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OBJECTIVE: To determine the effectiveness of pelvis diameters in determining postoperative outcomes in men who underwent open radical cystectomy + urinary diversion, it is aimed to predict the factors that may affect the operative difficulty and possible surgical outcomes before the operation. METHODS: A total of 79 radical cystectomy patients operated in our institution with preoperative computed tomography (CT) were included the study. Pelvic dimensions; symphysis angle (SA), upper conjugate, lower conjugate, pelvic depth, apical depth (AD), interspinous distance (ISD), bone femoral width and soft tissue width were measured by preoperative CT. ISD index were defined as ISD/AD. Postoperative outcomes and indicators of operative difficulty were recorded. Regression analyses were used to predict perioperative and postoperative outcomes. RESULTS: Total of 96 complications were observed in 52 of the 79 patients in ninety days (65,8%) with a mean age of 68.25 years. There were significant correlations between SA and body mass index (BMI) with operative time (p = 0.006, p < 0.001; respectively). For estimated blood loss, there were significant correlations between preoperative hematocrit (p = 0,031). Analysis of multivariate logistic regression revealed that higher Charlson comorbidity index (CCI) and BMI were found to be significant predictors for major complications while CCI, pathological T stage and ISD index are prominent predictors for surgical margin positivity. CONCLUSIONS: Pelvic dimensions are not significant with minor or major complications. However, operative time may be associated with SA. Also, narrow and deep pelvis may increase the risk of positive surgical margins.

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PURPOSE: To investigate the influence of comorbidities and tumor characteristics on outcomes following percutaneous cryoablation (PCA) of T1b renal cell carcinoma (RCC). MATERIALS AND METHODS: Age-adjusted Charlson comorbidity index (ACCI); standardized system for quantitating renal tumor size, location, and depth (RENAL nephrometry score [RNS]); and local tumor control and survival were retrospectively investigated in 28 patients who underwent PCA for stage T1b RCC. Risk factors for elevated serum creatinine levels were also investigated. RESULTS: Complete ablation was obtained in 27 of 28 patients. Two cases of metastasis were observed; one patient died 12 months after PCA. Overall survival at 5 years was 79.1%, with a mean follow-up of 42.0 ± 16.0 months. Local tumor control was not correlated with the ACCI and RNS. Worsening renal function 3 months after PCA was observed in ten patients, and it correlated with the presence of single kidneys (7/28 patients; p = 0.023). Significant worsening of renal function continued until 1 year after PCA (p = 0.013). Having a single kidney was a risk factor for worsened renal function after PCA (odds ratio, 8.00; 95% confidence interval 1.170-54.724). CONCLUSION: PCA for T1b RCC confers positive local tumor control regardless of comorbidities and tumor characteristics.

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BACKGROUND: Laparoscopic cholecystectomy (Lap-C) is generally performed following percutaneous transhepatic gallbladder drainage (PTGBD) in patients with acute cholecystitis (AC). However, the timing of Lap-C and risk factors for postoperative complications following PTGBD are still unclear. METHODS: We analyzed 331 patients with AC who underwent Lap-C following PTGBD. Univariate and multivariate logistic regression analyses were used for identifying risk factors associated with poor surgical outcomes, including postoperative complications in the total group and the early Lap-C subgroup (n = 152). Based on the Tokyo guideline 2013 (TG 13), all patients were divided into two groups according to the period (2009-2013, pre-TG 13 group; 2014-2020, post-TG 13 group), and each analysis was performed in those subgroups. RESULTS: We found that early Lap-C (≤ 42 days after PTGBD) was associated with postoperative complications (OR 2.04, P = .022). Importantly, subgroup analyses revealed that Charlson comorbidity index (CCI) (OR 6.15, P < .001) and cholecystitis severity grade (OR 2.93, P = .014) were independent risk factors of postoperative complications in the early Lap-C group. Among the early Lap-C group, high CCI was also an independent risk factor for surgical complications in both pre-TG 13 (OR 14.87, P = .003) and post-TG 13 (OR 3.23, P = .046) groups. Interestingly, we found that the incidence of postoperative complications in the low-risk early Lap-C group was not different from the delayed group, even in the cases of very early surgery (≤ 1 week following PTGBD). CONCLUSIONS: These findings suggest that early Lap-C is feasible following PTGBD, especially in low-risk patients, although future prospective large-scale studies are needed.

