Predictors of mortality and cost among surgical patients requiring rapid response team activation

BackgroundPrior studies of rapid response team (RRT) implementation for surgical patients have demonstrated mixed results with respect to reductions in poor outcomes. The aim of this study was to identify predictors of in-hospital mortality and hospital costs among surgical inpatients requiring RRT activation.MethodsWe analyzed data prospectively collected from May 2012 to May 2016 at The Ottawa Hospital. We included patients who were at least 18 years of age, who were admitted to hospital, who received either preoperative or postoperative care, and and who required RRT activation. We created a multivariable logistic regression model to describe mortality predictors and a multivariable generalized linear model to describe cost predictors.ResultsWe included 1507 patients. The in-hospital mortality rate was 15.9%. The patient-related factors most strongly associated with mortality included an Elixhauser Comorbidity Index score of 20 or higher (odds ratio [OR] 3.60, 95% confidence interval [CI] 1.96–6.60) and care designations excluding admission to the intensive care unit and cardiopulmonary resuscitation (OR 3.52, 95% CI 2.25–5.52). The strongest surgical predictors included neurosurgical admission (OR 2.09, 95% CI 1.17–3.75), emergent surgery (OR 2.04, 95% CI 1.37–3.03) and occurrence of 2 or more operations (OR 1.73, 95% CI 1.21–2.46). Among RRT factors, occurrence of 2 or more RRT assessments (OR 2.01, 95% CI 1.44–2.80) conferred the highest mortality. Increased cost was strongly associated with admitting service, multiple surgeries, multiple RRT assessments and medical comorbidity.ConclusionRRT activation among surgical inpatients identifies a population at high risk of death. We identified several predictors of mortality and cost, which represent opportunities for future quality improvement and patient safety initiatives.     

Anti–Trypanosoma cruzi effect of the photodynamic antiparasitic chemotherapy using phenothiazine derivatives as photosensitizers

Lasers in Medical Science - Chagas disease is endemic in Latin America and increasingly found in non-endemic countries. Its treatment is limited due to the variable efficacy and several side...     

Tocilizumab use in Kidney Transplant Patients with COVID-19

A potential benefit of immunomodulatory agents such as tocilizumab (TCZ) has been reported in patients with coronavirus disease 2019 (COVID-19) and severe pulmonary involvement. However, this therapy has been scarcely studied in kidney transplant (KT) recipients. Herein, we describe the clinical course and outcome of 10 KT patients with severe COVID-19 that were treated with TCZ. Mean age of the study group was 54 ± 10 years (70% females), and 30% of the cases were within 6 months from transplant. Mycophenolate mofetil was discontinued in all cases upon admission, whereas baseline steroids were maintained and tacrolimus dose was reduced. Initial treatment included hydroxychloroquine, antibiotics, and prophylactic anticoagulation. Before treatment with TCZ, 3 patients were receiving high-flow oxygen, 4 patients low-flow oxygen and 1 case non-invasive ventilation. All patients received a single dose of intravenous TCZ within a mean time of 7 ± 4 days since admission. During a median follow-up of 16 days (IQR: 10-29), 7 patients (70%) gradually improved and were finally discharged while three cases (30%) did not exhibited clinical improvement and ultimately died. In conclusion, although treatment with TCZ could be associated with improved clinical outcomes in a subset of KT recipients with COVID-19, further studies are warranted before drawing firm conclusions.     

Surgical Conditions Account for the Majority of Admissions to Three Primary Referral Hospitals in Rural Mozambique

Background

The World Health Organization has identified the primary referral hospital as its priority site for improving surgical care in low- and middle-income countries. Little is known about the relative burden surgical patients place on health care facilities at this level. This research estimates the fraction of admissions due to surgical conditions at three hospitals in rural Mozambique.

Methods

Prospective data were collected on all inpatients at three primary referral hospitals in Mozambique during a 12-day period. We compared the number of surgical patients and their length of stay (LOS) to the patients admitted to the medicine, pediatric, and maternity wards. These findings were validated using retrospective data collected from one hospital from January to May 2012.

Results

Patients with surgical conditions (i.e., patients admitted to the surgical or maternity ward) accounted for 57.5 % of admissions and 48.0 % of patient-days. The majority of patients were admitted to the maternity ward (32.3 %). The other admissions were evenly distributed to the pediatric (22.5 %), medical (20.0 %), and surgical (25.2 %) wards. Compared to patients from the three other wards, surgical patients had longer average LOS (8.7 vs. 1.9–7.7 days) and a higher number of total patient-days (891 vs. 252–703 days). The most prevalent procedures were cesarean section (33.3 %) and laceration repair/wound care (11.8 %).

Conclusions

Surgical conditions are the most common reason for admissions at three primary referral hospitals in rural Mozambique. These data suggest that surgical care is a major component of health care delivered at primary referral hospitals in Mozambique and likely other sub-Saharan African countries.     

Assessing Patterns of Practice of Sentinel Lymph Node Biopsy for Breast Cancer in Latin America

Introduction

There is a lack information regarding how sentinel lymph node biopsy (SLNB) for breast cancer is carried out today in developing countries and how it was adapted. To rectify this situation we performed a pattern-of-practice survey amongst practicing surgeons in Latin America (LA).

Methods

A survey was developed to assess current surgical practice in breast cancer, use of SLNB, limitations to the implementation, training, technique variations, and observed adverse events. A total of 30 surgical associations and breast surgery societies in 18 Latin American countries were invited to participate. Surveys were distributed among member of these associations and 76.7 % of those contacted answered the survey. Responses were limited only to those who reported treating breast cancer patients.

Results

A total of 463 surgeons who manage breast cancer responded. Over 53 % of surgeons do not have sub-specialty training. Only 47.7 % have a high-volume case load, of which 87.8 % routinely perform SLNB. The main limitations perceived to the implementation of SLNB were a lack of resources/equipment (48 %) and training opportunities (33 %). Over 60 % reported that fewer than half of their patients were eligible for SLNB and 67.8 % reported that they were involved in teaching this technique to residents.

Conclusions

A significant proportion of surgeons that treat breast cancer cases in LA have not had sub-specialty training or manage a low volume of cases. Among those surgeons with a high-volume caseload, SLNB is routinely performed. SLNB training during residency represents an opportunity for improvement in the region.     

Preoperative Education in Cholecystectomy in the Context of a Multimodal Protocol of Perioperative Care: A Randomized, Controlled Trial

Background

Preoperative education is a key point in multimodal protocols of perioperative care. We investigated whether preoperative education for patients undergoing open cholecystectomy would reduce the incidence of perioperative symptoms.

Methods

This was a randomized, single-blinded, clinical trial that included adult (18–65 years old) candidates for elective open cholecystectomy. All patients took part in the ERAS/ACERTO protocol of perioperative care except that only the intervention group received preoperative education. The main endpoints of the study were the presence and intensity of postoperative symptoms (e.g., nausea, vomiting, pain) measured by a visual analogue scale, 24 h after the operation.

Results

A total of 74 patients (34 in the intervention group, 40 in the control group) completed the study. The intervention group had significantly lower median (interquartile range) scores for nausea [0 (4) vs. 2.5 (5.8), p = 0.04] and pain [0.2 (2.3) vs. 3.1 (3.45), p < 0.01] than the controls. High well-being (score ≥6) was reported by 79.4 % (27 patients) of the intervention group in contrast to 57.5 % (23 patients) of the controls (p = 0.04).

Conclusions

Preoperative education is highly effective in the context of a multimodal protocol for enhancing the recovery of patients submitted to open cholecystectomy.