SP10.1.3 The presentation, management and outcomes of acute appendicitis: a comparison of patients presenting during the COVID-19 pandemic and those presenting in a pre-COVID-19 period

Abstract Aims This study assesses the impact of COVID-19 on the presentation and management of acute appendicitis (AA). Patients presenting with AA during the first wave of the COVID-19 pandemic are compared to a pre-COVID-19 cohort. Methods Patients admitted to a single acute NHS hospital with AA between April and July in 2019 and 2020 were retrospectively identified. Data on presentation, treatment and outcomes was collected. Results 56 patients were identified in 2019, and 37 in 2020. A greater proportion of patients presented later (>3 days of symptoms) in 2020 (2019=15.6%, 2020=32.4%, p < 0.05). There was no significant difference in the proportion of patients presenting systemically unwell (pyrexial & tachycardic) or with high inflammatory markers (CRP > 50 and white cell count > 15). In 2020, more patients were managed conservatively (2019=7.1%, 2020=35.1%, p < 0.05). Among those who were managed operatively, 75% underwent open appendicectomy in 2020, compared to 7.7% (including cases converted to open from laparoscopic) in 2019. Patients managed operatively during the COVID-19 pandemic had significantly more post-operative complications (2019=17.3%, 2020=50%, p < 0.05). Common post-operative complications in 2020 were abdominal collections (16.7%) and wound infections (12.5%). Median duration of admission was similar (2019=3 days, 2020=2 days) and there was no significant difference in 30-day readmissions (2019=8.9%, 2020=13.5%, p = 0.48). Conclusions AA patients in the COVID-19 pandemic were more likely to present later and were more likely to be managed conservatively or with open appendicectomy. There was a higher rate of post-operative complications for patients in 2020. Duration of stay and readmission rates were similar.

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The impact of COVID-19 on emergency surgical presentations in a university teaching hospital

Irish Journal of Medical Science (1971 -) ◽

10.1007/s11845-021-02709-w ◽

2021 ◽

Author(s):

Ahmed M. Kamil ◽

Matthew G. Davey ◽

Fadi Marzouk ◽

Rish Sehgal ◽

Amy L. Fowler ◽

...

Keyword(s):

Acute Appendicitis ◽

Teaching Hospital ◽

Historical Data ◽

Severe Disease ◽

University Teaching ◽

Readmission Rates ◽

Descriptive Data ◽

Operative Complications ◽

Hospital Patients ◽

The Impact

Abstract Introduction The Coronavirus-19 (COVID-19) pandemic has led to a 50–70% reduction in acute non-COVID-19 presentations to emergency departments globally. Aim To determine the impact of COVID-19 on incidence, severity, and outcomes of acute surgical admissions in an Irish University teaching hospital. Methods Descriptive data concerning patients presenting with acute appendicitis, diverticulitis, and cholecystitis were analysed and compared from March–May 2020 to March–May 2019. Results Acute surgical admissions decreased in March from 191 (2020) to 55 (2019) (55%), before increasing by 28% in April (2019: 119, 2020: 153). Admissions due to acute cholecystitis reduced by 33% (2019: 33, 2020: 22), with increased severity at presentation (P = 0.079) and higher 30-day readmission rates (P = 0.056) reported. Acute appendicitis presentations decreased by 44% (2019: 78, 2020: 43, P = 0.019), with an increase in severity (P < 0.001), conservative management (P < 0.001), and post-operative complications (P = 0.029) in 2020 compared to the same period in 2019. Conclusion COVID-19 has potentiated a significant reduction in acute surgical presentations to our hospital. Patients presenting with acute appendicitis during the pandemic had more severe disease, were more likely to have complications, and were significantly more likely to be managed conservatively when compared to historical data.

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Impact of Radiation Dose on Postoperative Complications in Esophageal and Gastroesophageal Junction Cancers

Frontiers in Oncology ◽

10.3389/fonc.2021.614640 ◽

2021 ◽

Vol 11 ◽

Author(s):

Noah Kastelowitz ◽

Megan D. Marsh ◽

Martin McCarter ◽

Robert A. Meguid ◽

Narine Wandrey Bhardwaj ◽

...

