Mean Difference In Days Research Articles

Enhancing timeliness of port placement for new treatment patients: A quality improvement initiative.

335 Background: Timely port placement is crucial for patients beginning new treatments, yet delays can impede care and satisfaction. This initiative aimed to address these delays and improve port placement efficiency for new treatment patients. Methods: A single-center prospective cohort study was conducted between July 2022 and December 2023. Data was collected to assess the time from port order to port placement. Interventions included concurrent scheduling of consult and port placement visits in coordination with interventional radiology (IR) and workflow redesign to enhance oncology navigator involvement by directing port orders to an oncology navigation pool for expedited processing and scheduling. The primary endpoint was to compare the mean difference in days between IR consult order and port placement among pre- and post-intervention groups. Results: The study included 144 patients: 102 in the pre-intervention group (July 2022-June 2023) and 42 in the post-intervention group (July 2023-December 2023). The post-intervention group showed a 26.35% improvement in time to port placement from appointment, compared to pre-intervention intervals. The combined quarterly mean indicated a 14.37% reduction in time to port placement from order. The mean interval between IR consult order and port placement was 15.59 days pre-intervention and 13.35 days post-intervention, with a mean difference of 2.24 days (CI -0.92 to 5.4; p = 0.08). Conclusions: This quality improvement initiative demonstrated substantial progress in reducing delays in port placement for new treatment patients. Optimizing workflow processes and increasing navigator involvement significantly improved timeliness and the overall patient experience. Continued monitoring and refinement of these interventions are essential for sustaining these improvements over time. Mean interval between IR consult order and port placement. Timeframe of Pre-intervention Group Mean of Pre-Intervention Group* Mean of Post-Intervention Group* (July 2023-Dec 2023) Mean Difference Between Pre and Post Intervention Group* Standard Error Confidence Interval p-value July 2022-Dec 2022 16.12 13.35 2.76 1.91 -1.04 to 6.57 0.07 Jan 2023-Jun 2023 14.93 13.35 1.58 1.59 -1.59 to 4.74 0.16 July 2022-Jun 2023 (overall) 15.59 13.35 2.24 1.60 -0.92 to 5.40 0.08 *Mean expressed in days.

Invasive and conservative management of elderly patients presenting with acute coronary syndrome: A meta-analysis of randomized controlled trials and adjusted observational studies

BackgroundElderly patients are often under-represented in studies about coronary revascularization in acute coronary syndromes (ACS) and undertreated in clinical practice. We sought to evaluate differences in outcomes between an initial invasive or conservative strategy in this subset of patients, MethodsThe analysis was performed following PRISMA guidelines. Randomized controlled trials (RCTs) and adjusted observational studies comparing an invasive and conservative strategy in old patients with ACS were systematically identified. Random or fixed effect model was used accordingly to heterogeneity testing results. Short-term mortality was the primary outcome. 30-day and longer-term re-infarction, MACE and all-cause mortality were secondary endpoints. Sensitivity analysis including RCTs only were performed for the primary endpoint and 1 year mortality and another analysis, stratifying NSTEMI and STEMI studies, was performed for short-term mortality. ResultsInvasive management was associated with lower short and long-term mortality (30 days OR 0.64, 95 % CI 0.54–0.76, p < 0.001; 1 year HR 0.60, 95 % CI 0.52–0.78, p < 0.001; Long-term HR 0.62, 95 % CI 0.55–0.71, p < 0.001) compared to a conservative strategy. In the short-term follow-up, the benefit was preserved when differentiating for NSTEMI or STEMI studies but not when considering only RCTs. Major bleedings were more frequent in the invasive group (30 days OR 1.61, 95 % CI 1.39–1.87, p < 0.001). The mean difference in length of stay was not significantly different between the two strategies (mean difference in days 0.14, 95 % CI -0.79 to 1.06, p = 0.77). ConclusionAn initial invasive strategy might lead to reduced short and long-term mortality in elderly patients presenting with acute coronary syndrome but it is associated with increased bleeding events rate. No difference in hospital stay length was observed. Results were mainly driven by non-randomized studies.

The effectiveness of vaginal progesterone in reducing preterm birth in high-risk patients diagnosed with short cervical length after 24 weeks: A retrospective cohort study.

To assess the impact of progesterone treatment on maternal and neonatal outcomes in women with a history of preterm birth and short cervical length diagnosed after 24 weeks of gestation. A retrospective cohort study included women with a history of preterm birth and a transvaginal sonographic cervical length measurement of ≤ 25 mm, diagnosed between 24+0 and 33+6 weeks of gestation. Exclusion criteria included prior progesterone treatment, cervical cerclage, or pessary. The study population was divided into the progesterone treatment group and the non-treatment group. The study included 104 women, with 46.2% (48/104) receiving progesterone treatment and 53.8% (56/104) not receiving treatment. The rate of spontaneous preterm birth before 37 weeks of gestation was 43% (24/56) in the non-treatment group and 31% (15/48) in the progesterone treatment group (P = 0.14); the rate of spontaneous preterm birth before 34 weeks was 7% (4/56) in the non-treatment group and 0% (0/48) in the progesterone treatment group (P = 0.05). Progesterone treatment was associated with a significant decrease in neonatal intensive care unit admissions (OR 0.20, 95% CI 0.05-0.74) and in the neonatal hospitalization period (mean difference in days 2.43, 95% CI 0.44-4.42). The risk of recurrent spontaneous preterm birth was highest (71%) among women with two or more previous preterm deliveries who did not receive progesterone treatment, and lowest (24%) among women with one previous preterm delivery who received progesterone treatment. Progesterone treatment was associated with a reduction in rates of spontaneous preterm birth before 34 weeks of gestation, neonatal intensive care unit admission, and neonatal length of stay in high-risk patients, even when initiated after 24 weeks of gestation.

