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ObjectiveMap multimorbidity-weighted index (MWI) conditions to International Classification of Diseases, 10th Revision (ICD-10), expand the conditions and codes to develop a new ICD-10-coded MWI (MWI-ICD10) and updated MWI-ICD9, and assess their consistency.DesignPopulation-based retrospective cohort.SettingLarge medical centre between 2013 and 2017.ParticipantsAdults ≥18 years old with encounters in each of 4 years (2013, 2014, 2016, 2017).Main outcome measuresMWI conditions mapped to ICD-10 codes, and additional conditions and codes added to produce a new MWI-ICD10 and updated MWI-ICD9. We compared the prevalence of ICD-coded MWI conditions within the ICD-9 era (2013–2014), within the ICD-10 era (2016–2017) and across the ICD-9–ICD-10 transition in 2015 (washout period) among adults present in both sets of comparison years. We computed the prevalence and change in prevalence of conditions when using MWI-ICD10 versus MWI-ICD9.Results88 175 adults met inclusion criteria. Participants were 60.8% female, 50.5% white, with mean age 54.7±17.3 years and baseline MWI-ICD9 4.47±6.02 (range 0–64.33). Of 94 conditions, 65 had <1% difference across the ICD-9–ICD-10 transition and similar minimal changes within ICD coding eras.ConclusionsMWI-ICD10 captured the prevalence of chronic conditions nearly identically to that of the validated MWI-ICD9, along with notable but explicable changes across the ICD-10 transition. This new comprehensive person-centred index enables quantification of cumulative disease burden and physical functioning in adults as a clinically meaningful measure of multimorbidity in electronic health record and claims data.

Collectively, the low rate of difficult airway letters in our study suggests unstudied barriers exist preventing appropriate communication of airway management difficulty, and improved definitions and education may be required.Ethical statement The University of Michigan Institutional Review Board determined this study to be exempt from regulation (HUM00157124).Disclosures Benjamin H. Cloyd was previously funded by the FAER/ABA Research in Education Grant and is currently funded by the American Board of Medical Specialties as a Visiting Scholar, both grants have involved studying the impact of the American Board of Anesthesiology certification programs on clinical performance in board-certified anesthesiologists and are not related to nor influence the submitted work. The authors have no competing interests to declare.Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Presentation Preliminary data was intended to be presented at the IARS meeting in 2020, which was canceled due to the COVID-19 pandemic.CRediT authorship contribution statement Benjamin H. Cloyd: Conceptualization, Methodology, Investigation, Writing – original draft, Writing – review & editing. Magnus Teig: Conceptualization, Writing – original draft, Writing – review & editing, Supervision.Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.Acknowledgments None.

Background Symptoms of COVID-19 including fatigue and dyspnea, may persist for weeks to months after SARS-CoV-2 infection. This study compared self-reported disability among SARS-CoV-2-positive and negative persons with mild to moderate COVID-19-like illness who presented for outpatient care before widespread COVID-19 vaccination. Methods Unvaccinated adults with COVID-19-like illness enrolled within 10 days of illness onset at three US Flu Vaccine Effectiveness Network sites were tested for SARS-CoV-2 by molecular assay. Enrollees completed an enrollment questionnaire and two follow-up surveys (7–24 days and 2–7 months after illness onset) online or by phone to assess illness characteristics and health status. The second follow-up survey included questions measuring global health, physical function, fatigue, and dyspnea. Scores in the four domains were compared by participants’ SARS-CoV-2 test results in univariate analysis and multivariable Gamma regression. Results During September 22, 2020 – February 13, 2021, 2712 eligible adults were enrolled, 1541 completed the first follow-up survey, and 650 completed the second follow-up survey. SARS-CoV-2-positive participants were more likely to report fever at acute illness but were otherwise comparable to SARS-CoV-2-negative participants. At first follow-up, SARS-CoV-2-positive participants were less likely to have reported fully or mostly recovered from their illness compared to SARS-CoV-2-negative participants. At second follow-up, no differences by SARS-CoV-2 test results were detected in the four domains in the multivariable model. Conclusion Self-reported disability was similar among outpatient SARS-CoV-2-positive and -negative adults 2–7 months after illness onset.

