Ready for the Frontline: Is Early Thoracoscopic Decortication the New Standard of Care for Advanced Pneumonia with Empyema?

Video-assisted thoracoscopic decortication (VATD) has been established as an effective and potentially less morbid alternative to open thoracotomy for the management of empyema. However, the timing and role of VATD for advanced pneumonia with empyema is still controversial. In assessing surgical outcome, the authors reviewed their VATD experience in children with empyema or empyema with necrotizing pneumonia. The charts of 42 children who underwent VATD at our institution between July 2001 and July 2005 were retrospectively reviewed for surgical outcome. For purposes of analysis, patients were cohorted into four classes with increasing severity of pneumonia: 1 (-) intraoperative pleural fluid cultures, (-) necrotizing pneumonia, 18 (43%); 2 (+) pleural fluid cultures, (-) necrotizing pneumonia, 10 (24%); 3 (-) pleural fluid cultures, (+) necrotizing pneumonia, 6 (14%); 4 (+) pleural fluid cultures, (+) necrotizing pneumonia, 8 (19%). A P value of <0.05 via Student's t test or Fischer's exact analysis was considered an indicator of significant difference in the comparison of group outcomes. VATD was successfully completed in all 42 patients with no mortality and without significant morbidity (82% had less than 20 cc blood loss). There was found to be no significant difference (p = NS) in time to surgical discharge (removal of chest tube) among all groups. Hospital length of stay postsurgery was found to be significantly increased between 1 and 4 (6 days vs 9 days; P = 0.038). 14/14 (100%) of children with necrotizing pneumonia were found to have evidence of lung parenchymal preservation with improved aeration on follow-up CT scan and/or chest x-rays. The authors conclude that early VATD in children with advanced pneumonia with empyema is indicated to avoid unnecessarily lengthy hospitalization and prolonged intravenous antibiotic therapy. Furthermore, early VATD can be safely performed in various stages of advanced pneumonia with empyema, promoting lung salvage, and accelerating clinical recovery.

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Outcomes of Total versus Partial Colectomy in Fulminant Clostridium Difficile Colitis. A Propensity Matched Analysis.

10.21203/rs.3.rs-1093539/v1 ◽

2021 ◽

Author(s):

Nasim Ahmed ◽

YenHong Kuo

Keyword(s):

Clostridium Difficile ◽

Univariate Analysis ◽

Length Of Hospital Stay ◽

Hospital Length ◽

Hospital Length Of Stay ◽

P Value ◽

Improvement Program ◽

Discharge Disposition ◽

Significant Difference ◽

Partial Colectomy

Abstract BackgroundThe Total Abdominal Colectomy (TAC) is the recommended procedure for Fulminant Clostridium Difficile Colitis (FCDC), however, occasionally, FCDC is also treated with partial colectomies. The purpose of the study was to identify the outcomes of partial colectomy in FCDC cases.MethodThe National Surgical Quality Improvement Program (NSQIP) database was accessed and eligible patients from 2012 through 2016 were reviewed. Patients 18 years and older who were diagnosed with FCDC and who underwent colectomies were included in the study. Patients’ demography, clinical characteristics, comorbidities, mortality, morbidities, length of hospital stay and discharge disposition were compared between the group who underwent partial colectomy and the group who underwent TAC. Univariate analysis followed by propensity matching were performed. A p value of <0.05 is considered as statistically significant. ResultsOut of 491 patients who qualified for the study, 93 (18.94%) patients underwent partial colectomy. The pair matched analysis showed no significant difference in patients’ characteristics and comorbidities in the two groups. There was no significant difference found in mortality between the two groups (30.1% vs. 30.15, P>0.99). There were no differences found in the median [95% CI] hospital length of stay [LOS] (23 days [19-31] vs. 21 [17-25], P=0.30), post-operative complications (P>0.05), and discharged disposition to home (43.1% vs. 33.8%) or transfer to rehab (21.55 vs. 12.3%, P=0.357) between the TAC and partial colectomy groups.Conclusion The overall 30 days mortality remains very high in FCDC. Partial colectomy did not increase risk of mortality or morbidities and LOS.

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Predictors of Inappropriate Helicopter Transport

The American Surgeon ◽

10.1177/0003134820951423 ◽

2020 ◽

pp. 000313482095142

Author(s):

Christopher Brown ◽

Wajeeh Irfan ◽

Jonathan E. Schoen ◽

Alan B. Marr ◽

Lance E. Stuke ◽

...