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PURPOSE: Comorbidity indices are often used to measure comorbidities in register-based research. We aimed to adapt the Charlson comorbidity index (CCI) to a Swedish setting. METHODS: Four versions of the CCI were compared and evaluated by disease-specific experts. RESULTS: We created a cohesive coding system for CCI to 1) harmonize the content between different international classification of disease codes (ICD-7,8,9,10), 2) delete incorrect codes, 3) enhance the distinction between mild, moderate or severe disease (and between diabetes with and without end-organ damage), 4) minimize duplication of codes, and 5) briefly explain the meaning of individual codes in writing. CONCLUSION: This work may provide an integrated and efficient coding algorithm for CCI to be used in medical register-based research in Sweden.

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PURPOSE: Insomnia, a common problem in older adults, may be precipitated by multiple factors including medical conditions, social, behavioral, and environmental factors. The aims of our study were to evaluate sleep pattern changes during hospitalization, determine the predictors of sleep quality and sleep disorders in geriatric inpatients. METHODS: In this prospective observational study, all ≥ 65-year-old patients hospitalized in internal medicine wards were assessed at the time of hospitalization and after 1 week. Insomnia Severity Index and Pittsburgh Sleep Quality Index (PSQI) were used to define insomnia and subjective sleep quality. All patients underwent comprehensive geriatric assessment. Data of factors contributing sleep disturbances during hospitalization were recorded. RESULTS: Totally 101 patients were recruited. Mean ± SD age was 73.5 ± 5.2 years and 53.5% were female. Frequency of poor sleepers was 58.4% at baseline and 64.7% after 1 week according to PSQI score (p 0.804). Although the total scores and frequency of insomnia did not change in the first week of hospitalization, sleep duration was significantly shortened (6.4 ± 2.6 h vs. 5.9 ± 2.7 h, respectively; p < 0.001). Age, pain, restless legs syndrome, Katz ADL, and Lawton-Brody IADL scores were independent correlates of insomnia during hospitalization. CONCLUSION: The study showed that insomnia was associated with geriatric syndromes in hospitalized geriatric patients, and hospitalization reduced duration of sleep. Sleep quality and insomnia evaluation should be a fundamental part of assessment in hospitalized older adults. Considering the negative outcomes of insomnia, sleep disrupting factors should be identified and corrected.

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Despite improvements in the management of patients in critical care, about 3% patients who have an operation with curative intent for oral squamous cell carcinoma (SCC) do not survive their stay in hospital. Our aim was to assess the risk factors for postoperative death that were independent of the stage of the cancer, or the age and sex of the patients. We screened 4760 consecutive inpatients at a maxillofacial tertiary care centre from 2011 to 2016, and 34 of them had died within the first three months after operation. We matched them with a further 34 patients with the same TNM stage, age, and sex. General personal and clinical data and preoperative laboratory values were screened, and we applied a Charlson Comorbidity Score (for anaesthetic risk) for each group. Patients' mean (SD) age was 66 (12) years old. There was no significant difference in sex (p=1), age (p=0.718), or TNM classification. Those who died after operation had significantly more renal (p=0.027) and gastrointestinal (p=0.006) diseases, but cardiac diseases (p=0.468) and diabetes mellitus (p=1) were not significant risk factors in themselves. Patients who died postoperatively had significantly worse risk scores (p=0.001) overall. The most common causes of death were septic shock (n=10) and acute cardiac (n=9) or respiratory failure (n=7). Our findings suggested that general diseases were not intrinsically a contraindication for operation with curative intent. The Charlson Comorbidity Score helped to detect potentially fatal courses and could be useful in the preoperative assessment of patients whose general health is not good.