Background Cranial nerve injury is an uncommon but significant complication of neck dissection. We examined the association between the use of intraoperative neuromuscular blockade and iatrogenic cranial nerve injury during neck dissection. Methods This was a single-center, retrospective, electronic health record review. Study inclusion criteria stipulated patients > 18 years who had ≥ 2 neck lymphatic levels dissected for malignancy under general anesthesia with a surgery date between 2008 – 2018. Use of neuromuscular blockade during neck dissection was the primary independent variable. This was defined as any use of rocuronium, cisatracurium, or vecuronium upon anesthesia induction without reversal with sugammadex prior to surgical incision. Univariate tests were used to compare variables between those patients with, and those without, iatrogenic cranial nerve injury. Multivariable logistic regression determined predictors of cranial nerve injury and was performed incorporating Firth’s estimation given low prevalence of the primary outcome. Results Our cohort consisted of 925 distinct neck dissections performed in 897 patients. Neuromuscular blockade was used during 285 (30.8%) neck dissections. Fourteen instances (1.5% of surgical cases) of nerve injury were identified. On univariate logistic regression, use of neuromuscular blockade was not associated with iatrogenic cranial nerve injury (OR: 1.73, 95% CI: 0.62 – 4.86, p  = 0.30). There remained no significant association on multivariable logistic regression controlling for patient age, sex, weight, ASA class, paralytic dose, history of diabetes, stroke, coronary artery disease, carotid atherosclerosis, myocardial infarction, and cardiac arrythmia (OR: 1.87, 95% CI: 0.63 – 5.51, p  = 0.26). Conclusions In this study, use of neuromuscular blockade intraoperatively during neck dissection was not associated with increased rates of iatrogenic cranial nerve injury. While this investigation provides early support for safe use of neuromuscular blockade during neck dissection, future investigation with greater power remains necessary.

Test-negative design (TND) studies are cornerstones of vaccine effectiveness (VE) monitoring for influenza. The introduction of SARS-CoV-2 and RSV vaccines complicate the analysis of this design, with control selection restriction based on other pathogen diagnosis proposed as a solution. We conducted a simulation study and secondary analysis of 2017–18 and 2018–19 TND estimates from a Southeast Michigan ambulatory population to evaluate RSV-status-based control restriction. Simulations suggest that with vaccine-preventable RSV, influenza VE could be moderately biased with RSV prevalence ≥25 % of controls. Real-world analysis showed 151 influenza-negative adults (10.4 %) had RSV detected from the enrollment nasal swab. There were minimal differences in results of adjusted models with or without RSV exclusion from control groups. Findings suggest that inclusion of RSV cases in the control group of TND studies for influenza VE, particularly where RSV is not vaccine preventable, does not currently pose a major concern for bias in VE estimates.

Intraoperative hypoglycemia is presumed to be rare, but generalizable multicentre incidence and risk factor data for adult patients are lacking. We used a multicentre registry to characterize adults with intraoperative hypoglycemia and hypothesized that intraoperative insulin administration would be associated with hypoglycemia. We conducted a cross-sectional retrospective multicentre cohort study. We searched the Multicenter Perioperative Outcomes Group registry to identify adult patients with intraoperative hypoglycemia (glucose < 3.3 mmol·L [< 60 mg·dL ]) from 1 January 2015 to 31 December 2019. We evaluated characteristics of patients with intraoperative glucose measurements and with intraoperative hypoglycemia. Of 516,045 patients with intraoperative glucose measurements, 3,900 (0.76%) had intraoperative hypoglycemia. Diabetes mellitus and chronic kidney disease were more common in the cohort with intraoperative hypoglycemia. The odds of intraoperative hypoglycemia were higher for the youngest age category (18-30 yr) compared with the odds for every age category above 40 yr (odds ratio [OR], 1.57-3.18; P < 0.001), and were higher for underweight or normal weight patients compared with patients with obesity (OR, 1.48-2.53; P < 0.001). Parenteral nutrition was associated with lower odds of hypoglycemia (OR, 0.23; 95% confidence interval [CI], 0.11 to 0.47; P < 0.001). Intraoperative insulin use was not associated with hypoglycemia (OR, 0.996; 95% CI, 0.91 to 1.09; P = 0.93). In this large cross-sectional retrospective multicentre cohort study, intraoperative hypoglycemia was a rare event. Intraoperative insulin use was not associated with hypoglycemia.

