COVID-19 associated infections in the ICU setting: A retrospective analysis in a tertiary-care hospital

IntroductionOur work describes the frequency of superinfections in COVID-19 ICU patients and identifies risk factors for its appearance. Second, we evaluated ICU length of stay, in-hospital mortality and analyzed a subgroup of multidrug-resistant microorganisms (MDROs) infections.MethodsRetrospective study conducted between March and June 2020. Superinfections were defined as appeared ≥48 h. Bacterial and fungal infections were included, and sources were ventilator-associated lower respiratory tract infection (VA-LRTI), primary bloodstream infection (BSI), secondary BSI, and urinary tract infection (UTI). We performed a univariate analysis and a multivariate analysis of the risk factors.ResultsTwo-hundred thirteen patients were included. We documented 174 episodes in 95 (44.6%) patients: 78 VA-LRTI, 66 primary BSI, 9 secondary BSI and 21 UTI. MDROs caused 29.3% of the episodes. The median time from admission to the first episode was 18 days and was longer in MDROs than in non-MDROs (28 vs. 16 days, p < 0.01). In multivariate analysis use of corticosteroids (OR 4.9, 95% CI 1.4–16.9, p 0.01), tocilizumab (OR 2.4, 95% CI 1.1–5.9, p 0.03) and broad-spectrum antibiotics within first 7 days of admission (OR 2.5, 95% CI 1.2–5.1, p < 0.01) were associated with superinfections. Patients with superinfections presented respect to controls prolonged ICU stay (35 vs. 12 days, p < 0.01) but not higher in-hospital mortality (45.3% vs. 39.7%, p 0.13).ConclusionsSuperinfections in ICU patients are frequent in late course of admission. Corticosteroids, tocilizumab, and previous broad-spectrum antibiotics are identified as risk factors for its development.     

Robotic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: Analysis of surgical outcomes and long-term prognosis in a high-volume center

Background: Robotic pancreaticoduodenectomy(RPD) has been reported to be safe and feasible for patients with pancreatic ductal adenocarcinoma(PDAC) of the pancreatic head. This study aimed to analyze the surgical outcomes and risk factors for poor long-term prognosis of these patients. Methods: Data from patients who underwent RPD for PDAC of pancreatic head were retrospectively analyzed. Multivariate Cox regression analysis was used to seek the independent prognostic factors for overall surviva...     

Off-label use of intrabronchial valves for persistent air leak is safe and effective: a retrospective case analysis

BackgroundPersistent air leak (PAL) is a challenging clinical problem associated with prolonged hospital stay and increased morbidity. Historically, treatment options were limited to thoracostomy tube drainage, pleurodesis, and surgical repair. The development of one-way airway valves has represented a paradigm shift in PAL management. We present our experience using intrabronchial valves (IBVs) for PAL management looking at both on-label (post-thoracic surgery) and off-label (all other) indications.MethodsWe performed a retrospective review of our single-center experience. Data collected included demographics, primary pathology leading to PAL, comorbidities, time to chest tube removal, complications, mortality, need for any additional procedure, and time to IBV removal.ResultsDuring the study period, 15 patients underwent IBV insertion for PAL. The on-label cohort contained three patients (post lobectomy or segmentectomy). The off-label cohort had 12 patients (6 empyema, 4 secondary spontaneous pneumothorax, 1 penetrating trauma, and 1 post percutaneous lung nodule biopsy). In the on-label cohort, chest tube was removed after a mean duration of 4.0±1.0 days for all patients. In the off-label cohort, 83.3% (10/12) had chest tube removal 16.2±5.7 days (P=0.396) after IBV placement. One patient developed hypoxic respiratory failure shortly after IBV insertion, necessitating removal of 2 out of 5 valves.ConclusionsIBVs are a minimally invasive, well tolerated treatment modality for patients with PAL and a viable alternative to invasive surgical interventions. Procedure or valve-related complications are uncommon. Valves can be removed and do not preclude surgical intervention. Updated guidelines are necessary to formalize PAL management.     