Outcomes of open vs laparoscopic vs robotic vs transanal total mesorectal excision (TME) for rectal cancer: a network meta-analysis.

Total mesorectal excision (TME) for rectal cancer can be achieved using open (OpTME), laparoscopic (LapTME), robotic (RoTME), or transanal techniques (TaTME). However, the optimal approach for access remains controversial. The aim of this network meta-analysis was to assess operative and oncological outcomes of all four surgical techniques. Ovid MEDLINE, EMBASE, and PubMed databases were searched systematically from inception to September 2020, for randomised controlled trials (RCTs) comparing any two TME surgical techniques. A network meta-analysis using a Bayesian random-effects framework and mixed treatment comparison was performed. Primary outcomes were the rate of clear circumferential resection margin (CRM), defined as > 1mm from the closest tumour to the cut edge of the tissue, and completeness of mesorectal excision. Secondary outcomes included radial and distal resection margin distance, postoperative complications, locoregional recurrence, disease-free survival, and overall survival. Surface under cumulative ranking (SUCRA) was used to rank the relative effectiveness of each intervention for each outcome. The higher the SUCRA value, the higher the likelihood that the intervention is in the top rank or one of the top ranks. Thirty-two RCTs with a total of 6151 patients were included. Compared with OpTME, there was no difference in the rates of clear CRM: LapTME RR = 0.99 (95% (Credible interval) CrI 0.97-1.0); RoTME RR = 1.0 (95% CrI 0.96-1.1); TaTME RR = 1.0 (95% CrI 0.96-1.1). There was no difference in the rates of complete mesorectal excision: LapTME RR = 0.98 (95% CrI 0.98-1.1); RoTME RR = 1.1 (95% CrI 0.98-1.4); TaTME RR = 1.0 (95% CrI 0.91-1.2). RoTME was associated with improved distal resection margin distance compared to other techniques (SUCRA 99%). LapTME had a higher rate of conversion to open surgery when compared with RoTME: RoTME RR = 0.23 (95% CrI 0.034-0.70). Length of stay was shortest in RoTME compared to other surgical approaches: OpTME mean difference in days (MD) 3.3 (95% CrI 0.12-6.0); LapTME MD 1.7 (95% CrI -1.1-4.4); TaTME MD 1.3 (95% CrI -5.2-7.4). There were no differences in 5-year overall survival (LapTME HR 1.1, 95% CrI 0.74, 1.4; TaTME HR 1.7, 95% CrI 0.79, 3.4), disease-free survival rates (LapTME HR 1.1, 95% CrI 0.76, 1.4; TaTME HR 1.1, 95% CrI 0.52, 2.4), or anastomotic leakage (LapTME RR = 0.92 (95% CrI 0.63, 1.1); RoTME RR = 1.0 (95% CrI 0.48, 1.8); TaTME RR = 0.53 (95% CrI 0.19, 1.2). The overall quality of evidence as per Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessments across all outcomes including primary and secondary outcomes was deemed low. In selected patients eligible for a RCT, RoTME achieved improved distal resection margin distance and a shorter length of hospital stay. No other differences were observed in oncological or recovery parameters between (OpTME), laparoscopic (LapTME), robotic (RoTME), or trans-anal TME (TaTME). However, the overall quality of evidence across all outcomes was deemed low.

Does chlorhexidine reduce the incidence of ventilator-associated pneumonia in ICU patients? A systematic review and meta-analysis

ObjectiveThis study aimed to investigate chlorhexidine’s efficacy in preventing ventilator-associated pneumonia (VAP). DesignA systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. SettingsThe data were obtained from Pubmed, Cochrane Library, and EMBASE. Patients or participantsOnly mechanically ventilated patients for at least 48h were included. InterventionsRandomized clinical trials applying any dosage form of chlorhexidine were eligible. Main variables of interestThe relative risk (RR) of the VAP incidence and all-cause mortality was assessed using the random-effects model. The mean difference in days of mechanical ventilation duration and intensive care unit (ICU) length of stay were also appraised. ResultsTen studies involving 1233 patients were included in the meta-analysis. The oral application of CHX reduced the incidence of VAP (RR, 0.73 [95% CI, 0.55, 0.97]) and did not show an increase in all-cause mortality (RR, 1.13 [95% CI, 0.96, 1.32]). ConclusionsCHX proved effective to prevent VAP. However, a conclusion on mortality rates could not be drawn because the quality of the evidence was very low for this outcome.

Impact of a Potential 20-Week Abortion Ban on Likelihood of Completing Required Views in Second-Trimester Fetal Anatomy Ultrasound.

