Distribution of Clinical Phenotypes in Patients With Chronic Obstructive Pulmonary Disease Caused by Biomass and Tobacco Smoke

IntroductionExposure to biomass smoke is a risk factor for chronic obstructive pulmonary disease (COPD). It is unknown whether COPD caused by biomass smoke has different characteristics to COPD caused by tobacco smoke.ObjectiveTo determine clinical differences between these two types of the disease.MethodsRetrospective observational study of 499 patients with a diagnosis of COPD due to biomass or tobacco smoke. The clinical variables of both groups were compared.ResultsThere were 122 subjects (24.4%) in the biomass smoke group and 377 (75.5%) in the tobacco smoke group. In the tobacco group, the percentage of males was higher (91.2% vs 41.8%, P<.0001) and the age was lower (70.6 vs 76.2 years, P<.0001). Body mass index and FEV₁% values were higher in the biomass group (29.4±5.7 vs 28.0±5.1, P=.01, and 55.6±15.6 vs 47.1±17.1, P<.0001, respectively). The mixed COPD-asthma phenotype was more common in the biomass group (21.3% vs 5%, P<.0001), although this difference disappeared when corrected for gender. The emphysema phenotype was more common in the tobacco group (45.9% vs 31.9%, P=.009). The prevalence of chronic bronchitis, exacerbator phenotypes, the comorbidity burden and the rate of hospital admissions were the same in both groups.ConclusionDifferences were observed between COPD caused by biomass and COPD caused by tobacco smoke, although these may be attributed in part to uneven gender distribution between the groups.     

Peptic ulcer disease and heart disease are associated with periprosthetic fractures after total hip replacement

Background and purpose There have been no published studies assessing the possible association of medical comorbidities with periprosthetic fracture risk. We therefore assessed whether medical comorbidity is associated with risk of periprosthetic fractures after total hip replacement (THR).

Material and methods We used prospectively collected data from 1989–2008 in the Mayo Clinic Total Joint Registry for 2 cohorts: primary THR and revision THR. The main variables of interest were Deyo-Charlson comorbidities at the time of surgery. Outcome of interest was p ostoperative periprosthetic fracture at postoperative day 1 onwards. Multivariable

Cox regression models were additionally adjusted for age, sex, body mass index, American Society of Anesthesiology (ASA) class, and operative diagnosis.

Results We identified 14,065 primary THRs and 6,281 revision THRs with mean follow-up times of 6.3 and 5.6 years, respectively. There were 305 postoperative periprosthetic fractures in the primary THR cohort and 330 in the revision THR cohort. In patients who underwent primary THR, 2 comorbidities were associated with higher risk of periprosthetic fracture: peptic ulcer disease with adjusted hazard ratio of 1.5 (95% CI: 1.1–2.2) and heart disease with adjusted hazard ratio of 1.7 (CI: 1.2–2.4). In patients with revision THR, peptic ulcer disease was associated with a higher adjusted risk of periprosthetic fracture, 1.6 (CI: 1.1–2.3).

Interpretation Peptic ulcer disease and heart disease in primary THR patients and peptic ulcer disease in revision THR patients were associated with higher postoperative periprosthetic fracture risk. Further studies are needed to understand whether disease severity or specific medications used for treatment, or both, are responsible for this association. This may allow identification of modifiable factors.     

Relationship Between Comorbidity and Asthma Control

IntroductionThe coexistence of potentially aggravating processes is common in asthmatics, particularly in patients with difficult control. The primary aim of this study is to ascertain whether comorbidity is more common in uncontrolled patients. As a secondary aim, we propose to evaluate the correlation between the asthma control test (ACT) and the fraction of exhaled nitric oxide (FENO).Patient and methodsA prospective, observational study comparing the function and clinical picture of two groups of asthmatics: controlled (ACT≥20) and uncontrolled (ACT<20). They were all assessed for, smoking, rhinosinusitis, obesity, anxiety, depression, vocal chord dysfunction, gastro-oesophageal reflux (GORD), allergic bronchopulmonary aspergillosis (ABPA), COPD and nasal polyps.ResultsA total of 50 patients with controlled asthma and 102 with sub-optimal control were included. The patients with an ACT≥20 had better lung function, less variation in PEF, less bronchial hyper-reactivity and lower FENO values. Comorbidities were found in 95% of the controlled asthmatics and in 97% of the uncontrolled. Only the presence of nasal polyps, GORD and ABPA was more frequent in the uncontrolled group. However, the simultaneous presence of 3 or more comorbidity factors was significantly more frequent in patients with sub-optimal control (P=.01). There was no significant correlation between the FENO and the ACT values (rho=?0.08; P=.32).ConclusionsAggravating comorbidities are more common in patients with sub-optimal control. There was no correlation between the FENO and the ACT values.     

