scholarly journals A ‘hot clinic’ for cold limbs: the benefit of urgent clinics for patients with critical limb ischaemia

2020 ◽  
Vol 102 (6) ◽  
pp. 412-417
Author(s):  
A Khan ◽  
M Hughes ◽  
M Ting ◽  
G Riding ◽  
J Simpson ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Outcome Measures ◽  
Odds Ratio ◽  
Smoking Status ◽  
Emergency Admission ◽  
Major Amputation ◽  
Critical Limb Ischaemia ◽  
Secondary Outcome ◽  
Limb Ischaemia ◽  
Emergency General Surgery

Introduction The national reconfiguration of vascular surgery means that arterial centres serve larger populations with increased demand on resources. Emergency general surgery ambulatory clinics facilitate timely review and intervention, avoiding admission; a critical limb ischaemia (CLI) ‘hot clinic’ (HC) was implemented to achieve similar for vascular patients. The aim of the study was to determine HC efficacy. Methods This was a prospective cohort study comparing HC patients with emergency admission (EA) patients between 1 May and 1 December 2017. Age, sex, comorbidities, CLI severity and smoking status were noted. HC patients were provided with satisfaction surveys. Primary outcome measures were freedom from reintervention and major amputation. Secondary outcome measures included time to procedure, length of stay, returns to theatre and 30-day readmission. Results A total of 147 patients (72 HC, 75 EA) were enrolled in the study. No statistical difference was found in age, sex, smoking status, severity of CLI or prevalence of comorbidities between the groups except that diabetes was more prevalent in EA patients (p=0.028). The median length of stay for the HC cohort was shorter (3 days vs 17 days, p<0.001), with no difference between time to procedure, return to theatre or 30-day readmission. HC patients were nearly 6 times more likely to experience freedom from reintervention (odds ratio: 5.824, p<0.001) and 2.5 times less likely to undergo amputation (odds ratio: 2.616, p=0.043). HC utilisation saved a total of 441 bed days. Over 90% of attendees responded with 100% positive feedback. Conclusions A vascular HC facilitates urgent review and revascularisation. It provides comparable in-hospital outcomes and better long-term outcomes, with greater efficiency than hospital admission, demonstrating its value in treating CLI.

The chaos of hospitalisation for patients with critical limb ischaemia approaching major amputation

2018 ◽  
Vol 27 (19-20) ◽  
pp. 3530-3543 ◽  
Author(s):  
Susan Monaro ◽  
Sandra West ◽  
Jana Pinkova ◽  
Janice Gullick
Keyword(s):  
Major Amputation ◽  
Critical Limb Ischaemia ◽  
Limb Ischaemia

scholarly journals Predictors of Clinical Outcomes after Proximal Hamstring Repairs

2019 ◽  
Vol 7 (7_suppl5) ◽  
pp. 2325967119S0026
Author(s):  
Eric N. Bowman ◽  
Nathan E. Marshall ◽  
Gerhardt Brenton Michael ◽  
Michael B. Banffy
Keyword(s):  
Patient Satisfaction ◽  
Clinical Outcomes ◽  
Outcome Measures ◽  
Smoking Status ◽  
Activity Level ◽  
Secondary Outcome ◽  
Functional Difference ◽  
Medical Comorbidities ◽  
Open Versus ◽  
Proximal Hamstring

Objectives: Proximal hamstring avulsions cause considerable morbidity. Operative repair results in improved pain, function, and patient satisfaction; however, outcomes remain variable. The purpose of this study was to evaluate the predictors of clinical outcomes after proximal hamstring repairs. Methods: A retrospective review of proximal hamstring avulsions undergoing repair between January 2014 and June 2017 was performed. Patients were excluded for skeletal immaturity, previous tear, revision surgery, allograft reconstruction, fracture, subsequent extremity injury or surgery. Independent variables included: patient demographics, medical comorbidities, tear characteristics, and repair technique. Primary outcome measures were the Single Assessment Numerical Evaluation (SANE), International Hip Outcome Tool (iHOT-12), and the Kerlan-Jobe Orthopaedic Clinic (KJOC) Athletic Hip Score. Secondary outcome measures included satisfaction, visual analog scale (VAS), and level and timing of return to running or sports. Results: Of 86 eligible patients, 58 were analyzed (67%), with 29-month mean follow-up. Average age was 51; 57% were female. Acute tears accounted for 66%; 78% were complete avulsions. Open repair was performed on 90%. Overall satisfaction was 94%, though runners were less satisfied (p=0.029). At 7.6 months on average, 88% returned to sports, 72% at the same level. Runners less often returned to the same level, and at a decreased number of miles (15.7 vs. 7.8, p<0.001). Post-operatively, SANE scores improved, but average Tegner decreased (5.5 to 5.1). Acute repairs had higher SANE Activity scores. Higher satisfaction without functional difference for those over 50 years (p=0.024). Conclusion: Overall, patient satisfaction and functionality were high. There were no significant differences in functional outcome scores based on age, sex, body-mass index, smoking status, medical comorbidities, tear grade, activity level, or open versus endoscopic technique. Acute repairs had better SANE Activity scores. Runners should be cautioned that they may be unable to return to the same pre-injury activity level following proximal hamstring repair. [Table: see text]