The aim of this study was to quantify the likelihood of assessing all mandated fetal views during the second-trimester anatomy ultrasound prior to the proposed federal 20-week abortion ban. Retrospective cohort study of a random sample of 1,983 patients undergoing anatomy ultrasound in 2017 at a tertiary referral center. The difference in proportion of incomplete anatomic surveys prior compared with after 20-week gestation was analyzed using X 2 and adjusted logistic regression; difference in mean days elapsed from anomaly diagnosis to termination tested using t-tests and survival analysis. Incomplete views were more likely with initial ultrasound before 20 weeks (adjusted relative risk: 1.70; 95% confidence interval: 1.50-1.94); 43.5% versus 26.1% were incomplete before and after 20 weeks, respectively. Fetal structural anomalies were identified in 6.4% (n = 127/1,983) scans, with 38.0% (n = 49) identified at follow-up after initial scan was incomplete. 22.8% (n = 29) with an anomaly terminated. A complete assessment of fetal views during an anatomy ultrasound prior to 20-week gestation is often not technically feasible. Legislation limiting abortion to this gestational age would greatly impact patient's ability to make informed choices about their pregnancies. · It is often not technically possible to complete anatomy ultrasound prior to 20-week gestation.. · Often, anomalies are missed during early, incomplete anatomy ultrasounds.. · After the diagnosis of a structural anomaly, one in five chose to terminate the pregnancy..

Assessment of the effects of rapid diagnostic biofire blood culture identification panel in hospitalized patients

Background: Bloodstream infections (BSIs) have life-threatening consequences; they contribute to increased global morbidity and mortality, particularly in critically ill patients. Consequently, early implementation of effective antimicrobial therapy is crucial. Microbiology stewardship efforts, such as rapid diagnostic testing, streamline healthcare resources while also optimizing clinical outcomes. These outcomes include decreased mortality, fewer days of hospitalization, and more efficient time to appropriate anti-infective regimens. Biofire Blood Culture Identification (BCID) is a 2-stage multiplexed PCR system yielding multiple pathogen etiologies, as well as antimicrobial resistance genes. Results are published ~60 minutes after a blood-culture Gram stain turns positive. The purpose of this study was to assess the clinical impact of rapid diagnostic PCR testing, which was introduced at Saint Francis Hospital in March 2020. Methods: We conducted a single-center, retrospective observational chart review before and after implementation of Biofire BCID, surveying all positive cultures from December 2019 through June 2020. Medical records were more thoroughly reviewed for patients who met study inclusion criteria. The primary outcome of interest, time to appropriate antimicrobial therapy, included both days to targeted therapy in the setting of a probable pathogen, and days to antibiotic discontinuation in the case of a likely contaminant (nonpathogenic normal skin flora introduced into culture at the time of collection or processing). Secondary outcomes included in-hospital mortality (death during hospitalization), and inpatient length of stay (LOS). Wilcoxon rank-sum tests were used for primary outcomes and Fisher exact tests were used for secondary outcomes. Results: Among 643 patients with positive blood cultures, 410 (63.8%) met the criteria. In the study, 220 patients before the intervention and 190 patients after the intervention were reviewed. The difference in mean days to targeted therapy with a probable pathogen and days to antibiotic discontinuation with a likely contaminant were both observed at a significance level (3.62 vs 1.79, P Inpatient mortality rates were higher prior to launching Biofire BCID, but they were not statistically significant (15.5% vs 14.2 %; P = .782). The average LOS before and after implementation was 12.6 days (range, 2–92 days), and 10 days (range, 2–68 days), respectively. This parameter was also not statistically significant (P = .597). Conclusions: We detected a trend toward a significant reduction in time to appropriate antimicrobial therapy following the launch of Biofire BCID. Incorporation of molecular rapid diagnostics for BSI evaluation should be the standard of care in hospital settings.Funding: NoneDisclosures: None

Minimally-invasive approach to emergent colorectal surgery in aging adults: A report from the Surgical Care Outcomes Assessment Program

BackgroundDespite known benefits of minimally invasive surgery(MIS) in elective settings, MIS use in emergency colorectal surgery(CRS) is limited. Older adults are more likely to require emergent CRS, and MIS is used less frequently with increasing age. MethodsA retrospective cohort was constructed of emergent CRS cases performed between 2011 and 2019. Discharge(DC) disposition, adverse events, and length of stay(LOS) between MIS and open surgery were compared and stratified by age. Adjustment was made for selected confounders using inverse probability weighting. ResultsOf 6913 emergent CRS cases across 50 hospitals, 1616(23%) were approached MIS. MIS cases were more likely [OR(95%CI)] to DC home [<65yo:1.7(1.3,2.2); 65–74:1.5(1.1,1.9); 75+:1.2(0.9,1.5)] and have fewer adverse events [<65yo:0.6(0.5,0.8); 65–74:0.7(0.5,0.9); 75+:0.7(0.5,0.9)]. LOS was shorter [Mean difference in days(95%CI)] [<65yo: 2.2(-2.9,-1.4); 65–74: 0.9(-2.7,1.0); 75+: 0.7(-1.7,0.2)]. ConclusionsMIS in emergent CRS is associated with increased DC to home, fewer adverse events, and shorter LOS. Benefits persisted with age after adjustment, suggesting an opportunity for improved MIS delivery in older adults.

