Operative management of colonic diverticular disease in the setting of immunosuppression: A systematic review and meta-analysis

BackgroundImmunosuppressed patients with diverticular disease are at higher risk of postoperative complications, however reported rates have varied. The aim of this study is to compare postoperative outcomes in immunosuppressed and immunocompetent patients undergoing surgery for diverticular disease.MethodsMedline, EMBASE, and CENTRAL were searched. Articles were included if they compared immunosuppressed and immunocompetent patients undergoing surgery for diverticular disease.ResultsFrom 204 citations, 11 studies with 2,977 immunosuppressed patients and 780,630 immunocompetent patients were included. Mortality was greater in immunosuppressed patients compared to immunocompetent patients for emergent surgery (RR 1.91, 95%CI 1.24–2.95, p < 0.01), but not elective surgery (RR 1.70, 95%CI 0.14–20.47, p = 0.68). Morbidity was greater in immunosuppressed patients compared to immunocompetent patients for elective surgery (RR 2.18, 95%CI 1.02–4.65, p = 0.04), but not emergent surgery (RR 1.40, 95%CI 0.68–2.90, p = 0.37).ConclusionsIncreased consideration for elective operation may preclude the need for emergent surgery and the associated increase in postoperative mortality.     

Elective surgery for diverticular disease in U.S. veterans: A VASQIP study of national trends and outcomes from 2004 to 2018

BackgroundTreatment for diverticular disease has evolved over time. In the United States, there has been a trend towards minimally invasive surgical approaches and fewer postoperative complications, but no study has investigated this subject in the Veterans Health Administration.MethodsThis retrospective review identified patients undergoing elective surgery for diverticular disease from 2004 to 2018. Demographics, comorbidities, operative approach, rates of ostomy creation, and 30-day outcomes were compared. The 15-year time period was divided into 3-year increments to assess changes over time.Results4198 patients were identified. Complication rate decreased significantly over time (28.1%–15.7%, p < 0.001), as did infectious complications (21.5–6.3%, p < 0.001). Median hospital length-of-stay decreased from 7 to 5 days (p < 0.001). Rates of laparoscopic surgery increased over time (17.7%–48.1%, p < 0.001).ConclusionsIncreased utilization of laparoscopy in veterans undergoing elective surgery for diverticular disease coincided with fewer complications and a shorter length-of-stay. These trends mirror outcomes reported in non-veterans.     

There is no increased risk for colorectal cancer and adenomas in patients with diverticulitis: a retrospective longitudinal study

Aim This study was designed to assess the relationship between diverticulitis and the development of colorectal cancer (CRC) and colonic adenomas. Method A retrospective study was longitudinally conducted. Patients who had been admitted to the hospital between 1990 and 2000 with diverticulitis were retrieved and the incidence of CRC and prevalence of colonic adenomas in these patients was determined. Data were collected from the electronic clinical and pathology records. The incidence of CRC and prevalence of adenomas in this patient cohort was compared with the general population. The patients were followed until 2008. Results A total of 288 patients with diverticulitis were included (167 of whom were female patients [58%]). The mean age of patients at admittance for diverticulitis was 66 years (range: 27–92). CRC was detected in five patients (1.7%) (95% CI 0.8–3.5) with a mean age of 77 years; colonic adenomas were found in 18 patients (6.3%) (95% CI 4.3–9.0) with a mean age of 62 years. The lifetime risks of developing CRC and adenomas were presumed to be 4% and 20% respectively. Expected rates for CRC and adenomas in our patients were calculated as 17 (95% CI 4.0–8.6) and 69 patients (95% CI 20.1–28.3) respectively. Conclusion This study showed a lower prevalence of CRC and colonic adenomas in patients with diverticulitis compared with the lifetime risk which means that diverticulitis is not a risk factor for development of CRC and adenomas. Long‐term colonic screening after a negative colonoscopy for diverticulitis (generally performed several weeks after recovery) does not seem to be justified.     