Keyword(s):

Injury Severity ◽

Univariate Analysis ◽

Hospital Length ◽

T Test ◽

Hospital Length Of Stay ◽

P Value ◽

Binary Logistic Regression Analysis ◽

Student’S T ◽

Chi Square Analysis ◽

Student’S T Test

Background Helicopter transport (HT) is an efficient, but costly, means for injured patients to receive life-saving, definitive trauma care. Identifying the characteristics of inappropriate HT presents an opportunity to improve the utilization of this finite medical resource. Methods Trauma registry records of all HT for a 3-year period (2016-2018) to an urban Level I trauma center were reviewed. HT was defined as inappropriate for patients who were discharged home from the emergency department or had a hospital length of stay <1 day, and who were discharged alive. Chi-square analysis and Student’s t-test were used for univariate analysis. Predictors with a P value of less than .15 were subject to binary logistic regression analysis. A P value ≤.05 was considered significant. Results There were 713 patients who received HT during the study period. One-hundred and forty-eight (20.8%) patients met the criteria as an inappropriate HT. In univariate analysis, Glasgow Coma Scale >8, Shock Index <0.9, and fall mechanism were found to be significantly associated with inappropriate HT. Age >55 was found to be associated with an appropriate HT. The average Injury Severity Score of the inappropriate HT group was 3.86 (±3.85) compared with 16.80 (±11.23) ( P = .0001, Student’s t-test). Discussion Our findings suggest that there are evidence-based predictors of patients receiving inappropriate HT. Triage of HT using these predictors has the potential to decrease unnecessary deployments and reduce health care costs.

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Clinical outcomes and survival analysis of Remdesivir as a treatment option for moderate to severe COVID-19 patients.

10.21203/rs.3.rs-848909/v1 ◽

2021 ◽

Author(s):

Iman Aboelsaad ◽

Rasha Ashmawy ◽

Doaa Mahrous ◽

Sandy Sharaf ◽

Shahinda Aly ◽

...

Keyword(s):

Survival Analysis ◽

Treatment Protocol ◽

Patient Characteristics ◽

Hospital Length ◽

Hospital Length Of Stay ◽

P Value ◽

Composite Outcome ◽

New Therapeutic Approaches ◽

Significant Difference ◽

The Difference

Abstract Background: Remdesivir is a broad-spectrum antiviral approved as promising medicine worldwide for deadly pandemic COVID-19 disease. The debate of its efficacy is interesting between different studies with consideration of several factors. We planned this study to evaluate a huge clinical outcome (primary composite outcome) of mortality rate, need for MV, and escalation of care among Remdesivir (RDV) and non-Remdesivir (NoRDV)groups.Methods: Patients with a PCR - confirmed diagnosis of moderate and severe COVID-19 were observed retrospectively as two comparative groups, before and after including remdesivir in the treatment protocol, from August 2020 to February 2021.Result: From 509 hospitalized patients; 35% received Remdesivir among them 64% were severe patients. Median age, 59 years, was equal in both groups, and there was no significant difference between the two groups regarding gender, baseline characteristics, and co-morbidities. Unlike, the median hospital length of stay was lower among the RDV group (8 days) than the NoRDV (9 days), P= 0.004.The composite outcome occurred in 17.7% in RDV and 22.2% in NoRDV but the difference was statistically insignificant (p-value 0.289). Adjusted logistic regression showed a non-significant lower association of the composite outcome with RDV use (OR 0.623, 95CI% 0.37-1.02), and a significant reduction occurred in patients <60 years old (OR 0.39, 95%CI 0.17 – 0.83). However, survival analysis for mortality, MV, and transfer to a higher level revealed insignificant differences in the median time between groups. Subgroup analyses showed that RDV utilization had a non-significant effect on the risk of all three outcomes across different groups. Conclusion: Despite controlling all patient characteristics, treatment with RDV did not show any improved impact on patient outcomes over other antivirals and standard care. There is a pressing need for further studies to explore and evaluate new therapeutic approaches or combinations.