Oropharyngeal colostrum immunotherapy and nutrition in preterm newborns: meta-analysis.

ABSTRACTOBJECTIVE To investigated the effect of oropharyngeal colostrum immunotherapy in reducing the time required for very low birth weight preterm newborns (VLBW-PTNB: < 1,500g and < 37 weeks) to achieve full enteral nutrition.METHODS Literature search was conducted using four databases, including gray literature, with additional manual search of the references of selected articles. Eligibility criteria consisted of randomized clinical trials, without restriction regarding the date or language of the publication. Two independent reviewers performed the article selection and data extraction. The random-effects meta-analysis used a non-standard technique to assess the mean difference in days to achieve full enteral nutrition, carried out by the Stata 15 statistic program.RESULTS The systematic review comprised 10 studies, and five were selected for meta-analysis, with a population of 764 VLBW-PTNB and gestational age of birth between 25 and 32 weeks. The studies were conducted between 2011 and 2018 in North America, Asia and Africa, with only one conducted in South America. Altogether, they reported the number of days it took 708 VLBW-PTNB to achieve full enteral nutrition, with newborns treated with immunotherapy showing a shorter time in only three studies. Meta-analysis showed a mean difference of -4.26 days, (95% CI -7.44; -1.08d), with high heterogeneity (I2 = 83.1%).CONCLUSION The use of oropharyngeal colostrum immunotherapy can reduce the time for VLBW-PTNB to achieve full nutrition when compared to those who used a placebo or received routine care.

Health Care Utilization and Cost of Allogeneic Hematopoietic Cell Transplantation in Children with Malignant and Non-Malignant Diseases

Introduction: Allogeneic hematopoietic cell transplant (alloHCT) represents a potentially life-saving treatment for patients with both malignant and non-malignant diseases. AlloHCT related costs accounted for the most rapid increase in total hospital cost, with a growth rate of 84.9%, from 2004 to 2007 according to an Agency for Health Care Research and Quality report (Stranges, HCUP Statistical Briefs, 2006). Higher cost has been associated with use of alternative donor sources and post-transplant complications. Transplant care improvements have led to better outcomes (Gooley, NEJM, 2010) but the effect on cost is not known.Methods: We obtained data for 240 patients who received an alloHCT at Columbia University Medical Center between 1/1/05 and 6/30/16 and were <21 years old at the time of alloHCT for the first year post-transplant. Patient clinical characteristics and outcomes were obtained from retrospective review of medical records. Hospitalization cost data was estimated from charges obtained from the Pediatric Health Information System (PHIS) database using hospital specific cost-to-charge ratios and adjusted for inflation. To analyze changes over time, patients were divided into three time periods 2005-08 (n=103 patients), 2009-12 (n=73 patients), 2013-16 (n=64 patients). Primary outcomes were overall survival (OS), transplant related complications (liver injury: total bilirubin >2, kidney injury (decrease in creatinine clearance by >50%), viremia, bacteremia, acute graft-versus-host-disease (aGVHD) and inpatient resource utilization. The comparisons among groups were carried out by Kruskal-Wallis test for continuous variables and Chi-square test for categorical variables.Results: There were no differences over time with respect to patient age, sex, related vs. unrelated donor, myeloablative vs. reduced intensity conditioning. The median age was 10.32 (range 0.34-20.96) years. There were significant differences in number of patients with nonmalignant disease (2005-08: 42%, 2009-12: 45%, 2013-16: 63%, p=0.027) and full HLA match (2005-08:44%, 2009-12: 56%, 2013-16: 64%, p=0.026). Liver injury in the first 30 days occurred in 2005-08: 30%, 2009-12: 32%, 2013-16: 27%, p=0.81. Kidney injury occurred in the first 30 days in 2005-08: 28%, 2009-12: 40%; 2013-16: 27%, p=0.22 and in the first year post-transplant in 2005-08: 85%, 2009-12: 78%, 2013-16: 66%, p=0.011 respectively. Viral infections were 2005-08: 27%, 2009-12: 51%, 2013-16: 41%, p=0.006, and there was a significant difference in mean days with bacteremia 2005-08: 3.4, 2009-12: 2.1, 2013-16: 1.8, p<0.001. There was also a significant difference in incidence of aGVHD 2005-08: 33%, 2009-12: 45%; 2013-16: 20%, p=0.009. There was no difference in OS 2005-08: 69%, 2009-12: 74%, 2013-16: 81%, p=0.21. There were significant differences in hospitalization lengths and costs between the three time periods with the lowest median inpatient days and costs for the 2013-16 group. The median lengths of transplant admission were 2005-08: 52 days, 2009-12: 48 days and 2013-16: 41 days (p<0.001). The median total inpatient days for the first year post-transplant were 2005-08: 98 days, 2009-12: 93 days, and 2013-16: 53 days (p<0.001). The median cost of the first transplant hospitalization was 2005-08: $184,450, 2009-12: $156,020, 2013-16: $130,244 (p<0.001), and median total one-year inpatient cost was 2005-08: $344,424, 2009-12: $308,826, 2013-16: $181,205 (p<0.001). The median cost per day survived was 2005-08: $433, 2009-12: $371, 2013-16: $202 (p<0.001). Stratifying the cohort by disease type and donor source, the median cost of alloHCT for matched related donors was 2005-08: $271,674, 2009-12: $213,546, 2013-16: $163,251 (p=0.012), for unrelated donors was 2005-08: $377,484, 2009-12: $380,211, 2013-16: $219,208 (p=0.007), for malignant diseases was 2005-08: $341,989, 2009-12: $363,676, 2013-16: $219,208 (p=0.07) and for non-malignant diseases was 2005-08: $344,424, 2009-12: $262,814, 2013-16: $184,280 (p<0.001).Conclusion: Cost of alloHCT for pediatric patients treated at our center from 2005 to 2016 appears to have decreased. This is most likely related to improved care practices stemming from various quality improvement projects, leading to decreased lengths of hospitalization as well as decreased incidence of complications most significantly kidney injury, aGVHD and bacterial infection. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Abstract P458: Systemic Inflammatory Response Syndrome is Associated With Hematoma Expansion in Intracerebral Hemorrhage