Assessment and documentation of non‐healing,chronic wounds in inpatient health care facilities in the Czech Republic: an evaluation study

The foundation of health care management of patients with non‐healing, chronic wounds needs accurate evaluation followed by the selection of an appropriate therapeutic strategy. Assessment of non‐healing, chronic wounds in clinical practice in the Czech Republic is not standardised. The aim of this study was to analyse the methods being used to assess non‐healing, chronic wounds in inpatient facilities in the Czech Republic. The research was carried out at 77 inpatient medical facilities (8 university/faculty hospitals, 63 hospitals and 6 long‐ term hospitals) across all regions of the Czech Republic. A mixed model was used for the research (participatory observation including creation of field notes and content analysis of documents for documentation and analysis of qualitative and quantitative data). The results of this research have corroborated the suspicion of inconsistencies in procedures used by general nurses for assessment of non‐healing, chronic wounds. However, the situation was found to be more positive with regard to evaluation of basic/fundamental parameters of a wound (e.g. size, depth and location of a wound) compared with the evaluation of more specific parameters (e.g. exudate or signs of infection). This included not only the number of observed variables, but also the action taken. Both were significantly improved when a consultant for wound healing was present (P = 0·047). The same applied to facilities possessing a certificate of quality issued by the Czech Wound Management Association (P = 0·010). In conclusion, an effective strategy for wound management depends on the method and scope of the assessment of non‐healing, chronic wounds in place in clinical practice in observed facilities; improvement may be expected following the general introduction of a ‘non‐healing, chronic wound assessment’ algorithm.     

Education and process change to improve skin health in a residential aged care facility

We report on an intervention and evaluation in relation to changes in staff knowledge, time spent on healing and wound prevention and proportion of wounds in the facilities before and after. A rapid review of recent peer‐reviewed literature (2006–2016) found 14 education‐based intervention articles and provided the background and context for this intervention. A cohort of 164 nurses and personal care workers and 261 residents at two aged care‐approved facilities contributed to this intervention on the effect of education, mentoring and practice change on staff knowledge and wound prevalence between 2015 and 2016. There was a significant decrease in pressure injury prevalence and an increase in the early identification of potential wounds between phase 1 and 3 across the two facilities. Overall, registered nurses and enrolled nurses showed significant increase in mean knowledge scores. There was a reorganisation of time spent on various wound care and prevention strategies that better represented education and knowledge. Wound management or prevention education alone is not enough; this study, using an educational intervention in conjunction with resident engagement, practice change, mentorship, onsite champions for healthy skin and product choice suggestions, supported by an organisation that focuses on a healthy ageing approach, showed improvement across two residential sites.     

Perioperative atrial arrhythmias in noncardiothoracic patients: a review of risk factors and treatment strategies in the veteran population

Background

Perioperative atrial arrhythmias (PAAs) in noncardiothoracic patients have poorly defined risk factors and management.

Methods

The surgical intensive care unit database was queried for patients who developed PAAs from 2008 to 2009. Demographics, comorbidities, preoperative data (electrocardiography, chest x-rays, laboratory results), medications, intraoperative variables, management, and outcomes of atrial arrhythmias were collected. Controls were randomly chosen in a 3:1 ratio. Comparisons were performed using χ² tests, Student's t tests, or nonparametric comparisons as appropriate. Multivariate logistic regression was performed.

Results

Five hundred sixty-one patients were admitted to the surgical intensive care unit. Three hundred fifty-four (63%) had noncardiothoracic surgery, and 30 (8.5%) developed PAAs. The mean age of patients with PAAs was 66 ± 7.3 years, compared with 64 ± 11 years for controls (P = NS), with most patients undergoing general (60%) and vascular (33%) surgery. PAA patients were more likely to have coronary artery disease (P = .029), cardiomegaly (P = .011), and premature atrial contractions (P = .016) and to take aspirin (P = .010). On multivariate logistic regression, predictors of atrial arrhythmias were premature atrial contractions, preoperative hypokalemia, intraoperative adverse events, and cardiomegaly. Most PAA patients received amiodarone (63%). Ten percent required electrical cardioversion, and 26% received anticoagulation. PAA patients had significantly longer intensive care unit lengths of stay (P = .032).