A novel risk prediction model for 30-day severe adverse events and readmissions following bariatric surgery based on the MBSAQIP database

BackgroundAlthough bariatric surgery is safe, some patients fear serious complications.ObjectivesThis retrospective study used the 2015 Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP) database to evaluate patient outcomes for gastric bypass (GB) and sleeve gastrectomy and to develop a risk prediction model for serious adverse events (SAEs) and readmission rates 30 days after surgery.SettingMBSAQIP national patient database.MethodsWe created separate exploratory multivariable logistic regression models for SAEs and readmissions. We then externally validated both models using the 2016 MBSAQIP Participant Use Data File.ResultsSignificant predictors of SAEs were preoperative body mass index (adjusted odds ratio [AOR] 1.07, P < .0001); GB surgery (AOR 2.08, P < .0001); cardiovascular disease (AOR 1.43, P < .0001); smoking (AOR 1.12, P = .04); diabetes (AOR 1.15, P = .0001); hypertension (AOR 1.17, P < .0001); limited ambulation (AOR 1.48, P < .0001); sleep apnea (AOR 1.12, P = .001); history of pulmonary embolism (AOR 2.81, P < .0001); and steroid use (AOR 1.40, P = .001). Significant predictors of readmissions were GB surgery (AOR 1.81, P < .0001); female sex (AOR 1.26, P < .0001); diabetes (AOR 1.08, P = .04); hypertension (AOR 1.11, P = .004); preoperative body mass index (AOR 1.05, P < .0001); sleep apnea (AOR 1.11, P = .002); history of pulmonary embolism (AOR 2.35, P < .0001); cardiovascular disease (AOR 1.61, P < .0001); smoking (AOR 1.14, P = .01); and limited ambulation (AOR 1.55, P < .0001). External validation supported these covariates, with similar model discriminative power.ConclusionsOur exploratory regression models may be used by clinicians to counsel patients about surgical risks, although future external validation should occur in non-North American populations.     

Preoperative Predictors of Patients Requiring Inpatient Admission for Total Hip Arthroplasty Following Removal From the Medicare Inpatient-Only List

BackgroundThe Centers for Medicare and Medicaid Services has removed total hip arthroplasty from the inpatient-only (IO) list in January 2020. Given the confusion created when total knee arthroplasty came off the IO list in 2018, this study aims to develop a predictive model for guiding preoperative inpatient admission decisions based upon readily available patient demographic and comorbidity data.MethodsThis is a retrospective review of 1415 patients undergoing elective unilateral primary THA between January 2018 and October 2019. Multiple logistic regression was used to develop a model for predicting LOS ≥2 days based on preoperative demographics and comorbidities.ResultsControlling for other demographics and comorbidities, increased age (odds ratio [OR], 1.048; P < .001), female gender (OR, 2.284; P < .001), chronic obstructive pulmonary disorder (OR, 2.249; P = .003), congestive heart failure (OR, 8.231; P < .001), and number of comorbidities (OR, 1.216; P < .001) were associated with LOS ≥2 days while patients with increased body mass index (OR, 0.964; P = .007) and primary hypertension (OR, 0.671; P = .008) demonstrated significantly reduced odds of staying in the hospital for 2 or more days. The area under the curve was found to be 0.731, indicating acceptable discriminatory value.ConclusionFor patients undergoing primary THA, increased age, female gender, chronic obstructive pulmonary disorder, congestive heart failure, and multiple comorbidities are risk factors for inpatient hospital LOS of 2 or more days. Our predictive model based on readily available patient presentation and comorbidity characteristics may aid surgeons in preoperatively identifying patients requiring inpatient admission with removal of THA from the Medicare IO list.     