Objective: Systemic inflammatory response syndrome (SIRS) and hematoma expansion are both associated with worse outcomes after intracerebral hemorrhage (ICH), but their relationship remains unclear. We sought to determine the association between SIRS and hematoma expansion after ICH. Methods: We performed a retrospective cohort study of patients admitted to our hospital from 2013 to 2020 with primary spontaneous ICH with at least two head CTs within the first 24 hours. Patients were excluded if they had a decompressive craniectomy, intracranial vascular lesions or malignancy, or coagulopathy. Hematoma volume was measured using the ABC/2 method; hematoma expansion was defined as 6mL or 33% growth between the first and second scan. We compared patients with and without SIRS using Pearson’s χ2, students T and Wilcoxon rank sum tests. The relationship between admission SIRS and hematoma expansion was assessed using univariate and multivariate regression analysis. Results: Of 187 patients with ICH, 73 (39%; mean age 6617, 40% female) met inclusion criteria. Of those, 38 (52%) had SIRS on admission. Admission systolic blood pressure (SBP) was significantly higher in patients with SIRS compared to those without (169 [IQR 133- 205] vs 152 [125- 179] mm Hg, p= 0.02). There was no difference in mean days to first antibiotic administration (6.3 vs 5.6, p=0.78), admission platelets (227 vs 243, p= 0.38) or initial hematoma volume (23 vs 15, p=0.16). Hematoma expansion occurred in 14 patients, 11 (79%) of whom also had SIRS. A significantly greater percentage of patients with SIRS had mRS 4-6 at discharge (87 vs 67%, p=0.05). SIRS was significantly associated with hematoma expansion (OR 4.35, 95% CI 1.10-17.20, p= 0.04) on univariate analysis. The association remained statistically significant after adjusting for admission SBP, platelets, and initial hematoma volume (OR 4.54, 95% CI 1.01-20.60, p= 0.05). Conclusion: Presence of SIRS on admission is associated with hematoma expansion within the first 24 hours. Further research is needed to better understand this association, which may enable us to identify early on and treat those patients at highest risk for decompensation.

Physical Restraints and Post-Traumatic Stress Disorder in Survivors of Critical Illness. A Systematic Review and Meta-analysis.

Rationale: Physical restraints are used liberally in some intensive care units (ICUs) to prevent patient harm from device removal or falls. Although the intention of restraint use is patient safety, their application may inadvertently cause physical or psychological harm. Physical restraints may contribute to post-traumatic stress disorder (PTSD), but there is a paucity of supportive data.Objectives: To investigate the association between physical restraint use and PTSD symptoms in ICU survivors. Secondary objectives were to examine the cognitive and physical outcomes associated with physical restraint use and to assess interventions that may be effective in reducing restraint use.Methods: A systematic review of English language studies in PubMed, Medline, Embase, CINAHL, and CENTRAL between January 1, 1990, to February 8, 2020 was performed. Observational or randomized studies that reported on restraint use and associated outcomes, or interventions to reduce restraint use, in critically ill adult patients were identified. Two independent reviewers completed the review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.Results: We identified 794 articles, of which 37 met inclusion criteria and were included. Thirty of these studies related to patient outcomes including PTSD, delirium, mechanical ventilation hours, and physical injury. Seven related to interventions to reduce physical restraint use. The quality of studies was not high; only four of the included studies were assessed to have a low risk of bias. Three studies found a significant relationship between restraint use and PTSD, but their results could not be pooled for analysis. Pooled data indicated a significant association between physical restraint use and delirium (odds ratio [OR], 11.54; 95% confidence interval [CI], 6.66-20.01; P < 0.001) and duration of mechanical ventilation (mean difference in days, 3.35; 95% CI, 1.95-4.75; P < 0.001). We also found that interventions, such as nursing education, may effectively reduce restraint use by approximately 50% (OR, 0.48; 95% CI, 0.32-0.73; P < 0.001). The impact that a reduction in restraint use may have on associated outcomes was not examined.Conclusions: Physical restraint use may be associated with PTSD in ICU survivors and is associated with delirium and longer duration of mechanical ventilation. Nurse education is likely effective in reducing rates of physical restraint among ICU patients.