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BACKGROUND: This study was designed to adapt the Elixhauser comorbidity index for 4 cancer-specific populations (breast, prostate, lung, and colorectal) and compare 3 versions of the Elixhauser comorbidity score (individual comorbidities, summary comorbidity score, and cancer-specific summary comorbidity score) with 3 versions of the Charlson comorbidity score for predicting 2-year survival with 4 types of cancer. METHODS: This cohort study used Texas Cancer Registry-linked Medicare data from 2005 to 2011 for older patients diagnosed with breast (n = 19,082), prostate (n = 23,044), lung (n = 26,047), or colorectal cancer (n = 16,693). For each cancer cohort, the data were split into training and validation cohorts. In the training cohort, competing risk regression was used to model the association of Elixhauser comorbidities with 2-year noncancer mortality, and cancer-specific weights were derived for each comorbidity. In the validation cohort, competing risk regression was used to compare 3 versions of the Elixhauser comorbidity score with 3 versions of the Charlson comorbidity score. Model performance was evaluated with c statistics. RESULTS: The 2-year noncancer mortality rates were 14.5% (lung cancer), 11.5% (colorectal cancer), 5.7% (breast cancer), and 4.1% (prostate cancer). Cancer-specific Elixhauser comorbidity scores (c = 0.773 for breast cancer, c = 0.772 for prostate cancer, c = 0.579 for lung cancer, and c = 0.680 for colorectal cancer) performed slightly better than cancer-specific Charlson comorbidity scores (ie, the National Cancer Institute combined index; c = 0.762 for breast cancer, c = 0.767 for prostate cancer, c = 0.578 for lung cancer, and c = 0.674 for colorectal cancer). Individual Elixhauser comorbidities performed best (c = 0.779 for breast cancer, c = 0.783 for prostate cancer, c = 0.587 for lung cancer, and c = 0.687 for colorectal cancer). CONCLUSIONS: The cancer-specific Elixhauser comorbidity score performed as well as or slightly better than the cancer-specific Charlson comorbidity score in predicting 2-year survival. If the sample size permits, using individual Elixhauser comorbidities may be the best way to control for confounding in cancer outcomes research. Cancer 2018;124:2018-25. © 2018 American Cancer Society.

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INTRODUCTION: The long-term prognosis of patients with community-acquired pneumonia (CAP) has attracted increasing interest in recent years. The objective of the present study is to investigate the short and long-term outcomes in hospitalized patients with CAP and to identify the predictive factors associated with mortality. PATIENTS AND METHODS: The study was designed as a retrospective, multicenter, observational study. Hospitalized patients with CAP, as recorded in the pneumonia database of the Turkish Thoracic Society between 2011 and 2013, were included. Short-term mortality was defined as 30-day mortality and long-term mortality was assessed from those who survived 30 days. Predictive factors for short- and long-term mortality were analyzed. RESULTS: The study included 785 patients, 68% of whom were male and the mean age was 67±16 (18-92). The median duration of follow-up was 61.2±11.8 (37-90) months. Thirty-day mortality was 9.2% and the median survival of patients surviving 30 days was 62.8±4.4 months. Multivariate analysis revealed that advanced age, the absence of fever, a higher Charlson comorbidity score, higher blood urea nitrogen (BUN)/albumin ratios and lower alanine aminotransferase (ALT) levels were all predictors of long-term mortality. CONCLUSION: Long-term mortality following hospitalization for CAP is high. Charlson score and lack of fever are potential indicators for decreased long-term survival. As novel parameters, baseline BUN/albumin ratios and ALT levels are significantly associated with late mortality. Further interventions and closer monitoring are necessary for such subgroups of patients.