The Use of Cryotherapy in the Early Postoperative Period after Total Hip Arthroplasty

2019 ◽  
Vol 21 (5) ◽  
pp. 339-348 ◽  
Author(s):  
Tosan Okoro ◽  
Yousef Ibrahim ◽  
Nadia Mansour ◽  
Phillip Alderman ◽  
Aled Evans
Keyword(s):  
Total Hip Arthroplasty ◽  
Length Of Stay ◽  
Blood Loss ◽  
Outcome Measures ◽  
Hip Arthroplasty ◽  
Early Period ◽  
Postoperative Blood Loss ◽  
Secondary Outcome ◽  
Postoperative Phase ◽  
Total Hip

Background. Recent evidence suggests that cryotherapy may be beneficial in reducing postoperative pain and blood loss in joint arthroplasty. The objective of this study was to review the use of cryotherapy in the early postoperative phase after total hip arthroplasty to assess the benefits in terms of pain relief and reduction in postoperative blood loss. Material and methods. A prospective cohort study of the use of a cryotherapy device (Hilotherm) was performed in patients following total hip arthroplasty. The primary outcome measures were visual analogue score (VAS) for pain (at 24 and 48 hours postoperatively), and amount of postoperative blood loss, measured by change in haemoglobin (g/L). The secondary outcome measures were length of stay (days), duration of patient controlled analgesia (PCA) administered postoperatively (hours) and amount of analgesia used (mg) in the first 48 hours. Results. 28 patients were recruited (n=13 Hilotherm; n= 15 non-Hilotherm). Hilotherm application reduced pain in the first 24 hours, non-significantly, (3.50±2.41 vs 4.90±2.95; p=0.185). This effect was not carried through at 48 hours postoperatively (5.68±1.94 vs 3.72±2.46; p=0.029). Hilotherm application significantly reduced postoperative blood loss (22.38±5.71 g/L vs 29.13±10.22 g/L; p=0.045). Hilotherm reduced length of stay by almost 1 day; however, this was not statistically significant (4.46±2.33 vs 5.20±3.55; p=0.528). There was no difference in the length of time PCA was administered (22.30±0.75 vs 22.02±3.26; p=0.763). Patients in the non-Hilotherm group required more paracetamol on average (p=0.001). Conclusions. 1. Hilotherm application does not appear to significantly reduce pain postoperatively but re­sults in less postoperative blood loss. 2. There may be a role for the continued use of cryotherapy in the early period of rehabilitation following total hip arthroplasty, as it appears to result in more rapid ambulatory rehabilitation in patients, resulting in reduced length of stay.

CLO19-043: Assessing the Risk of Chemotherapy Toxicity and Hospital Admission Due to Toxicity

2019 ◽  
Vol 17 (3.5) ◽  
pp. CLO19-043
Author(s):  
Samuel Malton
Keyword(s):  
Length Of Stay ◽  
Hospital Admission ◽  
Outcome Measures ◽  
Anticancer Agents ◽  
Toxicity Assessment ◽  
Health Economy ◽  
Secondary Outcome ◽  
University Hospitals ◽  
Lung Cancers ◽  
Chemotherapy Toxicity