Keyword(s):

Postoperative Complications ◽

Gastroesophageal Junction ◽

Neoadjuvant Chemoradiation ◽

Complication Rates ◽

Trimodality Therapy ◽

Significant Difference ◽

Operative Complications ◽

The Cross ◽

The Impact ◽

Post Operative Complications

Introduction: The impact of radiation prescription dose on postoperative complications during standard of care trimodality therapy for operable stage II-III esophageal and gastroesophageal junction cancers has not been established.Methods: We retrospectively reviewed 82 patients with esophageal or gastroesophageal junction cancers treated between 2004 and 2016 with neoadjuvant chemoradiation followed by resection at a single institution. Post-operative complications within 30 days were reviewed and scored using the Comprehensive Complication Index (CCI). Results were compared between patients treated with <50 Gy and ≥ 50 Gy, as well as to published CROSS study neoadjuvant chemoradiation group data (41.4 Gy).Results: Twenty-nine patients were treated with <50 Gy (range 39.6–46.8 Gy) and 53 patients were treated with ≥ 50 Gy (range 50.0–52.5 Gy) delivered using IMRT/VMAT (41%), 3D-CRT (46%), or tomotherapy IMRT (12%). Complication rates and CCI scores between our <50 Gy and ≥ 50 Gy groups were not significantly different. Assuming a normal distribution of the CROSS data, there was no significant difference in CCI scores between the CROSS study neoadjuvant chemoradiation, <50 Gy, or ≥ 50 Gy groups. Rates of pulmonary complications were greater in the CROSS group (50%) than our <50 Gy (38%) or ≥ 50 Gy (30%) groups.Conclusions: In selected esophageal and gastroesophageal junction cancer patients, radiation doses ≥ 50 Gy do not appear to increase 30 day post-operative complication rates. These findings suggest that the use of definitive doses of radiotherapy (50–50.4 Gy) in the neoadjuvant setting may not increase post-operative complications.

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Laparoscopic versus open partial nephrectomy for the management of highly complex renal tumors with PADUA score ⩾10: A single center analysis.

Urologia Journal ◽

10.1177/03915603211001677 ◽

2021 ◽

pp. 039156032110016

Author(s):

Francesco Chiancone ◽

Marco Fabiano ◽

Clemente Meccariello ◽

Maurizio Fedelini ◽

Francesco Persico ◽

...

Keyword(s):

Partial Nephrectomy ◽

Operation Time ◽

Renal Tumors ◽

Open Partial Nephrectomy ◽

Estimated Blood Loss ◽

Significant Difference ◽

Operative Complications ◽

Group A ◽

Group B ◽

Post Operative Complications

Introduction: The aim of this study was to compare laparoscopic and open partial nephrectomy (PN) for renal tumors of high surgical complexity (PADUA score ⩾10). Methods: We retrospectively evaluated 93 consecutive patients who underwent PN at our department from January 2015 to September 2019. 21 patients underwent open partial nephrectomy (OPN) (Group A) and 72 underwent laparoscopic partial nephrectomy (LPN) (Group B). All OPNs were performed with a retroperitoneal approach, while all LPNs were performed with a transperitoneal approach by a single surgical team. Post-operative complications were classified according to the Clavien-Dindo system. Results: The two groups showed no difference in terms of patients’ demographics as well as tumor characteristics in all variables. Group A was found to be similar to group B in terms of operation time ( p = 0.781), conversion to radical nephrectomy ( p = 0.3485), and positive surgical margins ( p = 0.338) while estimated blood loss ( p = 0.0205), intra-operative ( p = 0.0104), and post-operative ( p = 0.0081) transfusion rates, drainage time ( p = 0.0012), pain score at post-operative day 1 (<0.0001) were significantly lower in Group B. The rate of enucleation and enucleoresection/polar resection was similar ( p = 0.1821) among the groups. Logistic regression analysis indicated that preoperative factors were not independently associated with the surgical approach. There was a statistically significant difference in complication rate (<0.0001) between the two groups even if no significant difference in terms of grade ⩾3 post-operative complications ( p = 0.3382) was detected. Discussion: LPN represents a feasible and safe approach for high complex renal tumors if performed in highly experienced laparoscopic centers. This procedure offers good intraoperative outcomes and a low rate of post-operative complications.