Is it worth it? Determining the health benefits of sleeve gastrectomy in patients with a body mass index <35 kg/m2

BackgroundCriteria for undergoing sleeve gastrectomy (SG) is restricted among patients with a body mass index (BMI) <35 kg/m².ObjectivesTo determine if low-BMI patients experience similar health benefits after SG compared with patients with a BMI ≥35 kg/m².SettingTeaching and nonteaching hospitals in Michigan.MethodsPatients with a BMI <35 kg/m² at the time of primary SG were identified between 2006 and 2018 (n = 1073, 2.4%). Patient characteristics, 30-day risk-adjusted complication rates, and patient reported outcomes were compared with all patients who underwent SG with a BMI ≥35 kg/m² (n = 44,511, mean BMI 46.7 kg/m²).ResultsLow-BMI patients were more likely to be older (50.7 versus 45.4 yr, P < .0001), have diabetes (36.7 versus 30.9%, P < .0001), hypertension (54.2% versus 51.0%, P = .0372), and hyperlipidemia (57.1% versus 44.8%, P < .0001). Both groups had comparable rates of discontinuation of medications for hypertension (59.7% versus 54.1%, P = .0570), hyperlipidemia (54.3% versus 52.2%, P = .5537), and diabetes (oral, 79.2% versus 78.1%, P = .7294; insulin, 64.2% versus 62.2%, P = .7438). However, low-BMI patients were more likely to achieve a healthy BMI (i.e., BMI ≤25 kg/m²; 36.3% versus 6.01%, P < .0001), and had higher body image scores (50.6 versus 42.4, P < .0001).ConclusionsDespite being older and with higher rates of metabolic disease, low-BMI patients reported high-resolution rates for diabetes, hypertension, and hyperlipidemia (>50%) and were more likely to achieve a healthy weight after SG. Abolishing the BMI threshold for SG among patients with metabolic disease should be considered.     

Impact of comorbidities on oncological outcomes of Japanese patients with high grade soft tissue sarcomas

BackgroundConsidering the invasiveness of standard multidisciplinary approaches used for the treatment of soft tissue sarcoma, including surgery with wide margins, intensive chemotherapy, and radiotherapy, evaluation of comorbidities in high-grade soft tissue sarcoma patients is essential. Several previous studies have reported the impact of comorbidities on the survival of soft tissue sarcoma patients. Patient health status differs between nationalities or ethnic groups and only limited data has been reported with respect to the impact of comorbidities on Japanese soft tissue sarcoma patients.MethodsThe incidence of each comorbidity, relationship between comorbidities and underlying clinicopathological factors, relationship between treatment status and comorbidities, and impact of comorbidities on disease-specific death in 136 patients with high-grade soft tissue sarcoma at the authors' institution were analyzed. For the evaluation of comorbidities, the updated Charlson comorbidity index was applied.ResultsOf the patients, 25% presented with more than one comorbidity. Elderly patients showed a significantly higher incidence of comorbidities (p < 0.0001). Patients with congestive heart failure (p = 0.004), dementia (p < 0.0001), hemiplegia/paraplegia (p < 0.0001), and renal disease (p < 0.0001) showed worse prognosis. Tumor grade (p = 0.01) and updated Charlson comorbidity index (p < 0.0001) were independent risk factors for disease-specific death.ConclusionsComorbidity status was a significant risk factor for disease-specific death in Japanese patients with high-grade soft tissue sarcoma. Innovations in comorbidity management may be a means for the improvement of oncological outcomes in soft tissue sarcoma. Given the difficulties in conducting standard randomized control studies in this field, data accumulation from real-world cases appears to be the most practical approach in establishing and applying strategies for the treatment of patients with comorbidities or elderly patients.     

Gender and Health Status Response to Long-Term Oxygen Therapy in COPD Patients

IntroductionThe association of gender with health status (HS) response to long-term oxygen therapy (LTOT) in very severe COPD is unclear. The aims of this study were: (1) to compare dyspnea perception and HS between male and female with very severe COPD at baseline and (2) to provide a prospective assessment of HS response to LTOT, according to gender.Patients and methodsHypoxemic COPD (n=97, age: 65.5±9.6 years, 53% males) were enrolled in a prospective longitudinal study over 12 months or until death. St. George's Respiratory Questionnaire (SGRQ) and baseline dyspnea index (BDI) were assessed.ResultsAt baseline, HS impairment and dyspnea sensation were similar between genders. After 12 months of LTOT, women presented improvement in symptom (64.1±20.6 versus 40.6±22.9; P<.0001) and total SGRQ scores. Men also showed improvement in symptoms after 12 months (62.7±23.3 versus 49.6±22.8; P<.0005); however, they presented deterioration of activity, impact, and total scores during the study period, with markedly decline of activity domain (68.5±20.0 versus 75.9±16.9; P=.008). BDI did not show significant difference by gender over the study period.ConclusionsOur results show that the HS course in very severe COPD patients differs according to gender, as females show greater response longitudinally to LTOT.     