Ultrasound-guided dorsal penile nerve block is a safe block in hypospadias surgery: A retrospective clinical study

Caudal and dorsal penile nerve blocks are commonly used regional anesthesia methods in hypospadias surgery. Some studies have reported that regional anesthesia methods are risk factor for the development of postoperative complications following hypospadias surgery. The aim of the current study is to evaluate the relationship between postoperative complications and regional anesthesia methods used in distal hypospadias surgery.Forty-nine distal hypospadias patients were included. Patients had either received caudal or ultrasound (US)-guided dorsal penile nerve block. The age, type of hypospadias, regional anesthesia method, operation time, and postoperative complications were recorded. Fisher exact test and Mann–Whitney U tests were used to compare the data.Caudal epidural block was used in 25 (51%) patients and US-guided dorsal penile nerve block in 24 (49%) patients. There was no statistically significant difference between the groups regarding the types of hypospadias, operation time, and age. Fistula developed in 4 (16%) patients in the caudal block group and in none of the patients in the dorsal penile nerve block group. Fistula rates were statistically significantly different between the groups (P = .030).Conflicting data are found in the literature on the long-term postoperative complications of the regional anesthesia techniques used in hypospadias surgery. In our study, all patients with urethrocutaneous fistula were in the caudal block group. We believe that our study will contribute to the literature as it is the only study comparing caudal block with US-guided dorsal penile nerve block using in-plane technique in terms of postoperative complications in hypospadias surgery.     

Assessment of health care cost for complex surgical patients: review of cost,re-imbursement and revenue involved in pancreatic surgery at a high-volume academic medical centre

BackgroundPancreatic surgery is complex with the potential for costly hospitalization.MethodsA retrospective review of patients undergoing a pancreatic resection was performed.ResultsThe median age of the study population was 64 years. Half of the cohort was female (51%), and the majority were white (62%). Most patients underwent a pancreaticoduodenectomy (PD) (69%). The pre-operative age-adjusted Charlson comorbidity index was zero for 36% (n = 50), 1 for 31% (n = 43) and ≥2 for 33% (n = 45). The Clavien–Dindo grading system for post-operative complication was grade I in 17% (n = 24), whereas 45% (n = 62) were higher grades. The medians direct fixed, direct variable, fixed indirect and total costs were $2476, $15 397, $13 207 and $31 631, respectively. There was a positive contribution margin of $7108, whereas the net margin was a loss of $6790. On univariate analyses, age, type of operation and complication grade were associated with total cost (P ≤ 0.05), whereas operation type and complication grade were associated with a net margin (P = 0.01). These findings remained significant on multivariate analysis (P < 0.05).ConclusionsIncreased cost, reimbursement and revenue were associated with type of operation and post-operative complications.     

Distribution of patients between faculty and residents in a teaching hospital clinic

The authors tried to determine whether housestaff are systematically assigned clinic patients who are more "difficult": the elderly, the poor, those with many problems, and those who cannot speak English. This cross-sectional study was carried out in the outpatient department of a university health care insurance. A systematic sample of 1,870 patient visits to the medical clinic from 1980 to 1986 was studied. Housestaff were more likely to see patients who did not speak English, who had four or more medical problems, who had visited the clinic five or more times, who had been admitted to the hospital or emergency ward, or who had a skin problem. Multivariate analysis of these individual factors, allowing for the effect of each upon the others, showed that only previous hospital or emergency ward admission, native language, and skin disease retained a significant association with housestaff physicians. None of these factors was strongly associated with physician status, as shown by poor predictive accuracy when the multivariate models were used to predict accuracy when the multivariate models were used to predict physician status in 105 patient visits in 1987. While some factors were statistically associated with physician status, the magnitude of the effect of each was small. An explantation, other than bias in patient assignment, was usually apparent. It is possible to organize an outpatient clinic where housestaff care for patients who are similar to those seen by faculty.     

Short- and long-term outcomes of robotic-assisted laparoscopic surgery for rectal cancer: results of a single high-volume center in Japan

Purpose

Scientific evidence supporting robotic-assisted laparoscopic surgery (RALS) for rectal cancer remains inconclusive because most previous reports were retrospective case series or case-control studies, with few reports focusing on long-term oncological outcomes with a large volume of patients. The aim of this study was to clarify the short- and long-term outcomes of a large number of consecutive patients with rectal cancer who underwent RALS in a single high-volume center.

Methods

The records of 551 consecutive patients who underwent RALS for rectal adenocarcinoma between December 2011 and March 2017 were examined to reveal the short-term outcomes. The oncological outcomes of the 204 patients who underwent surgery between December 2011 and March 2014 were evaluated.

