Nomogram to predict postoperative complications in elderly with total hip replacement

lNTRODUCTlON

Hip replacement is a frequently done and highly successful surgical intervention[1]. More than one million hip arthroplasties are performed annually worldwide[2]. Kurtz

[3] projected the demand for primary total hip arthroplasty (THA) to grow 174% to 572000 procedures per year by 2030. These procedures carry a complication rate estimated to be between 2% and 14%; higher complication rates are associated with more elderly and comorbid patient populations[4]. Numerous clinical tools have been developed to predict a variety of THA patient outcomes[5-7], but the risk calculator to be a poor predictor of postoperative complications in Chinese. This is likely due to the complexity of the environment, race and personal differences. As an anesthetist, when we go to the inpatient ward for preoperative evaluation, patient often ask: what is the proportion of risk in my surgery? The answer is perhaps or we don’t know. So we want to create a tool not only can predict the risk precisely, but also guide the clinical work. Therefore this study will analyze clinical data, explored the independent risk factors for postoperative complications in elderly patients undergoing total hip replacement, develop a nomogram for accurate risk stratification of postoperative complications based on preoperative and intraoperative variables, and verify whether this tool would have good predictive for patients undergoing total hip replacement in our hospital.

MATERlALS AND METHODS

Patients

Approved by the Ethics Committee of the Affiliated Hospital of Guangdong Medical University committee (PJ2020-022), we were collected from all patients undergoing total hip replacement from March 1, 2017 to August 31, 2019 at the Affiliated Hospital of Guangdong Medical University. Inclusion criteria were age ＞ 65 years, elective surgical treatment with total hip replacement. Non-inclusion criteria were age ＜ 65 years, electronic medical records incomplete, patients or family members disagree with the study.

Research methods

Interestingly, our data suggest that low preoperative albumin levels can predict the incidence of postoperative complications following surgery for total hip replacement. The result is consistent with Kishawi

[25]. Since ALB is a biomarker of visceral protein and immune-competence status, it is commonly used for nutritional assessment[26]. Preoperative albumin bears strong potential as a practical metric to assess a patient’s overall health[27]. Recent studies even show that low ALB rather reflects a state of persistent inflammation[28]. The perhaps reason for ALB as an independent predictor of major complications is that ALB recapitulates the physiological stress intensity triggered by surgery,which is determined by several factors, such as the invasiveness of surgery and its duration, as well as the intrinsic characteristics of the patient[29]. Our results pointed out that the weight of 12.7 points in the nomogram model score will be increased for every 5 g/L decrease in ALB. We recommend surgeons and anesthetists should ideally attempt to optimize patient nutritional status before total hip replacement in elderly in order to avoid a greater likelihood of postoperative complications or mortality.

Using nomogram model to predict postoperative complications in elderly total hip replacement patients risk receive operating characteristic (ROC) curve, area under curve (AUC) is 0.8254 (95%CI:0.78-0.87), indicating that the nomogram model has a good bootstrap-corrected concordance (Figure 2).

另外，借助專門的辦公軟件，醫院的5家分院跟本部的檢查預約通道基本打通。宣姝姝指出，天臺分院目前沒有部分大型儀器設備，如3.0MRI，如果患者要求到本部來做大型檢查，醫生在辦公軟件上發起檢查申請，預約中心處理好以后將信息反饋給他們。然后，這些轉診患者按照預約時間到醫院，現場交費就可以進行檢查，讓基層患者享受便捷就醫的實惠。

寫作是指學生以文字的形式來描述自己的經歷與真情實感。但是在這個過程中，多數學生為了完成老師留下來的任務而應付式的寫作。由于缺乏教師針對性的指導，很多學生不重視實際生活中素材積累的意識，在寫作的過程中多是以模仿的形式去創作，缺乏自己的真實情感，導致創作出來的文章太過形式化，毫無獨特性。還有普遍的虛假作文、“造文”現象非常嚴重，作為缺少創新，文章缺少靈性。

選取CBOE的新興市場ETF波動率指數作為衡量原油金融屬性的指標，代碼VXEEM，該指標于2011年3月16日開始發布。VXEEM是采用CBOE的VIX計算方法對跟蹤新興市場ETF的期權計算出來，反映MSCI新興市場指數基金的隱含波動率（見圖9）。股市是經濟的晴雨表，相較于滯后公布的許多宏觀數據，股市的波動率直接反映了投資者對于未來宏觀經濟的信心。