Background: Acute chemotherapy toxicity is common and can have negative effects for the patient and the health economy. Finding overall toxicity incidence for a typical teaching hospital population proved difficult, although a 2008 report into deaths within 30 days of chemotherapy found that 43% of patients who died reported a grade 3 or 4 toxicity (Mort D et al, available at: http://www.ncepod.org.uk/2008report3/Downloads/SACT_report.pdf). At Nottingham University Hospitals (NUH), a Cancer Admissions and Triage Team was established, who undertake a telephone assessment 24 hours following the administration of a first cycle of chemotherapy, in which a proactive toxicity assessment is completed. This had the aim of reducing hospital admission due to toxicity through timely advice and intervention and allowed the accrual of data regarding reported toxicity. Methods: Data was obtained from the telephone assessment of acute toxicity 24 hours after administration of a first cycle of chemotherapy, once the service had been in use for 1 year. Descriptive statistics were produced to establish toxicity incidence and severity and hospital admission rates as well as length of stay. Regression modelling was used to identify predictors of the 4 outcome measures. The commonest toxicities were explored as secondary outcome measures. Results: 1,539 patients were studied, and the overall incidence of toxicity was 35.6%. Disease site and number of chemotherapy agents given were shown to predict toxicity, with breast and upper gastrointestinal cancers having a higher likelihood of toxicity. The more anticancer agents used, the higher the risk of toxicity. Disease was predictive of toxicity grade, with urology, gynecology, and lung patients experiencing higher grades of toxicity than other tumor sites. The rate of hospital admission due to toxicity was 13.1% and mean length of stay 4.4 days. The risk of admission had some risk factors in common with toxicity. Disease and the number of drugs in the regimen affected the risk of admission, with gynecology, head and neck, and lung cancer patients and patients who received 3 drugs having a higher likelihood of admission. No predictors could be reliably identified for length of stay. Predictors in the subgroups of breast, lower gastrointestinal, and lung cancers did not differ greatly from the whole population, and the number of drugs was shown to be a predictor of nausea, vomiting, and fatigue when explored as secondary outcomes. Conclusion: Predictors were identified for occurrence of toxicity, severity of toxicity, risk of hospital admission, but not for length of stay. Subgroup analyses were undertaken. The overall burden of acute chemotherapy toxicity of a heterogeneous population was elucidated.

Abstract TP376: Infections in Patients With Spontaneous Intraventricular Hemorrhage- Results From the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage (CLEAR) III Trial

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Jharna N Shah ◽  
Santosh B Murthy ◽  
Nichol McBee ◽  
Rachel Dlugash ◽  
Malathi Ram ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Intracerebral Hemorrhage ◽  
Outcome Measures ◽  
Intraventricular Hemorrhage ◽  
External Ventricular Drain ◽  
Randomized Study ◽  
Multivariable Analysis ◽  
Hospital Length Of Stay ◽  
Secondary Outcome ◽  
Clot Lysis

Introduction: Intraventricular hemorrhage (IVH) occurs in about 40% of patients with intracerebral hemorrhage (ICH) and is associated with higher mortality and worse outcomes than ICH patients without IVH. Infections are common in ICH patients but data in IVH patients are limited. Methods: Prospective analysis of adjudicated adverse event infection reporting during first 180 days in 500 patients enrolled in the CLEAR III trial, a multicenter, double-blind, randomized study comparing external ventricular drain (EVD) + intraventricular recombinant tissue plasminogen activator (rtPA) vs. EVD + placebo for treatment of obstructive IVH and intracerebral hemorrhage (ICH) volume <30cc. Primary outcome measures were 90-day and 180-day mortality. Secondary outcome measures were hospital length of stay (LOS). We constructed binary logistic and linear regression models for multivariable analysis. Results: Infection was reported in 269 patients (53.8%). Pneumonia was the most common infection (33%), followed by UTI (16%), and bacterial ventriculitis (4.4%). Overall 180-day mortality was 20%. Patients with infection were more likely to have older age (p=0.012), lower admission GCS (p=0.007), higher ICH volume (8.8 vs 6.7ml, p=0.001), and higher ICH+IVH volume (37.7 vs 31.7 ml, p=0.002). In the regression model, IVH volume was associated with higher odds of 90-day or 180-day mortality, but presence of any infection was not a significant predictor of mortality. Infection was however associated with longer length of stay (26 vs 22 days, p<0.001). Subgroup analysis of individual infections, showed only bacterial ventriculitis to be associated with 90-day (OR: 3.84, CI: 1.36-10.82), and 180-day mortality (OR: 2.9, CI: 1.05-8.06), while pneumonia and UTI were not. Conclusion: Patients with IVH have a high incidence of infections, which is associated with longer hospitalization but does not appear to influence mortality. Of the infections, bacterial ventriculitis is a significant predictor of mortality in our 7-factor model. IVH volume did not predict infections but predicted mortality.These results form a basis for future correlation of infectious complications with treatment rendered (thrombolysis versus placebo), with upcoming unblinding of the trial.

scholarly journals Impact of the implementation of a fast-track on emergency department length of stay and quality of care indicators in the Champagne-Ardenne region: a before–after study

BMJ Open ◽  
2019 ◽  
Vol 9 (6) ◽  
pp. e026200 ◽  
Author(s):  
Jan Chrusciel ◽  
Xavier Fontaine ◽  
Arnaud Devillard ◽  
Aurélien Cordonnier ◽  
Lukshe Kanagaratnam ◽  
...  
Keyword(s):  
Emergency Department ◽  
Quality Of Care ◽  
Length Of Stay ◽  
Outcome Measures ◽  
Fast Track ◽  
Secondary Outcome ◽  
Large Hospital ◽  
Intervention Hospital ◽  
Hospital Bed

