The impact of the ARRIVE trial on elective inductions at a tertiary academic center

Abstract Background Crohn’s disease recurrence after ileocolic resection is common and graded with the Rutgeerts score. There is controversy whether anastomotic ulcers represent disease recurrence and should be included in the grading system. The aim of this study was to determine the impact of anastomotic ulcers on Crohn’s disease recurrence in patients with prior ileocolic resections. Secondary aims included defining the prevalence of anastomotic ulcers, risk factors for development, and their natural history. Methods We conducted a retrospective cohort study of patients undergoing an ileocolic resection between 2008 and 2017 at a large academic center, with a postoperative colonoscopy assessing the neoterminal ileum and ileocolic anastomosis. The primary outcome was disease recurrence defined as endoscopic recurrence (>5 ulcers in the neoterminal ileum) or need for another ileocolic resection among patients with or without an anastomotic ulcer in endoscopic remission. Results One hundred eighty-two subjects with Crohn’s disease and an ileocolic resection were included. Anastomotic ulcers were present in 95 (52.2%) subjects. No factors were associated with anastomotic ulcer development. One hundred eleven patients were in endoscopic remission on the first postoperative colonoscopy. On multivariable analysis, anastomotic ulcers were associated with disease recurrence (adjusted hazard ratio [aHR] 3.64; 95% CI, 1.21–10.95; P = 0.02). Sixty-six subjects with anastomotic ulcers underwent a second colonoscopy, with 31 patients (79.5%) having persistent ulcers independent of medication escalation. Conclusion Anastomotic ulcers occur in over half of Crohn’s disease patients after ileocolic resection. No factors are associated with their development. They are associated with Crohn’s disease recurrence and are persistent.

Download Full-text

Impact of Septal Deviation on Recurrent Chronic Rhinosinusitis after Primary Surgery: A Matched Case-Control Study

Otolaryngology ◽

10.1177/0194599818815106 ◽

2018 ◽

Vol 160 (5) ◽

pp. 922-927

Author(s):

Terence Fu ◽

Daniel Lee ◽

Jonathan Yip ◽

Alisha Jamal ◽

John M. Lee

Keyword(s):

Chronic Rhinosinusitis ◽

Case Control Study ◽

Multivariable Analysis ◽

Case Control ◽

Sinus Surgery ◽

Deviated Nasal Septum ◽

Primary Surgery ◽

Academic Center ◽

The Impact ◽

Control Study

Objective To evaluate the impact of untreated deviated nasal septum (DNS) on recalcitrant chronic rhinosinusitis (CRS) among patients undergoing revision endoscopic sinus surgery (ESS). Study Design Case-control study. Setting Tertiary academic center. Subjects and Methods We performed a retrospective review of 489 patients undergoing revision ESS for CRS at a tertiary academic center. Patients undergoing septoplasty were matched to nonseptoplasty controls based on age and sex. Preoperative Lund-Mackay score (LMS) was compared between cohorts. Linear regression was used to identify predictors of LMS and ostiomeatal complex (OMC) obstruction. Results Thirty-six matched pairs (72 patients) were selected for analysis: 36 undergoing septoplasty and revision ESS and 36 undergoing revision ESS alone. Compared with nonseptoplasty controls, the septoplasty group had a significantly higher average LMS (17.8 vs 14.6, P = .02) and a greater rate of OMC obstruction (89% vs 61%, P < .01). The septoplasty group also had significantly higher opacification scores in the maxillary (1.5 vs 1.2, P = .03) and posterior ethmoid (1.8 vs 1.4, P = .02) sinuses. On multivariable analysis, DNS was an independent predictor of LMS ( P = .02) and OMC obstruction ( P < .01). Conclusion Untreated DNS is associated with radiographic markers of CRS severity among patients undergoing revision ESS and may contribute to the multifactorial pathogenesis of persistent CRS.

Download Full-text

Compliance with enhanced recovery after surgery program in gynecology: are all items of equal importance?

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2019-000268 ◽

2019 ◽

Vol 29 (4) ◽

pp. 810-815 ◽

Cited By ~ 4

Author(s):

Basile Pache ◽

Jonas Jurt ◽

Fabian Grass ◽

Martin Hübner ◽

Nicolas Demartines ◽

...