Association of the Charlson comorbidity index and hypertension with survival in men with metastatic castration-resistant prostate cancer

ObjectivesThe independent prognostic effect of comorbidities on outcomes in men with metastatic castration-resistant prostate cancer (mCRPC) is unclear. We sought to determine whether the Charlson comorbidity index (CCI) and hypertension (HTN) are associated with overall survival (OS) independent of known clinical prognostic factors in mCRPC.Patients and methodsA retrospective analysis was conducted on 221 patients with mCRPC treated with docetaxel plus prednisone combined with AT-101 (bcl-2 antagonist) or placebo on a prospective randomized phase II trial. The Cox regression analysis was performed to identify whether the CCI or HTN or both (by medical history) independently predicted OS after adjusting for baseline variables known to be associated with OS. The Wilcoxon rank sum test and the Fisher exact test were used to compare data by comorbidity groups (CCI as a continuous variable, CCI = 6 vs. CCI ≥ 7 and HTN vs. no HTN).ResultsThe CCI was 6 in 116 patients (52.7%), 7 in 70 (31.8%), 8 in 23 (10.5%), 9 in 4 (1.8%), and 10 in 7 patients (3.2%). HTN was present in 107 (48.6%) patients. Patients with CCI of ≥7 were older and exhibited worse performance status and anemia than patients with CCI of 6 (P<0.05). The CCI was not independently predictive of OS on univariable and multivariable analyses. HTN alone or in combination with the CCI was borderline significantly associated with OS (P ~0.09) on both univariable and multivariable analyses.ConclusionsThe CCI did not predict OS independent of known prognostic factors in mCRPC. Age, performance status, and anemia may adequately capture comorbidities in the context of mCRPC, given their association with higher CCI. Further prospective study of comorbidities in a larger data set may be warranted. The study of HTN in a larger data set may also be warranted given its borderline-independent association with OS.     

Hypoalbuminemia as a risk factor for complications in revisional/conversional bariatric surgery: an MBSAQIP analysis

BackgroundHypoalbuminemia (HA) is a risk factor for serious complications after elective bariatric surgery. Patients undergoing revisional/conversional bariatric surgery may represent a higher-risk group who often have underlying co-morbid medical illnesses and more complex surgery.ObjectivesThis study investigated the postoperative complications in patients with HA undergoing revisional/conversional bariatric surgery.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), years 2015–2019.MethodsThe MBSAQIP database was used to evaluate patients undergoing non-banding revisional/conversional bariatric surgery between 2015 and 2019. Patients were categorized by serum albumin (≤3.5 g/dL). Variables were assessed via bivariate analysis and multivariable regression. Propensity score matching was conducted to compare gastric bypass (RYGB) to sleeve gastrectomy (VSG).ResultsOne hundred forty-seven thousand four hundred thirty patients underwent revisional/conversional procedures. After applied exclusions, 58,777 patients were available for analysis. The HA group had a significantly (P < .05) higher prevalence of being black (22.95% versus 17.76%), renal insufficiency (1.08% versus .36%), smoking history (9.47% versus 6.91%), chronic obstructive pulmonary disease (COPD) (2.54% versus 1.33%), and history of deep vein thrombosis (DVT) (4.03% versus 2.3%). Postoperative complications associated with HA included perioperative blood transfusion (3.1% versus 1.27%; P < .001), 30day readmission (10.87 versus 6.77%; P < .001), 30day reoperation (4.9% versus 3.18%; P < .001), and 30day mortality (.40% versus .14%; P < .0001). HA was a significant predictor of 30day readmission in the RYGB versus VSG matched cohort (odds ratio [OR], 1.30; 95% confidence interval [CI], [1.14, 1.48]; P < .001).ConclusionsHA is a risk factor requiring attention for patients undergoing revisional/conversional bariatric surgery and optimization of nutritional status or medical comorbidities associated with HA prior to bariatric surgery may help avoid postoperative complications.     