A comparative study of Lichtenstein tension free hernioplasty with prolene hernia system hernioplasty for ingunial hernia

Background: Lichtenstein tension-free hernioplasty (LTH) has become the gold standard for hernia repair. It is easy to learn and perform with minimal complications and low recurrence rate. But it deals with only superior half of the myopectineal orifice. Prolene hernia system (PHS) hernioplasty is safe, causes minimal pain and has minimal recurrence rate but is still not popular due to high cost. The aim of the study is to compare the Lichtenstein tension-free hernioplasty with hernioplasty using prolene hernia system.Methods: A total of 60 patients with inguinal hernia were equally grouped into cases (PHS) and controls (LTH). Outcome measures were compared with regards to postoperative pain, hospital stay and complications.Results: There was no significant difference in mean days of post-operative hospital stay among cases and controls. On post-operative days 1 and 3, most of the patients experienced moderate pain and by 8th post-operative day most of the patients had no pain. The pain intensity decreased with increase in post-operative days. Seroma formation was seen among 2 (6.67%) cases (PHS) group in comparison to 3 (10.0%) controls (Lichtenstein) group. Post-operative wound infection was seen among 1 (3.33%) cases (PHS) group and controls (Lichtenstein) group each. Recurrence was seen neither among patients treated with either technique.Conclusions: Prolene Hernia System mesh repair could be a suitable alternative to time honored Lichtenstein hernia repair with added advantage of strengthening the whole of myopectineal orifice, and virtually eliminating any risk of recurrence.

Early occupational intervention for people with low back pain in physically demanding jobs: A randomized clinical trial.

BackgroundOccupational medicine seeks to reduce sick leave; however, evidence for an add-on effect to usual care is sparse. The objective of the GOBACK trial was to test whether people with low back pain (LBP) in physically demanding jobs and at risk of sick leave gain additional benefit from a 3-month complex intervention that involves occupational medicine consultations, a work-related evaluation and workplace intervention plan, an optional workplace visit, and a physical activity program, over a single hospital consultation and an MRI.Methods and findingsWe enrolled people from the capital region of Denmark to an open-label, parallel-group randomized controlled trial with a superiority design from March 2014 through December 2015. In a hospital setting 305 participants (99 women) with LBP and in physically demanding jobs were randomized to occupational intervention (n = 153) or no additional intervention (control group; n = 152) added to a single hospital consultation giving a thorough explanation of the pain (i.e., clinical examination and MRI) and instructions to stay active and continue working. Primary outcome was accumulated sick leave days due to LBP during 6 months. Secondary outcomes were changes in neuropathic pain (painDETECT questionnaire [PDQ]), pain 0–10 numerical rating scale (NRS), Fear-Avoidance Beliefs Questionnaire (FABQ), Roland–Morris Disability Questionnaire (RMDQ), Short Form Health Survey (SF-36) for physical and mental health-related quality of life (HRQoL), and self-assessed ability to continue working (range 0–10). An intention-to-treat analysis of sick leave at 6 months showed no significant difference between groups (mean difference in days suggestively in favor of no additional intervention: 3.50 [95% CI –5.08 to 12.07], P = 0.42). Both groups showed significant improvements in average pain score (NRS), disability (RMDQ), fear-avoidance beliefs about physical activities and work (FABQ), and physical HRQoL (SF-36 physical component summary); there were no significant differences between the groups in any secondary outcome. There was no statistically significant improvement in neuropathic pain (PDQ score), mental HRQoL (SF-36 mental component summary), and self-assessed ability to stay in job. Four participants could not complete the MRI or the intervention due to a claustrophobic attack or accentuated back pain. Workplace visits may be an important element in the occupational intervention, although not always needed. A per-protocol analysis that included the 40 participants in the intervention arm who received a workplace visit as part of the additional occupational intervention did not show an add-on benefit in terms of sick leave (available cases after 6 months, mean difference: –0.43 days [95% CI –12.8 to 11.94], P = 0.945). The main limitations were the small number of sick leave days taken and that the comprehensive use of MRI may limit generalization of the findings to other settings, for example, general practice.ConclusionsWhen given a single hospital consultation and MRI, people in physically demanding jobs at risk of sick leave due to LBP did not benefit from a complex additional occupational intervention. Occupational interventions aimed at limiting biopsychological obstacles (e.g., fear-avoidance beliefs and behaviors), barriers in the workplace, and system barriers seem essential to reduce sick leave in patients with LBP. This study indicates that these obstacles and barriers may be addressed by thorough usual care.Trial registrationClinical Trials.gov: NCT02015572

Exploiting Time Series of Sentinel-1 and Sentinel-2 Imagery to Detect Meadow Phenology in Mountain Regions

A synergic integration of Synthetic Aperture Radar (SAR) and optical time series offers an unprecedented opportunity in vegetation phenology monitoring for mountain agriculture management. In this paper, we performed a correlation analysis of radar signal to vegetation and soil conditions by using a time series of Sentinel-1 C-band dual-polarized (VV and VH) SAR images acquired in the South Tyrol region (Italy) from October 2014 to September 2016. Together with Sentinel-1 images, we exploited corresponding Sentinel-2 images and ground measurements. Results show that Sentinel-1 cross-polarized VH backscattering coefficients have a strong vegetation contribution and are well correlated with the Normalized Difference Vegetation Index (NDVI) values retrieved from optical sensors, thus allowing the extraction of meadow phenological phases. Particularly for the Start Of Season (SOS) at low altitudes, the mean difference in days between Sentinel-1 and ground sensors is compatible with the acquisition time of the SAR sensor. However, the results show a decrease in accuracy with increasing altitude. The same trend is observed for senescence. The main outcomes of our investigations in terms of inter-satellite comparison show that Sentinel-1 is less effective than Sentinel-2 in detecting the SOS. At the same time, Sentinel-1 is as robust as Sentinel-2 in defining mowing events. Our study shows that SAR-Optical data integration is a promising approach for phenology detection in mountain regions.