Keyword(s):

Hospital Stay ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Gynecologic Oncology ◽

Length Of Hospital Stay ◽

Gynecologic Surgery ◽

Complication Rates ◽

Prolonged Length ◽

Academic Center ◽

The Impact

IntroductionEnhanced recovery after surgery (ERAS) guidelines in gynecologic surgery are a set of multiple recommendations based on the best available evidence. However, according to previous studies, maintaining high compliance is challenging in daily clinical practice. The aim of this study was to assess the impact of compliance to individual ERAS items on clinical outcomes.MethodsRetrospective cohort study of a prospectively maintained database of 446 consecutive women undergoing gynecologic oncology surgery (both open and minimally invasive) within an ERAS program from 1 October 2013 until 31 January 2017 in a tertiary academic center in Switzerland. Demographics, adherence, and outcomes were retrieved from a prospectively maintained database. Uni- and multivariate logistic regression was performed, with adjustment for confounding factors. Main outcomes were overall compliance, compliance to each individual ERAS item, and impact on post-operative complications according to Clavien classification.ResultsA total of 446 patients were included, 26.2 % (n=117) had at least one complication (Clavien I–V), and 11.4 % (n=51) had a prolonged length of hospital stay. The single independent risk factor for overall complications was intra-operative blood loss > 200 mL (OR 3.32; 95% CI 1.6 to 6.89, p=0.001). Overall compliance >70% with ERAS items (OR 0.15; 95% CI 0.03 to 0.66, p=0.12) showed a protective effect on complications. Increased compliance was also associated with a shorter length of hospital stay (OR 0.2; 95% CI 0.435 to 0.93, p=0.001).ConclusionsCompliance >70% with modifiable ERAS items was significantly associated with reduced overall complications. Best possible compliance with all ERAS items is the goal to achieve lower complication rates after gynecologic oncology surgery.

Download Full-text

A Diagnostic Stewardship Intervention To Improve Blood Culture Use among Adult Nonneutropenic Inpatients: the DISTRIBUTE Study

Journal of Clinical Microbiology ◽

10.1128/jcm.01053-20 ◽

2020 ◽

Vol 58 (10) ◽

Author(s):

Valeria Fabre ◽

Eili Klein ◽

Alejandra B. Salinas ◽

George Jones ◽

Karen C. Carroll ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Blood Culture ◽

Surgical Intensive Care Unit ◽

Surgical Intensive Care ◽

Control Units ◽

Stewardship Program ◽

Academic Center ◽

Before And After ◽

The Impact

ABSTRACT Interventions to optimize blood culture (BCx) practices in adult inpatients are limited. We conducted a before-after study evaluating the impact of a diagnostic stewardship program that aimed to optimize BCx use in a medical intensive care unit (MICU) and five medicine units at a large academic center. The program included implementation of an evidence-based algorithm detailing indications for BCx use and education and feedback to providers about BCx rates and indication inappropriateness. Neutropenic patients were excluded. BCx rates from contemporary control units were obtained for comparison. The primary outcome was the change in BCxs ordered with the intervention. Secondary outcomes included proportion of inappropriate BCx, solitary BCx, and positive BCx. Balancing metrics included compliance with the Centers for Medicare and Medicaid Services (CMS) SEP-1 BCx component, 30-day readmission, and all-cause in-hospital and 30-day mortality. After the intervention, BCx rates decreased from 27.7 to 22.8 BCx/100 patient-days (PDs) in the MICU (P = 0.001) and from 10.9 to 7.7 BCx/100 PD for the 5 medicine units combined (P < 0.001). BCx rates in the control units did not decrease significantly (surgical intensive care unit [ICU], P = 0.06; surgical units, P = 0.15). The proportion of inappropriate BCxs did not significantly change with the intervention (30% in the MICU and 50% in medicine units). BCx positivity increased in the MICU (from 8% to 11%, P < 0.001). Solitary BCxs decreased by 21% in the medicine units (P < 0.001). Balancing metrics were similar before and after the intervention. BCx use can be optimized with clinician education and practice guidance without affecting sepsis quality metrics or mortality.

Download Full-text

The Impact of Multidisciplinary Discussion (MDD) in the Diagnosis and Management of Fibrotic Interstitial Lung Diseases

Canadian Respiratory Journal ◽

10.1155/2020/9026171 ◽

2020 ◽

Vol 2020 ◽

pp. 1-6

Author(s):

Ghofran Ageely ◽

Carolina Souza ◽

Kaissa De Boer ◽

Saly Zahra ◽

Marcio Gomes ◽

...

