Staphylococcus aureus bacteremia after thermal injury: The clinical impact of methicillin resistance

Objective

To evaluate the impact of methicillin resistance in Staphylococcus aureus bacteremia (SAB) on mortality and length of stay in burn patients.

Design

Retrospective cohort study.

Setting

A 750-bed tertiary care university hospital in Cologne, Germany.

Patients

Patients registered in the database of the burn intensive care unit (BICU) between 1989 and 2009 with complete data sets (n = 1688).

Results

Over the 21-year study period, 74 patients with SAB were identified; 33 patients had methicillin-resistant S. aureus (MRSA) and 41 methicillin-susceptible S. aureus (MSSA). Comparing the MRSA with the MSSA population the following parameters were significantly different in the univariate analysis: BMI (27.2 kg/m² vs. 23.6 kg/m²; P = 0.05), extent of deep partial thickness burns (17.8% vs. 9.0% of total body surface area; P = 0.007), antibiotic requirement on admission (45.5% vs. 22.0%; P = 0.046), median length of hospitalization prior SAB (24 days vs. 7 days; P < 0.001), packed red blood cells administration (47.6 units vs. 26.1 units; P = 0.003), intubation requirement (100% vs. 80.5%; P = 0.007), intubation period (43.5 days vs. 26.8 days; P = 0.008), catecholamine requirement (90.9% vs. 61.0%; P = 0.004), sepsis (60.6% vs. 34.1%; P = 0.035) and organ failures (81.8% vs. 39.0%; P < 0.001). Regarding outcome parameters, methicillin resistance was not significantly related with mortality (adjusted OR 1.55, 95% CI 0.56–4.28; P = 0.40) and length of BICU stay after SAB (Kaplan–Meier analysis log-rank test P = 0.32; Cox's proportional hazards regression HR 1.22, 95% CI 0.65–2.27, P = 0.535) in the univariate and multivariate analyses.

Conclusion

Our data suggest that methicillin resistance is not associated with significant increases in mortality and length of BICU stay among burn patients with SAB.     

Empleo,eficacia y repercusión clínica del apoyo radiológico al diagnóstico de la apendicitis aguda

Objective

The aim of this study is to analyze the increasing need of radiological support in the diagnosis of acute appendicitis (AA), the clinical repercussions associated, and the parameters of diagnostic accuracy of ultrasound and computed tomography (CT) scan for AA.

Material and methods

Observational and analytical study. Cohort, patients operated on for suspected AA at a tertiary referral hospital. Pregnancy and <14 years were exclusion criteria. Study group: January 2010-December 2011 (n1 = 419). Control group: set of patients aged 18 to 65 years old operated between October 2001-September 2003 (n2 = 237). Variables analyzed in both groups: 1) percentage of radiological support for diagnosis of acute appendicitis; 2) sensitivity and positive predictive value (PPV) of ultrasound and CT scan; 3) rate of surgical explorations with negative result or with diagnosis other than acute appendicitis. Statistical analysis: SPSS software, χ² test, statistical significance accepted with P<.05, 95% confidence interval (95% CI) for the odds ratio (OR).

Results

Age, gender, percentage of atypical locations and gangrenous/perforated episodes were similar in both groups. The number of radiological examinations needed for diagnosis was significantly higher in the study group (78.8% vs. 30.4%, P<.0,000). Sensitivity was significantly superior for CT than for ultrasound scan (97% vs. 86%), but PPV was similar in both tests (92% vs. 94%). Surgical exploration percent values with diagnosis of acute appendicitis was significantly higher in the study group (94.5% vs. 88.6%; P<.006, OR 2.2; CI 95% 1.25-4).

Conclusions

CT and ultrasound scan are excellent diagnostic tools for acute appendicitis, and have contributed to a significant increase in surgical explorations with correct diagnosis.     

Laparoscopy utilization and outcomes for appendicitis in small children

Purpose

To examine the trends in laparoscopic appendectomy (LA) utilization and outcomes for children 5 years or younger.

Methods

We studied 16,028 inpatient admissions for children 5 years of age or less undergoing an appendectomy for acute appendicitis in 2000, 2003, and 2006 using the Kids' Inpatient Database (KID). Laparoscopy frequency, hospital length of stay, and complications were reviewed.