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Mortality after cardiopulmonary resuscitation on a medical ICU

Wiener klinische Wochenschrift ◽

10.1007/s00508-021-01831-0 ◽

2021 ◽

Author(s):

Richard Rezar ◽

Bernhard Wernly ◽

Michael Haslinger ◽

Clemens Seelmaier ◽

Philipp Schwaiger ◽

...

Keyword(s):

Cardiopulmonary Resuscitation ◽

Neurological Outcome ◽

Cox Regression ◽

Cerebral Performance Category ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Study Endpoint ◽

Primary Study ◽

Postresuscitation Care ◽

Significant Difference

Summary Background Performing cardiopulmonary resuscitation (CPR) and postresuscitation care in the intensive care unit (ICU) are standardized procedures; however, there is evidence suggesting sex-dependent differences in clinical management and outcome variables after cardiac arrest (CA). Methods A prospective analysis of patients who were hospitalized at a medical ICU after CPR between December 2018 and March 2020 was conducted. Exclusion criteria were age < 18 years, hospital length of stay < 24 h and traumatic CA. The primary study endpoint was mortality after 6 months and the secondary endpoint neurological outcome assessed by cerebral performance category (CPC). Differences between groups were calculated by using U‑tests and χ2-tests, for survival analysis both univariate and multivariable Cox regression were fitted. Results A total of 106 patients were included and the majority were male (71.7%). No statistically significant difference regarding 6‑month mortality between sexes could be shown (hazard risk, HR 0.68, 95% confidence interval, CI 0.35–1.34; p = 0.27). Neurological outcome was also similar between both groups (CPC 1 88% in both sexes after 6 months; p = 1.000). There were no statistically significant differences regarding general characteristics, pre-existing diseases, as well as the majority of clinical and laboratory parameters or measures performed on the ICU. Conclusion In a single center CPR database no statistically significant sex-specific differences regarding post-resuscitation care, survival and neurological outcome after 6 months were observed.

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Laparoscopy in Liver Transplantation: The Future Has Arrived

HPB Surgery ◽

10.1155/2012/148387 ◽

2012 ◽

Vol 2012 ◽

pp. 1-7 ◽

Cited By ~ 3

Author(s):

Quirino Lai ◽

Rafael S. Pinheiro ◽

Giovanni B. Levi Sandri ◽

Gabriele Spoletini ◽

Fabio Melandro ◽

...

Keyword(s):

Liver Transplantation ◽

Scientific Progress ◽

Laparoscopic Approach ◽

Standard Of Care ◽

Radical Change ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Therapeutic Laparoscopy ◽

Stage Disease ◽

End Stage

In the last two decades, laparoscopy has revolutionized the field of surgery. Many procedures previously performed with an open access are now routinely carried out with the laparoscopic approach. Several advantages are associated with laparoscopic surgery compared to open procedures: reduced pain due to smaller incisions and hemorrhaging, shorter hospital length of stay, and a lower incidence of wound infections. Liver transplantation (LT) brought a radical change in life expectancy of patients with hepatic end-stage disease. Today, LT represents the standard of care for more than fifty hepatic pathologies, with excellent results in terms of survival. Surely, with laparoscopy and LT being one of the most continuously evolving challenges in medicine, their recent combination has represented an astonishing scientific progress. The intent of the present paper is to underline the current role of diagnostic and therapeutic laparoscopy in patients waiting for LT, in the living donor LT and in LT recipients.

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Racial Disparity in Immediate Breast Reconstruction; a Gap That is not Closing

Plastic Surgery ◽

10.1177/22925503211055525 ◽

2021 ◽

pp. 229255032110555

Author(s):

Mahdi Malekpour ◽

Sean Devitt ◽

Joseph DeSantis ◽

Christian Kauffman

Keyword(s):