Pneumonia as Comorbidity in Chronic Obstructive Pulmonary Disease (COPD). Differences Between Acute Exacerbation of COPD and Pneumonia in Patients With COPD

IntroductionPneumonia is considered an independent entity in chronic obstructive pulmonary disease (COPD), to be distinguished from an infectious exacerbation of COPD. The aim of this study was to analyze the clinical characteristics and progress of the exacerbation of COPD (ECOPD) compared to pneumonia in COPD (PCOPD) patients requiring hospitalization.Patients and methodsProspective, longitudinal, observational cohort study including 124 COPD patients requiring hospital admission for lower respiratory tract infection. Patients were categorized according to presence of ECOPD (n=104) or PCOPD (n=20), depending on presence of consolidation on X-ray. Demographic, clinical, laboratory, microbiological and progress variables were collected.ResultsPatients with ECOPD showed more severe respiratory disease according to the degree of obstruction (P<.01) and need for oxygen therapy (P<.05). PCOPD patients showed increased presence of fever (P<.05), higher blood pressure (P<.001), more laboratory abnormalities (P<.05; leukocytosis, elevated CRP, low serum albumin) and increased presence of crepitus (P<.01). Microbiological diagnosis was achieved in 30.8% of cases of ECOPD and 35% of PCOPD; sputum culture yielded the highest percentage of positive results, predominantly Pseudomonas aeruginosa. Regarding the progress of the episode, no differences were found in hospital stay, need for ICU or mechanical ventilation.ConclusionsOur data confirm clinical and analytical differences between ECOPD and PCOPD in patients who require hospital admission, while there were no differences in subsequent progress.     

Identifying Risk Factors for Complication and Readmission with Same-Day Discharge Arthroplasty

BackgroundThe COVID-19 pandemic caused a surge of same-day discharge (SDD) for total joint arthroplasty. However, SDD may not be beneficial for all patients. Therefore, continued investigation into the safety of SDD is necessary as well as risk stratification for improved patient outcomes.MethodsThis retrospective cohort study examined 31,851 elective SDD hip and knee arthroplasties from 2016 to 2020 in a large national database. Logistic regression models were used to identify patient variables and preoperative comorbidities that contribute to postoperative complication or readmission with SDD. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated.ResultsSDD increased from 1.4% in 2016 to 14.6% in 2020. SDD is associated with lower odds of readmission (AOR: 0.994, CI: 0.992-0.996) and postoperative complications (AOR: 0.998, CI: 0.997-1.000). Patients who have preoperative dyspnea (AOR: 1.03, CI: 1.02-1.04, P < .001), chronic obstructive pulmonary disease (AOR: 1.02, CI: 1.01-1.03, P = .002), and hypoalbuminemia (AOR: 1.02, CI: 1.00-1.03, P < .001), had higher odds of postoperative complications. Patients who had preoperative dyspnea (AOR: 1.02, CI: 1.01-1.03), hypertension (AOR: 1.01, CI: 1.01-1.03, P = .003), chronic corticosteroid use (AOR: 1.02, CI: 1.01-1.03, P < .001), bleeding disorder (AOR: 1.02; CI: 1.01-1.03, P < .001), and hypoalbuminemia (AOR: 1.01, CI: 1.00-1.02, P = .038), had higher odds of readmission.ConclusionSDD is safe with certain comorbidities. Preoperative screening for cardiopulmonary comorbidities (eg, dyspnea, hypertension, and chronic obstructive pulmonary disease), chronic corticosteroid use, bleeding disorder, and hypoalbuminemia may improve SDD outcomes.     