Results

In 2000, 2003 and 2006 appendectomies were done laparoscopically 11.4%, 18.7% and 31.3% of the time, respectively. Children were more likely to undergo LA at a children's hospital (P < 0.001). LA complications were less likely overall (OR: 0.80, CI: 0.70–0.92, P = 0.002) and in perforated cases (OR: 0.78, CI: 0.67-0.91, P = 0.001). LA decreased hospital length of stay by 0.54 days for all patients and 0.70 days for perforated cases (P < 0.001).

Conclusions

Open appendectomy has historically been the standard in children 5 years of age and younger. Laparoscopic appendectomy has slowly gained acceptance for the treatment of appendicitis in smaller children. The use of laparoscopy has increased significantly at all facilities. Furthermore, laparoscopic appendectomy in this age group has a comparatively low complication rate and short hospital length of stay, and is safe in complicated perforated appendicitis cases.     

Surgical complications after immediate nephrectomy versus preoperative chemotherapy in non-metastatic Wilms' tumour: Findings from the 1991–2001 United Kingdom Children's Cancer Study Group UKW3 Trial

Purpose

To compare surgical complication rates after immediate nephrectomy versus delayed nephrectomy following preoperative chemotherapy in children with non-metastatic Wilms’ tumour enrolled in UKW3, both in randomised patients and in those for whom the treatment approach was defined by parental or physician choice.

Methods

Records for all patients enrolled into UKW3 were reviewed. Any record of tumour rupture or surgical complication was extracted and comparisons made between the two treatment strategies in both populations of randomised and non-randomised patients.

Results

Of 525 children enrolled, 205 patients were randomised to either immediate nephrectomy (n = 103) or pre-operative chemotherapy followed by delayed nephrectomy (n = 102). Of the 320 children not randomised, data were available on 189 cases treated with immediate nephrectomy and 103 treated with pre-operative chemotherapy. There were significantly fewer surgical complications in randomised children given pre-operative chemotherapy before surgery compared to children undergoing immediate nephrectomy (1% vs. 20.4%, P < 0.001); this difference was most marked for tumour rupture (0% vs. 14.6%, P < 0.001).

Conclusions

Delayed nephrectomy for Wilms’ tumour, preceded by pre-operative chemotherapy was associated with fewer surgical complications compared with immediate nephrectomy.     

Œsophagectomie carcinologique : 16 ans d’évolution des pratiques anesthésiques ventilatoires,hémodynamiques et analgésiques

Objective

To describe the evolution of perioperative anesthesia practices in for esophageal cancer surgery.

Patients and methods

We conducted an observational retrospective study in a single center evaluating main perioperative practices during 16 years (1994–2009). Statistical analysis was done on 4 chronologic quartiles of same sample size.

Results

Two hundred and seven consecutive patients were included during the 4 periods 1994–1997 (n = 52), 1997–1999 (n = 52), 1999–2003 (n = 52) and 2004–2009 (n = 51). The main significant evolutions between the first and the fourth period were observed: (i) in ventilation: lower tidal volume (9.6[8.6–10.6] vs 7.6[7.0–8.3] mL/kg of ideal body weight (IBW), p < 0.01), increased use of Positive End Expiratory Pressure (0 vs 83 %, p < 0.001) and increased use of post-operative non-invasive ventilation (0 vs 51 %, p < 0.001); (ii) in hemodynamic management: lower fluid replacement (20.6 [16.0–24.6] vs 12.6 [9.7–16.2] mL/h/kg of IBW, p < 0.001); (iii) in analgesia: increased use of epidural thoracic anesthesia (31 vs 57 %, p < 0.001). Peroperative bleeding, type of fluid replacement, length of mechanical ventilation, length of stay in intensive care unit, ventilatory free days and mortality at day 28 didn’t change.

Conclusions

During these previous years, anesthesia practices in ventilation, hemodynamics and analgesia for esophageal cancer surgery have changed.     

Undescended testes: Does age at orchiopexy affect survival of the testis?

Purpose

The optimal age at which to perform orchiopexy for cryptorchidism has long been debated. The aim of this study was to determine if age at orchiopexy affected testicular atrophy.