Background Many women experience declines in physical function across and beyond menopause. While there is an established bidirectional association between gait speed and cognition, longitudinal studies are needed to quantify the magnitude of these relationships. Additionally, prospective studies, particularly among older adults, are prone to selection bias due to differential loss‐to‐follow‐up. We leveraged data from the Study of Women's Health Across the Nation (SWAN) to quantify the associations between gait speed and cognitive function, accounting for loss‐to‐follow‐up. Methods SWAN is a multi‐ethnic, community‐based cohort of women followed through menopause into older adulthood. At study visits in 2012‐13 (V13) and 2015‐16 (V15), participants completed a timed four‐meter walk to assess gait speed and tests of working memory, processing speed, and verbal memory. A summary measure of cognition, the cognitive z‐score, averaged z‐scores across cognitive tests. Linear regressions were employed to predict V15 cognitive z‐score from V13 gait speed and vice versa, adjusting for demographic and socioeconomic characteristics. Inverse probability weights for missingness due to death, stroke, poor physical function, and other reasons adjusted for differential loss‐to‐follow‐up from baseline. Results The sample included 1,258 women who completed gait speed and cognitive tests at visits 13 and 15, with a mean age of 65.5 years (SD=2.7) at V15. Half the sample was White, 23.5% Black, 12.2% Chinese, 10.8% Japanese, and 3.5% Hispanic. Adjusting for race, education, age, and financial strain, faster gait speeds at V13 were associated with higher global cognitive z‐scores at V15 (β=0.20, 95%CI:0.05,0.35) but higher global cognitive z‐scores at V13 were not significantly associated with faster gait speeds at V15 (β=0.017, 95%CI:‐0.002,0.036). Adjusting for covariates and loss‐to‐follow‐up, weighted models indicated gait speeds at V13 were positively associated with global cognitive z‐score (β=0.22, 95%CI:0.06,0.37) and global cognitive z‐scores at V13 were positively associated with gait speeds at V15 (β=0.022, 95%CI: 0.000,0.044). Conclusions This SWAN sample exhibited a bidirectional relationship between gait speed and cognitive performance across time. Weighted estimates exceeded unweighted estimates, suggesting that models not accounting for selection bias underestimate associations. Future research will examine the longitudinal associations between specific domains of cognition and other measures of physical functioning among SWAN women.

Background Physical functioning is positively associated with cognitive performance but estimates of this association from longitudinal studies may be subject to selection bias due to differential loss‐to‐follow‐up via poor physical function, death, or comorbidities. We estimated the potential impact and drivers of differential selection on this association among a cohort of older women. Method The Study of Women's Health Across the Nation (SWAN) is a community‐based, longitudinal study of women. From the initial cohort (n = 3,302), only 59.4% (n = 1345) participants completed gait speed and cognitive functioning tests at study visit 15 (V15, 2015‐16). To address potential selection bias for each of the reasons above, inverse probability weighting was used to upweight participants at V15 who resembled those lost to follow‐up. A global cognitive z‐score was derived by averaging z‐scores from processing speed, verbal memory, and working memory tests; higher z‐score indicates better overall cognitive functioning. Linear regression models (with and without weights) estimated the relationship between gait speed and global cognitive z‐score. Models were stratified by financial strain and education. Result Our sample included 1345 women with a mean age of 65.5 (± 2.6 SD) years. The unweighted, unstratified model estimated a faster gait speed was associated with a 0.82‐unit increase in global z‐score (95% CI:0.66,0.98). The weighted model estimate was 17% higher (β:0.96, 95%CI:0.77,1.15). Among women who reported any financial strain, the unweighted model found that a faster gait speed was associated with a 1.08‐unit increase in global z‐score (β:1.08, 95%CI:0.74,1.42), whereas the weighted model estimated this association to be 13.9% higher (β:1.23, 95%CI: 0.86,1.60). Comparatively, among women who reported no financial strain, the weighted model estimate was 6.8% higher than the unweighted model (weighted β:0.63, 95%CI:0.44,0.83; unweighted β:0.59, 95%CI:0.42,0.77). Similar results were observed in models stratified by education. Conclusion Results indicate that loss to follow‐up in SWAN leads to underestimation of the relationship between gait speed and cognitive performance. The association is strongest among the most disadvantaged, who are also more likely to drop out. Accounting for differential loss‐to‐follow‐up is critical for a more accurate characterization of the association between gait speed and cognitive performance.