Active listing and more consultations in primary care are associated with reduced hospitalisation in a Swedish population

BackgroundHealthcare systems are complex networks where relationships affect outcomes. The importance of primary care increases while health care acknowledges multimorbidity, the impact of combinations of different diseases in one person. Active listing and consultations in primary care could be used as proxies of the relationships between patients and primary care. Our objective was to study hospitalisation as an outcome of primary care, exploring the associations with active listing, number of consultations in primary care and two groups of practices, while taking socioeconomic status and morbidity burden into account.MethodsA cross-sectional study using zero-inflated negative binomial regression to estimate odds of any hospital admission and mean number of days hospitalised for the population over 15 years (N = 123,168) in the Swedish county of Blekinge during 2007. Explanatory factors were listed as active or passive in primary care, number of consultations in primary care and primary care practices grouped according to ownership. The models were adjusted for sex, age, disposable income, education level and multimorbidity level.ResultsMean days hospitalised was 0.94 (95%CI 0.90–0.99) for actively listed and 1.32 (95%CI 1.24–1.40) for passively listed. For patients with 0–1 consultation in primary care mean days hospitalised was 1.21 (95%CI 1.13–1.29) compared to 0.77 (95%CI 0.66–0.87) days for patients with 6–7 consultations. Mean days hospitalised was 1.22 (95%CI 1.16–1.28) for listed in private primary care and 0.98 (95%CI 0.94–1.01) for listed in public primary care, with odds for hospital admission 0.51 (95%CI 0.39–0.63) for public primary care compared to private primary care.ConclusionsActive listing and more consultations in primary care are both associated with reduced mean days hospitalised, when adjusting for socioeconomic status and multimorbidity level.Different odds of any hospitalisation give a difference in mean days hospitalised associated with type of primary care practice.To promote well performing primary care to maintain good relationships with patients could reduce mean days hospitalised.

Systematic review and meta-analysis of the efficacy of liposomal bupivacaine in colorectal resections

Objective: The objective of the study was to systematically investigate the outcomes of Liposomal Bupivacaine following major colorectal resections.Patients and methods: We conducted a comprehensive literature search of PubMed, Medline, Google scholar, Cochrane Central Registry and clinical trials.gov databases through May 2017 for studies published regarding liposomal bupivacaine. Studies were filtered based on relevance to perioperative analgesia in colorectal resections. Data comparing type of study, techniques of resection, mode of administration of liposomal bupivacaine, details of control group, outcomes were collected.Results: A total of 1008 patients from seven studies were included in this systematic review and meta-analysis. The studies were mostly retrospective or prospective cohort studies with one randomized controlled trial (RCT). Meta-analysis showed that liposomal bupivacaine was associated with decreased length of stay, standard mean difference in days (SMD) − 0.34, (95% confidence intervals [CI] − 0.56, −0.13, p = .001) and decreased IV opioid use (expressed as intravenous morphine equivalent in milligrams) in the first 48–72 h, SMD −0.49 (95% CI −0.69, −0.28, p < .00001). Pain scores were also significantly low in patients who received liposomal bupivacaine, SMD −0.56 (95% CI −1.07, −0.06, p = .03]. There was no significant difference in hospitalization costs between the two groups.Conclusions: Use of liposomal bupivacaine is associated with decreased IV opioid use, length of stay and lower pain scores. However, our data needs to be interpreted cautiously given the relative paucity of randomized controlled trials.

Olmesartan Reduces New-onset Atrial Fibrillation and Atrial Fibrillation Burden after Dual-chamber Pacemaker Implantation in Atrioventricular Block Patients.