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The diagnostic value of white cell count, C-reactive protein and bilirubin in acute appendicitis and its complications

Annals of The Royal College of Surgeons of England ◽

10.1308/003588413x13511609957371 ◽

2013 ◽

Vol 95 (3) ◽

pp. 215-221 ◽

Cited By ~ 28

Author(s):

I G Panagiotopoulou ◽

D Parashar ◽

R Lin ◽

S Antonowicz ◽

AD Wells ◽

...

Keyword(s):

Acute Appendicitis ◽

Diagnostic Accuracy ◽

Cell Count ◽

Inflammatory Markers ◽

White Cell Count ◽

Perforated Appendicitis ◽

Diagnostic Value ◽

White Cell ◽

C Reactive Protein ◽

Reactive Protein

Introduction Inflammatory markers such as white cell count (WCC) and C-reactive protein (CRP) and, more recently, bilirubin have been used as adjuncts in the diagnosis of appendicitis. The aim of this study was to determine the diagnostic accuracy of the above markers in acute and perforated appendicitis as well as their value in excluding the condition. Methods A retrospective analysis of 1,169 appendicectomies was performed. Patients were grouped according to histological examination of appendicectomy specimens (normal appendix = NA, acute appendicitis = AA, perforated appendicitis = PA) and preoperative laboratory test results were correlated. Receiver operating characteristic (ROC) curve area analysis (area under the curve [AUC]) was performed to examine diagnostic accuracy. Results ROC analysis of all laboratory variables showed that no independent variable was diagnostic for AA. Good diagnostic accuracy was seen for AA when all variables were combined (WCC/CRP/bilirubin combined AUC: 0.8173). In PA, the median CRP level was significantly higher than that of AA (158mg/l vs 30mg, p<0.0001). CRP also showed the highest sensitivity (100%) and negative predictive value (100%) for PA. CRP had the highest diagnostic accuracy in PA (AUC: 0.9322) and this was increased when it was combined with WCC (AUC: 0.9388). Bilirubin added no diagnostic value in PA. Normal levels of WCC, CRP and bilirubin could not rule out appendicitis. Conclusions CRP provides the highest diagnostic accuracy for PA. Bilirubin did not provide any discriminatory value for AA and its complications. Normal inflammatory markers cannot exclude appendicitis, which remains a clinical diagnosis.

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The impact of pre-operative biologic therapy on post-operative surgical outcomes in ulcerative colitis: a systematic review and meta-analysis

Therapeutic Advances in Gastroenterology ◽

10.1177/1756284820937089 ◽

2020 ◽

Vol 13 ◽

pp. 175628482093708

Author(s):

Jasmine Zanelli ◽

Subashini Chandrapalan ◽

Abhilasha Patel ◽

Ramesh P. Arasaradnam

Keyword(s):

Ulcerative Colitis ◽

Biologic Therapy ◽

Meta Analysis ◽

Complication Rates ◽

Surgical Morbidity ◽

Biologic Treatment ◽

Operative Care ◽

Operative Complications ◽

The Impact ◽

Post Operative Complications

Background and aims: Biologic therapy has emerged as an effective modality amongst the medical treatment options available for ulcerative colitis (UC). However, its impact on post-operative care in patients with UC is still debatable. This review evaluates the risk of post-operative complications following biologic treatment in patients with UC. Methods: A systematic search of the relevant databases was conducted with the aim of identifying studies that compared the post-operative complication rates of UC patients who were either exposed or not exposed to a biologic therapy prior to their surgery. Outcomes of interest included both infection-related complications and overall surgical morbidity. Pooled odds-ratio (OR) and 95% confidence intervals (CI) were calculated using Review Manager 5.3. Results: In all, 20 studies, reviewing a total of 12,494 patients with UC, were included in the meta-analysis. Of these, 2254 patients were exposed to a biologic therapy prior to surgery. The pooled ORs for infection-related complications ( n = 8067) and overall complications ( n = 11,869) were 0.98 (95% CI 0.66–1.45) and 1.14 (95% CI 1.04–1.28), respectively, which suggested that there was no significant association between the use of pre-operative biologic therapy and post-operative complications. Interestingly, the interval between the last dose of biologic therapy and surgery did not influence the risk of having a post-operative infection. Conclusions: This meta-analysis suggests that pre-operative biologic therapy does not increase the overall risk of having post-operative infection-related or other complications. PROSPERO registration id-CRD42019141827.