Results

Most patients had tumors located in the lower or mid-rectum (86.0%). Only 7.6% of patients underwent neoadjuvant chemoradiotherapy. Lateral lymph node dissection was performed for 191 patients (34.7%). The median operative time was 257 min, median blood loss was 10 mL, and no transfusions were needed. No conversion to open surgery was necessary. Eighteen patients (3.3%) had Clavien-Dindo grade III postoperative complications. Six patients (1.1%) had positive resection margins. The mean follow-up duration of the 204 patients was 43.6?±?9.8 (months). The 5-year cancer-specific survival rate for stage I/II/III/IV was 100%/100%/100%/not reached, respectively. The 5-year relapse-free survival rate for stage I/II/III/IV was 93.6%/75.0%/77.6%/ not reached, respectively. The rate of local recurrence was 0.5%.

Conclusions

Our results suggest that RALS is technically feasible for rectal cancer and has good short- and long-term outcomes.

     

Adult cardiac surgery during COVID-19 lockdown: Impact on activity and outcomes in a high-volume centre

Central illustration. Impact of coronavirus disease 2019 (COVID-19) on adult cardiac surgery activity.

     

Long-term outcomes and life quality in the elderly after cardiac surgery:A single-center retrospective analysis

Background In the past of China,both doctors and patients have historically been reluctant to pursue cardiac surgery in the elderly because of various reasons. Nowadays,this situation is changing. However,few studies have been performed to assess quality of life(QoL)in elderly patients after cardiac surgery in China. In this study,we evaluated long-term surgical outcomes and QoL and identified the factors associated with each in elderly patients who underwent cardiac surgery. Methods We recruited 320 patients aged ≥70 years old who underwent cardiac surgery in our hospital from January 2003 to December 2018. Risk factors for mortality were identified using a logistic regression analysis. Among survivors,QoL was assessed using the Short Form 36,and the results were compared to those in an age-matched population cohort in China. Results Overall hospital mortality was 7.2%. However,it has dropped to 3.7% in the last five years. The 1-,3-,5-,and 10-year survival rates were 95.5%,85.7%,74.7%,and 30.5%,respectively. Cardiopulmonary bypass time and Euro SCOREs significantly predicted in-hospital mortality. Chronic pulmonary disease was the only risk factor for long-term mortality. Scores for bodily pain and role emotional were significantly higher in our population than in the general Chinese aged population. However,scores were lower for physical functions and vitality in our population than in the controls. Conclusions Cardiac surgery in elderly patients (≥70 years old)can have low in-hospital mortality,excellent long-term survival and high QoL,which are associated with comprehensive preoperative evaluation assesses and excellent perioperative management and post-surgery cardiac rehabilitation.[S Chin J Cardiol 2019;20(3):182-189]     

Laparoendoscopic single-site surgery versus conventional laparoscopic surgery for adnexal tumors: a comparison of surgical outcomes and postoperative pain outcomes

The objective of this study was to show the feasibility of laparoendoscopic single-site surgery (LESS) by comparing the surgical outcomes and postoperative pain of LESS with conventional laparoscopic surgery (CLS) for gynecologic adnexal tumor. This is a prospective case-control study. We enrolled 33 patients-one in 18 patients for LESS and the other in 15 patients for CLS-who were diagnosed with evident adnexal tumor consecutively from September 2009 to February 2010 and were performed by a single surgeon. In LESS, all procedures were performed successfully without any case of conversion to CLS. There were no differences in the demographic characteristics between the two groups. The pathological findings were similar in both groups; a mucinous cystadenoma was the most common pathological feature. The most common operative type performed was cystectomy (22/33, 66%). There were no differences between the LESS and CLS groups in median operation time (62.8 minute vs. 51.3 minutes, p=0.073); estimated blood loss during operation (100 mL vs. 128 mL, p=0.068); and postoperative pain intensity measured by visual analog scale. There were no major complications in either group, including operative wound complications. Our study suggested that LESS for adnexal tumor is a feasible surgical technique through the comparable data of the surgical outcomes and postoperative pain outcomes.     

Diagnosis and tactical approach to surgery for early gastric carcinoma: a retrospective analysis of the past 16 years in an Austrian general hospital

In principle, many authors advocate a radical surgical approach for early gastric cancer (gastrectomy on principle). Our own experience with subtotal gastrectomy (including N1 + N2 lymphadenectomy; limited resection even without groups 11, 12) shows that this method yields comparable results. With an operative mortality of 2%, the survival rate was 84.3% after 5 years and 70.5% after 10 years, instead of the predicted values of 82.8% and 63.4%, respectively. Applied to the same age group without gastric carcinoma, this yields a 5-year survival rate of 101.8% and thus almost reaches Japanese standards.