ObjectivesWe aimed to evaluate the effect of the implementation of a fast-track on emergency department (ED) length of stay (LOS) and quality of care indicators.DesignAdjusted before–after analysis.SettingA large hospital in the Champagne-Ardenne region, France.ParticipantsPatients admitted to the ED between 13 January 2015 and 13 January 2017.InterventionImplementation of a fast-track for patients with small injuries or benign medical conditions (13 January 2016).Primary and secondary outcome measuresProportion of patients with LOS ≥4 hours and proportion of access block situations (when patients cannot access an appropriate hospital bed within 8 hours). 7-day readmissions and 30-day readmissions.ResultsThe ED of the intervention hospital registered 53 768 stays in 2016 and 57 965 in 2017 (+7.8%). In the intervention hospital, the median LOS was 215 min before the intervention and 186 min after the intervention. The exponentiated before–after estimator for ED LOS ≥4 hours was 0.79; 95% CI 0.77 to 0.81. The exponentiated before–after estimator for access block was 1.19; 95% CI 1.13 to 1.25. There was an increase in the proportion of 30 day readmissions in the intervention hospital (from 11.4% to 12.3%). After the intervention, the proportion of patients leaving without being seen by a physician decreased from 10.0% to 5.4%.ConclusionsThe implementation of a fast-track was associated with a decrease in stays lasting ≥4 hours without a decrease in access block. Further studies are needed to evaluate the causes of variability in ED LOS and their connections to quality of care indicators.

scholarly journals Time to Laryngoscopy for Hoarseness in Canada: Are the American Academy of Otolaryngology Guidelines Feasible?

OTO Open ◽  
2020 ◽  
Vol 4 (2) ◽  
pp. 2473974X2093250
Author(s):  
Joel Howlett ◽  
Joel Singer ◽  
Terry Lee ◽  
Amanda Hu
Keyword(s):  
Clinical Practice ◽  
American Academy ◽  
Head And Neck ◽  
Outcome Measures ◽  
Clinical Practice Guideline ◽  
Practice Guideline ◽  
Odds Ratio ◽  
Neck Surgery ◽  
Secondary Outcome ◽  
Chart Audit

Objectives To determine if a Canadian voice center is meeting the recommended time to laryngoscopy for hoarseness per the clinical practice guideline of the American Academy of Otolaryngology–Head and Neck Surgery. Study Design Retrospective chart audit. Setting Tertiary referral Canadian voice center. Participants and Methods A total of 149 adult patients presenting with hoarseness over 6 months were included. Primary outcome measures were the time from onset of symptoms to laryngoscopy and the time from referral to laryngoscopy. Secondary outcome measures included patient- and disease-modifying factors, diagnosis, and clinical management. Analysis was performed to determine what factors were associated with meeting the guideline. Results Patients were evaluated by the laryngologist after 21.9 ± 37.6 months (mean ± SD) of symptoms. One-third (34.2%) of patients were seen within 3 months; 10.7% were seen within 4 weeks. Logistic regression showed that patients with neurologic symptoms (odds ratio, 4.04; 95% CI, 1.31-12.43; P = .015) and endotracheal intubation (odds ratio, 5.94; 95% CI, 2.21-15.95; P < .001) were associated with being seen within 3 months. Patients who had recent intubation (odds ratio, 6.04; 95% CI, 1.99-18.34; P = .002) were associated with being seen within 4 weeks. Conclusion It is an ongoing challenge for our Canadian voice center to meet the American Academy of Otolaryngology–Head and Neck Surgery’s clinical practice guideline for recommended time to laryngoscopy. Patients with more severe pathologies were consistently triaged more urgently. It is debatable whether this 4-week time recommendation is generalizable to a socialized health care system.