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An observational cohort study of bacterial co-infection and implications for empirical antibiotic therapy in patients presenting with COVID-19 to hospitals in North West London

Journal of Antimicrobial Chemotherapy ◽

10.1093/jac/dkaa475 ◽

2020 ◽

Author(s):

Liyang Wang ◽

Amit K Amin ◽

Priya Khanna ◽

Adnan Aali ◽

Alastair McGregor ◽

...

Keyword(s):

Cohort Study ◽

Antibiotic Treatment ◽

Inflammatory Markers ◽

White Cell Count ◽

Antimicrobial Treatment ◽

Observational Cohort Study ◽

North West ◽

Empirical Antibiotic Treatment ◽

Significant Difference ◽

Observational Cohort

Abstract Objectives To describe the prevalence and nature of bacterial co-infections in COVID-19 patients within 48 hours of hospital admission and assess the appropriateness of empirical antibiotic treatment they received. Methods In this retrospective observational cohort study, we included all adult non-pregnant patients who were admitted to two acute hospitals in North West London in March and April 2020 and confirmed to have COVID-19 infection within 2 days of admission. Results of microbiological specimens taken within 48 hours of admission were reviewed and their clinical significance was assessed. Empirical antibiotic treatment of representative patients was reviewed. Patient age, gender, co-morbidities, inflammatory markers at admission, admission to ICU and 30 day all-cause in-hospital mortality were collected and compared between patients with and without bacterial co-infections. Results Of the 1396 COVID-19 patients included, 37 patients (2.7%) had clinically important bacterial co-infection within 48 hours of admission. The majority of patients (36/37 in those with co-infection and 98/100 in selected patients without co-infection) received empirical antibiotic treatment. There was no significant difference in age, gender, pre-existing illnesses, ICU admission or 30 day all-cause mortality in those with and without bacterial co-infection. However, white cell count, neutrophil count and CRP on admission were significantly higher in patients with bacterial co-infections. Conclusions We found that bacterial co-infection was infrequent in hospitalized COVID-19 patients within 48 hours of admission. These results suggest that empirical antimicrobial treatment may not be necessary in all patients presenting with COVID-19 infection, although the decision could be guided by high inflammatory markers.

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Thromboelastrography Reduces Blood Product Transfusion in Pediatric Cardiac Surgery

Blood ◽

10.1182/blood.v120.21.1176.1176 ◽

2012 ◽

Vol 120 (21) ◽

pp. 1176-1176

Author(s):

Michael Ritchie ◽

Cathy Woodward ◽

Lauren Kane ◽

Melissa Frei-Jones

Keyword(s):