Conclusion

Coronary artery disease, cardiomegaly, hypokalemia, and premature atrial contractions were significantly associated with PAAs in noncardiothoracic patients. Prospective studies are needed to define treatment guidelines.     

Prevalence of chronic kidney disease and end-stage renal disease in a bariatric versus nonbariatric population: a retrospective analysis of the U.S. National Inpatient Sample database

BackgroundIn the past five 5 years our team has studied the effects of bariatric surgery on chronic kidney disease (CKD) at our institution.ObjectivesThe objective of this study was to assess the impact of bariatric surgery (BaS) on the prevalence and likelihood of CKD and end-stage renal disease (ESRD) nationwide.SettingAcademic hospital, United States.MethodsWe conducted a retrospective analysis of the U.S. National Inpatient Sample (NIS) database for the years 2010–2015 and compared. Univariate and multivariable analysis were performed to assess the impact of BaS on the point prevalence and the probability of CKD and ESRD. Similarly, a multivariable logistic regression was conducted to measure the impact of the most important risk factors for CKD exclusively in a severely obese population.ResultsData on 296,041 BaS cases and 2,004,804 severely obese controls was extracted from the NIS database and relative to controls, all baseline CKD risk factors were less common among bariatric surgery cases. Nonetheless, even after adjusting for all CKD risk factors, controls exhibited marked increases in the odds of CKD-stage III (odds ratio [OR] 3.10 [3.05–3.14], P < .0001) and modes increase for ESRD (OR 1.13 [1.09–1.18], P < .0001). Overall, even after adjusting for risk factors we observed that the rate of CKD is significantly higher in the control group, 12% when compared with 5.3% in the bariatric surgery group (P < .0001).ConclusionIn this retrospective, case control study of a large, representative national sample of patients with severe obesity, BaS was found to be associated with significantly reduced point-prevalence and likelihood for CKD when adjusted for baseline CKD risk factors as compared with patients with obesity who did not undergo BaS. Overall, BaS resulted in a reduced rate and a moderate decrease in the likelihood of ESRD.     

Late initiation of combination antiretroviral therapy in Canada: a call for a national public health strategy to improve engagement in HIV care

Introduction

Combination antiretroviral therapy (ART) significantly decreases morbidity, mortality and HIV transmission. We aimed to characterize the timing of ART initiation based on CD4 cell count from 2000 to 2012 and identify factors associated with late initiation of treatment.

Methods

Participants from the Canadian Observational Cohort (CANOC), a multi-site cohort of HIV-positive adults initiating ART naively after 1 January 2000, in three Canadian provinces (British Columbia, Ontario and Québec) were included. Late initiation was defined as a CD4 count <200 cells/mm³ or an AIDS-defining illness before ART initiation (baseline). Temporal trends were assessed using the Cochran–Armitage test, and independent correlates of late initiation were identified using logistic regression.

Results

In total, 8942 participants (18% female) of median age 40 years (Q1–Q3 33–47) were included. The median baseline CD4 count increased from 190 cells/mm³ (Q1–Q3 80–320) in 2000 to 360 cells/mm³ (Q1–Q3 220–490) in 2012 (p<0.001). Overall, 4274 participants (48%) initiated ART with a CD4 count <200 cells/mm³ or AIDS-defining illness. Late initiation was more common among women, non-MSM, older individuals, participants from Ontario and BC (vs. Québec), persons with injection drug use (IDU) history and individuals starting ART in earlier calendar years. In sub-analysis exploring recent (2008 to 2012) predictors using an updated CD4 criterion (<350 cells/mm³), IDU and residence in BC (vs. Québec) were no longer significant correlates of late initiation.

Conclusions

This analysis documents increasing baseline CD4 counts over time among Canadians initiating ART. However, CD4 counts at ART initiation remain below contemporary treatment guidelines, highlighting the need for strategies to improve earlier engagement in HIV care.     