Differential changes in self-reported quality of life in elderly populations after diagnosis of a genitourinary malignancy

BackgroundThe time of cancer diagnosis is a major event during which quality of life (QOL) can be affected and represents a crucial time to identify patients at high risk of decline. We sought to compare the differential effects of the diagnosis of 3 major urologic malignancies on QOL.MethodsThe Surveillance, Epidemiology, and End Results–Medicare Health Outcomes Survey database was queried for patients who completed a QOL questionnaire (SF-36 or VR-12) before and after a diagnosis of bladder, kidney, or prostate cancer. Primary outcome measures were the mental component summary (MCS), and physical component summary (PCS) scores. Mixed effects linear regression was performed with cancer diagnosis as the primary variable of interest, with race and cardiovascular comorbidity status included as potentially confounding independent variables.ResultsThere were 3,258 patients with urologic cancers. Both MCS and PCS scores dropped after diagnosis in all disease states. Bladder and kidney cancer patients demonstrated the greatest decline in MCS score (-1.762 points, 95% CI-2.571 to -0.952, P < 0.001) and PCS score (-3.769 points, 95% CI-5.042 to -2.496, P < 0.001), respectively, after adjustment for potential confounders. By contrast, prostate cancer patients demonstrated the smallest decline in both domains. Race and cardiovascular comorbidity status were independently associated with QOL, with an association 2 to 3 times greater than that of cancer diagnosis.ConclusionsDiagnosis of a urologic cancer was associated with a decline in patient-reported QOL, particularly in those with bladder or kidney cancer. Changes in physical health were more prominent than in mental health. Race and cardiovascular comorbidity status influenced QOL domains to a greater extent than specific urologic cancer diagnosis.     

Geriatric Assessment and Prognostic Factors of Mortality in Very Elderly Patients With Community-Acquired Pneumonia

IntroductionTo assess the relationship between the parameters obtained in the geriatric assessment and mortality in elderly people with community-acquired pneumonia in an acute care geriatric unit.MethodsFour hundred fifty-six patients (≥75 years). Variables: age, sex, referral source, background, consciousness level, heart rate, breathing rate, blood pressure, laboratory data, pleural effusion, multilobar infiltrates, functional status (activities of daily living) prior to admission [Lawton index (LI), Barthel index (BIp)] prior to and at admission (BIa), cognitive status [Pfeiffer test (PT)], comorbidity [Charlson index (ChI)] and nutrition (total protein, albumin).ResultsA hundred ten patients died (24.2%) during hospitalization. These patients were older (86.6±6.4 vs 85.1±6.4, P<.04), had more comorbidity (ChI 2.35±1.61 vs 2.08±1.38; P<.083), worse functional impairment [(LI: 0.49±1.15 vs 1.45±2.32, P<.001) (BIp: 34.6±32.9 vs 54.0±34.1, P<.001) (BIa: 5.79±12.5 vs 20.5±22.9, P<.001)], a higher percentage of functional loss at admission (85.9±23.2 vs 66.4±28.6; P<.0001), worse cognitive impairment (PT: 7.20±3.73 vs 5.10±3.69, P<.001) and malnutrition (albumin 2.67±0.54 vs 2.99±0.49, P<.001). Mortality was higher with impaired consciousness [49.2% (P<.01)], tachypnea [33.3% (P<.01)], tachycardia [44.4% (P<.002), high urea levels [31.8 (P<.001)], anemia [44.7% (P<.02)], pleural effusion [42.9% (P<.002)], and multilobar infiltrates [43.2% (P<.001)]. In the multivariate analysis, variables associated with mortality were: age≥90 years [OR: 3.11 (95% CI: 1.31–7.36)], impaired consciousness [3.19 (1.66–6.15)], hematocrit<30% [2.87 (1.19–6.94)], pleural effusion [3.77 (1.69–8.39)] and multilobar infiltrates [2.76 (1.48–5.16)]. Female sex and a preserved functional status prior (LI≥5) and during admission (BIa≥40) were protective of mortality [0.40 (0.22–0.70), 0.09 (0.01–0.81) and 0.11 (0.02–0.51)].ConclusionsGeriatric assessment parameters and routine clinical variables were associated with mortality.     