Cardiac Surgery ◽

Congenital Heart ◽

Blood Product ◽

Pediatric Cardiac Surgery ◽

Blood Product Transfusion ◽

Red Cell ◽

Time Period ◽

Significant Difference ◽

Operative Complications ◽

Post Operative Complications

Abstract Abstract 1176 Thromboelastography (TEG) has emerged as an important tool to guide blood product transfusions in pediatric cardiac surgery requiring cardio-pulmonary bypass (CPB). Blood product transfusions are associated with risk including transfusion transmitted infections, transfusion reactions, and allo-immunization. Previous studies have reported fewer red cell and plasma transfusions but increased platelet transfusions with no difference in post-operative bleeding in pediatric CPB using TEG to determine transfusion needs. In this study, we evaluated the use of intra-operative TEG to reduce blood product transfusion in pediatric cardiac surgery with CPB. A retrospective case control study of 150 patients, age birth to 18 years, who required CPB during cardiac surgery, was performed from January 1, 2010 to May 31, 2012. Cases were chosen serially during the time period when TEG was utilized by anesthesia. Controls were chosen from the time period before TEG was available. Exclusion criteria were a personal or family history of bleeding or clotting disorder. Controls were matched 2:1 on age and Risk Adjustment for Congenital Heart Surgery score (RACHS). The type and amount of blood product transfusions were compared between cases and controls in addition to post-operative complications including bleeding, infection and thrombosis. This study included 50 cases and 100 controls. Average age and gender were not different between cases and controls (19 mo (0–213) vs 20 mo (0–255), p=0.86; 52% (26/50) males vs 62% (62/100), p=0.24). Ethnicity was similar between groups and primarily Hispanic (66% (33/50) vs 70% (70/100), p=0.71). The most common congenital heart defect was Tetralogy of Fallot (20% (10/50) vs 22% (22/100); p=0.84). The median RACHS score between groups was the same (3 (2–6) vs 3 (2–6), p=0.88). There was no significant difference in pre-surgical or post-surgical blood counts, coagulation testing or CPB pump time. The average number of TEGs performed per case was 2.6 (1–6). Cases received significantly fewer platelet and cryoprecipitate (cryo) units but similar red cell and plasma units to controls as shown in Figure 1. The difference persisted when transfusions were adjusted for weight. Cases received fewer platelets (13 (0–49) ml/kg vs 21 (0–119) ml/kg, p=0.015), and cryo (3 (0–36) ml/kg vs 6.3 (0–47) ml/kg, p=0.029) with the most significant difference seen in patients less than 10 kg (platelets 15 ml/kg vs 25 ml/kg, p=0.007; cryo 4 ml/kg vs 8 ml/kg, p=0.03). There was no difference in red cell volume (130 (0–332) ml/kg vs 133 (0–680) ml/kg, p=0.88), or plasma volume (109 (0–277) ml/kg vs 107 (0–553) ml/kg, p=0.9) at any weight between groups. There was no statistical difference in PICU length of stay (LOS), hospital LOS, mechanical ventilation, survival to discharge or frequency of post-operative bleeding or thrombosis. There was a 50% reduction in hospital cost of platelet transfusions ($29,750 vs $65,450) and cryo ($1,950 vs $4,700) for the 50 cases compared to controls. The cost of three TEGs per 50 cases was $3,450 ($23/TEG) for a total cost savings of $35,000. Intra-operative TEG reduced the amount of platelet and cryoprecipitate transfusions used during pediatric CPB without an increase in post-operative complications. The reduction in blood product administration by using TEG resulted in decreased cost. Disclosures: No relevant conflicts of interest to declare.

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Impact of Pharmacy Student and Resident-Led Discharge Counseling on Heart Failure Patients

Journal of Pharmacy Practice ◽

10.1177/0897190013491768 ◽

2013 ◽

Vol 26 (6) ◽

pp. 574-579 ◽

Cited By ~ 30

Author(s):

Andrew Szkiladz ◽

Katherine Carey ◽

Kimberly Ackerbauer ◽

Mark Heelon ◽

Jennifer Friderici ◽

...

Keyword(s):

Heart Failure ◽

Medication Errors ◽

Pharmacy Student ◽

Control Groups ◽

Readmission Rates ◽

Cost Avoidance ◽

Significant Difference ◽

Heart Failure Readmissions ◽

And Control ◽

The Impact

Purpose: Many health systems have implemented interventions to reduce the rate of heart failure readmissions. Pharmacists have the training and expertise to provide effective medication-related education. However, few studies have examined the impact of discharge education provided by pharmacy students and residents on patients hospitalized with heart failure exacerbations. Methods: This was a nonrandomized intervention study evaluating the impact of a pharmacy student and resident-led discharge counseling program on heart failure readmissions. The primary end point was the 30-day heart failure readmission rate. Secondary end points included self-reported patient understanding of medications, number of medication errors documented, and estimated associated cost avoidance. Results: A total of 86 and 94 patients were enrolled into the intervention and control groups, respectively. No statistically significant difference in readmission rates was detected between the intervention and the control groups. Thirty-four medication errors and discrepancies were documented, or 1 for every 2.5 patients counseled, resulting in an estimated cost avoidance of $4241 for the institution. Eighty-nine percent of patients who received discharge counseling agreed they had a better understanding of their medications after speaking with a pharmacy resident or student. Conclusions: There was no statistically significant difference in readmission rates; however, several medication errors were prevented, and a large percentage of patients expressed an improved understanding of their medications.