Methods

A retrospective review of patients undergoing orchiopexy from 2000 to 2010 was conducted. An individual testis, rather than patient, was used as the dependent variable. A total of 349 testicles from 1126 charts (ICD-9 = 752.51) were identified. Primary study outcome was testicular survival without atrophy.

Results

Mean follow up for the study was 25 months. There was postoperative atrophy in 27 testes (7.7%). Intraabdominal testicle was independently associated with increased postsurgical atrophy (p < 0.0001). The odds of postsurgical atrophy were 15.66 times higher for an abdominal vs. inguinal location (95% CI: 5.5–44.6). Testicular atrophy was highest for orchiopexy at ages 13–24 months (n = 16 of 133, 12%) vs. those less than 13 months (n = 3 of 64, 5%), and those greater than 24 months (n = 8 of 152, 5%) (p = 0.0024). After adjusting for location, age was not statistically significant with postsurgical atrophy (p = 0.055).

Conclusions

From this study we conclude that there is no increase in testicular atrophy in patients less than 13 months.     

LAPAROSCOPIC VERSUS OPEN APPENDICECTOMY FOR SUSPECTED APPENDICITIS: A PROSPECTIVE STUDY

Despite recent advances in minimally invasive surgery, laparoscopic appendicectomy has been questioned as a feasible method of treating patients with suspected appendicitis because open appendicectomy carries few risks and complications. Between February 1992 and January 1993 a non-randomized prospective study comparing open and laparoscopic appendicectomy was designed to assess differences in postoperative morbidity, pain, inpatient hospital stay and a return to normal lifestyle. One hundred and sixty-seven patients with suspected clinical appendicitis were assigned to open (n= 74) or laparoscopic (n= 93) appendicectomy. Six patients were excluded due to the presence of other significant pathology such that the appendix was not removed. Eighty-seven patients underwent attempted laparoscopic appendicectomy, of which 81 were completed. The diagnosis of appendicitis was confirmed histologically in 63.5% of patients undergoing open appendicectomy and 63% of patients undergoing laparoscopic appendicectomy. There were no significant differences in anaesthetic times, postoperative morbidity and analgesic requirements. There was a significant reduction in both postoperative inpatient stay (P < 0.0001) and time taken to return to work or normal activities (P < 0.0001) for the laparoscopic group. The use of laparoscopy for patients with suspected appendicitis aids definitive diagnosis and should reduce the negative appendicectomy rate to an acceptable figure. The results suggest that laparoscopic appendicectomy is safe and offers advantages over open appendicectomy in the management of patients with suspected appendicitis.     

Primary malignant pancreatic neoplasms in children and adolescents: A 20 year experience

Background

Malignant pancreatic neoplasms in children and adolescents are rare. The clinical presentation, pathologic characteristics, management, and outcomes at two institutions are discussed.

Methods

We retrospectively reviewed all pediatric patients (age < = 18 years) treated for malignant pancreatic neoplasms at two institutions between 1991 and 2011.

Results

Thirty-one patients were identified with median age of 14.7 years (4–18 years). The most common histology was solid pseudopapillary tumor (SPT) (n = 22, 71%) followed by neuroendocrine tumors (n = 4, 13%), pancreatoblastoma (n = 4, 13%), and one unclassified spindle cell neoplasm (3%). Most patients presented with abdominal pain (n = 22, 71%). Complications included pancreatic leak, pseudocyst formation, pancreatitis, pancreatic insufficiency, and small bowel obstruction. The overall 1- and 5-year survival was 96% (95% CI 74%–99%) and 78% (95% CI 43%–93%). Median follow-up among patients alive at the end of follow-up was 20 months (< 1 month–16.2 years). Patients with SPT had better overall survival compared to patients with neuroendocrine tumors or pancreatoblastomas (Log-rank; p = 0.0143).

Conclusion

The majority of pediatric and adolescent patients present with SPTs which are usually resectable and associated with an excellent prognosis. Other histologic subtypes more often present with distant metastases and portend a worse prognosis.     