Association between renal mass biopsy and upstaging to perinephric fat involvement in a contemporary cohort of patients with clinical T1a renal cell carcinoma

Background

Although tumor tract seeding from renal mass biopsy (RMB) is exceedingly rare, the possibility of tumor capsule violation from RMB leading to perinephric fat invasion has not been quantified. We evaluated the association between RMB and perinephric fat invasion in patients with clinical T1a renal cell carcinoma who underwent partial or radical nephrectomy.

Revealing geographical and population heterogeneity in HIV incidence,undiagnosed HIV prevalence and time to diagnosis to improve prevention and care: estimates for France

Introduction

To close gaps in HIV prevention and care, knowledge about locations and populations most affected by HIV is essential. Here, we provide subnational and sub‐population estimates of three key HIV epidemiological indicators, which have been unavailable for most settings.

Methods

We used surveillance data on newly diagnosed HIV cases from 2004 to 2014 and back‐calculation modelling to estimate in France, at national and subnational levels, by exposure group and country of birth: the numbers of new HIV infections, the times to diagnosis, the numbers of undiagnosed HIV infections. The denominators used for rate calculations at national and subnational levels were based on population size (aged 18 to 64) estimates produced by the French National Institute of Statistics and Economic Studies and the latest national surveys on sexual behaviour and drug use.

Results

We estimated that, in 2014, national HIV incidence was 0.17‰ (95% confidence intervals (CI): 0.16 to 0.18) or 6607 (95% CI: 6057 to 7196) adults, undiagnosed HIV prevalence was 0.64‰ (95% CI: 0.57 to 0.70) or 24,197 (95% CI: 22,296 to 25,944) adults and median time to diagnosis over the 2011 to 2014 period was 3.3 years (interquartile range: 1.2 to 5.7). Three mainland regions, including the Paris region, out of the 27 French regions accounted for 56% of the total number of new and undiagnosed infections. Incidence and undiagnosed prevalence rates were 2‐ to 10‐fold higher than the national rates in three overseas regions and in the Paris region (p‐values < 0.001). Rates of incidence and undiagnosed prevalence were higher than the national rates for the following populations (p‐values < 0.001): born‐abroad men who have sex with men (MSM) (respectively, 108‐ and 78‐fold), French‐born MSM (62‐ and 44‐fold), born‐abroad persons who inject drugs (14‐ and 18‐fold), sub‐Saharan African‐born heterosexuals (women 15‐ and 15‐fold, men 11‐ and 13‐fold). Importantly, affected populations varied from one region to another, and in regions apparently less impacted by HIV, some populations could be as impacted as those living in most impacted regions.

Conclusions

In France, some regions and populations have been most impacted by HIV. Subnational and sub‐population estimates of key indicators are not only essential to adapt, design implement and evaluate tailored HIV interventions in France, but also elsewhere where similar heterogeneity is likely to exist.

     

Epilepsy surgery in children: from a multidisciplinary network to the creation of an expertise and care centre

We report on the experience of a network created in 1994 to evaluate children with drug-resistant epilepsies who are candidates for surgical treatment. The network includes epilepsy units from several university hospitals in France that decided to share not only their clinical expertise to better respond to the need for a multidisciplinary approach of epilepsy surgery in children, but also all the technical and human resources available in the various teams. This mode of operation has certainly provided concrete proof of its efficacy since it undoubtedly facilitated, and even accelerated, access to optimal presurgical evaluation and epilepsy surgery for hundreds of children. However, after 10 years of this very enriching practice it became evident that our approach was certainly necessary but not sufficient. It is estimated that every year in France nearly 500 children are candidates for surgical treatment, and following a presurgical evaluation, 50% of them could be operated on. Today, only 150-200 children have access to a presurgical evaluation every year. This is a highly paradoxical situation since, even if the human suffering component that such a situation generates is set aside, the direct and indirect life-time costs for every 100 nonoperated patients is estimated at 40 million euros. As a result of our cumulated experience, in 2004 we proposed a different operating model with the creation of an expertise center that will combine not only medical care services provided by a fully equipped multidisciplinary team, but also a pole of applied clinical and fundamental research, a medicosocial center managed by a lay association and an industrial development pole. The project has been recently validated by the Ministry of Health and is supported by a number of national and regional institutions. The Institute for Children and Adolescents with Epilepsy--IDEE--is designed to accelerate diagnostic procedures and, when indicated, access to optimal presurgical evaluation, while also serving as a model for a medical and economic evaluation of epilepsy care in children.     