盡管國外如此重視無障礙網絡教育，但是仍然存在一些問題。比如：設計和開發時沒有完全符合無障礙標準, 一些障礙學習者使用時仍存在障礙。

Statistical analysis

All statistical analyses were performed using the STATA14.0 statistical software package and R software(R3.2.3) with rms package added. Differences between patients with and without complications were compared with t-test or Wilcoxon rank-sum test using the mean ± SD and the median (range) for quantitative variables and chi-squared test using

(%) for qualitative variables. Univariate logistic regression for patients clinical data were analyzed to identify the independent risk factors for postoperative complications after surgery. A multivariate logistic regression model was built using the factors associated with

values ＜ 0.05 by univariate analysis. Selection values of

＜ 0.05 variables by multivariate analysis to create a nomogram model by R software (R3.2.3) rms package, evaluated the nomogram by assessing discrimination and calibration.

RESULTS

In our study 414 elderly total hip replacement patients of 59 cases with postoperative complications after surgery, the incidence was 14.3%. The demographics and descriptive statistics for our patient cohort are given in Table 1. Multivariable logistic regression of each clinical variable of patients related factors for postoperative complications include patients age (OR = 1.05, 95%CI: 1.00-1.09), renal failure(OR = 0.90, 95%CI: 0.83-0.97), diabetes (OR = 2.37, 95%CI: 1.04-5.40) and ALB (OR = 0.91, 95%CI: 0.83-0.99) (Table 2).

According to the above multivariable logistic regression analysis results, choose

＜ 0.05 variable apply R software to build a nomogram model of postoperative complications in elderly total hip replacement patients (Figure 1).

西雙說這仍然不是問題的關鍵，大不了我真的喪盡天良，結了婚就盼著她死掉，結果她真的死掉了，可是，后面的問題呢？你知道樓蘭有個女兒吧？本來是她和禿頭的女兒，但是復婚以后，就會變成她和我的女兒，對不對？等于從結婚那天起，我就得替她養個女兒。然后，她去了，一了百了，我呢？我敢撒手不管？我能撒手不管？我是她父親?。∥业盟退ビ變簣@，送她讀小學，讀中學，讀大學，直到她有經濟來源，這是什么概念？無底深淵??！還有樓蘭那個媽，老成那樣，一身窮病，怎么辦？我敢不管？我能不管？復了婚，我還得管她叫媽啊！我管？我心里怎么能痛快？再說我拿什么管？一邊是假女兒一邊是假媽，把我賣十遍也供不起啊。

The primary outcome measure was the incidence of a postoperative complication or death during hospitalization. Complications were identified from diagnoses in discharge summaries, operative reports, and International Classification of Diseases-9 codes by a single investigator. Included: cardiac arrest, deep venous thrombosis, myocardial infarction, pneumonia, pulmonary embolism, systemic inflammatory response syndrome, infection, dislocation, delirium, according to definitions from the National Quality Improvement Project[8].

Perform Hosmer-Lemeshow goodness-of-fit test and evaluate nomogram Model accuracy, Hosmer-Lemeshow fit goodness test

= 10.16,

= 0.4264 (Figure 3), calibration in rms package by R software E

= 0.176, E

= 0.027 (Figure 4), all shows that the model appears to be well-calibrated, with predicted outcome rates closely reflecting the observed rates.

DlSCUSSlON

China is the most populated country in the world, and now has the second-largest economy in the world[9]. As nearly 166 million Chinese are aged more than 65 years[10]. The demand for healthcare,including hip arthroplasty is increasing[11,12]. There are several predict complications model have be reported[13-15], but on one is modeling by Chinese. In this study, 59 of the 414 elderly total hip replacement patients who underwent surgical treatment were developed postoperative complication,the incidence is 14.3%, morbidity is much higher than 3.9%[16]. Probably because our definition of complications not only included dislocation, pulmonary embolism, and infection as reported previously, but included systemic inflammatory response syndrome, delirium which are common in elderly. Among 566 older patients (mean age, 76.7 years) undergoing a variety of elective operations(including orthopedic, general, and vascular), 23.9% patients developed postoperative delirium[17]. The incidence of postoperative delirium was reported as 7.0%-30.2% in hip arthroplasty[18,19]. In this study the average age is 75.09 ± 7.8. As a result, the morbidity 14.3% is considered to be reasonable.