Physician-based emergency medical service deployment characteristics in severe traumatic brain injury: A Dutch multicenter study

Introduction

Prehospital guidelines advise advanced life support in all patients with severe traumatic brain injury (TBI). In the Netherlands, it is recommended that prehospital advanced life support is particularly provided by a physician-based helicopter emergency medical service (P-HEMS) in addition to paramedic care (EMS). Previous studies have however shown that a substantial part of severe TBI patients is exclusively treated by an EMS team. In order to better understand this phenomenon, we evaluated P-HEMS deployment characteristics in severe TBI in a multicenter setting.

Methods

The database included patient demographics, prehospital and injury severity parameters and determinants of EMS or EMS/P-HEMS dispatch in 334 patients with severe TBI admitted to level 1 trauma centres in the Netherlands.

Results

P-HEMS was deployed in 62% of patients with severe TBI. Patients treated by the P-HEMS had a higher injury severity score (29 (20–38)) vs. (25 (16–30); P < 0.001), more frequently required blood product transfusions (41% vs. 29%; P = 0.03) and recurrently suffered from TBI with extracranial injuries (33% vs. 6%; P < 0.001) than patients solely treated by an EMS. The prehospital endotracheal intubation rate was higher in the P-HEMS group in isolated TBI (93% vs. 19%; P < 0.001) or TBI with extracranial injuries (96% vs. 43%; P < 0.001) compared to the EMS group. In the EMS group, more patients were secondary referred to a level 1 trauma centre (32% vs. 4%; P < 0.001 vs. P-HEMS). Despite higher injury severity levels in P-HEMS patients, 6-month mortality rates were similar among groups, irrespective of the presence of extracranial injuries in addition to TBI. Deployment of P-HEMS estimated 52% and 72% (P < 0.001) in urban and rural regions, respectively, with comparable endotracheal intubation rates among regions.

Conclusions

This study shows that a physician-based HEMS was more frequently deployed in patients with severe TBI in the presence of extracranial injuries, and in rural trauma regions. Treatment of severe TBI patients by a paramedic EMS only was associated with a higher incidence of secondary referrals to a level I trauma centre. Our data support adjustment of local prehospital guidelines for patients with severe TBI to the geographical context.     

Does delay in appendectomy affect surgical site infection in children with appendicitis?

Purpose

The purpose of this study was to investigate the association between time from diagnosis to operation and surgical site infection (SSI) in children undergoing appendectomy.

Methods

Pediatric patients undergoing appendectomy in 2010–2012 were included. We collected data on patient demographics; length of symptoms; times of presentation, admission and surgery; antibiotic administration; operative findings; and occurrence of SSI.

Results

1388 patients were analyzed. SSI occurred in 5.1% of all patients, 1.4% of simple appendicitis (SA) patients, and 12.4% of complex appendicitis (CA) patients. SSI did not increase significantly as the length of time between ED triage and operation increased (all patients, p = 0.51; SA patients, p = 0.91; CA patients, p = 0.44) or with increased time from admission to operation (all patients, p = 0.997; SA patients, p = 0.69; CA patients, p = 0.96). However, greater length of symptoms was associated with an increased risk of SSI (p < 0.05 for all, SA and CA patients). In univariable analysis, obesity, and increased admission WBC count were each associated with significantly increased SSI. In multivariable analysis, only CA was a significant risk factor for SSI (p < 0.0001).

Conclusion

We found no significant increase in the risk of SSI related to delay in appendectomy. A future multi-institutional study is planned to confirm these results.     

Effet d’une dose unique intramusculaire de déxaméthasone sur la douleur après circoncision. Étude randomisée contrôlée

Objective

To assess the effect of a preoperative single dose of dexamethasone associated with penile block on pain after circumcision.

Study design

Prospective randomized controlled study.

Patients and methods

Forty male children aged 2 to 5 years, scheduled for circumcision under general anaesthesia, combined with penile block, were randomized into two groups. The dexamethasone group received dexamethasone 0.4 mg/kg preoperatively. The control group received the same volume of normal saline. Data compared between two groups were: postoperative pain assessed by the Objective Pain Scale collected in the recovery room, at 8 and 24 hours postoperatively (h0, h8 and h24), time to first analgesic request and the quality of sleep on the first postoperative night.