Sociodemographic disparities in distance traveled to receive primary shoulder arthroplasty

BackgroundShoulder arthroplasty is a common procedure, but patterns in patient travel distance to undergo this operation are unknown. This study aims to describe the relationships between patient travel distance, patient demographics, and surgical outcomes after primary shoulder arthroplasty. We hypothesized that older age, higher Charlson comorbidity index, white race, and higher socioeconomic status would be associated with increased travel distance.MethodsData from the Healthcare Cost and Utilization Project, American Hospital Association database, and UnitedStatesZipCodes.org Enterprise database were used to collect patient data and geographic coordinates for patients’ home zip codes and the hospitals at which they underwent shoulder arthroplasty. The distances from population-weighted zip code centroid points and hospital coordinates were calculated. The relationships between the distance traveled to receive care and patient demographic data and postoperative adverse outcomes were then assessed using analysis of variance test and logistic regression analysis.ResultsA total of 49,567 patients who underwent elective primary shoulder arthroplasty in Florida and New York between 2005 and 2015 were included for analysis. Age and number of medical comorbidities were inversely related to travel distance (P < .0001). White race (P < .0001), private insurance coverage (P = .03), and anatomic shoulder arthroplasty were each associated with increased travel distance (P < .0001). Hemiarthroplasty patients traveled less distance than patients who underwent anatomic or reverse shoulder arthroplasty (P < .0001). No significant associations were observed between travel distance and postoperative adverse outcomes.ConclusionThis study provides robust evidence of differences in distance traveled to undergo primary shoulder arthroplasty based on patient age, medical comorbidities, race, socioeconomic status, insurance provider, and type of shoulder arthroplasty. Future work may elucidate whether disparities in travel distance are based on patient preference or necessity and may offer additional insights with respect to access to care for this specialized procedure.     

Clinical significance of iron deficiency among candidates for metabolic surgery

BackgroundIron deficiency (ID), a known complication after metabolic surgery, is common among preoperative patients in the presence of inflammation. Evidence is now accumulating that preoperative ID may adversely affect perioperative outcomes.ObjectivesTo investigate the relationship between preoperative iron status and the risk of postoperative severe anemia. In addition, this study investigates the relationship between preoperative iron status and length of surgical staySettingA large regional tertiary health system.MethodsAmong patients who underwent metabolic surgery between 2004 and 2020, 5171 patients had a full iron nutritional assessment prior to surgery. Study patients were divided into multiple smaller groups (10 female groups and 7 male groups) on the basis of levels of serum ferritin and Transferrin Saturation (T Sat) < or ≥20%. Study patients were followed after surgery and the time to the development of severe anemia (hemoglobin < 8 gm/dL) was recorded. Hospital length of stay (LOS) was analyzed in relation to preoperative iron status.ResultsLower ferritin levels were associated with older age in males (P = .0001) and younger age in females (P < .0001). For males, after adjustment for age, body mass index (BMI), and year of surgery, surgical LOS was prolonged in those with T Sat <20% (P = .0041). For females the time until the development of severe anemia was associated with baseline iron status (P < .0001).ConclusionsMale preoperative patients for metabolic surgery with T Sat <20% are at risk for increased surgical LOS. Females with low ferritin levels consistent with ID are at increased risk for the development of postoperative severe anemia.     

Predictors of marginal ulcers after laparoscopic Roux-en-Y gastric bypass

BackgroundLaparoscopic Roux-en-Y gastric bypass (LRYGB) is a highly effective therapy for morbid obesity. As the most common postoperative complication, marginal ulcers (MU) present a significant disease burden. The etiology of marginal ulcers after gastric bypass has not been clearly defined. The purpose of this study was to identify independent risk factors for MU.MethodsWe performed a retrospective study of a single surgeon's experience performing LRYGB between July 2001 and January 2006 in a United States private practice and university hospital. We investigated patient factors and comorbidities associated with the development of marginal ulcers. The five most common comorbidities were hypertension, type 2 diabetes mellitus, gastroesophageal reflux disease, hyperlipidemia, and obstructive sleep apnea. We analyzed these factors using multivariate logistic regression adjusting for demographics, BMI, and all comorbidities.ResultsIn our 763 patients, 89% were female, 84.7% were African-American, and the mean BMI was 50.2 kg/m² before surgery. Marginal ulcers occurred in 23 patients (3.01%) over a mean of 64 months. On χ² analysis, hypertension, gastroesophageal reflux disease, hyperlipidemia, and sleep apnea were significantly correlated with MU. On multivariate analysis, the odds of marginal ulcer formation were 7.84 among hypertensive patients with a 95% confidence interval of 1.75–35.06 (P = 0.007). Hypertension was the only significant predictor of marginal ulcer disease.ConclusionIn our study, marginal ulcers occurred more frequently in patients with preoperative hypertension. At higher risk, these patients could be good candidates for extended acid suppression prophylaxis after LRYGB.