Surgical treatment strategies and outcome in patients with breast cancer metastatic to the spine: a review of 87 patients

Aggressive surgical management of spinal metastatic disease can provide improvement of neurological function and significant pain relief. However, there is limited literature analyzing such management as is pertains to individual histopathology of the primary tumor, which may be linked to overall prognosis for the patient. In this study, clinical outcomes were reviewed for patients undergoing spinal surgery for metastatic breast cancer. Respective review was done to identify all patients with breast cancer over an eight-year period at a major cancer center and then to select those with symptomatic spinal metastatic disease who underwent spinal surgery. Pre- and postoperative pain levels (visual analog scale [VAS]), analgesic medication usage, and modifed Frankel grade scores were compared on all patients who underwent surgery. Univariate and multivariate analyses were used to assess risks for complications. A total of 16,977 patients were diagnosed with breast cancer, and 479 patients (2.8%) were diagnosed with spinal metastases from breast cancer. Of these patients, 87 patients (18%) underwent 125 spinal surgeries. Of the 76 patients (87%) who were ambulatory preoperatively, the majority (98%) were still ambulatory. Of the 11 patients (13%) who were nonambulatory preoperatively, four patients were alive at 3 months postoperatively, three of which (75%) regained ambulation. The preoperative median VAS of six was significantly reduced to a median score of two at the time of discharge and at 3, 6, and 12 months postoperatively (P < 0.001 for all time points). A total of 39% of patients experienced complications; 87% were early (within 30 days of surgery), and 13% were late. Early major surgical complications were significantly greater when five or more levels were instrumented. In patients with spinal metastases specifically from breast cancer, aggressive surgical management provides significant pain relief and preservation or improvement of neurological function with an acceptably low rate of complications.     

30 years of polytrauma care: An analysis of the change in strategies and results of 4849 cases treated at a single institution

The quality and progress of treatment of 4849 multiple trauma patients treated at one institution was reviewed retrospectively. Three periods, 1975-1984 (decade I; n = 1469) and 1985-1994 (decade II; n = 1937) and 1995-2004 (decade III; n = 1443) were compared.65% of multiple trauma patients had cerebral injuries, 58% thoracic trauma and 81% extremity fractures (37% open injuries). Injury combinations decreased during all decades with head/extremity injuries being the most common combination. Throughout the three decades pre-hospital care became more aggressive with an increase of intravenous fluid resuscitation (I: 80%, II: 97%, III: 98%). Chest tube insertion decreased after an initial increase (I: 41%, II: 83%, III: 27%) as well as intubation (I: 82%, II: 94%, III: 59%). Rescue times were progressively shortened. For initial clinical diagnosis of massive abdominal haemorrhage ultrasound (I: 17%, II: 92%, III: 97%) replaced peritoneal lavage (I: 44%, II: 28%, III: 0%). CT-scans were used more frequently for the initial diagnosis of head injuries and other injuries to the trunk throughout the observation time. With regard to complications, acute renal failure decreased by half (I: 8.4%; II: 3.7%; III: 3.9%), ARDS initially decreased but increased again in the last decade (I: 18.1%, II: 13.4%, III: 15.3%), whereas the rate of multiple organ dysfunction syndrome (MODS) increased continuously (I: 14.2%, II: 18.9%, III: 19.8%) probably due to a decline of the mortality rate from 37% in the first to 22% in the second and 18% in the third decade and parallel increase of the time of death.These treatment results summarise the enormous clinical effort as well as medical progress in polytrauma management over the past 30 years. Further reduction of mortality is desirable, but probably only possible when immediate causal therapy of later posttraumatic organ failure can be established.     

