Intravenous versus Oral Step-Down for the Treatment of Staphylococcus aureus Bacteremia in a Pediatric Population

Limited data are available regarding optimal antimicrobial therapy for Staphylococcus aureus bacteremia (SAB) in pediatric patients. The purpose of this study was to assess clinical characteristics and outcomes associated with intravenous (IV) versus oral step-down treatment of pediatric SAB. This study evaluated patients aged 3 months to 18 years that received at least 72 h of inpatient treatment for SAB. The primary endpoint was 30-day readmission. Secondary endpoints included hospital length of stay and inpatient mortality. One hundred and one patients were included in this study. The median age was 7.9 years. Patients who underwent oral step-down were less likely to be immunocompromised and more likely to have community-acquired SAB from osteomyelitis or skin and soft tissue infection (SSTI). More patients in the IV therapy group had a 30-day readmission (10 (25.6%) vs. 3 (5.3%), p = 0.006). Mortality was low (5 (5%)) and not statistically different between groups. Length of stay was greater in patients receiving IV therapy only (11 vs. 7 days, p = 0.001). In this study, over half of the patients received oral step-down therapy and 30-day readmission was low for this group. Oral therapy appears to be safe and effective for patients with SAB from osteomyelitis or SSTIs.

The Impact of Selenium Supplementation on Trauma Patients—Systematic Review and Meta-Analysis

This study aimed to assess current evidence regarding the effect of selenium (Se) supplementation on the prognosis in patients sustaining trauma. MEDLINE, Embase, and Web of Science databases were searched with the following terms: “trace element”, “selenium”, “copper”, “zinc”, “injury”, and “trauma”. Seven studies were included in the meta-analysis. The pooled results showed that Se supplementation was associated with a lower mortality rate (OR 0.733, 95% CI: 0.586, 0.918, p = 0.007; heterogeneity, I2 = 0%). Regarding the incidence of infectious complications, there was no statistically significant benefit after analyzing the four studies (OR 0.942, 95% CI: 0.695, 1.277, p = 0.702; heterogeneity, I2 = 14.343%). The patients with Se supplementation had a reduced ICU length of stay (standard difference in means (SMD): −0.324, 95% CI: −0.382, −0.265, p < 0.001; heterogeneity, I2 = 0%) and lesser hospital length of stay (SMD: −0.243, 95% CI: −0.474, −0.012, p < 0.001; heterogeneity, I2 = 45.496%). Se supplementation after trauma confers positive effects in decreasing the mortality and length of ICU and hospital stay.

What are the risk factors of hospital length of stay in the novel coronavirus pneumonia (COVID-19) patients? A survival analysis in southwest China

Background The global epidemic of novel coronavirus pneumonia (COVID-19) has resulted in substantial healthcare resource consumption. Since patients’ hospital length of stay (LoS) is at stake in the process, an investigation of COVID-19 patients’ LoS and its risk factors becomes urgent for a better understanding of regional capabilities to cope with COVID-19 outbreaks. Methods First, we obtained retrospective data of confirmed COVID-19 patients in Sichuan province via National Notifiable Diseases Reporting System (NNDRS) and field surveys, including their demographic, epidemiological, clinical characteristics and LoS. Then we estimated the relationship between LoS and the possibly determinant factors, including demographic characteristics of confirmed patients, individual treatment behavior, local medical resources and hospital grade. The Kaplan-Meier method and the Cox Proportional Hazards Model were applied for single factor and multi-factor survival analysis. Results From January 16, 2020 to March 4, 2020, 538 human cases of COVID-19 infection were laboratory-confirmed, and were hospitalized for treatment, including 271 (50%) patients aged ≥ 45, 285 (53%) males, and 450 patients (84%) with mild symptoms. The median LoS was 19 (interquartile range (IQR): 14–23, range: 3–41) days. Univariate analysis showed that age and clinical grade were strongly related to LoS (P<0.01). Adjusted multivariate analysis showed that the longer LoS was associated with those aged ≥ 45 (Hazard ratio (HR): 0.74, 95% confidence interval (CI): 0.60–0.91), admission to provincial hospital (HR: 0.73, 95% CI: 0.54–0.99), and severe illness (HR: 0.66, 95% CI: 0.48–0.90). By contrast, the shorter LoS was linked with residential areas with more than 5.5 healthcare workers per 1,000 population (HR: 1.32, 95% CI: 1.05–1.65). Neither gender factor nor time interval from illness onset to diagnosis showed significant impact on LoS. Conclusions Understanding COVID-19 patients’ hospital LoS and its risk factors is critical for governments’ efficient allocation of resources in respective regions. In areas with older and more vulnerable population and in want of primary medical resources, early reserving and strengthening of the construction of multi-level medical institutions are strongly suggested to cope with COVID-19 outbreaks.

