 database. We compared a primary composite outcome consisting of post-surgery outcomes between independent and partially/totally dependent patients. The primary outcome was defined as experiencing any of the following adverse events: superficial incisional/deep incisional/organ space surgical site infection, death within 30 days post-operation, stroke/cerebral vascular accident (CVA), cardiac arrest requiring cardiopulmonary resuscitation (CPR), myocardial infarction, pulmonary embolism (PE), deep vein thrombosis (DVT)/thrombophlebitis, progressive renal insufficiency, ventilator use for more than 48 hours post-operation, unplanned intubation or reoperation, sepsis, septic shock, and pneumonia. Confounding variables were age, gender, race, emergency case, comorbidities, and baseline laboratory markers. We used multivariable logistic regression analysis to obtain adjusted odds ratio (OR) and 95% confidence intervals (CIs). Results Of the 42,917 patients included in the study, 30.6% were female and 69.4% were male, with 46.5% of the group being 65-79 years old. The prevalence of dependent status was 2.6%. Compared to independent patients, those who were dependent had a higher incidence of the primary outcome (35.68% vs. 20.93%), yielding a crude OR of 2.09 (95% CI 1.85-2.37). The association remained significant: OR of 1.21 (95% CI 1.04-1.41) after adjustment for age, gender, race, body mass index (BMI), emergency case, and other comorbidities such as diabetes, hypertension, heart failure, preoperative blood transfusion or sepsis, and laboratory markers. Conclusion Patients with preoperative dependent functional status were found to have a significantly greater risk of complications after cardiac surgery, even after adjusting for demographics, comorbidities, laboratory markers, and perioperative characteristics. Further investigation is needed to explore the development and clinical application of a predictive tool that includes functional status, which could help identify high-risk patients and facilitate timely interventions such as prehabilitation programs to enhance functional capacity.

Approaches to characterising multimorbidity in older people accessing hospital care: a scoping review

PURPOSE

An increasing proportion of older adults accessing hospital care are living with multimorbidity, with a high degree of complexity of multimorbidity in older hospital populations expected. We aimed to assess approaches taken to characterise multimorbidity in older adults accessing hospital care, including how complexity is considered.

METHODS

Following established scoping review guidelines, all published studies that characterised multimorbidity in a hospital population, with average age ≥ 65 years, were identified via a prespecified search strategy. Six electronic databases were searched to identify peer-reviewed literature published to September 2023 meeting eligibility criteria. Screening was undertaken by two independent reviewers, and data extracted using a standard proforma.

RESULTS

Of 5305 titles and abstracts screened, 75 papers, reporting on 72 unique study populations across 24 countries, met inclusion criteria. There was heterogeneity in most aspects of characterisation. Multimorbidity was defined in 43% (n = 31/72) of studies; most (n = 59/72, 82%) aimed to describe a multimorbidity-outcome association. Number of conditions considered ranged from 2 to 285 and weighted indices were used as a measure of multimorbidity in 75% (n = 54/72) of studies, with 56% (n = 40/72) using a version of the Charlson Comorbidity Index. Complexity was explicitly studied in 17% (n = 12/72) of studies.

DISCUSSION

Our review highlights heterogeneity in characterisation of multimorbidity in older adults accessing hospital care, with limited consideration of complexity. As the proportion of older adults accessing hospital care who are living with multimorbidity increases, better characterisation of their multiple conditions and associated complexity is a priority to ensure delivery of appropriately tailored care.

Predictive model of risk factors for 28-day mortality in patients with sepsis or sepsis-associated delirium based on the MIMIC-IV database

Research on the severity and prognosis of sepsis with or without progressive delirium is relatively insufficient. We constructed a prediction model of the risk factors for 28-day mortality in patients who developed sepsis or sepsis-associated delirium. The modeling group of patients diagnosed with Sepsis-3 and patients with progressive delirium of related indicators were selected from the MIMIC-IV database. Relevant independent risk factors were determined and integrated into the prediction model. Receiver operating characteristic (ROC) curves and the Hosmer-Lemeshow (HL) test were used to evaluate the prediction accuracy and goodness-of-fit of the model. Relevant indicators of patients with sepsis or progressive delirium admitted to the intensive care unit (ICU) of a 3A hospital in Xinjiang were collected and included in the verification group for comparative analysis and clinical validation of the prediction model. The total length of stay in the ICU, hemoglobin levels, albumin levels, activated partial thrombin time, and total bilirubin level were the five independent risk factors in constructing a prediction model. The area under the ROC curve of the predictive model (0.904) and the HL test result (χ2 = 8.518) indicate a good fit. This model is valuable for clinical diagnosis and treatment and auxiliary clinical decision-making.