Assessing the risk of chemotherapy toxicity and hospital admission due to toxicity.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e14508-e14508
Author(s):  
Samuel Robert Malton
Keyword(s):  
Length Of Stay ◽  
Hospital Admission ◽  
Outcome Measures ◽  
Anticancer Agents ◽  
Toxicity Assessment ◽  
Health Economy ◽  
Secondary Outcome ◽  
University Hospitals ◽  
Lung Cancers ◽  
Chemotherapy Toxicity

e14508 Background: Acute chemotherapy toxicity can have negative effects for the patient and the health economy. Finding overall toxicity incidence for a typical teaching hospital population proved difficult, although the 2008 report in to deaths within 30 days of chemotherapy found that 43% of patients who died reported a grade 3 or 4 toxicity1. At Nottingham University Hospitals (NUH) a Cancer Admissions and Triage Team was established, who undertake a proactive telephone toxicity assessment 24 hours following the administration of a first cycle of chemotherapy. This had the aim of reducing hospital admission due to toxicity through timely advice and intervention and allowed the accrual of data regarding reported toxicity. Methods: Data was obtained from the telephone assessment of acute toxicity 24 hours after administration of a first cycle of chemotherapy, once the service had been in use for 1 year. Descriptive statistics were produced to establish toxicity incidence and severity and hospital admission rates as well as length of stay. Regression modelling was used to identify predictors of the four outcome measures. The commonest toxicities were explored as secondary outcome measures. Results: 1539 patients were studied and the overall incidence of toxicity was 35.6%. Disease site and number of chemotherapy agents given were shown to predict toxicity, with breast and upper gastrointestinal cancers having a higher likelihood of toxicity. The more anticancer agents used, the higher the risk of toxicity. Disease was predictive of toxicity grade, with urology, gynaecology and lung patients experiencing higher grades of toxicity than other tumour sites. The rate of hospital admission due to toxicity was 13.1% and median length of stay 3 days. The risk of admission had some risk factors in common with toxicity. Disease and the number of drugs in the regimen affected the risk of admission, with gynaecology, head and neck and lung patients and patients who received 3 drugs having a higher likelihood of admission. No predictors could be reliably identified for length of stay. Predictors in the sub-groups of breast, lower gastrointestinal and lung cancers did not differ greatly from the whole population and the number of drugs was shown to be a predictor of nausea, vomiting and fatigue when explored as secondary outcomes. Conclusions: Predictors were identified for occurrence of toxicity, severity of toxicity, risk of hospital admission but not for length of stay. Sub-group analyses were undertaken. The overall burden of acute chemotherapy toxicity of a heterogeneous population was elucidated.

scholarly journals Quality of Life and not Health Status Improves After Major Amputation in the Elderly Critical Limb Ischaemia Patient

2019 ◽  
Vol 57 (4) ◽  
pp. 547-553 ◽  
Author(s):  
Chloé M.L. Peters ◽  
Jolanda de Vries ◽  
Paul Lodder ◽  
Stijn L. Steunenberg ◽  
Eelco J. Veen ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Health Status ◽  
The Elderly ◽  
Major Amputation ◽  
Critical Limb Ischaemia ◽  
Limb Ischaemia

scholarly journals Endovascular management of Critical Limb Ischaemia: Study of 100 Cases

2019 ◽  
Vol 12 (1) ◽  
pp. 40-44
Author(s):  
Md Humayun Kabir ◽  
Munshi Md Mojibur Rahman ◽  
AKM Musa Khan ◽  
Rumman Idris
Keyword(s):  
Limb Ischemia ◽  
Major Amputation ◽  
Severe Form ◽  
Tissue Loss ◽  
Critical Limb Ischaemia ◽  
Military Hospital ◽  
Limb Ischaemia ◽  
Rest Pain ◽  
Excellent Outcome ◽  
Number Of Patients

Background: Critical limb ischemia (CLI) is the most severe form of Peripheral Artery Disease (PAD) and represents approximately 1% of the total number of patients with PAD. CLI is associated with a higher risk of limb loss in the absence of revascularization. Objectives of the study are to find out the modality of treatment in CLI, different types of endovascular therapy in CLI and their outcome. Methods: A retrospective study evaluated 100 patients with CLI reported to cardiovascular surgery department in Combined Military Hospital (CMH), Dhaka between July 2016 to June 2018. Patients with disabling claudication or rest pain and tissue loss are included in the study. All patients were evaluated by peripheral angiogram and revascularisation of limbs was done by endovascular procedure in 79 patients, by surgical intervention in 12 patients. Results: Forty-four patients (44%) presented with rest pain and disabling claudication, 56 patients (56%) presented with tissue loss. Revascularization of limbs was done in 91 patients (93%). No intervention could be done in 9 patients (9%). Endovascular interventions were done in 79 patients (87%). Twelve patients (13%) underwent surgical bypass. All patients with rest pain remains asymptomatic in 6 months follow up; 2 patients developed reocclusion within 1 year. No major amputation in patients with only rest pain. Conclusion: Revascularization is the main modality of treatment in CLI. Most of the patient can be treated by endovascular percuteneous procedure. Early intervention in CLI patient without tissue loss carries excellent outcome. Cardiovasc. j. 2019; 12(1): 40-44

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