Keyword(s):

Lung Diseases ◽

Significant Proportion ◽

Real Life ◽

Interstitial Lung Diseases ◽

Limited Information ◽

Reference Standard ◽

Provisional Diagnosis ◽

Surgical Biopsy ◽

Academic Center ◽

The Impact

Accurate diagnosis of interstitial lung disease (ILD) is crucial for management and prognosis but can be challenging even for experienced clinicians. Expert multidisciplinary discussion (MDD) is considered the reference standard for ILD diagnosis; however, there remain concerns regarding lack of validation studies and relative limited information on the impact of MDD in real-life clinical practice. The goal of this study was to assess the effect of MDD in providing a specific ILD diagnosis, changing the diagnosis provided upon referral, and to determine how often and in which way MDD altered management. Material and Methods. Retrospective observational study in an ILD referral tertiary academic center. MDD diagnoses were categorized as specific, provisional, and unclassifiable ILD. Pre-MDD and MDD diagnoses were compared for change in diagnosis and concordance rates for specific diagnoses. Relevant change in management including initiation or change in pharmacological treatment, referral to surgical biopsy, and nonpharmacological management were recorded. Results. 126 cases were included (79M, 47F, 36–93 years, mean 70 y). Specific MDD diagnosis was provided in 62% (78/126); 12% (15/126) had provisional diagnosis, and 21% (27/126) was unclassifiable. Overall agreement for specific pre-MDD and MDD diagnosis was 41% (52/126) and 80% for idiopathic pulmonary fibrosis (IPF) diagnosis. MDD altered diagnosis in 37% (47/126) and changed management in 39% (50/126). Amongst concordant diagnoses, management was altered in 46% (24/52). In summary, MDD provided a specific diagnosis discordant with pre-MDD diagnosis in a significant proportion of cases and was particularly valuable in the diagnosis of non-IPF ILD. MDD often altered management and had relevant impact on management even in cases with concordant pre-MDD diagnosis.

Download Full-text

Impact of the Affordable Care Act on early-stage diagnosis and treatment for women with ovarian cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.18_suppl.lba5563 ◽

2019 ◽

Vol 37 (18_suppl) ◽

pp. LBA5563-LBA5563

Author(s):

Anna Jo Smith ◽

Amanda Nickels

Keyword(s):

Ovarian Cancer ◽

Affordable Care Act ◽

Early Stage ◽

Stage At Diagnosis ◽

Time To Treatment ◽

Academic Center ◽

Morbidity Score ◽

Co Morbidity ◽

The Affordable Care Act ◽

The Impact

LBA5563 Background: The 2010 Affordable Care Act (ACA) expanded access to insurance and care for many Americans. Our objective was to evaluate the impact of the ACA on stage at diagnosis and time to treatment for women with ovarian cancer. Methods: We utilized a difference-in-differences (DD) approach to assess stage at diagnosis and time to treatment before and after the 2010 ACA among women with ovarian cancer ages 21-64 years compared to women ages 65 years and older. We used the National Cancer Database with the 2004-2009 surveys as the pre-reform years and the 2011-2014 surveys as the post-reform years. Outcomes were analyzed for women overall and by insurance type, adjusting for patient race, living in a rural area, area-level household income and education level, Charlson co-morbidity score, distance traveled for care, Census region, and care at an academic center. Results: A total of 35,842 ovarian cancer cases pre-reform and 37,145 post-reform were identified for women 21-64 years compared with 28,895 cases pre-reform and 30,604 post-reform for women 65 years and older. The ACA was associated with increased early-stage diagnosis for women 21-64 years compared to women 65 and older with ovarian cancer (DD=1.7%, p-for-trend=0.001). Additionally, the ACA was associated with more women receiving treatment within 30 days of ovarian cancer diagnosis (DD=1.6%, p<0.001). Specifically, among women with public insurance, the ACA was associated with a significant improvement in early-stage diagnosis and receipt of treatment within 30 days of diagnosis (DD=2.5%, p=0.003 and DD=2.5%, p=0.006). Improvements in stage at diagnosis and time to treatment were seen across race, income, and education groups. Conclusions: Under the Affordable Care Act, women with ovarian cancer were more likely to be diagnosed at an early stage and receive treatment within 30 days of diagnosis. As stage and treatment are major determinants of survival, these gains under the ACA may have long-term impacts on women with ovarian cancer.