Results

Pain scores at h0 were similar between the two groups. The dexamethasone group showed significantly lower pain scores at h8 [0 (0–1) vs. 2 (0–3); P = 0.04] and h24 [0 (0–0) vs. 0 (0–1); P = 0.02]. The time to first analgesic administration was also significantly delayed in the dexamethasone group compared to the control group (240 vs 180 min; P = 0.035). The quality of sleep was also better in children in the dexamethasone group (P = 0.018).

Conclusion

This study showed that the combination of a preoperative single dose of dexamethasone 0.4 mg/kg with penile block significantly improves the quality of analgesia after circumcision.     

Transumbilical laparoscopic-assisted appendectomy is associated with lower costs compared to multiport laparoscopic appendectomy

Background/Purpose

Single-incision laparoscopic appendectomy has been associated with improved cosmetic benefits, and decreased postoperative pain. Less is known about costs and other outcomes. Our aim was to evaluate the costs and outcomes between transumbilical laparoscopic-assisted appendectomy (TULAA) and multiport laparoscopic appendectomy (MLA).

Methods

IRB-approved retrospective review (September 2010–July 2013) of institutional medical records identified 372 pediatric patients undergoing laparoscopic appendectomy. Outcomes included costs, LOS and readmission. Costs were fully loaded operating costs from the hospital’s cost accounting database. Generalized linear regression was used to assess costs of MLA and TULAA. A subgroup analysis was performed using only patients with non-perforated appendicitis.

Results

There were 132 patients (35.5%) that underwent TULAA while 240 patients (65.5%) underwent MLA. Compared to MLA, TULAA was associated with decreased operative time (0.6 vs. 1.0 h, p < 0.0001), used in comparable proportions of interval appendectomies, but was performed less often for perforated appendicitis (9.8% vs. 22.9%, p = 0.002). Readmission and postoperative complications were similar between both groups. In the setting of non-perforated appendicitis, TULAA was associated with lower costs of $1378 relative to MLA (p = 0.009).

Conclusions

In non-perforated appendicitis, TULAA is associated with lower costs and comparable rates of readmission and postoperative complications.     

Facteurs prédictifs de défaillance d’organes chez les patients admis en réanimation pour hémorragie digestive aiguë

Introduction

Gastrointestinal hemorrhage is an emergency requiring usually an admission in intensive care unit (ICU), which may prove abusive secondarily. The aim of this study was to identify predictive risk factors of organ failure in patients admitted for GH in our ICU.

Design

Retrospective and observational

Methods and measurements

Between January 2008 and December 2011, all patients admitted in our ICU for gastrointestinal hemorrhage were consecutively included. The primary endpoint was the occurrence of at least an organ failure. We realized an univariate analysis then a backward regression to identify independent risk factors associated with the occurrence of at least one organ failure during the ICU hospitalization.

Results

During this period study, 441 consecutive patients with a mean age of 67 ± 15 years were included. The median ICU length of stay was of 4 (3–7) days and 116 (26% [IC95%: 22–30]) patients presented at least one organ failure. The multivariate analysis identified predictive risk factors of organ failure: history of cirrhosis (OR = 3.5 [IC95%: 1.9–6.7], P < 0.001) and an increase in troponin at the admission above the 99th percentile (OR = 3.1 [IC95%: 1.8–5.5], P < 0.001).

Conclusion

Our results confirmed that a large proportion of patients admitted in ICU for the primary diagnosis of gastrointestinal hemorrhage developed any organ failure. The history of cirrhosis and the systemic consequences of the hemorrhagic syndrome as myocardial damage represents important risk factors of morbidity and mortality and thus should be considered during the management.     

A comparison of laparoscopic and open restorative proctocolectomy in children

Aim

Restorative proctocolectomy (RP) is the gold standard for children requiring removal of their colon and rectum. The aim of this study is to contrast conventional (open) and laparoscopic RP.

Methods

All children undergoing RP by one surgeon were prospectively recorded in a customised database. Outcome variables were length of stay in days (LOS), duration of surgery in minutes (DS), blood loss in ml, and complications. Explanatory variables included technique of resection (open or laparoscopic (lap)) and presenting disease. Lap resection was adopted after patient 37. Data are presented as median (range). P < 0.05 was regarded as significant.