Medication Changes and Diagnosis of New Chronic Illnesses in COVID-19 Intensive Care Unit Survivors

Background Currently, there is limited literature on the impact of the COVID-19 infection on medications and medical conditions in COVID-19 intensive care unit (ICU) survivors. Our study is, to our knowledge, the first multicenter study to describe the prevalence of new medical conditions and medication changes at hospital discharge in COVID-19 ICU survivors. Objective To determine the number of medical conditions and medications at hospital admission compared to at hospital discharge in COVID-19 ICU survivors. Methods Retrospective multicenter observational study (7 ICUs) evaluated new medical conditions and medication changes at hospital discharge in patients with COVID-19 infection admitted to an ICU between March 1, 2020, to March 1, 2021. Patient and hospital characteristics, baseline and hospital discharge medication and medical conditions, ICU and hospital length of stay, and Charlson comorbidity index were collected. Descriptive statistics were used to describe patient characteristics and number and type of medical conditions and medications. Paired t-test was used to compare number of medical conditions and medications from hospital discharge to admission. Results Of the 973 COVID-19 ICU survivors, 67.4% had at least one new medical condition and 88.2% had at least one medication change. Median number of medical conditions (increased from 3 to 4, P < .0001) and medications (increased from 5 to 8, P < .0001) increased from admission to discharge. Most common new medical conditions at discharge were pulmonary disorders, venous thromboembolism, psychiatric disorders, infection, and diabetes. Most common therapeutic categories associated with medication change were cardiology, gastroenterology, pain, hematology, and endocrinology. Conclusion and Relevance Our study found that the number of medical conditions and medications increased from hospital admission to discharge. Our results provide additional data to help guide providers on using targeted approaches to manage medications and diseases in COVID-19 ICU survivors after hospital discharge.

Similar Efficacy of Arthroscopy and Arthrotomy in Infection Eradication in the Treatment of Septic Knee: A Systematic Review and Meta-Analysis

Aim: To compare the arthroscopy vs. arthrotomy for the treatment of native knee septic arthritis.Methods: Electronic databases of PubMed, Embase and Cochrane Library were searched for eligible studies. Retrospective comparative studies comparing arthroscopy or arthrotomy for patients with septic arthritis of the native knee were eligible for this review. The primary outcome was recurrence of infection after first procedure. The secondary outcomes included hospital length of stay, operative time, range of motion of the involved knee after surgery, overall complications and mortality rate,Results: Thirteen trials were included in this study. There were a total of 2,162 septic arthritis knees treated with arthroscopic debridement and irrigation, and 1,889 septic arthritis knees treated with open debridement and irrigation. Arthroscopy and arthrotomy management of the knee septic arthritis showed comparable rate of reinfection (OR = 0.85; 95% CI, 0.57–1.27; P = 0.44). No significant difference was observed in hospital length of stay, operative time and mortality rate between arthroscopy and arthrotomy management group, while arthroscopy treatment was associated with significantly higher knee range of motion and lower complication rate when compared with arthrotomy treatment.Conclusion: Arthroscopy and arthrotomy showed similar efficacy in infection eradication in the treatment of native septic knee. However, arthroscopy treatment was associated with better postoperative functional recovery and lower complication rate.

Endoscopic retrograde appendicitis therapy vs. Laparoscopic appendectomy for uncomplicated acute appendicitis

Background and study aims: To assess the efficacy and clinical outcomes of endoscopic retrograde appendicitis therapy (ERAT) versus laparoscopic appendectomy (LA) for patients with uncomplicated acute appendicitis (AA). Patients and methods: We adopted propensity score matching (1:1) to compare ERAT and LA patients with uncomplicated AA from April 2017 to March 2020. We reviewed a total of 2880 patients with suspected acute appendicitis, of whom 422 patients with uncomplicated AA met the matching criteria (ERAT, 79; LA, 343), yielding 78 pairs of patients. Results: The rate of curative treatment within one year after ERAT was 92.1%; 95% CI, [83.8% - 96.3%]. The percentage of Visual Analog Scale (VAS) ≤ 3 at six hours after treatment was 94.7%; 95% CI [87.2% - 97.9%] in the ERAT group, and significantly higher than that in the LA group 83.3%; 95% CI [73.5% - 90.0%]. Median operative/procedure time and median hospital length of stay in the ERAT group were significantly lower compared to the LA group. At one year, the median recurrence time was 50 days (IQRs, 25-127) in the ERAT group. The overall adverse event rate was 24.3%; 95% CI [14.8% - 33.9%] in the LA group and 18.4%; 95% CI [9.7% - 27.1%] in the ERAT group, with no significant difference between the two groups. Conclusions: ERAT is a technically feasible method to treat uncomplicated AA compared to LA.