Age is a recognized risk factor for postoperative complications. The results of this study indicate that elderly patients with renal failure and diabetes are more likely to have postoperative complications after total hip replacement. It is Consistent with the research results of Merrill

[20]. One possible reason is that elderly patients have more comorbidities will make them less able to withstand the stresses of anesthesia and surgery[21,22]. Diabetes have been reported to be significant predictors for complications such as surgical site infections[23]. The available data suggest that diabetes may promote the development of osteoarthritis[24]. Our results for the outcome measure indicate that elderly patients with renal failure and diabetes increase the weight of the nomogram model score by 25 points and 24 points, respectively.

Data on general patient information, comorbidities, laboratory test results, intraoperative variables, and postoperative complications during hospitalization were collected from electronic medical records and electronic Anesthesia Information Management System. Known patient-related factors of complications are age, gender, fractures or not and comorbidity such as renal failure, hypertension, diabetes, coronary heart disease, stroke, laboratory test results of white blood cells, red blood cells, hemoglobin, platelets,albumin (ALB) and blood urea nitrogen. Intraoperative variables included estimated blood loss, lowest heart rate, the type of anesthesia, preoperative American Society of Anesthesiologists Score and operation time.

No additional data are available.

Risk calculators should serve as a tool to help clinical decision-making, promote individualized medicine, and aid in the shared decision-making process[30]. Many of the studies report poor discrimination and calibration of the investigated risk calculators. In our study, founded that age, diabetes,renal failure, and Albumin value are independent risk factors for postoperative complications in elderly patients with total hip replacement, ROC curve shows the AUC is 0.8254, indicating that the nomogram model has a good discrimination. The Hosmer-Lemeshow fit goodness test

= 10.16,

= 0.4264 and calibration curve is a straight line with a slope close to 1, indicating that the nomogram model has good accuracy in predicting the risk of postoperative complications in elderly patients with total hip replacements surgery and has clinical application value.

CONCLUSlON

We have no financial relationships to disclose.

ARTlCLE HlGHLlGHTS

FOOTNOTES

Tan ΧJ is first Author, participated in protocol writing, collecting data, statistical analysis,interpretation of results and manuscript writing; Ge FM helped collection of cases; Li ZY participated in protocol writing, essay writing; Gu ΧΧ helped interpretation of results and manuscript writing; Zhang LQ did the statistical analysis and reviewed the manuscript.

This study was reviewed and approved by the Ethics Committee of the Affiliated Hospital of Guangdong Medical University with the reference number PJ2020-022.

This study created a nomogram model based on age, diabetes, renal failure, and albumin value independent risk factors for postoperative complications, has good indexing and accuracy can provide scientific guidance for individualized clinical prevention and treatment of postoperative complications in elderly patients with total hip replacements surgery in our hospital. This four variables are easy to get in clinical practice, has clinical application value especially for basic-level hospital.

However our study has several limitations. First, our data were limited only 414 patients, it only represents an elective patient population. Second, complications were only collected while in hospital,some of these complications could have occurred after discharge. Third, the predict model quality checks only with internal validation, so external validation will have to be included in future studies in order to promote use. Fourth, this was a retrospective study that relied on 9th edition coding, which can lead to errors and/or incomplete coding.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

(3)Mg2+和礦化度變異系數均呈現出：哈拉湖南部高山區﹤北側區域﹤四周河谷平原﹤周圍湖泊融區，反應了Mg2+和礦化度在地下水中的含量逐步變大；

Χiu-Juan Tan 0000-0003-0608-9045; Χiao-Χia Gu 0000-0002-6059-9479; Feng-Min Ge 0000-0001-5462-9654; Zhi-Yi Li 0000-0001-5775-9593; Liang-Qing Zhang 0000-0003-4131-2097.

Zhang H

A

另外，在漢語中是謂語動詞如以下的“順應”，以謂語出現，但是在英語中卻可以翻譯成狀語或就是狀語，這類情況也要善于識別。因為漢語的表達有時是多樣性的，不是唯一性，而英語變化性較小。

Zhang H

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