Propensity Score ◽

Breast Reconstruction ◽

Racial Disparity ◽

Standard Of Care ◽

Immediate Breast Reconstruction ◽

P Value ◽

National Cancer Database ◽

Black Females ◽

Black And White ◽

Significant Difference

Background: Immediate breast reconstruction (IBR) is offered as part of the standard-of-care to females undergoing mastectomy. Racial disparity in IBR has been previously reported with a longstanding call for its elimination, though unknown if this goal is achieved. The aim of this study was to examine the current association between race and IBR and to investigate whether racial disparity is diminishing. Methods: Data was extracted from the National Cancer Database (NCDB) from 2004 to 2016. All variables in the database were controlled so that the comparison would be made solely between Black and White females. We also analyzed the trend in racial disparity to see if there has been a change from 2004 to 2016 after several calls for healthcare equality. Results: After propensity score matching, 69,084 White females were compared to 69,084 Black females. There was a statistically significant difference between the rate of IBR and race (23,386 [33.9%] in White females vs 20,850 [30.2%] in Black females, P-value < .001). Despite a twofold increase in the rate of IBR in both White and Black females, a persistent gap of about 4% was observed over the study period, which translates to more than 2,500 Black females not receiving IBR. Conclusions: Using the NCDB database, a racial disparity was identified for IBR between White and Black females from 2004 and 2016. Unfortunately, the gap between the groups remained constant over this 13-year period.

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Does emergency medicine length of stay predict trauma outcomes at a Level 1 Trauma Center?

Journal of Hospital Administration ◽

10.5430/jha.v4n5p1 ◽

2015 ◽

Vol 4 (5) ◽

pp. 1 ◽

Cited By ~ 2

Author(s):

Erin Powers Kinney ◽

Kamal Gursahani ◽

Eric Armbrecht ◽

Preeti Dalawari

Keyword(s):

Length Of Stay ◽

Trauma Center ◽

Injury Severity ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Hospital Capacity ◽

Significant Difference ◽

Level 1 ◽

Level 1 Trauma Center

Objective: Previous studies looking at emergency department (ED) crowding and delays of care on outcome measures for certain medical and surgical patients excluded trauma patients. The objectives of this study were to assess the relationship of trauma patients’ ED length of stay (EDLOS) on hospital length of stay (HLOS) and on mortality; and to examine the association of ED and hospital capacity on EDLOS.Methods: This was a retrospective database review of Level 1 and 2 trauma patients at a single site Level 1 Trauma Center in the Midwest over a one year period. Out of a sample of 1,492, there were 1,207 patients in the analysis after exclusions. The main outcome was the difference in hospital mortality by EDLOS group (short was less than 4 hours vs. long, greater than 4 hours). HLOS was compared by EDLOS group, stratified by Trauma Injury Severity Score (TRISS) category (< 0.5, 0.51-0.89, > 0.9) to describe the association between ED and hospital capacity on EDLOS.Results: There was no significant difference in mortality by EDLOS (4.8% short and 4% long, p = .5). There was no significant difference in HLOS between EDLOS, when adjusted for TRISS. ED census did not affect EDLOS (p = .59), however; EDLOS was longer when the percentage of staffed hospital beds available was lower (p < .001).Conclusions: While hospital overcrowding did increase EDLOS, there was no association between EDLOS and mortality or HLOS in leveled trauma patients at this institution.

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Effects of statins on clinical outcomes in hospitalized patients with community-acquired pneumonia

Journal of International Medical Research ◽

10.1177/0300060520938586 ◽

2020 ◽

Vol 48 (8) ◽

pp. 030006052093858

Author(s):

Rony M. Zeenny ◽

Hanine Mansour ◽

Wissam K Kabbara ◽

Nibal Chamoun ◽

Myriam Audi ◽

...

Keyword(s):

Retrospective Study ◽

Length Of Stay ◽

Hospital Length ◽

Community Acquired Pneumonia ◽

Hospital Length Of Stay ◽

Comorbid Conditions ◽

C Reactive Protein ◽

Reactive Protein ◽

Significant Difference ◽

Chronic Use

Objective We evaluated the effect of chronic use of statins based on C-reactive protein (CRP) levels and hospital length of stay (LOS) in patients admitted with community-acquired pneumonia (CAP). Methods We conducted a retrospective study over 12 months at a teaching hospital in Lebanon comparing patients with CAP taking chronic statins with patients not taking statins. Included patients with CAP were older than age 18 years and had two CRP level measures during hospitalization. CURB-65 criteria were used to assess the severity of pneumonia. A decrease in CRP levels on days 1 and 3, LOS, and normalization of fever were used to assess the response to antibiotics. Results Sixty-one patients were taking statins and 90 patients were not taking statins. Patients on statins had significantly more comorbid conditions; both groups had comparable CURB-65 scores. In both groups, no statistically significant difference was seen for the decrease in CRP level on days 1 and 3 and LOS. No difference in days to normalization of fever was detected in either group. Conclusion No association was found between the chronic use of statins and CRP levels, LOS, or days to fever normalization in patients with CAP.