Pressure by design: How to improve the consistency of pressure garments in the clinical environment and implement a simple method for gathering evidence to establish efficacy

Pressure garments are used to treat scars after major trauma including burns. However, the ideal pressure for treatment is not known. Pressures exerted are not routinely measured and garments exert a wide range of pressures. Therefore, current treatment and its efficacy are variable.Pressure Garment Design Tools were introduced in 2012 but their application in hospitals has not been reported. A Garment Dimension and Pressure Calculator was used to audit pressures delivered by 8 pressure garments made for children using the hospital department’s standard reduction factor. The tool was easy to use and showed that pressures exerted by standard garments ranged from 15 to 54 mmHg with highest pressures exerted on wrists.Results of our pilot study indicated that the Garment Dimension and Pressure Calculator was slightly quicker to use than our normal manual process for calculating garment dimensions and enabled easy auditing of past treatment. The Pressure Garment Design Tool was easy to use and calculated garments that exerted the mean target pressures of 15 mmHg and 25 mmHg, improving consistency.Pressures exerted by garments were difficult and time consuming to measure with the Picopress sensor. Pressure was not distributed evenly around the limbs and measurements were inaccurate on the smallest limbs.     

Clinical and economic burden of wound care in the tropics: a 5‐year institutional population health review

The aim of this study is to evaluate the clinical and economic burden of wound care in the Tropics via a 5‐year institutional population health review. Within our data analysis, wounds are broadly classified into neuro‐ischaemic ulcers (NIUs), venous leg ulcers (VLUs), pressure injuries (PIs), and surgical site infections (SSIs). Between 2013 and 2017, there were a total of 56 583 wound‐related inpatient admissions for 41 461 patients, with a 95.1% increase in wound episodes per 1000 inpatient admissions over this period (142 and 277 wound episodes per 1000 inpatient admissions in 2013 and 2017, respectively). In 2017, the average length of stay for each wound episode was 17.7 days, which was 2.4 times that of an average acute admission at our institution. The average gross charge per wound episode was USD $12 967. Among the 12 218 patients with 16 674 wound episodes in 2017, 71.5% were more than 65 years of age with an average Charlson Comorbidity Index (CCI) of 7.2. Half (51.9%) were moderately or severely frail, while 41.3% had two or more wound‐related admission episodes. In 2017, within our healthcare cluster, the gross healthcare costs for all inpatient wound episodes stand at USD $216 million within hospital care and USD $596 000 within primary care. Most NIU patients (97.2%) had diabetes and they had the most comorbidities (average CCI 8.4) and were the frailest group of patients (44.9% severely frail). The majority of the VLU disease burden was at the specialist outpatient setting, with the average 1‐year VLU recurrence rate at 52.5% and median time between healing and recurrence at 9.5 months. PI patients were the oldest (86.5% more than 65 years‐old), constituted the largest cohort of patients with 3874 patients at an incidence of 64.6 per 1000 admissions in 2017, and have a 1‐year all‐cause mortality rate of 14.3%. For SSI patients, there was a 125% increase of 14.2 SSI wound episodes per 1000 inpatient admissions in 2013 to 32.0 in 2017, and a 413% increase in wound‐related 30‐day re‐admissions, from 40 in 2013 (4.1% of all surgeries) to 205 (8.3% of all surgeries) in 2017. The estimated gross healthcare cost per patient ranges from USD $15789–17 761 across the wound categories. Similar to global data, there is a significant and rising trend in the clinical and economic burden of wound care in Tropics.     

Transitions in care from pediatric to adult general surgery: Evaluating an unmet need for patients with anorectal malformation and Hirschsprung disease

Background

The provision of timely and comprehensive transition of care from pediatric to adult surgical providers for patients who have undergone childhood operations remains a challenge. Understanding the barriers to transition from a patient and family perspective may improve this process.