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BACKGROUND AND AIM: The availability and access of hospital administrative data [coding for Charlson comorbidity index (CCI)] in large data form has resulted in a surge of interest in using this information to predict mortality from stroke. The aims of this study were to determine the minimum clinical data set to be included in models for predicting disability after ischemic stroke adjusting for CCI and clinical variables and to evaluate the impact of CCI on prediction of outcome. METHOD: We leverage anonymized clinical trial data in the Virtual International Stroke Trials Archive. This repository contains prospective data on stroke severity and outcome. The inclusion criteria were patients with available stroke severity score such as National Institutes of Health Stroke Scale (NIHSS), imaging data, and outcome disability score such as 90-day Rankin Scale. We calculate CCI based on comorbidity data in this data set. For logistic regression, we used these calibration statistics: Nagelkerke generalised R2 and Brier score; and for discrimination we used: area under the receiver operating characteristics curve (AUC) and integrated discrimination improvement (IDI). The IDI was used to evaluate improvement in disability prediction above baseline model containing age, sex, and CCI. RESULTS: The clinical data among 5,206 patients (55% males) were as follows: mean age 69 ± 13 years, CCI 4.2 ± 0.8, and median NIHSS of 12 (IQR 8, 17) on admission and 9 (IQR 5, 15) at 24 h. In Model 2, adding admission NIHSS to the baseline model improved AUC from 0.67 (95% CI 0.65-0.68) to 0.79 (95% CI 0.78-0.81). In Model 3, adding 24-h NIHSS to the baseline model resulted in substantial improvement in AUC to 0.90 (95% CI 0.89-0.91) and increased IDI by 0.23 (95% CI 0.22-0.24). Adding the variable recombinant tissue plasminogen activator did not result in a further change in AUC or IDI to this regression model. In Model 3, the variable NIHSS at 24 h explains 87.3% of the variance of Model 3, follow by age (8.5%), comorbidity (3.7%), and male sex (0.5%). CONCLUSION: Our results suggest that prediction of disability after ischemic stroke should at least include 24-h NIHSS and age. The variable CCI is less important for prediction of disability in this data set.

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OBJECTIVE: Some previously developed risk scores contained a mathematical error in their construction: risk ratios were added to derive weights to construct a summary risk score. This study demonstrates the mathematical error and derived different versions of the Charlson comorbidity score (CCS) using regression coefficient-based and risk ratio-based scoring systems to further demonstrate the effects of incorrect weighting on performance in predicting mortality. STUDY DESIGN AND SETTING: This retrospective cohort study included elderly people from the Clinical Practice Research Datalink. Cox proportional hazards regression models were constructed for time to 1-year mortality. Weights were assigned to 17 comorbidities using regression coefficient-based and risk ratio-based scoring systems. Different versions of CCS were compared using Akaike information criteria (AIC), McFadden's adjusted R2, and net reclassification improvement (NRI). RESULTS: Regression coefficient-based models (Beta, Beta10/integer, Beta/Schneeweiss, Beta/Sullivan) had lower AIC and higher R2 compared to risk ratio-based models (HR/Charlson, HR/Johnson). Regression coefficient-based CCS reclassified more number of people into the correct strata (NRI range, 9.02-10.04) compared to risk ratio-based CCS (NRI range, 8.14-8.22). CONCLUSION: Previously developed risk scores contained an error in their construction adding ratios instead of multiplying them. Furthermore, as demonstrated here, adding ratios fail to even work adequately from a practical standpoint. CCS derived using regression coefficients performed slightly better than in fitting the data compared to risk ratio-based scoring systems. Researchers should use a regression coefficient-based scoring system to develop a risk index, which is theoretically correct.

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The management of acute cholecystitis is still based on clinical expertise. This study aims to investigate whether the outcome of acute cholecystitis can be related to the severity criteria of the Tokyo guidelines and additional clinical comorbidities. A total of 103 patients with acute cholecystitis were retrospectively enrolled and their medical records were reviewed. They were all classified according to therapeutic modality, including early cholecystectomy and antibiotic treatment with or without percutaneous cholecystostomy. The impact of the Tokyo guidelines and the presence of comorbidities on clinical outcome were assessed by univariate and multivariate regression analyses. According to Tokyo severity grading, 48 patients were Grade I, 31 patients were Grade II, and 24 patients were Grade III. The Grade III patients had a longer hospital stay than Grade II and Grade I patients (15.2 days, 9.2 days, and 7.3 days, respectively, p < 0.05). According to multivariate analysis, patients with Grade III Tokyo severity, higher Charlson's Comorbidity Score, and encountering complications had a longer hospital stay. Based on treatment modality, surgeons selected the patients with less severity and fewer comorbidities for cholecystectomy, and these patients had a shorter hospital stay. In addition to the grading of the Tokyo guidelines, comorbidities had an additional impact on clinical outcomes and should be an important consideration when making therapeutic decisions.

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