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Guided Bone Regeneration with Concentrated Growth Factor Enriched Bone Graft Matrix (Sticky Bone) vs. Bone-Shell Technique in Horizontal Ridge Augmentation: A Retrospective Study

Journal of Clinical Medicine ◽

10.3390/jcm10173953 ◽

2021 ◽

Vol 10 (17) ◽

pp. 3953

Author(s):

Horia Mihail Barbu ◽

Stefania Andrada Iancu ◽

Antonio Rapani ◽

Claudio Stacchi

Keyword(s):

Bone Regeneration ◽

Graft Infection ◽

Multivariate Logistic Regression Analysis ◽

Guided Bone Regeneration ◽

Control Group ◽

Ridge Augmentation ◽

Significant Difference ◽

Operative Complications ◽

Ridge Width ◽

Post Operative Complications

Background: The purpose of this study was to compare clinical results of two different horizontal ridge augmentation techniques: guided bone regeneration with sticky bone (SB) and the bone-shell technique (BS). Methods: Records of patients who underwent horizontal ridge augmentation with SB (test) and BS (control) were screened for inclusion. Pre-operative and 6-month post-operative ridge widths were measured on cone beam computer tomography (CBCT) and compared. Post-operative complications and implant survival rate were recorded. Results: Eighty consecutive patients were included in the present study. Post-operative complications (flap dehiscence, and graft infection) occurred in ten patients, who dropped out from the study (12.5% complication rate). Stepwise multivariate logistic regression analysis showed a significant inverse correlation between the occurrence of post-operative complications and ridge width (p = 0.025). Seventy patients (35 test; 35 control) with a total of 127 implants were included in the final analysis. Mean ridge width gain was 3.7 ± 1.2 mm in the test and 3.7 ± 1.1 mm in the control group, with no significant difference between the two groups. No implant failure was recorded, with a mean follow-up of 42.7 ± 16.0 months after functional loading. Conclusions: SB and BS showed comparable clinical outcomes in horizontal ridge augmentation, resulting in sufficient crestal width increase to allow implant placement in an adequate bone envelope.

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Preoperative endoscopic biliary stenting before pancreatico duodenectomy: Does timing matter?

10.21203/rs.3.rs-37972/v1 ◽

2020 ◽

Author(s):

Abu Bakar Hafeez Bhatti ◽

Roshni Zahra Jafri ◽

M Kashif Khan ◽

Faisal Saud Dar

Keyword(s):

Obstructive Jaundice ◽

Hospital Stay ◽

Mortality Rates ◽

Infectious Complications ◽

Wound Infections ◽

Biliary Stenting ◽

Endoscopic Biliary Stenting ◽

Significant Difference ◽

The Impact ◽

Surgery Duration

Abstract BackgroundRole of preoperative biliary stenting (PBS) before pancreaticodoudenectomy (PD) in patients with obstructive jaundice is debatable. The objective of the current study was to assess outcomes after PD in patients who underwent upfront surgery or PBS and determine the impact of stent to surgery duration on outcomes after PD. Methods We reviewed 147 patients who underwent PD between 2011 and 2019. Patients were grouped based on whether they underwent upfront surgery (N=76) or PBS (N=71). We further assessed outcomes based on stent to surgery interval < 4 weeks or > 4 weeks. We looked at 30 and 90 day morbidity and mortality rates in these patients.Results A significant increase in wound infections (7% vs 25%)(P=0.003), overall infectious complications (22.5% vs 38.1%)(P=0.04), re admissions (0 vs 10.5%)(P=0.005) and hospital stay (9 vs 10 days)(P=0.006) was seen in the PBS group. There was no significant difference in 30 day mortality (2.8 % vs 6.5%)(P=0.4). When compared with upfront surgery group, patients with stent to surgery duration > 4 weeks had higher rates of wound infection (7% vs 29%)(P=0.009), sepsis (11.2% vs 29%)(P=0.02), overall infectious complications (22.5% vs 45.1%)(P=0.02), re admissions (0 vs 12.9%) (P=0.007) and hospital stay (9 vs 10 days)(P=0.03). The lowest rate of infectious complications was seen when PD was performed within 2 weeks (22.2%) or 6-8 weeks (12.5%) after stenting. None of the patients with stent-surgery duration < 2 weeks developed sepsis. ConclusionsPBS appears to increase infection related morbidity after PD. In patients with PBS, low morbidity is seen with early (< 2 weeks) and delayed PD (6-8weeks).

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