Abstract Purpose Previous work has focused on the role of diabetes in peripheral neuropathy (PN), but PN often occurs before, and independently from, diabetes. This study measures the association of cardiometabolic and inflammatory factor with PN, independent of diabetes. Methods Study of Women's Health Across the Nation participants (n = 1910), ages 60 to 73 (mean 65.6) were assessed for PN by symptom questionnaire and monofilament testing at the 15th follow-up visit (V15). Anthropometric measures and biomarkers were measured at study baseline approximately 20 years prior, and C-reactive protein (CRP) and fibrinogen were measured longitudinally. Log-binomial regression was used to model the association between metabolic syndrome (MetS), obesity (≥35 body mass index), CRP, and fibrinogen with PN, adjusting for sociodemographic and health behavior measures. Results Baseline MetS [prevalence ratio (PR) 1.79, 95% CI (1.45, 2.20)], obesity [PR 2.08 (1.65, 2.61)], median CRP [PR 1.32 per log(mg/dL), (1.20, 1.45)], and mean fibrinogen (PR 1.28 per 100 mg/dL, (1.09, 1.50)] were associated with PN symptoms at V15. After excluding participants with baseline diabetes or obesity, MetS [PR 1.59 (1.17, 2.14)] and CRP [PR 1.19 per log(mg/dL), (1.06, 1.35)] remained statistically significantly associated with PN. There was a negative interaction between MetS and obesity, and the association between these conditions and PN was mediated by CRP. Conclusions Cardiometabolic factors and inflammation are significantly associated with PN, independent of diabetes and obesity. CRP mediates the relationship of both obesity and MetS with PN, suggesting an etiological role of inflammation in PN in this sample.

PurposeIntraoperative hypoglycemia can result in devastating neurologic injury if not promptly diagnosed and treated. Few studies have defined risk factors for intraoperative hypoglycemia. The authors sought to characterize children with intraoperative hypoglycemia and determine independent risk factors.MethodsThis retrospective observational single-institution study included all patients < 18 yr of age undergoing an anesthetic from January 1 2012 to December 31 2016. The primary outcome was blood glucose < 3.3 mmol·L−1 (60 mg·dl−1). Data collected included patient characteristics, comorbidities, and intraoperative factors. A multivariable logistic regression model was used to identify independent predictors of intraoperative hypoglycemia.ResultsBlood glucose was measured in 7,715 of 73,592 cases with 271 (3.5%) having a glucose < 3.3 mmol·L−1 (60 mg·dl−1). Young age, weight for age < 5th percentile, developmental delay, presence of a gastric or jejunal tube, and abdominal surgery were identified as independent predictors for intraoperative hypoglycemia. Eighty percent of hypoglycemia cases occurred in children < three years of age and in children < 15 kg.ConclusionYoung age, weight for age < 5th percentile, developmental delay, having a gastric or jejunal tube, and abdominal surgery were independent risk factors for intraoperative hypoglycemia in children. Frequent monitoring of blood glucose and judicious isotonic dextrose administration may be warranted in these children.