Results

Eighty-two (43 girls) children underwent RP at median age 12 (0.5–20) years. RP was performed as Open (n = 37) or Laparoscopic (n = 45). Indications were: colitis (n = 56), polyposis (n = 12), constipation (n = 7), Hirschsprung’s (n = 5), fibrosing colonopathy (n = 2). Significantly, more children had three-stage surgery among the lap group (P = 0.04). LOS was significantly shorter in the lap group [15 (8-114) days vs 17(13– 60) days; P = 0.04], but there was no difference in DS or complication rates between laparoscopic and open surgery. Laparoscopic surgery was associated with significantly lower blood loss [150 (0–840) ml vs. 334 (0-1480) ml; P = 0.02].

Conclusion

Laparoscopic RP is associated with lower blood loss, shorter LOS, but no difference in duration of surgery or complication rate.     

Diagnostic markers in acute appendicitis

Background

An adequate medical history combined with clinical examination is usually enough to make the diagnosis of acute appendicitis. The aim of this study was to determine the value of elevated white cell count (WCC), C-reactive protein (CRP), and bilirubin as diagnostic markers of acute appendicitis.

Methods

A retrospective analysis was carried out on consecutive patients who underwent appendicectomy over a 3-year period. All data including patients' age, sex, blood test results, and appendix histology were summarized. Sensitivities, specificities, positive, and negative predictive values of WCC, CRP, and bilirubin were calculated separately or in combination for all patients.

Results

A total of 447 patients were included. There is a significant difference in the results between patients with negative and positive appendicitis with regards to CRP (32 vs 73; P < .001), mean total WCC (10.9 vs 14.0; P < .001), and the mean levels of bilirubin (10.9 vs 17.2; P < .001).

Conclusions

The diagnosis of appendicitis remains multifactorial and blood tests may help to guide the surgeon in the decision making.     

Plasmakinetic Enucleation of the Prostate Compared with Open Prostatectomy for Prostates Larger Than 100 Grams: A Randomized Noninferiority Controlled Trial with Long-term Results at 6 Years

Background

Studies have demonstrated that plasmakinetic enucleation of the prostate (PKEP) and open prostatectomy (OP) have equivalent short-term efficacy for large prostates, but no comparison concerning their long-term results was reported.

Objective

To demonstrate the noninferiority of PKEP to OP concerning maximum urinary flow rate (Q_max) at 1 yr postoperatively and to compare the long-term results of both procedures.

Design, setting, and participants

From 2004 to 2007, 160 patients with prostates >100 g were randomized to receive PKEP or OP. A total of 153 patients (95.6%) completed the noninferiority study, and 123 patients (76.9%) finished a 6-yr follow-up assessment.

Intervention

The PKEP procedures were performed with 27F Karl Storz continuous flow resectoscopy and the Gyrus PlasmaKinetic device. OP was performed by a suprapubic transvesical approach.

Outcome measurements and statistical analysis

The primary end point was Q_max at 1 yr postoperatively. Secondary end points included other perioperative parameters and postoperative micturition variables. The student t test, Mann-Whitney U test, chi-square test, or Fisher exact probability test was used as appropriate.

Results and limitations

PKEP was noninferior to OP regarding Q_max at 1 yr postoperatively. Compared with OP, PKEP was associated with less perioperative hemoglobin decrease, shorter catheterization time, and shorter postoperative hospital stay (1.0 vs 3.2 g/dl, 40 vs 148 h, and 3 vs 8 d, respectively; p < 0.001 for all), as well as fewer short-term complications (22.5% vs 42.5%, p = 0.031). On intention-to-treat analysis, both the PKEP and OP groups had equivalent Q_max (25.2 ± 7.0 ml/s vs 25.7 ± 7.6 ml/s, respectively; p = 0.688), International Prostate Symptom Score (3.5 [2–5] vs 3 [2–5], respectively p = 0.755), quality of life (2 [1–3] vs 2 [1–3], respectively; p = 0.950), and postvoid residual urine (20 [9–33.5] vs 16.5 [7–31] ml, respectively; p = 0.469) at 72 mo postoperatively. No patients required reoperation because of recurrence of BPH. The relatively small sample size is the limitation.

Conclusions

PKEP is a durable procedure with short- to long-term micturition improvement equivalent to OP and significantly lower perioperative morbidity.