Background:Atrial fibrillation (AF) is the most frequent tachyarrhythmia in patients with a permanent pacemaker. Angiotensin II receptor antagonists have a protective effect against the occurrence of AF in patients with heart diseases. This study aimed to assess the effectiveness of olmesartan in the prevention of new-onset AF and AF burden in atrioventricular block (AVB) patients with dual-chamber (DDD) pacemaker implantation.Methods:This was a single-center, prospective, randomized, single-blind, controlled clinical study. A total of 116 AVB patients, who received DDD pacemakers implantation with the percentage of ventricular pacing (VP%) ≥40% from April 22, 2011 to December 24, 2012, were prospectively randomized to olmesartan group (20 mg per day; n = 57) or control group (n = 59). Patients were followed up using pacemaker programming, 12-lead electrocardiography in the intrinsic sinus rhythm, laboratory examinations, and transthoracic echocardiography at 24 months. Atrial high rate events (AHREs) were defined as 180 beats/min over a minimum of 5 min. AF burden was calculated by the number of hours with AHREs divided by the number of measurement hours.Results:Ten (17.5%) patients in the olmesartan group and 24 patients (40.7%) in the control group occurred new-onset AF, and the difference between two groups was statistically significant (P = 0.04). AF burden was lower in olmesartan group than that in control group (8.02 ± 3.10% vs. 13.66 ± 6.14%, P = 0.04). There were no significant differences in mean days to the first occurrence of AHREs and mean cumulative numbers of AHREs between two groups (P = 0.89 and P = 0.42, respectively). Moreover, olmesartan group had smaller values of maximal P-wave durations and P-wave dispersion (PD) after 24 months follow-up compared with the control group (109.5 ± 7.4 ms vs. 113.4 ± 7.1 ms, P = 0.00; and 40.6 ± 4.5 ms vs. 43.3 ± 4.4 ms, P = 0.02, respectively). Left ventricular end-diastolic diameter and left ventricular ejection fraction were not significantly different between two groups (both P > 0.05).Conclusion:This study suggested that 24-month of olmesartan therapy could reduce new-onset AF and AF burden in patients with DDD pacemakers.Clinical Trial Registration:ChiCTR-TRC-12004443; http://www.chictrdb.org.

320 - Obesity Does Not Impact 1 Year Survival After LVAD Implantation

Purpose: The obesity paradox is well described in patients with heart failure. Among those who undergo heart transplantation, morbid obesity has been shown to adversely impact survival. We sought to determine the effect of obesity on survival after LVAD implantation. Methods: A single center retrospective review of all patients implanted with a LVAD between January, 2010 and September, 2015. Obesity was defined as BMI ≥ 30 kg/m2. The study population was stratified based on BMI. Results: 275 patients underwent LVAD implantation, of whom 108 (39%) were obese. Mean BMI was 34.8 ± 4.1 and 24.4 ± 3.1 kg/m2 in obese and non-obese groups, respectively. There was no significant difference in mean days on LVAD support (514.9 ± 470.7 obese vs 507.8 ± 465.4 non-obese, P = .9). Compared to non-obese patients, those in the obese group were younger (52.1 ± 11.4 vs 58.0 ± 13.7 years, P < .01), more likely to be African-American (73.1% vs 53.3%, P < .01), and have a non-ischemic etiology as the cause of heart failure (70.4% vs 56.9%, P = .02). They were also more likely to suffer from diabetes (51.9% vs 31.7%, P < .01) and OSA (26.9% vs 7.2%, P < .01). There were no significant differences between the 2 groups in the pre-op INTERMACS profiles, implant strategy at time of LVAD (BTT: 56.5% vs 48.5%, P = .2), type of LVAD (axial vs centrifugal), kidney/liver function. During the index hospitalization for LVAD implant, there were no significant differences between the 2 groups in the days on vasopressors (6.4 ± 6.4 vs 6.0 ± 6.7, P = .58) and on inotropic therapy (11.9 ± 9.3 vs 11.1 ± 11.9, P = .54). Importantly, the obese and non-obese groups had similar lengths of stay for index LVAD surgery (30.3 ± 21.7 vs 28.1 ± 20.4, P = .39) and similar rates of 30 day re-hospitalization (27% vs 26%, P = .84). Furthermore, the 1 year survival (Fig. 1) did not differ between the 2 groups (82.4% obese vs 75.5% non-obese, P = .21). Conclusion: In this single center experience, obesity does not appear to adversely impact length of stay, 30-day re-hospitalization, or 1 year survival after LVAD implantation. Whether more severe forms of obesity affect clinical outcomes deserve further study.

Respiratory viral coinfection and disease severity in children: A systematic review and meta-analysis

BackgroundWith advent of molecular diagnostic technologies, studies have reported detection of two or more respiratory viruses in about 30% of children with respiratory infections. However, prognostic role of coinfection remains unclear. ObjectiveEvaluate relation between respiratory viral confection and illness severity in children. Study designMEDLINE (through PUBMED), EMBASE, EBSCO, LILACS databases were searched up to March 2015 by two independent reviewers. Studies assessing severity of viral coinfection in patients aged less than 18 years were included. Standardized forms were used for data extraction of population, study design, clinical syndromes, virus combinations compared and severity outcomes. Risk of bias and quality of evidence were assessed through EPHPP and GRADE. Subgroup analysis was performed according to age and viral combinations. ResultsOf 5218 records screened, 43 were included in analysis. Viral coinfection did not influence risks of all outcomes assessed: length of stay (mean difference in days in coinfection, −0.10 [95% confidence interval: −0.51 to 0.31]), length of supplemental oxygen (−0.42 [−1.05 to 0.20]), need of hospitalization (odds ratio of coinfection, 0.96 [95% confidence interval: 0.61–1.51]), supplemental oxygen (0.94 [0.66 to 1.34]), need of intensive care (0.99 [0.64 to 1.54]), mechanical ventilation (0.81 [0.33 to 2.01]) and death (2.22 [0.83 to 5.95]). Sub-analyses according to age and viral combinations have not shown influence of these factors in outcomes. ConclusionsRespiratory viral coinfection did not increase severity in all outcomes assessed. Further studies are necessary to confirm this finding, especially regarding role of specific viral interactions.