Factors Associated With Emergency Department Visits Among Patients Receiving Publicly-Funded Homecare Services: A Retrospective Chart Review From Southern Taiwan Regional Hospital

BACKGROUND

The public health strategy of increasing access to comprehensive home or community-based healthcare services and emergency home visits is intent on reducing the overcrowding of emergency departments. However, scientific evidence regarding the association between home-based healthcare services and emergency department uses is surprisingly insufficient and controversial so far. The present retrospective study identified the risk factors for emergency department visits among patients receiving publicly-funded homecare services.

METHODS

The personal demographic and medical information, caregiver characteristics, and behaviours related to homecare services and emergency department visits from the medical records and structured questionnaires of 108 patients who were recipients of integrated homecare services in a regional hospital in southern Taiwan between January 1, 2020, and December 31, 2020, were collected. After screening the potential predictor variables using the preliminary univariate analyses, the multivariate logistic regression with best subset selection approach was conducted to identify best combination of determinants to predict unplanned emergency department utilizations.

RESULTS

Best subset selection regression analysis showed Charlson Comorbidity Index (odds ratio (OR)=1.33, 95% CI=1.05 to 1.70), male caregiver (OR=0.18, 95% CI=0.05 to 0.66), duration of introducing homecare services (OR=0.97, 95% CI=0.95 to 1.00), working experience of dedicated nurses (OR=0.89, 95% CI=0.79 to 0.99) and number of emergency department utilizations within previous past year before enrollment (OR=1.54, 95% CI=1.14 to 2.10) as significant determinants for unplanned emergency department visits.

CONCLUSIONS

The present evidence may help government agencies propose supportive policies to improve access to integrated homecare resources and promote appropriate care recommendations to reduce unplanned or nonurgent emergency department visits among patients receiving homecare services.

Myocardial injury determination improves risk stratification and predicts mortality in COVID-19 patients

BACKGROUND

Despite being associated with worse prognosis in patients with COVID-19, systematic determination of myocardial injury is not recommended. The aim of the study was to study the effect of myocardial injury assessment on risk stratification of COVID-19 patients.

METHODS

Seven hundred seven consecutive adult patients admitted to a large tertiary hospital with confirmed COVID-19 were included. Demographic data, comorbidities, laboratory results and clinical outcomes were recorded. Charlson comorbidity index (CCI) was calculated in order to quantify the degree of comorbidities. Independent association of cardiac troponin I (cTnI) increase with outcomes was evaluated by multivariate regression analyses and area under curve. In addition, propensity-score matching was performed to assemble a cohort of patients with similar baseline characteristics.

RESULTS

In the matched cohort (mean age 66.76 ± 15.7 years, 37.3% females), cTnI increase above the upper limit was present in 20.9% of the population and was associated with worse clinical outcomes, including all-cause mortality within 30 days (45.1% vs. 23.2%; p = 0.005). The addition of cTnI to a multivariate prediction model showed a significant improvement in the area under the time-dependent receiver operating characteristic curve (0.775 vs. 0.756, DC-statistic = 0.019; 95% confidence interval 0.001-0.037). Use of renin-angiotensin-aldosterone system inhibitors was not associated with mortality after adjusting by baseline risk factors.

CONCLUSIONS

Myocardial injury is independently associated with adverse outcomes irrespective of baseline comorbidities and its addition to multivariate regression models significantly improves their performance in predicting mortality. The determination of myocardial injury biomarkers on hospital admission and its combination with CCI can classify patients in three risk groups (high, intermediate and low) with a clearly distinct 30-day mortality.