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Significance of serum-pleural effusion albumin gradient in differentiating transudative and exudative pleural effusions in comparison to light’s criteria

International Journal of Advances in Medicine ◽

10.18203/2349-3933.ijam20171041 ◽

2017 ◽

Vol 4 (2) ◽

pp. 457

Author(s):

Sujatha G. ◽

Vindhya P. ◽

Kalyan Kumar K.

Keyword(s):

Pleural Effusion ◽

Clinical Outcome ◽

Pleural Fluid ◽

Venous Blood ◽

P Value ◽

Protein Ratio ◽

Clinical Disorder ◽

Significant Difference ◽

The Difference ◽

Sensitivity Specificity

Background: Approximately one million patients develop pleural effusion every year. It is a common clinical disorder and is either a manifestation or a complication of one or other respiratory or non-respiratory disorders. It leads to serious prognosis, if not diagnosed and treated properly. To calculate SEAG and Light’s criteria and to compare SEAG with Light’s criteria in analyzing pleural effusions.Methods: A total of hundred patients were selected for the study. Pleural fluid of patients who met the inclusion and exclusion criteria were collected, when pleural fluid is being tapped for diagnostic thoracocentesis. Venous blood sample was collected along with diagnostic thoracocentesis or within 24 hours of thoracocentesis. Written informed consent was obtained from them for thoracocentesis.Results: In our study we compared the clinical outcome with outcome as per Pleural fluid/Serum protein ratio (p value of <0.0001), pleural fluid/serum LDH (p value of <0.0001) and pleural fluid LDH (p value of <0.0001) separately and the p values were statistically significant. The sensitivity, specificity, PPV and NPV of Light’s criteria were 77.2%, 100%, 100%, 93.9% respectively. We compared Light’s criteria outcome with clinical outcome and the difference was statistically significant (p value of <0.0001). SEAG showed 100% sensitivity, 97.43% specificity, 91.6% PPV and is 91.66% and NPV is 100%. We compared the clinical outcome with SEAG and there was statistically significant difference (p value of <0.0001). We compared SEAG with Light’s criteria and the difference was statistically significant (p <0.0001). We compared Light’s plus pleural fluid protein gradient with SEAG and the difference is statistically significant (p value of <0.0001).Conclusions: SEAG is more sensitive for classifying transudates and more specific for exudates than Light’s criteria.

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Outcomes of Tube Thoracostomies Performed by Advanced Practice Providers vs Trauma Surgeons

American Journal of Critical Care ◽

10.4037/ajcc2008.17.4.357 ◽

2008 ◽

Vol 17 (4) ◽

pp. 357-363 ◽

Cited By ~ 18

Author(s):

Laura C. Bevis ◽

Gina M. Berg-Copas ◽

Bruce W. Thomas ◽

Donald G. Vasquez ◽

Ruth Wetta-Hall ◽

...

Keyword(s):

Nurse Practitioners ◽

Insertion Site ◽

Physician Assistants ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Complication Rates ◽

Advanced Practice ◽

Trauma Centers ◽

Significant Difference ◽

Trauma Surgeons

Background The role of advanced registered nurse practitioners and physician assistants in emergency departments, trauma centers, and critical care is becoming more widely accepted. These personnel, collectively known as advanced practice providers, expand physicians’ capabilities and are being increasingly recruited to provide care and perform invasive procedures that were previously performed exclusively by physicians. Objectives To determine whether the quality of tube thoracostomies performed by advanced practice providers is comparable to that performed by trauma surgeons and to ascertain whether the complication rates attributable to tube thoracostomies differ on the basis of who performed the procedure. Methods Retrospective blinded reviews of patients’ charts and radiographs were conducted to determine differences in quality indicators, complications, and outcomes of tube thoracostomies by practitioner type: trauma surgeons vs advanced practice providers. Results Differences between practitioner type in insertion complications, complications requiring additional interventions, hospital length of stay, and morbidity were not significant. The only significant difference was a complication related to placement of the tube: when the tube extended caudad, toward the feet, from the insertion site. Interrater reliability ranged from good to very good. Conclusions Use of advanced practice providers provides consistent and quality tube thoracostomies. Employment of these practitioners may be a safe and reasonable solution for staffing trauma centers.

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