Download Full-text

Drainless Parotidectomy Using Tissue Fibrin Sealant -- A Case-Control Study

10.22541/au.161841734.41378170/v1 ◽

2021 ◽

Author(s):

Oded Cohen ◽

Hen Chaushu ◽

Keren Hod ◽

Tzur Kirshenbaum ◽

Avi Khafif

Keyword(s):

Fibrin Sealant ◽

Statistical Significance ◽

Length Of Hospital Stay ◽

Case Control ◽

Control Group ◽

Control Series ◽

Parotid Tumors ◽

Suction Drain ◽

Academic Center ◽

The Impact

Objectives: Drainless parotidectomy has been reported infrequently, mostly in patients undergoing limited partial parotidectomies. Evicel is a fibrin sealant (FS) glue whose use has not been reported in head and neck surgeries so far. The aim of the study was to investigate the impact of drainless parotidectomy using FS on the surgical outcome. Design: A retrospective matched case-control series. Settings: A single academic center, Participants: All cases of patients who underwent drainless parotidectomies, including deep lobe tumors and revision surgeries, were compared to age, sex, body mass index and tumor-matched controls in which a suction drain was inserted. Main outcome measures: length of hospital stay (LOS). Secondary outcomes included post-operative seroma and related complications. Results: A total of 123 patients (41 cases and 82 controls) were included in the study. Pre-operative and intra-operative characteristic did not differ significantly between the FS group and controls. A borderline significance was found for surgery type as the FS group had higher rates of total parotidectomy compared with the control group (25.0% vs. 10.5%, p=0.054). LOS was significantly shorter in the FS group (1.0±0.3 vs. 1.5±0.6 days, p<0.001). The rates of post-operative seroma, aspirations, local infection and post-operative antibiotic treatment were all lower in the FS group compared with the control group, but did not reach statistical significance. Conclusion: A drainless parotidectomy using the EVICEL FS is safe, reduces LOS, and may reduce post-operative seroma and its associated complications. This procedure may be applied to deep parotid tumors, parapharyngeal involvement and revision surgery.

Download Full-text

NCOG-75. ESTIMATED PHYSICIAN COST OF A NEURO-ONCOLOGY MULTIDISCIPLINARY TEAM (MDT) TUMOR BOARD MEETING AT A SINGLE ACADEMIC CENTER

Neuro-Oncology ◽

10.1093/neuonc/noaa215.612 ◽

2020 ◽

Vol 22 (Supplement_2) ◽

pp. ii146-ii146

Author(s):

Brett Schroeder ◽

Jerome Graber ◽

Emmanuel Cuevas

Keyword(s):

Performance Metrics ◽

Tumor Board ◽

Multidisciplinary Teams ◽

Radiation Oncologists ◽

Annual Salary ◽

Academic Center ◽

Tumor Boards ◽

The Mean ◽

Patient Prognosis ◽

The Impact

Abstract BACKGROUND Multidisciplinary teams (MDTs) to improve coordination across disciplines have become commonplace in oncology. Quantifying the impact of MDTs is challenging, and they carry significant costs. Weekly neuro-oncology tumor boards are attended by neuro-oncologists, neurosurgeons, radiation-oncologists, neuro-radiologists, neuro-pathologists, and support staff including mid-level practitioners, research coordinators, social workers, nurses and trainees. Our aim was to estimate costs associated with neuro-oncology MDTs. METHODS The estimated physician cost of MDT meetings were calculated from reported salaries of each physician specialty. Annual salaries from the Doximity 2019 Physician Compensation Report (PCR) included data for 4 neurosurgeons, 4 radiation-oncologists, 2 radiologists, 2 oncologists, and 2 neurologists. Medscape 2019 PCR data was compiled for 4 general surgeons, 2 radiologists, 2 oncologists, 2 pathologists, and 2 neurologists. The Physician Wages Across Specialties by Leigh in 2011 (JAMA) was utilized for 4 neurosurgeons, 4 radiation oncologists, 2 oncologists, and 2 neurologists. Annual salary data was divided by annual hours per specialty as reported by the Annual Work Hours Across Specialties, 2011. These values were then applied to an MDT for one patient, one hour, weekly, and annually. RESULTS The Doximity 2019 PCR yielded a per meeting cost of $2,520.84, and an annual cost of $131,083.68. The Medscape 2019 PCR produced a cost of $1,570.60 weekly, and $81,671.20 annually. JAMA data estimated a per meeting cost of $1,448.06, and $75.299.12. The mean per meeting and annual costs were $1846.50, and $96,018.00, respectively. With 6-10 cases per MDT, the mean costs per patient were $184.65 to $307.75. CONCLUSIONS Costs of MDT are not negligible. The impact of MDTs on patient outcomes are harder to quantify, but evidence exists that organized MDTs improve patient prognosis, and unorganized MDTs may negatively affect prognosis. Processes to streamline MDTs could help answer outcomes research questions, improve efficiency, and generate clinically relevant performance metrics.