An explainable machine learning framework for lung cancer hospital length of stay prediction

This work introduces a predictive Length of Stay (LOS) framework for lung cancer patients using machine learning (ML) models. The framework proposed to deal with imbalanced datasets for classification-based approaches using electronic healthcare records (EHR). We have utilized supervised ML methods to predict lung cancer inpatients LOS during ICU hospitalization using the MIMIC-III dataset. Random Forest (RF) Model outperformed other models and achieved predicted results during the three framework phases. With clinical significance features selection, over-sampling methods (SMOTE and ADASYN) achieved the highest AUC results (98% with CI 95%: 95.3–100%, and 100% respectively). The combination of Over-sampling and under-sampling achieved the second-highest AUC results (98%, with CI 95%: 95.3–100%, and 97%, CI 95%: 93.7–100% SMOTE-Tomek, and SMOTE-ENN respectively). Under-sampling methods reported the least important AUC results (50%, with CI 95%: 40.2–59.8%) for both (ENN and Tomek- Links). Using ML explainable technique called SHAP, we explained the outcome of the predictive model (RF) with SMOTE class balancing technique to understand the most significant clinical features that contributed to predicting lung cancer LOS with the RF model. Our promising framework allows us to employ ML techniques in-hospital clinical information systems to predict lung cancer admissions into ICU.

Impact of Maternal–Fetal Environment on Mortality in Children With Single Ventricle Heart Disease

BACKGROUND Children with single ventricle heart disease have significant morbidity and mortality. The maternal–fetal environment (MFE) may adversely impact outcomes after neonatal cardiac surgery. We hypothesized that impaired MFE would be associated with an increased risk of death after stage 1 Norwood reconstruction. METHODS AND RESULTS We performed a retrospective cohort study of children with hypoplastic left heart syndrome (and anatomic variants) who underwent stage 1 Norwood reconstruction between 2008 and 2018. Impaired MFE was defined as maternal gestational hypertension, preeclampsia, gestational diabetes, and/or smoking during pregnancy. Cox proportional hazards regression models were used to investigate the association between impaired MFE and death while adjusting for confounders. Hospital length of stay was assessed with the competing risk of in‐hospital death. In 273 children, the median age at stage 1 Norwood reconstruction was 4 days (interquartile range [IQR], 3–6 days). A total of 72 children (26%) were exposed to an impaired MFE; they had more preterm births (18% versus 7%) and a greater percentage with low birth weights <2.5 kg (18% versus 4%) than those without impaired MFE. Impaired MFE was associated with a higher risk of death (hazard ratio [HR], 6.05; 95% CI, 3.59–10.21; P <0.001) after adjusting for age at surgery, Hispanic ethnicity, genetic syndrome, cardiac diagnosis, surgeon, and birth era. Children with impaired MFE had almost double the risk of prolonged hospital stay (HR, 1.95; 95% CI, 1.41–2.70; P <0.001). CONCLUSIONS Children exposed to an impaired MFE had a higher risk of death following stage 1 Norwood reconstruction. Prenatal exposures are potentially modifiable factors that can be targeted to improve outcomes after pediatric cardiac surgery.

Thromboelastography after Cardiopulmonary Bypass: Does it Save Blood Products?

Introduction. This study aimed to determine if thromboelastography (TEG) is associated with reduced blood product use and surgical re-intervention following cardiopulmonary bypass (CPB) compared to traditional coagulation tests. Methods. A retrospective review was conducted of 698 patients who underwent CPB at a tertiary-care, community-based, university-affiliated hospital from February 16, 2014 – February 16, 2015 (Period I) and May 16, 2015 - May 16, 2016 (Period II). Traditional coagulation tests guided transfusion during Period I and TEG guided transfusion during Period II. Intraoperative and postoperative administration blood products (red blood cells, fresh frozen plasma, platelets, and cryoprecipitate), reoperation for hemorrhage or graft occlusion, duration of mechanical ventilation, hospital length of stay and mortality were recorded. Results. Use of a TEG-directed algorithm was associated with a 13.5% absolute reduction in percentage of patients requiring blood products intraoperatively (48.2% vs. 34.7%, p <0.001). TEG resulted in a 64.3% and 43.1% reduction in proportion of patients receiving FFP and platelets, respectively, with a 50% reduction in volume of FFP administered (0.3 vs. 0.6 units, p < 0.001). Use of TEG was not observed to significantly decrease postoperative blood product usage or mortality. The median length of hospital stay was reduced by 1 day after TEG guided transfusion was implemented (nine days vs. eight days, p = 0.01). Conclusions. Use of TEG-directed transfusion of blood products following CPB appears to decrease the need for intraoperative transfusions, but the effect on clinical outcomes has yet to be clearly determined.