Patient summary

We compared PKEP with OP for large prostates and found that PKEP is less invasive, with short- to long-term micturition improvement equivalent to OP.

Trial registration

Plasmakinetic Enucleation of the Prostate and Open Prostatectomy to Treat Large Prostates. ClinicalTrials.gov identifier NCT01952912. http://www.clinicaltrials.gov/ct2/show/NCT01952912?term=NCT016301952912&rank=1.     

Gender and Age Differences in the Perception of Bother and Health Care Seeking for Lower Urinary Tract Symptoms: Results from the Hospitalised and Outpatients’ Profile and Expectations Study

Background

Few comparisons have been made of health care seeking behaviour for lower urinary tract symptoms (LUTS) between men and women, as well as trends across age groups.

Objective

To investigate the bother from LUTS and effect on health care seeking in both men and women of different age groups and in comparison between the two genders.

Design, setting, and participants

A representative cross section of each of 13 clinics of a general academic hospital, with equal numbers of subjects recruited in each of six design cells that were defined by age (18–40, 41–60, 61–80 yr) and gender.

Intervention

A 2-h in-person interview, conducted by a trained psychologist/interviewer in a clinic office.

Measurements

Severity of LUTS was measured by the International Prostate Symptom Score (IPSS). Treatment seeking was measured by a single item. A bother question was modified to assess overall bother. Impact on quality of life (QoL) was measured by the IPSS QoL question.

Results and limitations

The final study sample comprised 415 patients. More women than men reported the presence of LUTS (85.5% vs 75.2%; p = 0.01). LUTS were more bothersome in women (25.4% of women vs 17.6% of men with bother “some” or “a lot”; p = 0.02). Severity of LUTS increased with age in both genders (men: p < 0.001; women: p = 0.03). Bother from LUTS increased as severity of symptoms increased in both genders (p < 0.001) but was associated with age only in men (p < 0.001). QoL showed similar results as bother. Although men and women had equal prevalence of treatment seeking (27.9% vs 23.7%; p = 0.40), men, but not women, were more likely to seek treatment as age (p < 0.01) and severity of LUTS (p < 0.001) increased. In multivariate logistic regressions, only bother from LUTS was associated with treatment seeking in women, compared with bother, age, and the presence of voiding symptoms in men.

Conclusions

In our hospital-based sample, differences in LUTS frequency, bother, and health care seeking profiles between men and women suggest a different perception and response to LUTS between the two genders.     

Non-operative management of early,acute appendicitis in children: Is it safe and effective?

Purpose

The purpose of this study was to determine if early, acute appendicitis in children can be safely and effectively managed with antibiotics alone.

Methods

A retrospective review was performed of children (< 18 yrs) treated non-operatively (NOM) for early, acute appendicitis since May 2012. These were compared to patients treated with appendectomy between January 2011 and October 2011 (OM). Inclusion criteria included: (a) symptoms < 48 h, (b) localized peritonitis, and (c) ultrasound findings consistent with early, acute appendicitis.

Results

Twelve patients (66% female, mean age 12.2,SD = 4.2 yrs) were treated non-operatively, while 12 (50% female, mean age 12.5,SD = 3.2 yrs) were treated operatively. Two NOM children (16.7%) required initial appendectomy. One patient developed recurrent appendicitis requiring appendectomy 7 months post-discharge. Four other NOM patients returned with symptoms but did not require admission or surgery. Two OM patients (8.3%) had hospital visits and admissions related to surgical site infections. Mean length of stay (LOS) for the first visit was 1.5 days (SD = 1.0d) (NOM) vs. 1.3 days (SD = 0.5d) (OM) (p = 0.61). Including first and subsequent admissions, mean LOS was 1.8 days (SD = 1.1d) (NOM) vs. 1.7 days (SD = 1.5d) (OM) (p = 0.97).

Conclusion

Early acute appendicitis in appropriately selected children can be successfully treated non-operatively. Randomized trials with longer follow-up are required.     

Risk of perforation increases with delay in recognition and surgery for acute appendicitis

Background

Appendicitis remains a common indication for urgent surgical intervention in the United States, and early appendectomy has long been advocated to mitigate the risk of appendiceal perforation. To better quantify the risk of perforation associated with delayed operative timing, this study examines the impact of length of inpatient stay preceding surgery on rates of perforated appendicitis in both adults and children.