Download Full-text

Keeping the Family in Family Medicine

American Journal of Hospice and Palliative Medicine® ◽

10.1177/1049909120933273 ◽

2020 ◽

pp. 104990912093327

Author(s):

Amelita Woodruff

Keyword(s):

Chronic Illness ◽

Family Medicine ◽

Personal Reflection ◽

Family Medicine Resident ◽

Medicine Resident ◽

Academic Center ◽

The Family ◽

Practice Of Medicine ◽

The Future ◽

The Impact

In this personal reflection, as a Family Medicine resident at an Academic Center in Northeast Florida, as well as being a chronic illness patient myself, I explore the notion of dying alone and away from family. Although COVID-19 has changed the practice of medicine in many ways, prior to that, and before the instillation of hospital no-visitor policies and stay at home orders, I experienced a case of a patient dying alone in the hospital. These chronicles that case and the impact it had on me afterward in regard to my own family and how I hope the future of medicine can address this.

Download Full-text

Higher Frequency of Hospital-Acquired Infections but Similar In-Hospital Mortality Among Admissions With Alcoholic Hepatitis at Academic vs. Non-academic Centers

Frontiers in Physiology ◽

10.3389/fphys.2020.594138 ◽

2020 ◽

Vol 11 ◽

Author(s):

Muhammad Waleed ◽

Mohamed A. Abdallah ◽

Yong-Fang Kuo ◽

Juan P. Arab ◽

Robert Wong ◽

...

Keyword(s):

Logistic Regression ◽

Liver Disease ◽

Hospital Mortality ◽

Alcoholic Hepatitis ◽

Academic Status ◽

Hospital Acquired Infections ◽

Academic Center ◽

Hospital Acquired ◽

The Impact ◽

Total Charges

BackgroundAlcoholic hepatitis (AH) is a unique syndrome characterized by high short-term mortality. The impact of the academic status of a hospital (urban and teaching) on outcomes in AH is unknown.MethodsNational Inpatient Sample dataset (2006–2014) on AH admissions stratified to academic center (AC) or non-academic center (NAC) and analyzed for in-hospital mortality (IHM), hospital resource use, length of stay in days (d), and total charges (TC) in United States dollars (USD). Admission year was stratified to 2006–2008 (TMI), 2009–2011 (TM2), and 2012–2014 (TM3).ResultsOf 62,136 AH admissions, the proportion at AC increased from 46% in TM1 to 57% in TM3, Armitage trend, p < 0.001. On logistic regression, TM3, younger age, black race, Medicaid and private insurance, and development of acute on chronic liver failure (ACLF) were associated with admission to an AC. Of 53,264 admissions propensity score matched for demographics, pay status, and disease severity, admissions to AC vs. NAC (26,622 each) were more likely to have liver disease complications (esophageal varices, ascites, and hepatic encephalopathy) and hospital-acquired infections (HAI), especially Clostridioides difficile and ventilator-associated pneumonia. Admissions to AC were more likely transfers from outside hospital (1.6% vs. 1.3%) and seen by palliative care (4.8% vs. 3.3%), p < 0.001. Use of endoscopy, dialysis, and mechanical ventilation were similar. With similar IHM comparing AC vs. NAC (7.7% vs. 7.8%, p = 0.93), average LOS and number of procedures were higher at AC (7.7 vs. 7.1 d and 2.3 vs. 1.9, respectively, p < 0.001) without difference on total charges ($52,821 vs. $52,067 USD, p = 0.28). On multivariable logistic regression model after controlling for demographics, ACLF grade, and calendar year, IHM was similar irrespective of academic status of the hospital, HR (95% CI): 1.01 (0.93–1.08, p = 0.70). IHM decreased over time, with ACLF as strongest predictor. A total of 63 and 22% were discharged to home and skilled nursing facility, respectively, without differences on academic status of the hospital.ConclusionAdmissions with AH to AC compared to NAC have higher frequency of liver disease complications and HAI, with longer duration of hospitalization. Prospective studies are needed to reduce HAI among hospitalized patients with AH.

Download Full-text