Methods

This study was a cross-sectional analysis using the National Inpatient Sample and Kids’ Inpatient Database from 1988–2008. We selected patients with a discharge diagnosis of acute appendicitis (perforated or nonperforated) and receiving appendectomy within 7 d after admission. Patients electively admitted or receiving drainage procedures before appendectomy were excluded. We analyzed perforation rates as a function of both age and length of inpatient hospitalization before appendectomy.

Results

Of 683,590 patients with a discharge diagnosis of appendicitis, 30.3% were recorded as perforated. Over 80% of patients underwent appendectomy on the day of admission, approximately 18% of operations were performed on hospital days 2–4, and later operations accounted for <1% of cases. During appendectomy on the day of admission, the perforation rate was 28.8%; this increased to 33.3% for surgeries on hospital day 2 and 78.8% by hospital day 8 (P < 0.001). Adjusted for patient, procedure, and hospital characteristics, odds of perforation increased from 1.20 for adults and 1.08 for children on hospital day 2 to 4.76 for adults and 15.42 for children by hospital day 8 (P < 0.001).

Conclusions

Greater inpatient delay before appendectomy is associated with increased perforation rates for children and adults within this population-based study. These findings align with previous studies and with the conventional progressive pathophysiologic appendicitis model. Randomized prospective studies are needed to determine which patients benefit from nonoperative versus surgically aggressive management strategies for acute appendicitis.     

Athermal Division and Selective Suture Ligation of the Dorsal Vein Complex During Robot-Assisted Laparoscopic Radical Prostatectomy: Description of Technique and Outcomes

Background

Apical dissection and control of the dorsal vein complex (DVC) affects blood loss, apical positive margins, and urinary control during robot-assisted laparoscopic radical prostatectomy (RALP).

Objective

To describe technique and outcomes for athermal DVC division followed by selective suture ligation (DVC-SSL) compared with DVC suture ligation followed by athermal division (SL-DVC).

Design, settings, and participants

Retrospective study of prospectively collected data from February 2008 to July 2010 for 303 SL-DVC and 240 DVC-SSL procedures.

Surgical procedure

RALP with comparison of DVC-SSL prior to anastomosis versus early SL-DVC prior to bladder-neck dissection.

Measurements

Blood loss, transfusions, operative time, apical and overall positive margins, urine leaks, catheterization duration, and urinary control at 5 and 12 mo evaluated using 1) the Expanded Prostate Cancer Index (EPIC) urinary function scale and 2) continence defined as zero pads per day.

Results and limitations

Men who underwent DVC-SSL versus SL-DVC were older (mean: 59.9 vs 57.8 yr, p < 0.001), and relatively fewer white men underwent DVC-SSL versus SL-DVC (87.5% vs 96.7%, p < 0.001). Operative times were also shorter for DVC-SSL versus SL-DVC (mean: 132 vs 147 min, p < 0.001). Men undergoing DVC-SSL versus SL-DVC experienced greater blood loss (mean: 184.3 vs 175.6 ml, p = 0.033), and one DVC-SSL versus zero SL-DVC were transfused (p = 0.442). Overall (12.2% vs 12.0%, p = 1.0) and apical (1.3% vs 2.7%, p = 0.361) positive surgical margins were similar for DVC-SSL versus SL-DVC. Although 5-mo postoperative urinary function (mean: 72.9 vs 55.4, p < 0.001) and continence (61.4% vs 39.6%, p < 0.001) were better for DVC-SSL versus SL-DVC, 12-mo urinary outcomes were similar. In adjusted analyses, DVC-SSL versus SL-DVC was associated with shorter operative times (parameter estimate [PE] ± standard error [SE]: 16.84 ± 2.56, p < 0.001), and better 5-mo urinary function (PE ± SE: 19.93 ± 3.09, p < 0.001) and continence (odds ratio 3.39, 95% confidence interval 2.07–5.57, p < 0.001).

Conclusions

DVC-SSL versus SL-DVC improves early urinary control and shortens operative times due to fewer instrument changes with late versus early DVC control.